Guidelines for Using Estrogen Safely
By John R. Lee, M.D.
Here's a story that I hear every day: Joan, a premenopausal woman in her mid-40s goes to her doctor complaining of hot flashes, poor sleep, and lack of energy. She is still having regular periods. Her doctor tests her estradiol, FSH, LH, and progesterone levels, and finds them all to be normal except for very low progesterone. He then prescribes estradiol supplementation! Within three months Joan gains 25 pounds, is sleeping even less, feels irritable and anxious, and has headaches.
Another estrogen supplementation scenario that I hear every day is the woman who is prescribed estrogen alone (without progesterone) and within a year has a pap smear that shows cervical dysplasia, soon followed by a hysterectomy. I consider this medical malpractice, but it happens to hundreds of women every day.
Confusion reigns on the subject of estrogen replacement: What time of life? How much? Which kind? How often? Is it safe? Here are some fairly simple guidelines to help you make your own educated decisions. The two most important basic guidelines in estrogen supplementation are:
- Only women who are clearly deficient in estrogen should take it.
- Estrogen should always be taken with progesterone regardless of your age or whether you have a uterus.
Conventional medicine also fails to discriminate between different estrogens whether natural or synthetic, phytoestrogens, horse estrogen or human. They fail to consider the interaction between estrogen and diet, or estrogen and progesterone, let alone its interrelationship to testosterone, other androgens, thyroid, or corticosteroids.
Another issue I have with estrogen supplementation in conventional medicine is gross overdosing. For decades I have been suggesting that women who need estrogen take only half or a quarter of the usual recommended dosages.
A study reported in the New England Journal of Medicine supports this point of view. In a group of women 65 to 80 years of age who had never used hormone replacement therapy of any kind, blood levels of estradiol (one of the human estrogens) were measured. It was found that two-thirds of these women had blood serum estradiol levels greater than 5 pg/ml, a level consistent with optimal bone benefit. In the one-third of women who had estradiol levels lower than 5 pg/ml, the estrogen dose necessary to raise it to 5 pg/ml was about one-tenth of that routinely prescribed in conventional medicine.
NATURAL ESTROGEN: WHICH ONE AND HOW MUCH?
There are many ways to increase estrogen levels in the body. Here are some suggestions, from simple dietary changes to actual estrogen supplementation.
- Diet modification with less starch and more phytoestrogens (plant-based estrogens) may be all that's needed. Avoid all processed foods and include plenty of fresh organic veggies, seeds, legumes (the bean family) and fish.
- Stress management may help. Stress can increase cortisol levels that blockade progesterone from its receptors, thus down regulating estrogen receptors as well. Further, stress can alter the production of pituitary hormones and endogenous (made in the body) estrogen.
- Women who exercise regularly pass through menopause with fewer problems.
- Consult with an herbalist to select herbs containing phytoestrogens. In this regard, a trial of Remifemin is a possibility.
- Use of “natural” (human) estrogens, i.e., estrone, estradiol, and estriol. Each of these hormones differs in certain aspects, but with all of them the goal is to find the smallest dose that relieves symptoms and/or creates the desired blood or saliva level.
Estriol is safer in regard to cancer risk than estradiol or estrone and is the preferred estrogen for vaginal use. I have found good results with twice-weekly vaginal dosing always along with progesterone. (The progesterone does not need to be used vaginally.) Begin with half the usual prescribed dose. Since estriol is considerably less potent than the others, orally it requires 0.5 to 2 mg/day for 25 days/month.
Estradiol – For an oral dose I recommend only 0.25 mg/day for 25 days/month. An estrogen patch is the most effective and efficient delivery system, and the 0.025 patch delivers enough estrogen to relieve symptoms for most women.
Postmenopausal Women and Estrogen
Estrogen levels decline at menopause, but not to zero. Estradiol falls generally to about 15 percent of premenopausal levels, and estrone falls only 40 to 50 percent of premenopausal levels. Androstenedione, a hormone made in the ovary long after menopause, is converted in body fat into estrone, which is partially converted in the gut and liver into estradiol. Therefore, the question becomes: Is this estrogen sufficient for normal bodily functions excluding pregnancy? That is, did Mother Nature intend that women should become estrogen deficient after menopause? I think not. Estrogen deficiency at menopause is a myth created by drug companies to justify selling supplemental estrogen.
It should be obvious that postmenopausal women do not need estrogen levels so high that the endometrium is stimulated as much as it would be in preparing every month for pregnancy (i.e. premenopausal levels).
Use Symptoms as a Guide
Blood or saliva tests can measure your estrogen levels, but symptoms alone can be a reliable indicator of estrogen excess or deficiency. The symptoms of estrogen deficiency are persistent vaginal dryness or vaginal mucosal atrophy (thinning), or persistent hot flashes despite adequate progesterone treatment. Estrogen deficiency can also cause urinary tract problems. Postmenopausal women with these symptoms might benefit from small doses of estrogen as a supplement.
The most common excess estrogen symptoms are weight gain, water retention, breast swelling and lumpiness, headaches, hypertension, insomnia and anxiety.
Premenopausal Women Don't Need Estrogen
Conventional medicine has long held that estrogen production declines during premenopausal years. This is not true. Dr. Jerilyn C. Prior thoroughly reviewed all pertinent references from 1990 to the present and found no evidence that estrogen levels fall before menopause. All evidence indicates that overall estrogen production remains at normal premenopausal levels.
It has also been assumed that premenopausal hot flashes are caused by estrogen deficiency. If estrogen levels are normal, what causes the hot flashes? It is fluctuating hormones against a background of progesterone deficiency. Remember, women begin to have non-ovulating menstrual cycles in their mid-thirties. Any month that you don't ovulate you don't make any progesterone (although you will still have a menstrual period). Without progesterone you can't maintain good estrogen receptor sensitivity, so even when there's plenty of estrogen available, your cells can't use it as effectively.
Thus, treating the underlying progesterone deficiency first to reduce the overall hormone fluctuations allows you to take advantage of the estrogen you have.
Estrogen for Hot Flashes, Heart Disease and Osteoporosis?
Even for women who have reached menopause, progesterone supplementation alone usually relieves hot flashes. As Dr. Helene Leonetti reports in her study of osteoporosis treatment in recently menopausal women, the majority experienced excellent relief of hot flashes using progesterone cream alone.
Some argue that estrogen provides protection against coronary heart disease, but we still don't have one good study proving this, because they have all been done either in combination with progestins (i.e. Provera), or with Premarin, which contains pregnant horse urine that has hundreds of active ingredients besides estrogen, including progesterone and other steroid hormones.
Some women lose bone very rapidly right around menopause. The decline of estrogen combined with low progesterone may be more than the body can keep up with for a few years, even with supplemental progesterone. Most women regain bone balance and maintain good bone density within a few years after menopause, especially if they use progesterone cream. However, a small percentage of women with low estrogen and estrogen deficiency symptoms combined with indications of osteoporosis will benefit from using a small amount of supplemental estrogen with progesterone at this time of their life. These women are often petite, thin (with not enough body fat to make significant estrogen), and have small bones.
Handle with Care
Estrogen is necessary to maintain progesterone receptors; it is necessary to maintain good brain function and healthy bones; and a true estrogen deficiency may compromise the ability of blood vessels to relax and thus help protect against a heart attack. But a true estrogen deficiency is rare because we live in a highly estrogen-contaminated world (see What Your Doctor May Not Tell You About Menopause). When estrogen levels are too high the risk of cancer increases steeply; its protective value in heart disease is reversed as the risk of blood clots and fluid imbalances rises; and the brain benefits are lost. Estrogens are indeed the angels of life and the angels of death. They should be used only when needed, with moderation and respect, and with a goal of overall hormone balance.
Here's where you can test your estrogen levels
Note to Reader from Virginia Hopkins
Dr. John Lee was my great friend, mentor, co-author and business partner. This website is dedicated to continuing the work that Dr. Lee and I did together to educate and inform women and men about natural hormones, hormone balance and achieving optimal health. Dr. John Lee was a courageous pioneer who changed the face of medicine by introducing the concepts of natural progesterone, estrogen dominance and hormone balance to a large audience of women and men seeking answers to their hormone questions. Dr. Lee has left us a wonderful collection of writings from his newsletters that are, in large part, freely shared on this website. Enjoy!