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Understanding estrogens.

When I start talking with my menopausal and postmenopausal patients about estrogen replacement therapy (ERT) their eyes glaze over.

They've heard horror stories about problems with estrogen (breast and endometrial cancers) and horror stories of the consequences of not taking them (osteoporosis and heart disease). So they come to me for understanding. I tell them their confusion begins with thinking that there's one hormone called estrogen. There's not. It's estrogens -- plural.

It's time to stop thinking about estrogen as being one hormone. The substance we think of as estrogen is really a group of hormones. The number of estrogen compounds that make up what we think of as "estrogen" varies in humans and horses. Women have three primary estrogen compounds: estrone (E1), estradiol (E2), and estriol (E3). Some are natural -- made to be identical to those our bodies make. Then there are estrogens made from pregnant horse's urine (Premarin, Premphase, Prempro) that contain a dozen estrogen compounds. Only one of them is exactly like one of ours. Horse urine estrogens are not identical to ours and can't function like ours. Phytoestrogens are found in plants, like soy. Some people say they are beneficial; others say they can be harmful, especially if you've had breast cancer And xenoestrogens are estrogens found in the environment that can be harmful. So let's unravel the confusion about estrogens and begin by understanding what estrogens do.

Human estrogens

When I talk about estrogens, I'm talking about the three major estrogen compounds found in our bodies: estrone, estradiol, and estriol. They are made primarily in our ovaries, starting at puberty, and are made there for the rest of our lives. They play an important role in our menstrual cycle when we're young, and are responsible for our feelings of vitality and sensuality as we age. Estrogens help us feel young, while estrogen deficiency is associated with signs of aging.

In our youth, an excess of estrogens can cause side effects like breast tenderness, swollen breasts, water retention, impatience, nausea, and cramps. Many of these symptoms occur before menstruation each month and are signs of premenstrual syndrome (PMS). After menopause, too much estrogen can increase our risk for some cancers.

After menopause, our estrogen decreases along with a myriad of estrogen deficiency symptoms. They include depression, anxiety, forgetfulness, moodiness, difficulty sleeping, hot flashes or night sweats, fatigue, feeling less sensual, dry skin (and vaginal dryness), weight gain, sagging breasts, heart palpitations, headaches, bloating, and back pain. If you have some of these symptoms, the right kind of natural estrogens could help.

Estrone (E1) -- Estrone promotes the formation of bone tissue and is important in preventing osteoporosis. It also reduces hot flashes and other menopausal symptoms. But, estrone is an aggressive estrogen that promotes cancer. To reduce this risk you need estriol, as well.

Estradiol (E2) -- Estradiol is the most prevalent estrogen in our body, made in the ovaries from androgens (male hormones). It's one that doctors tend to give alone because it's most prevalent and prevents bone loss. After menopause, androgen production drops as much as 50 percent, and so does estradiol. Doctors of integrative medicine know that taking estradiol alone is dangerous because it's the most aggressive type of estrogen. Even natural estradiol taken alone can increase your risk for endometriosis and various cancers. Like estrone, estradiol needs to be balanced with estriol.

Estriol (E3) -- Most gynecologists and other doctors know little about estriol. This is unfortunate, because estriol is both beneficial and safe. Estriol keeps your skin young, increases vaginal lubrication, reduces hot flashes, and seems to be protective against cancers. Estriol balances the negative effects of other estrogens.

Estriol does not prevent osteoporosis or heart disease (look to magnesium for these conditions). My friend and colleague Dr. Uzzi Reiss, MD, has improved mental clarity in many of his postmenopausal patients with estriol when nothing else helps.

If you're afraid of getting breast cancer from taking estrogen replacement therapy, or if you're at a high risk for this disease, estriol may be your answer. The few studies that exist suggest estriol prevents breast tumors in rats, and does not cause the formation of a lot of potentially carcinogenic substances (estrone and estradiol do). Estriol may not protect your bones and heart as much as estrone and estradiol, but it offers some protection. You can use a healthier diet and regular exercise to lower your risk for these conditions.

A new patient recently told me her doctor had given her estrogen. Which kind, I asked? Natural estrogen, she replied. The estrogen she was taking was estradiol, the estrogen that increased her risk for cancers. After we spoke about the different natural estrogens available, she talked with her doctor and got a prescription for Tri-Est, a compound of the three estrogens.

Foreign estrogens

By foreign estrogens, I mean estrogens that are not identical to those in our bodies. Foreign estrogens are made from pregnant horse's urine (like Premarin). Or they may be estrogens made outside the body from pesticides and plastics called xenoestrogens. Neither act like natural estrogens.

Pregnant mare's urine (Premarin) -- Mare's urine contains a dozen types of estrogens and only one is identical with one in our bodies. The other 11 are foreign estrogens that our bodies don't know how to use. Premarin and other estrogens made from horse urine have been shown in studies to protect against osteoporosis and heart disease. But this protection comes with a high price. These estrogens have also been associated with endometrial, breast, and other cancers. They can increase plaque in the arteries of your heart and contribute to heart disease. And they often increase insulin sensitivity, leading to diabetes.

Xenoestrogens -- Dioxin, some pesticides, and residues of plastics act like estrogens -- except that they are more aggressive. They are one reason why young girls reach sexual maturity earlier than before. When added to ERT, they increase estrogen levels and contribute to breast and uterine cancers, endometriosis, and uterine fibroids. You can't escape xenoestrogens, but you can reduce your exposure to them by lowering your intake of beef (cows eat grass that has been permeated with dioxin) and by eating more organic foods. And avoid plastic containers for food and water

Plant-based estrogens

Plants, such as soy, contain substances called phytoestrogens that can activate your estrogen receptors (spaces where estrogens can get into the body). They have a weak estrogenic effect, and also prevent other estrogens (like estradiol), from occupying the same space. In this way, they are protective against the negative effects of estrogens.

If your estrogen levels are high, phytoestrogens won't boost them. But if they're low, like after menopause, they accumulate and help increase your total estrogen. My suggestion: After menopause, add a little soy to your diet. Small amounts of soy have been found to be safe and beneficial.

Soy-based supplements are different. They emphasize substances called isoflavones and do not contain the same balance of ingredients as soy foods. These supplements may reduce your hot flashes, but I'm not convinced they will lower your risk for heart disease or improve your brain function. I haven't seen studies showing that soy products increase vaginal lubrication, either, but a patient of mine who ate half a cup of edamame (green soybeans) a day for two weeks reported to me that her vaginal dryness was greatly reduced. You can increase soy in your diet to see if you get similar results. But I wouldn't buy a lot of high-isoflavone supplements at this point. If you suffer from hot flashes, try Women's Preferred's Hot Flash Formula. My patients say it works really well.

The benefits of natural estrogens

Natural estrogens provide you with protection against many losses associated with aging: memory, libido, bone density, and skin moisture, to name just a few. Don't be put off by the frightening information you hear about estrogens made from pregnant mare's urine. Natural estrogens are safe when you're given just exactly what your body needs.

Natural estrogens are identical with those your body makes and are made by natural compounding pharmacies like Women's International Pharmacy (800-279-5708). Your specific hormonal needs can be assessed through blood, urine, and saliva tests (saliva tests alone are not accurate). You and your doctor can get specific information on these tests and where to get them from Women's International Pharmacy or by reading Natural Hormone Balance for Women by Uzzi Reiss, MD (Pocket Books, 2001).

How much do you need?

Some doctors believe you should be getting as much estrogen now as your body produced before menopause. I think this is too much. Consider this. Our ancestors were women who were pregnant or nursing much of their adult lives. There were few years their bodies made a lot of estrogens. We're menstruating earlier and stopping later in life than they did. Our lifetime exposure to estrogens is much higher than theirs. There's no reason for you to continue taking high amounts of estrogens when smaller amounts can be sufficient. This is something for you to discuss with your doctor.

Also ask your doctor about bi-estrogen and tri-estrogen. Biestrogen is estriol with estradiol. Tri-estrogen is estriol with both estradiol and estrone. Both are safer than estradiol alone. Tri-Est is a natural estrogen formula developed in the 1980s by Dr Jonathan V. Wright. It contains 80 percent estriol, 10 percent estrone, and 10 percent estradiol. Dr Wright has found that 2.5 mg of Tri-Est a day often relieves menopausal symptoms and is the equivalent of 0.625 mg of conjugated estrogens like Premarin. Many doctors have turned to Tri-Est for their menopausal patients.

Natural hormones can be beneficial if you really need them. When used properly they can be very safe, as well. Estrogens made from pregnant horse's urine may protect your bones and heart (although we're less sure of its heart-protective abilities right now). But conventional ERT may cause cancers and do cause a lot of worrying. Don't lump all estrogens into one category and say, "Estrogen is not for me." A combination of natural estrogens may be exactly what you need for a clear mind and healthy body. But keep an open mind and explore the subject more thoroughly.

Hudson, Tori, ND. Women's Encyclopedia of Natural Medicine, Keats Publishing, 1999.

Lobbo, Rogerio A., MD. "Menopause management for the millennium," Women's Health Clinical Management, Volume I, 2001.

Reiss, Uzzi, MD. Natural Hormone Balance for Women, Pocket Books, 2001.
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Author:Fuchs, Nan Kathyrn
Publication:Women's Health Letter
Geographic Code:1USA
Date:Mar 1, 2002
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