|
There is no perfect method of HRT and none precisely mimics nature. Fortunately
this isn't all bad. During a woman's reproductive years, peaks and valleys of hormone concentration in the blood
are necessary to trigger ovulation and if conception does not occur, menstruation. These swings in hormone levels
can effect mood and sense of well being. For example many women experience a sense of euphoria during pregnancy
when their levels of sex hormones are very high and PMS is related to the decline in hormone levels prior to menstruation.
It is of note that some patients request that they be given the "lowest possible dose" of HRT a reflection
of a perception that somehow HRT is unwise, dangerous, unnatural or all of the above. This is contradicted by the
weight of medical research which suggests HRT increases longevity and enhances quality of life. Ideally, HRT should
be given in a dose appropriate for each specific individual as everyone differs in their needs and capacity to
absorb and metabolize hormones. Ideally, this would be in an amount sufficient to fully accomplish its beneficial
effect.
The hormones replaced in menopausal women include:
Estrogen
The ovarian hormone responsible for the development and maintenance of what we refer to as secondary sexual characteristics.
Progesterone
The ovarian hormone responsible for protecting the uterine lining from being overly stimulated by estrogen. Estrogen
given alone (unopposed) when the uterus is present can result in the development of abnormal changes of the endometrium
(uterine lining) including cancer. The addition of adequate amounts of progesterone to a program of HRT prevents
this from occurring. Progesterone is not usually given following a hysterectomy as there is no uterine lining present
to protect. Unfortunately, although necessary progesterone causes "PMS" like symptoms in approximately
30-40% of patients. This is mild in the majority of patients but can be severe in a small percentage.
Testosterone
The ovarian hormone responsible for sex drive, energy, muscle mass and assertiveness. Thought by many to be exclusively
a male hormone it has important functions in women. Along with the other ovarian hormones it is markedly diminished
following ovarian removal or injury and consideration should be given to appropriate replacement.
Any of these sex hormones, estrogen, testosterone and progesterone can be administered alone or in combination.
In addition there are a number of routes of administration available to get these hormones into your system. They
include:
Oral
Transdermal Patch
Transdermal Gel
Sublingual
Injections
Creams
Suppositories
Subcutaneous implants
There is no "best" method for everybody and your choice may be influenced by:
- Type of menopause
- Concurrent medical conditions
- Age at menopause
- Response to previous therapy
- Current age
- Intolerance to previous HRT program
- Symptoms
- Individual perception of HRT program
- Hormones to be replaced
- Individual psychological makeup
Ultimately, the choice of which hormone or hormones and which route of administration should depend on what each
individual is comfortable with in view of what she perceives to be her needs, goals and lifestyle.
Estrogen, progesterone and testosterone can all be given using any of the described methods. But, for the sake
of clarity and simplicity and to lessen confusion (mine, because I can't figure out how to do it all at once) I
will first discuss the routes of administration using estrogen alone. I will then go on to progesterone, testosterone,
combination therapy, indications for each and rationales.
Estrogen Therapy
The oral route of HRT, usually a tablet taken
daily is the most frequently utilized method of HRT in the world. The most well known oral estrogen replacement
product is sold under the brand name Premarin and is a "conjugated equine estrogen" and is extracted
from pregnant mare's urine. There are several other oral estrogen products available and each manufacturer gives
various reasons why their product is superior. I prefer to use brand name over generic products when possible because
I believe some generic formulations of estrogen are not bioequivelent. The advantages of the oral route include
that for most people it's easy to take a pill, it's relatively inexpensive and for most women it effectively delivers
estrogen into the bloodstream. There are some disadvantages. It is not effective in everyone and causes nausea
or other gastrointestinal upsets and occasionally headaches. Infrequently it may cause an elevation in blood pressure.
Some of these problems may be related to what is termed the bolus effect on the liver. After an estrogen tablet
is absorbed by the upper gastrointestinal tract it is transported directly to the liver. This supraphysiologic
amount of estrogen arriving all at once induces the the cells of the liver to alter its production of enzymes.
The Transdermal Patch method of estrogen administration has the
hypothetical advantage of avoiding this "first liver pass" and at times can be effective in patients
who don't respond to tablets. There are a number of patches available today and they share some common elements.
Estradiol the bioactive estrogen, a delivery system which allows the hormone to be gradually absorbed by the skin
and an adhesive to keep it on. It is applied to the skin and replaced once or twice weekly as contrasted to the
daily estrogen tablet. The estrogen is absorbed gradually over the length of time each individual patch is worn
and this is more physiologic. It has the disadvantage of causing skin irritation in 10-30% of those who try it.
Sometimes this is mild and can be alleviated simply by moving the patch to a different area of skin daily but can
be severe enough to require its discontinuance. It is not as acceptable to some women who exercise strenuously
or live in warmer climates as there is greater difficulty with adherence to the skin with increased perspiration.
When skin irritation is the caused by the adhesive in the patch delivery system estrogen gel is available from
a number of pharmacies and can be rubbed directly on the skin daily without the use of the patch system and is
an effective alternative.
Transdermal Gel is a very useful method of estrogen replacement. A measured amount of gel is rubbed on
the skin once daily. It is absorbed and in theory at least, the skin acting as a reservoir releases it gradually
into the bloodstream. It is simple, well tolerated, relatively inexpensive, there is no "bolus" effect
and it avoids the "first liver pass". It is basically the patch minus the adhesive and "delivery
system". Pretty nifty, eh! And of course is not widely available in this country.
Sublingual administration of estrogen can be used and in this method a tablet, usually "estradiol"
the bioactive form of estrogen is placed under the tongue. It is absorbed through the lining of the mouth into
the blood vessels located under the tongue and then into the bloodstream. It avoids the "first liver pass"
but is delivered into the blood all at one time as opposed to the gradual "trickle" delivery of the patch.
Intramuscular
injection is a common method of estrogen replacement and is used by many physicians.
The hormone is usually mixed with a substance to slow its release into the bloodstream and depending on the dose
and patient response is usually given at 2-4 week intervals. It has the disadvantage of relatively high levels
soon after administration which decline rapidly after a week or so. Unfortunately, this may perpetuate menopausal
symptoms which are often associated with declining rather than absolute hormone levels.
Creams have been used as a method of HR. for several years and is an interesting story. Vaginal
dryness and loss of elasticity of the "vaginal barrel" can be a distressing symptom of hormone deficiency.
Estrogen cream was considered a " local" nonsystemic therapy and was an effective treatment for this
problem. Years ago (and I'm sure today) it was prescribed in those instances when the doctor(presumably not knowledgeable
about HRT) or the patient or both were not comfortable using other methods. The rational being that since it was
local therapy it wouldn't pose any of the "dreaded risks" of systemic HRT. Incredibly, most doctors and
patients were not aware that the vaginal absorption of estrogen is much more efficient and in the doses prescribed
results in significantly higher blood levels of hormone than the oral or transdermal route of administration. Wait!
It gets better! Some women found it convenient to regularly use the cream as a lubricant to facilitate intercourse.
After all they put in in at night anyway. Well folks, the skin of the penis absorbs estrogen pretty well too. Not
as efficiently as the vagina, but well enough to result in feminizing changes and impotence in the partners of
these women.
Suppositories perform the same function as the cream delivery method. They are preferred by some users
who find them less messy.
Subcutaneous
Implantation of estrogen pellets is a method used primarily by physicians
who special interest or training in the treatment of menopausal women. It is an effective treatment for menopausal
symptoms which have been unresponsive to other therapies. I have found it to be the therapy of choice when other
methods of HRT have failed as is too often the case following hysterectomy and ovarian removal. It can restore
quality of life when the problem is diminished interest in sex, insomnia or persistent hot flashes. The pellets
which consist of estradiol, are derived from Soy a naturally occurring substance. They are inserted into the subcutaneous
tissue of the abdomen or buttock usually at 3-6 month intervals.
 |
Dr Nosanchuk is currently in practice in Southeastern Michigan
and is accepting new patients. His office is located in Bingham Farms, a suburb of the Detroit Metropolitan Area.
Dr N specializes in the care and treatment of menopausal women and has a special interest providing treatment to
women whose lives have been altered by their menopause, hysterectomy, or both. This includes strategies to restore
quality of life, by resolving problems, such as persistent symptoms, loss of libido and disturbances of sexual
function.
Appointments with Dr Nosanchuk can be scheduled by calling (248) 644-7200
|
 |
IMPORTANT
This web site is for educational purposes only. It is not intended to suggest
a specific therapy for any individual and must not be construed to establish a physician/patient relationship.
Website By Athena
All Contents Copyright © 2000-2005 menopausehysterectomy.com/drn4u.com
|
|