The natural decline of hormone levels known as perimenopause, menopause, and andropause (for men) can be life-changing experiences for many women and men. A few lucky people sail through these times with minimal changes in energy and few symptoms. Others lose the ability to sleep, gain weight, and can have debilitating symptoms of anxiety, depression, hot flashes, or more. For 15 years, I have been treating patients with both traditional as well as bio-identical hormone therapy and also with non-hormonal symptom relief when appropriate. How we treat, whom we treat, and why we treat have all been moving parts in the complicated, and sometimes controversial world of hormone health. For more than a decade hormone therapy research has been moving in a positive direction, to not only provide symptom relief for those suffering, but to possibly also decrease risk factors that inevitably increase with age (implicating the natural decline of hormones as playing a role in increased risk). So, where are we now, and is hormone therapy something that you should consider with your physician?
I write this hormone update about every two years, and I can assure you that even in the relatively short span of a couple of years the research and methods in this field change, and this has been the case for nearly two decades. The consistent portion of this information is that the vast blanket of fear we used to associate with hormone use is behind us. The worry that estrogens cause increased cardiovascular and cancer risk has been slowly but steadily decreased with studies following the initial fear-inducing Women’s Health Initiative (WHI) in the early 2000s. Since then, it has been verified that much of the risks noted in this study were related to a specific synthetic progesterone that is now rarely used or to the type of administration of estrogen. We don’t see an increase risk for the average woman with bio-identical estradiol or progesterone, both of which are used as the standard now by both traditional and integrative physicians, and again, this has continually been verified in studies since the WHI.
As useful as it has been, we can easily help woman with the right kind of estrogens and progesterone. There has been an even more exciting and potentially beneficial subfield within the hormone field regarding the use of testosterone in both men and women.
Hormonal imbalance can cause a myriad of symptoms. Some of these symptoms include fatigue, stress, hot flashes, low libido, mood disturbance, foggy thinking, weight gain, sleep disturbances, achiness, and more. Research and clinical experience is consistently showing that increasing testosterone levels for both men and women can decrease many if not all of these symptoms for many sufferers.
Beyond addressing symptoms that arise with menopause and andropause, correcting testosterone has shown to be beneficial in bone health and body composition, in improving cardiovascular risk factors, and in decreasing breast cancer risk. When we consider estrogen therapy for women, we still take personal and familial risk factors for cardiovascular disease and cancer into consideration.
If you have had an event in the past, or if you have a close family member who has, we still weigh risks and benefits in deciding whether you are a good candidate. In the case of breast cancer, certain types of breast and ovarian cancer can be estrogen receptor positive. This means that there are receptors that respond to estrogen, and in the case of a cancerous cell or tumor, exposure to any estrogen, whether endogenous, synthetic, or bio-identical, can cause an increase of risk. However, we don’t seem to take on these risks with the use of testosterone alone, which again, can serve on its own to relieve many of the symptoms associated with menopause. In fact, testosterone seems to down-regulate estrogen receptors, thereby decreasing risk, making it ideal for menopause sufferers who have avoided treatment with any hormones due to a family history.
Hormone therapy has also been avoided by some for cardiovascular risk related to the potential increase in clotting. However, testosterone via transdermal or pellet (placed under the skin) has not shown this clotting potential and thus opens up the possibility of symptom relief even for those with risk history. Furthermore, in men it has been shown that falling testosterone levels are associated with increasing cholesterol levels. Cholesterol is the backbone in the hormone production process, so it would make sense that as your hormone levels are falling, your body would produce more of the ingredients necessary to try to make more. This is probably also true in women; we just haven’t seen the studies yet.
For both men and women, increasing testosterone to higher levels seems to be at the forefront of optimal aging medicine and hormone health. Many practitioners are choosing to elevate levels higher than what we have done in the past to gain these effects and preventive advantages.
For men, this optimization is typically thought to occur in the upper quartile of the “normal” range on lab work. It has previously been common to keep men over 50 closer to mid-range.
For women, the changes in dosage have been even more extreme, with many practitioners choosing to raise some women up to twice as high or more over the “normal” range. It is postulated that the norms might be skewed due to our limited history of consistently measuring testosterone in women and our longer history of altering women’s hormones (with oral contraceptives primarily). Regardless, some women are finding benefits in attainingthese higher levels, and with low side effects and risk (again for both men and women ideally using pellet or transdermal).
A common concern with increasing testosterone levels is the fear of side effects. Men who are taken to a high normal, with bio-identical transdermals or pellets, do not become angry or aggressive (this is not the same as a bodybuilder testosterone). Women typically worry about hair loss (on their head) or hair growth (anywhere but their head) but in reality side effects are typically lower than 2%.
Proper hormone care should include screening and monitoring of hormone levels with a baseline and then again usually every 6-12 months. It goes without saying that if you decide you want to consider any kind of hormone therapy, you should talk to a physician about the risks and benefits specific to you. Hormone health remains complicated and somewhat controversial, but it likely holds within it one of our biggest keys to optimal aging to ensure both quality of life and decreased disease. Whether you should consider hormone therapy should always be an individual decision, but it is at the very least worth a conversation and baseline studies if you feel anything but your best.
Stay well & be healthy!
-Dr. Amy Whittington