It’s Your Choice

 

It’s Your Choice

Approximately 50% of women with an intact uterus, who elect to have estrogen therapy, (especially the pellet implant) will experience bleeding.  If a menopausal patient has bleeding, she must notify her gynecologist or family physician for a follow-up evaluation which may include a vaginal ultrasound and endometrial biopsy.  The primary cause of uterine bleeding is inadequate use of progesterone.  Estrogen stimulates the uterine lining to grow and progesterone protects it from growing too thick.  This may result in bleeding.  Higher levels of estrogen are needed for procreation.  Most women feel better with lower estrogen levels.

  • Many patients choose a testosterone pellet alone.  In most women, symptoms including hot flashes are relieved with testosterone pellets alone.  A study by Sherwin in 1985 looked at testosterone, testosterone and estradiol, estradiol alone and placebo.  The group of women who responded best (somatic, psychological and total score)…testosterone alone!  The groups that did the worst…estrogen alone and placebo.  Higher levels of testosterone were associated with a better response.  These results are expected. Testosterone,not circulating estradiol, is the major ‘substrate’ for estrogen production in the brain, bones, vascular system, breast and adipose tissue. Women have 15 times the amount of circulating testosterone as estradiol.
  • A patient may choose not to use estradiol (stronger estrogen) at all.  Many women continue to make estrogen (estrone and estradiol) into their 70’s and 80’s.  Also, there is exposure to many estrogen-like chemicals.  Excess estrogen and estradiol therapy can cause weight gain, belly fat, tender breasts, emotional lability, symptoms of PMS, and mood swings.  Long-term exposure to stronger estrogens like estradiol and Premarin can increase the incidence of breast cancer.
  •  Most patients choose not to use an estrogen pellet.  If needed, estrogen may be given as a transdermal patch, topical gel, oral capsule or vaginal cream/ring. 
    One of the most effective and safest ways to deliver estrogen is by a vaginal cream.  This treats vaginal symptoms like dryness and discomfort, along with urinary symptoms like urgency, frequency, hesitancy, nocturia (waking at night to urinate) and incontinence.  Estriol (E3), is less stimulatory to the breast tissue and uterus than estradiol and may be combined with progesterone in a single cream. The vaginal cream may be used daily for 14 days, then 2 to 6 days per week as needed. Once tissue is healed and symptoms are no longer present, the vaginal cream may be discontinued.
  • A patient may choose to have an estradiol pellet placed if she has had a hysterectomy (removal of the uterus).  If a patient has trouble maintaining weight and body fat, the estradiol pellet may help with this.  Testosterone will increase muscle mass and bone density while decreasing fat mass.  However, a diet of refined carbohydrates/sugars will prevent weight loss and fat loss along with other benefits of testosterone pellet therapy.  Diet and lifestyle (exercise) are important to health and well being.
  • Oral or sublingual (under the tongue) progesterone may be used.  This may help some women who have difficulty with sleep, hot flashes or increased anxiety.  Vaginal progesterone may work better for vaginal dryness, urinary problems or heavy bleeding.  Progesterone, used vaginally, bypasses the liver, gets a higher dose to the uterus and forms fewer metabolites (breakdown products). 
     

Remember, hormones may need to be adjusted during therapy.  Patient input is important to achieving optimal hormone balance and patient satisfaction.