Written by Dr. Dayle A. Imperato, Rejuvenation Wellness & Aesthetic Medicine
Menopause is defined as the cessation of the production of estrogens and progesterone by the ovaries causing one year or more without menstrual bleeding. When your hormonal symphony is out of balance, you could start experiencing symptoms of menopause years before you experience menopause.
This time before menopause is called perimenopause and it can start as early as fifteen years prior to actual menopause. Your estrogen rises and falls unevenly during this time, leading to symptoms commonly experienced during menopause.
Estrogen receptors sites are found all over the body. Estrogen is synthesized primarily in the ovaries and other areas of the body via aromatization of testosterone.
The three major estrogens are estradiol, estriol and estrone.
Estradiol (E2) is the strongest form of estrogen and is primarily made in the ovaries. It is the main form of estrogen produced in the body before menopause and is necessary for the beneficial effects on the heart and brain to occur.
Estrone (E1) is the main estrogen your body produces postmenopausally. High levels of E1 stimulate breast tissue and uterine tissue and many researchers believe this increases your risks for developing breast and uterine cancer. Before menopause E1 is made by your ovaries, adrenal glands, liver, and fat cells. It is converted to E2 in the ovaries. Postmenopausally, very little E1 becomes E2, since the ovaries stop working. In later years, E1 is made in your fat cells and to a lesser degree, in your adrenals and liver. Therefore, the more body fat you have the more E1 you make. Consequently, obese women have an increased E1 to E2 ratio.
Estriol (E3), is a weak estrogen and has been shown to have anti-cancer effects by competitively binding estrogen receptors, effectively decreasing the estrogen activity in breast tissue. The usual ratio of E1:E2:E3 is 10/10/80 in the premenopausal female. During menopause the E1 level can raise dramatically to about 80% and the E2 and E3 levels drop leading to a deficiency syndrome.
When a woman transitions into perimenopause, which often can start as early as age 35, hormone levels begin to transiently decline. Hormone deficiencies can have a deleterious effect on the cardiovascular, neurocognitive and musculoskeletal system. These hormone deficiencies contribute to an inflammatory state. When hormones are replaced and balanced levels are achieved, inflammation is decreased. Replacing deficient hormones in the body with bio-identical hormones can decrease the onset of heart disease, decrease cholesterol levels, control carbohydrate metabolism, improve memory, reduce the onset of osteoporosis and decrease the incidence of Alzheimer’s disease. The symptoms associated with menopause (hot flashes, vaginal dryness, mood swings, night sweats, fatigue and urinary symptoms) are the main indications for physician treatment and patient visits. However, the major benefits are found in reduction of cardiovascular and neurological decline.
Conjugated equine estrogen (CEE) is not a human hormone. It is mostly sodium equilin sulfate and has a low estradiol (E2) levels (which is needed for cardiovascular benefits) and has no E3 (which is cancer protective). CEE has a long half-life (the time it takes for the hormone to decrease 50%), which results in accumulation of the hormone in the body. Switching to bio-identical hormones is done over 4-6 weeks. With a gradual decrease in dosing from daily to every other day to twice a week, etc., while gradually increasing the dose of bio-identical hormone, until a balance is achieved.
Oral estrogens increase inflammation. Estrogens should not be given orally. Oral estrogens, by way of the first pass liver effects, increase the acute phase proteins including C-Reactive Protein (CRP), fibrinogen and serum amyloid A, increasing the risk of thrombosis (clot formation). Transdermal estrogens and bio-identical progesterone, instead of progestin, do not increase the risk of deep vein thrombosis (DVT) or pulmonary emboli (PE). Oral estrogens also increase blood pressure, increase triglycerides, increase estrone, can cause gallstones, elevate liver enzymes, increase sex hormone binding globulin (decreasing testosterone), interrupt tryptophan metabolism and consequently serotonin metabolism, lower growth hormone and increase carbohydrate cravings.
If estrogen deficiency is present clinically, then replacement is usually indicated. Biest is an estrogen transdermal cream, commonly comprised of 20% estradiol and 80% estriol. With compounding pharmacies, we can individualize the dose and the percentage of the concentrations to blend a product that is effective for each individual patient. Biest is usually applied in the morning and should be applied over a large area in a thin layer to improve absorption. It is recommended to avoid showering, swimming or heavy work outs immediately after application as this can reduce the amount of hormone absorbed.
Before you begin hormone replacement therapy, it is necessary that you have your levels of all three estrogens measured. You should also have them measured regularly thereafter, to help your doctor ensure you maintain the optimal amount of each estrogen.
Dayle A. Imperato, M.D.
Rejuvenation Wellness & Aesthetic Medicine
9180 Elk Grove Blvd, Elk Grove.
Dr. Dayle A. Imperato
A Board Certified physician, she has served the Sacramento community for the past 20 years. Owner of Rejuvenation Wellness & Aesthetic Medicine in Old Town, Elk Grove.
This story first appeared in Ardent
for Life Summer 2019 issue.