1. Natural Therapy for Menopause By Lisa Beth Freedman, M.D.

3. Definition Menopause, as the name suggests, signals the time in a woman’s life when she no longer has a menstrual cycle Menopause, as the name suggests, signals the time in a woman’s life when she no longer has a menstrual cycle It is the time that the female ovaries cease to produce certain sex hormones, most notably estrogens It is the time that the female ovaries cease to produce certain sex hormones, most notably estrogens When menopause occurs the only source of estrogen is that which is produced by the adrenal glands When menopause occurs the only source of estrogen is that which is produced by the adrenal glands

4. “The Change” The onset of menopause signals the end of a woman’s reproductive cycle The onset of menopause signals the end of a woman’s reproductive cycle Some of the most common symptoms of menopause are: Vasomotor Symptoms, vaginal atrophy, vaginal dryness, memory loss, loss of libido Some of the most common symptoms of menopause are: Vasomotor Symptoms, vaginal atrophy, vaginal dryness, memory loss, loss of libido

5. Ages The average age of the onset of menopause is 51 although it can occur earlier or much later The average age of the onset of menopause is 51 although it can occur earlier or much later Menopause that starts before the age of 45 is termed early menopause and menopause that occurs before the age of 40 is termed premature menopause Menopause that starts before the age of 45 is termed early menopause and menopause that occurs before the age of 40 is termed premature menopause Perimenopause Perimenopause

6. Hormone Decline When ovarian function ceases, circulating levels of the estrogens, progesterone, and testosterone decrease dramatically When ovarian function ceases, circulating levels of the estrogens, progesterone, and testosterone decrease dramatically These sex hormones play vital roles in countless bodily functions These sex hormones play vital roles in countless bodily functions

7. Hormones The word hormone is derived from the Greek word “horman” which means to set in motion The word hormone is derived from the Greek word “horman” which means to set in motion Hormones serve to send messages from one cell to another Hormones serve to send messages from one cell to another There are 4 types of hormones in the human body : There are 4 types of hormones in the human body : 1. Amine Hormones – i.e thyroxine 1. Amine Hormones – i.e thyroxine 2. Peptide hormones – i.e. insulin 2. Peptide hormones – i.e. insulin 3. Lipid and Phospholipid Hormones – i.e. prostaglandins 3. Lipid and Phospholipid Hormones – i.e. prostaglandins 4. Steroid Hormones – testosterone and cortisol 4. Steroid Hormones – testosterone and cortisol

8. Estrogen The role of estrogen is to prepare the lining of the uterus for pregnancy, promoting the growth of the fetus, preventing bone destruction, preventing hypertension and lowering insulin levels The role of estrogen is to prepare the lining of the uterus for pregnancy, promoting the growth of the fetus, preventing bone destruction, preventing hypertension and lowering insulin levels Estrogens also increase body fat, and increase water and sodium retention Estrogens also increase body fat, and increase water and sodium retention Many physicians also believe that circulating estrogens provide cardiac protection and protection from Alzheimers Disease Many physicians also believe that circulating estrogens provide cardiac protection and protection from Alzheimers Disease

9. Progesterone & Testosterone The role of progesterone is to promote bone growth, prepare the endometrium for the implantation of the fertilized ovum, prevent water retention, serve as a natural antidepressant and as a precursor to other sex hormones The role of progesterone is to promote bone growth, prepare the endometrium for the implantation of the fertilized ovum, prevent water retention, serve as a natural antidepressant and as a precursor to other sex hormones The role of testosterone is to increase libido, increase strength, and improve and protect cardiac function The role of testosterone is to increase libido, increase strength, and improve and protect cardiac function

10. Symptoms The delicate balance of the these hormones is critical in the physical, emotional and mental health of all women The delicate balance of the these hormones is critical in the physical, emotional and mental health of all women During the onset of menopause the decreased level of these circulating sex hormones manifests themselves in a variety of ways During the onset of menopause the decreased level of these circulating sex hormones manifests themselves in a variety of ways

11. Symptoms (continue) Many women complain of weight gain, depression, migraine headaches, breast tenderness, acne, sleep disorders, hot flashes and hair loss Many women complain of weight gain, depression, migraine headaches, breast tenderness, acne, sleep disorders, hot flashes and hair loss In an effort to alleviate these symptoms many physicians will institute hormone replacement therapy In an effort to alleviate these symptoms many physicians will institute hormone replacement therapy Some other symptoms of the menopause are insomnia, osteoporosis, increased cholesterol and Alzheimers Some other symptoms of the menopause are insomnia, osteoporosis, increased cholesterol and Alzheimers

13. Therapy For years, hormone replacement therapy used a cookie cutter approach to treatment. Most women were placed on conjugated estrogen (Premarin) and medroxyprogesterone (Provera) For years, hormone replacement therapy used a cookie cutter approach to treatment. Most women were placed on conjugated estrogen (Premarin) and medroxyprogesterone (Provera) There was little choice of doses and drugs available and women were presented with a”take it or leave it” approach to therapy There was little choice of doses and drugs available and women were presented with a”take it or leave it” approach to therapy Hormone replacement therapy involves the introduction of exogenous hormones to the body Hormone replacement therapy involves the introduction of exogenous hormones to the body The goal of therapy is to elevate circulating levels of sex hormones and the removal of all menopausal symptoms The goal of therapy is to elevate circulating levels of sex hormones and the removal of all menopausal symptoms

14. Synthetic Conjugated estrogens are a combination of many different types of estrogens, some of which are not even present in humans Conjugated estrogens are a combination of many different types of estrogens, some of which are not even present in humans These estrogens were obtained primarily from the urine of pregnant mare, hence the blockbuster drug we now know as Premarin was launched These estrogens were obtained primarily from the urine of pregnant mare, hence the blockbuster drug we now know as Premarin was launched This was coupled with the progestational agent medroxyprogesterone and doctors now had the tools to treat menopausal symptoms This was coupled with the progestational agent medroxyprogesterone and doctors now had the tools to treat menopausal symptoms For many women these therapies proved to be very helpful. They were able to sleep well at night, concentrate on the tasks at hand, and get relief from their annoying hot flashes For many women these therapies proved to be very helpful. They were able to sleep well at night, concentrate on the tasks at hand, and get relief from their annoying hot flashes

15. Synthetic (continue) But for many other women the side effects produced by these drugs were sometimes worse than the symptoms they were meant to treat But for many other women the side effects produced by these drugs were sometimes worse than the symptoms they were meant to treat Medroxyprogesterone was found to cause depression and breast tenderness and conjugated estrogens were linked to breast cancer Medroxyprogesterone was found to cause depression and breast tenderness and conjugated estrogens were linked to breast cancer While these drugs were similar to the hormones produced by the female body there were not exact While these drugs were similar to the hormones produced by the female body there were not exact It is believed that these slight structural differences in the molecules are what causes the unwanted side effects of therapy It is believed that these slight structural differences in the molecules are what causes the unwanted side effects of therapy

16. Synthetic (continue) Estrone Estrone Equilin Equilin Estradiol Estradiol Estriol Estriol

17. Natural When we use the term “natural” or “bio- identical” hormone therapy we are referring to the chemical structure of the hormones When we use the term “natural” or “bio- identical” hormone therapy we are referring to the chemical structure of the hormones They are chemically identical to the hormones your body produces They are chemically identical to the hormones your body produces They are, however, still estrogen and progesterone, etc. They have all the positive and negative effects of these chemicals They are, however, still estrogen and progesterone, etc. They have all the positive and negative effects of these chemicals The hormones that I prescribe are derived from both the soy and yam plants The hormones that I prescribe are derived from both the soy and yam plants

18. Natural (continue) The basic sterol molecule, the building block of all hormones is extracted from the soy and yam plants, and then in a laboratory they are converted to the various hormones we are discussing (estriol,testosterone, DHEA, etc.) The basic sterol molecule, the building block of all hormones is extracted from the soy and yam plants, and then in a laboratory they are converted to the various hormones we are discussing (estriol,testosterone, DHEA, etc.) It is my thought that when a physician is going to initiate any hormone replacement therapy, whether it is insulin therapy, thyroid replacement therapy, or sex hormone replacement therapy, it makes the most sense to use drugs that are identical to the hormones in which you are deficient. It is my thought that when a physician is going to initiate any hormone replacement therapy, whether it is insulin therapy, thyroid replacement therapy, or sex hormone replacement therapy, it makes the most sense to use drugs that are identical to the hormones in which you are deficient.

19. DHEA DHEA – DHEA is a natural steroid produced by the adrenal gland DHEA – DHEA is a natural steroid produced by the adrenal gland It is the most abundant steroid in the body It is the most abundant steroid in the body It is a precursor to testosterone, and estrogen. DHEA is also produced in adipose tissue, the gonads, and the brain It is a precursor to testosterone, and estrogen. DHEA is also produced in adipose tissue, the gonads, and the brain When determining levels of DHEA it is best to measure DHEA Sulfate as it is more stable When determining levels of DHEA it is best to measure DHEA Sulfate as it is more stable

20. Estrogen Estrogen – Estrogen is the primary sex hormone for females Estrogen – Estrogen is the primary sex hormone for females The 3 main estrogens are estriol, estradiol, and estrone The 3 main estrogens are estriol, estradiol, and estrone Estradiol is produced from testosterone and estrone is produced from androstendione Estradiol is produced from testosterone and estrone is produced from androstendione

21. Progesterone Progesterone is a steroid hormone that is involved in the female menstrual cycle, pregnancy and embryogenesis Progesterone is a steroid hormone that is involved in the female menstrual cycle, pregnancy and embryogenesis Progesterone is formed from the precursor hormone pregnenolone Progesterone is formed from the precursor hormone pregnenolone Progesterone is produced by the adrenals, the gonads, the brain and the placenta during pregnancy Progesterone is produced by the adrenals, the gonads, the brain and the placenta during pregnancy In women progesterone levels are low during the pre- ovulatory phase of the menstrual cycle, they rise after ovulation, and are elevated during the luteal phase In women progesterone levels are low during the pre- ovulatory phase of the menstrual cycle, they rise after ovulation, and are elevated during the luteal phase

22. Testosterone Testosterone is produced by the testis in males and in smaller quantities by the ovaries in women Testosterone is produced by the testis in males and in smaller quantities by the ovaries in women It plays a key role in health and well being in both males and female It plays a key role in health and well being in both males and female It is believed to increase libido, energy, and immune function and protect women from osteoporosis It is believed to increase libido, energy, and immune function and protect women from osteoporosis Testosterone is produced from progesterone and is a precursor to estradiol Testosterone is produced from progesterone and is a precursor to estradiol

23. BHRT BHRT can be implemented utilizing several different dosage forms based on physician and patient preferences BHRT can be implemented utilizing several different dosage forms based on physician and patient preferences The primary modes of administration are oral, sublingual vaginal and topical The primary modes of administration are oral, sublingual vaginal and topical Each method has its pro and cons, we will discuss these now Each method has its pro and cons, we will discuss these now

24. Capsules Oral- Capsules can be compounded by your pharmacist and used orally Oral- Capsules can be compounded by your pharmacist and used orally This is a convenient mode of administration This is a convenient mode of administration The downside of oral administration is that this method places more stress on the liver and would be contraindicated in patients with hepatic dysfunction The downside of oral administration is that this method places more stress on the liver and would be contraindicated in patients with hepatic dysfunction

25. Troches Oral Troches – these are small flavored lozenges which are dissolved in the buccal cavity of your mouth Oral Troches – these are small flavored lozenges which are dissolved in the buccal cavity of your mouth This mode of administration bypasses first-pass metabolism and places little or no stress on the liver This mode of administration bypasses first-pass metabolism and places little or no stress on the liver These troches can be flavored based on pt preferences. The downside of troche administration is taste or palatability These troches can be flavored based on pt preferences. The downside of troche administration is taste or palatability Depending on the ingredients and the doses taste can sometimes become an issue with compliance Depending on the ingredients and the doses taste can sometimes become an issue with compliance

26. Vaginal Vaginal – Not the best method for HRT, however it is the best method for treating vaginal dryness and recurring UTI’s associated with menopause Vaginal – Not the best method for HRT, however it is the best method for treating vaginal dryness and recurring UTI’s associated with menopause Usually estriol only is used to treat these symptoms Usually estriol only is used to treat these symptoms It’s use in vaginal atrophy is well documented. It also has been used as a prophylactic treatment for recurring UTI It’s use in vaginal atrophy is well documented. It also has been used as a prophylactic treatment for recurring UTI

27. Topical Topical – Many physicians prefer this method because it puts no stress on the liver and is generally well received by patients Topical – Many physicians prefer this method because it puts no stress on the liver and is generally well received by patients Combinations of estrogen, progesterone DHEA, testosterone, etc are compounded in a hypo- allergenic cream base and patients apply a measured amount to their forearms, wrists, abdomen or thighs Combinations of estrogen, progesterone DHEA, testosterone, etc are compounded in a hypo- allergenic cream base and patients apply a measured amount to their forearms, wrists, abdomen or thighs

28. Physician/Pharmacist Not all physicians are experienced in BHRT, you must find physicians in your area that utilize this method of hormone replacement Not all physicians are experienced in BHRT, you must find physicians in your area that utilize this method of hormone replacement Not all pharmacies compound BHRT products Not all pharmacies compound BHRT products You must locate a compounding pharmacy and have prescriptions prepared by a trained compounding pharmacist You must locate a compounding pharmacy and have prescriptions prepared by a trained compounding pharmacist It is critical to find a pharmacist that works closely with your physician to customize your therapy It is critical to find a pharmacist that works closely with your physician to customize your therapy Every woman is different and one size HRT does not fit all Every woman is different and one size HRT does not fit all

29. Follow Up Initially, it is not uncommon for your doses of ingredients to change over several months depending on how you feel Initially, it is not uncommon for your doses of ingredients to change over several months depending on how you feel That is the advantage of customized BHRT, working with your physician and pharmacist to individualize your therapy That is the advantage of customized BHRT, working with your physician and pharmacist to individualize your therapy Costs of therapy – The cost of therapy for BHRT is roughly $30 per month. Costs of therapy – The cost of therapy for BHRT is roughly $30 per month.