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Menopause: What If Estrogen Is Not For You?

Like any medicine, estrogen is not for everyone. In general, there are three categories of patients who either can't or won't take estrogen.

Category I: Patients with contraindications.

These women have preexisting conditions or risk factors that essentially disqualify them from being able to take estrogen. These include:

  1. Pregnancy or Breastfeeding.
  2. Liver disease
  3. Undiagnosed vaginal bleeding.
  4. History of certain cancers.
  5. History of deep vein thromboses or other blood clotting disorders.

Category II: Women who have been on one or more estrogen preparations and/or doses but who have had side effects that are unacceptable to them.

For women in this category, it's important to remember that there are many different preparations, doses and combinations of estrogen in hormone replacement therapy- and that many side effects may be related to the progesterone in the combination therapy. If you are on HRT and having side effects, they will generally resolve within three months. If they do not, speak with your doctor about adjusting your medication regimen. If you are still uncomfortable, speak to your doctor about alternatives. Don't discontinue taking any prescription medication without first speaking with your doctor.

Common side effects of HRT:

  1. Return of periods
  2. Irregular vaginal bleeding/spotting
  3. Headache
  4. Nausea
  5. Breast tenderness
  6. Bloating (progesterone)
  7. Weight gain (progesterone): generally only 2-3 pounds can be "blamed" on the hormones: the rest is decreased metabolism associated with menopause, increased caloric intake and/or decreased exercise.
  8. May exacerbate depression (progesterone)
  9. Enlargement of uterine fibroids
  10. Exacerbation of endometriosis
  11. Fluid retention (may exacerbate asthma, epilepsy, migraine, heart disease, kidney disease)
  12. Spotty darkening of the skin

Category III: Women who fear the potential or possible connection between estrogen and its serious risks.

Franklin Delano Roosevelt said, "The only thing to fear is fear itself", but he wasn't a menopausal woman. While many of the risks of estrogen are exaggerated by media reports, there are legitimate concerns and women who are afraid have every reason to be cautious. Recent results of the Women's Health Initiative (Journal of the American Medical Association, 7/16/02) have shown that women who took combination estrogen plus progestin (Prempro) for an average of 5.2 years had an increased risk of invasive breast cancer, heart attacks, strokes and blood clots. (They also had a reduced risk of osteoporotic fractures and colon cancer). While the group on estrogen alone did not show as much increase in these risks, we do know that estrogen can increase the incidence of endometrial hyperplasia, which is a precancerous condition of the uterus. This is why progesterone is given with estrogen in women who have not had a hysterectomy.

Serious potential risks of ERT:

  • Abnormal blood clotting (may increase risk of stroke, pulmonary emboli, or blood clots known as deep vein thromboses).

  • Endometrial hyperplasia which increases the risk of endometrial cancer

  • Increased risk of gall bladder disease

  • Small increased risk of invasive breast cancer.

Most of the risks of estrogen therapy are further increased in smokers. This is yet another strong reason to stop smoking. Women who can't stop, however, need to consider this in when evaluating their treatment options.

Category IV: Women who believe that menopause is a "natural" transition and therefore they want to approach it naturally, without medication.

This is a valid belief system and is your choice. Don't reject your doctor's input, however, because you worry that s/he will just pressure you to take medication. As with any condition, discuss your concerns openly and honestly, and ask all of your questions about your alternatives.

What is Alternative Medicine? What is it Alternative To?

In general, when we talk about alternative medicine, we're talking about medicines, foods or modalities that do not meet the research-based standards of what we call "evidence-based medicine"- this doesn't mean that they don't have value, it just means that the products have not gone through the extensive research and scrutiny of the FDA approval process. In general, the products are not regulated with the same level of scrutiny and oversight as prescription or over-the-counter medicines, nor is their marketing or labeling information.

When we talk about alternative medicine, we're also generally talking about products with alternative sources of distribution, information, and payment. This is changing daily, however, so do your best to keep up-to-date if you are using alternative medical therapies.

Categories of alternative medicine include vitamins, herbs, foods, dietary supplements, and modalities of intervention (e.g. acupuncture, massage, meditation, biofeedback, etc.). When we talk about alternatives to estrogen replacement therapy for menopause, however, we're also talking about other prescription medicines, depending upon which aspect of menopause you are looking to treat or to prevent. We have discussed these therapies at length in previous menopausal segments. For example, there are several prescription alternatives to estrogen to prevent and treat osteoporosis; numerous drugs to prevent and treat heart disease; and a few medicines to prevent and treat hot flashes and related menopausal symptoms such as sleep disturbances and vaginal dryness, so they are not discussed here. Keep in mind that there are no known medicines-traditional or alternative-which can provide all of the benefits of estrogen in each of these categories, so you may need to use a combination of alternative therapies.

National surveys estimate that between 12%--17% of Americans have tried herbal remedies, and women are the primary users of alternative therapies in general. We have no data on what percent of these people were satisfied with their choices, however.

The Office of Alternative Medicine (OAM) at the National Institutes of Health was created in 1992 to address these and other related research questions about alternative medicines. It's initial budget, however was only $2 million! That annual budget has since been increased to $50 million (equivalent to the average weekly ticket sales for a popular movie in its 6th week!); this can only begin to scratch the surface of what we need to know regarding this industry with $12 billion in annual sales. To put this in perspective, remember that the entire annual budget for the National Institutes of Health is only $13 billion.

What is the Difference Between Alternative Medicine and Complimentary Medicine?

"Alternative" medicine generally refers to an either-or situation; "complimentary" medicine generally refers to interventions and approaches proven to provide additional health benefits in conjunction with other traditional or alternative approaches. This includes having sufficient and regular weight bearing and aerobic exercise, eating a well balanced and calorically reasonable low-fat diet; and getting an adequate calcium and Vitamin D intake (premenopausal women need a total calcium intake of 1,000 mg/day and postmenopausal women need a total calcium intake of 1,500 mg/day).

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 Each day, 4,000 women in the United States and Canada reach menopause, which is simply the end of a woman's menstrual cycle. 

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