Hormonal Health

Dame Shirley Bond, one of London’s top doctors specialising in hormonal health, discusses how to deal with hormonal issues around the time of menopause.

Hormones in Havoc
The main cause of menopausal symptoms is a decline in the production of both oestrogen and progesterone. One of the biggest medical mistakes in the past century was to give women oestrogen on its own, and in dosages that were much too high. Oestrogen-only HRT has since been found to increase the risk of breast and endometrial cancers. That’s why current conventional HRT drugs generally include progestins, which are synthetic progesterone-like hormones. However, it’s now well-established that these too can increase breast cancer risk. Progestins, by the way, are completely different from the natural progesterone produced by your body. And while synthetic progestins can increase breast cancer risk, natural progesterone tends to decrease it.

Natural Solutions for Menopause
So what’s the natural solution to menopausal problems if conventional HRT is out of the picture? First, there’s no doubt that a decline in both oestrogen and progesterone is linked with hot flushes and sweats. Dr Bond likes to start by running a salivary hormone test. This is very good for identifying whether or not a person is deficient in either oestrogen or progesterone, as well as if there’s oestrogen dominance (a relative excess of oestrogen to progesterone). In most cases, there’s both a deficiency in oestrogen and oestrogen dominance (meaning very low progesterone). Since the body can make oestrogen from progesterone if it needs to, the first option is to use a transdermal progesterone cream.

I asked Dr Bond what she recommends. “I start with a 3% progesterone cream, giving a dollop (the equivalent of 20 to 40mg) per day in the second half of the menstrual cycle,” she says. “If there’s no menstrual cycle, then I recommend three weeks on progesterone and one week off. Hormone expert Dr John Lee used to say that progesterone was good for sweats and hot flushes. I don’t find that it always works. Some women do better with a combination of progesterone and isoflavones – a red clover supplement, for example.” “If that doesn’t do the trick, then I give Uterogestan, which is a progesterone pill, combined with Hormonin. Hormonin is a combination of estradiol, estrone and estriol, which are the three types of oestrogen that a woman’s body produces. This is much more sophisticated and safer than giving just estradiol. As soon as it starts working, I reduce the oestrogen dose to half a Hormonin tablet per day, or even a quarter-tablet per day. In fact, I like to get the dose as low as possible. “When the oestrogen dose is low enough, I switch from the progesterone pill to a cream (which provides less progesterone). Occasionally, I’ll add the herb black cohosh in combination with Phytosoya vaginal gel (made by Arkopharma).”

Restoring Desire for Sex 

Menopause can cause some women to give up sex, because it becomes more painful due to vaginal dryness and thinning of the vaginal mucosa. I asked Dr Bond what she recommends. “For vaginal dryness there are two approaches. I start by recommending Phytosoya gel,” she says. “It’s high in phyto-oestrogens and improves the mucosal membranes, as well as the production of mucus. “If that doesn’t work, I recommend Ovestin, which is an estriol cream. This is a gentler form of oestrogen than estradiol, and I always advise using it in conjunction with progesterone cream.” I also asked Dr Bond about testosterone for women. “I think it can be very important, especially for women who have lost their sex drive. It can help with libido,” she says. “I may recommend Testogel, a transdermal testosterone cream designed for men, but women should use less than the full dose. I don’t like testosterone implants. They often deliver too much testosterone, which can make women too aggressive.”

Help for Joints and Bones
Another common symptom of menopause is the growing risk of osteoporosis. “Osteoporosis is a sadly neglected problem,” says Dr Bond. “It is much more prevalent and starts at a much younger age than anyone realises. In the UK, the National Institute of Clinical Excellence (NICE) guidelines for doctors say that osteoporosis occurs in 5 out of 12 women over age 50, but it’s not worth screening before age 65! I like to start screening my patients in their 40s. Instead of x-ray screening, I use a Sahara ultrasound. It has been compared to the more-accepted DEXA bone density screening and correlates well.”

Bone mass loss starts in most women by the time they reach age 40, due to a drop-off in progesterone production. If a woman isn’t ovulating, then she’s not producing progesterone – and progesterone stimulates osteoblast cells which build new bone. “Progesterone certainly does build new bone. There’s no doubt about it,” says Dr Bond. “Giving progesterone cream almost invariably increases bone mass density. But there’s no point in checking for increased bone mass density on an x-ray or ultrasound, because it won’t show up immediately. You have to wait a year. You can check after three months with a deoxypyridinoline (DPD) test, which is a urine test that tells you if bone is being lost. If progesterone doesn’t reverse bone loss, then something else is going on.” In addition, both Dr Bond and I recommend taking a high-strength multinutrient, vitamin C, essential fats and a bone-friendly mineral formula containing calcium, magnesium, zinc, boron and vitamin D. Weight bearing exercise – such as walking, jogging, climbing stairs and weight training – is also important for boosting and maintaining bone mass.

Alternatives to HRT
Doctors are now advised not to prescribe HRT for osteoporosis prevention. That’s because it’s only effective with long-term use (and even then, not as effective as progesterone), and the risk for breast cancer with long-term use just isn’t worth it. Many doctors now prescribe Fosamax, which is a bisphosphonate that slows the breakdown of bone by suppressing osteoclasts. But it only works when you take it, and it can have digestive side effects. When I asked Dr Bond about alternative drugs, she said: “Some doctors recommend tibolone (Livial) which is a steroid drug, but it has side effects. I’m not a fan.” With the market for HRT drying up, drug companies try to drum up business for new products such as tibolone by giving doctors free samples for patients. Dr Bond refuses to see drug reps, and prefers reading medical journals to find out about any new breakthroughs.

The Inside Story on Oestrogen
Oestrogen is not one hormone, but a family of three – namely estradiol, estriol and estrone. There are also other substances – both natural and artificial – with oestrogen-like properties.

Estradiol is the strongest, and the one most often used in conventional HRT preparations. It’s also the form of oestrogen most associated with side effects, including increased risk of breast and uterine cancers.
• Estriol is available by itself as a cream and in tablets. The cream is excellent for vaginal dryness, while the tablets often help women with hot flushes – with a fraction of the risk associated with estradiol. Estriol is best given together with progesterone cream.
• Some HRT preparations contain all three forms of oestrogen. These preparations are more balanced for your body, since they provide what your body produces. For post-menopausal women with low oestrogen and progesterone levels, this type of preparation – taken together with progesterone cream – is a more logical way to restore hormone balance.
• Phyto-oestrogens are weak plant-based oestrogens that are classified as ‘adaptogens’. This means if your oestrogen is low, they will boost your levels, and if it’s high, they will compete with what’s circulating to reduce any negative effects.
• Xeno-oestrogens are environmental chemicals that mimic oestrogen. They can also attach to oestrogen-receptor sites, but they trigger a growth message – an excess of which can lead to hormonal cancers. Xeno-oestrogens are found in plastics and some detergents (eg anything ending in ‘phenols’), industrial pollutants (eg PCBs and dioxins), and 
pesticides and herbicides (eg DDT, lindane, toxaphene, dieldrin and heptachlor).

Dietary Recommendations for Hormonal Health
• Include plenty of beans and seeds in your diet. Eat soya on a regular basis, but not to excess.
• Choose organic food as much as possible, especially for meat, milk, cheese and butter.
• Eat dairy products in moderation.
• Drink filtered water or mineral water, preferably in glass bottles rather than plastic.