Using natural hormones to treat estrogen, progesterone, and testosterone deficiency

Townsend Letter for Doctors and Patients, May, 2004 by Jacob Teitelbaum

Many people going through midlife develop fatigue, low libido, or depression. This includes men and women alike. Experience has shown that if the estrogen level in females or testosterone level in males or females is low, a trial replacement of these hormones can bring about dramatic improvement and is therefore worth considering. An underactive adrenal gland can aggravate testosterone deficiency. Although the ovaries make most of a woman's estrogen and the testicles make most of a man's testosterone, the adrenals make significant amounts of both.

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Unfortunately, the large amount of media coverage given to problems caused by Premarin has resulted in many people stopping all hormonal support.

As most of you are aware, Premarin contains a form of the hormone that comes from pregnant horse urine. Most complementary physicians have not used Premarin for over a decade. Fortunately, natural options other than Premarin are available.

Low Estrogen and Progesterone

Although not likely to be a problem with men, deficiencies of estrogen and/or progesterone can be major problems in women with CFIDS/FMS. In a wonderful book by Dr. Elizabeth Lee Vliet, Screaming To Be Heard: Hormonal Connections Women Suspect ... and Doctors Ignore (M. Evans and Company, 2000), the role of estrogen deficiency in causing fatigue, brain fog, disordered sleep, fibromyalgia, poor libido, PMS, low levels of serotonin and other neurotransmitters, interstitial cystitis, as well as other problems is reviewed in detail. She notes, appropriately, that the perimenopausal period has a gradual onset, and symptoms of estrogen deficiency can occur 5-12 years before the patients' blood tests and periods become abnormal. As noted previously, hypothalamic dysfunction can cause estrogen deficiency as well.

By checking blood levels and noting if symptoms are cyclic through the month (that is, worse during ovulation, and especially worse the week before the patient's period), one can tell if a trial of natural estrogen supplementation is warranted. For example, panic attacks, migraines, and palpitations that occur for one to two days around ovulation or around the period often are triggered by dropping estrogen levels. The key questions to ask the patient however are:

* Are your CFS/fibromyalgia symptoms worse the week before your period?

* Do you have decreased vaginal lubrication?

It can be helpful to have the patient keep a symptom log relative to their periods.

Part of the difficulty in checking estradiol (the most active form of estrogen) and progesterone levels is that the normal range fluctuates widely during the patients' cycle. Dr. Vliet feels that at menopause, estradiol levels should be kept over 100 picograms per milliliter (pg/mL) of blood, and that symptoms are likely if levels are under 50 pg/ml (normal peak levels are over 200 pg/ml at ovulation). If levels of follicle-stimulating hormone (FSH) or luteinizing hormone (LH), two other hormones involved in regulating the menstrual cycle, are high or low normal and/or the patients' symptoms cycle with their periods, a trial of estrogen is helpful.

Treating Low Estrogen and Progesterone

In my experience, and that of Dr. Vliet, many of the symptoms noted above can improve dramatically with estrogen replacement. Dr. Vliet notes that 17-beta-estradiol is the major active form of estrogen naturally found in the human female. For menopausal women, this can be found in Estrace tablets or Climara or Estraderm patches. Many physicians prefer natural biestrogen from a compounding pharmacy. This contains estradiol plus estriol, a weaker form of estrogen that is much higher when the patient is pregnant. I prefer using this form as excellent work by Dr. Jonathan Wright, as well as a number of other studies, suggests that higher levels of estriol are actually protective against breast cancer. For example, the younger a woman is when she first gets pregnant and the more time she spends being pregnant, the lower her risk of breast cancer.

Unless a woman has had a hysterectomy, if they take supplemental estrogen, they must also take progesterone to prevent uterine cancer. I prefer natural progesterone--for example, 200 milligrams of Prometrium a day for the first ten days of each month, or 100 milligrams every day. Taking both estrogen and progesterone every day will often result in the patients' periods ceasing after six to nine months, and most women over 48 or so prefer this approach. Many compounding pharmacists are happy to help you and the patient adjust treatment based on the patient's symptoms to determine the optimum dosing and timing--at no charge. Below are the treatment recommendations from the treatment checklist that I give patients.

For those of you who are adequately trained in using these hormones, but are not yet allowed to prescribe in some states, I have also noted how one can get similar hormones for patients without a prescription.

Natural Estrogen (Rx)- _____ take Estrace (estradiol) 1 mg, 1 to 2 times
a day, OR _____ put a Climara .05 to .1 mg patch on each Sunday, OR take
a Biestrogen 2-1/2mg 1 to 2 times a day. If you have not had a
hysterectomy, you must be on progesterone with the estrogen to prevent
uterine cancer. If you are on the patch and it seems to stop working the
last 1 to 2 days of the week, you can change the patch every 5 days.

Use the Estrogen _____ every day; _____ day 1 through 25 of your cycle
(day 1 of your period is day 1 of your cycle). It is normal for your
periods to be irregular for 3 to 4 months. If your symptoms (including
migraines and anxiety) worsen for the week you are off the Estrogen, we
can add a Climara .025 mg patch for that week. If they worsen a few
hours before you take the Estrogen by mouth, divide the dose up through
the day (e.g., 1/2 tablet--4 times a day vs. 2 tablets each morning).