Related Topics: Features, Menopause

A Fresh Look At Menopause

Menopause is different for every woman, but what is behind it is the same for all of us. One of the UK’s leading bioidentical hormone doctors gives her view.

Dame Dr Shirley Bond

The main cause of menopausal symptoms is a decline in the production of both oestrogen and progesterone. One of the biggest medical mistakes in the past century was to give women oestrogen on its own, and in dosages that were much too high. Oestrogen-only HRT has since been found to increase the risk of breast and endometrial cancers. That’s why current conventional HRT drugs generally include progestins, which are synthetic progesterone-like hormones. However, it’s now well-established that these too can increase breast cancer risk. Progestins, by the way, are completely different from the natural progesterone produced by your body. And while synthetic progestins can increase breast cancer risk, natural progesterone tends to decrease it.

Natural Solutions for Menopause
So what’s the natural solution to menopausal problems if conventional HRT is out of the picture? First, there’s no doubt that a decline in both oestrogen and progesterone is linked with hot flushes and sweats.  In most cases, there’s both a deficiency in oestrogen and oestrogen dominance (meaning very low progesterone). Since the body can make oestrogen from progesterone if it needs to, the first option is to use a transdermal progesterone cream.

You would use this twice a day in the second half of the menstrual cycle, and if there’s no menstrual cycle, then three weeks on progesterone and one week off.

Help for Joints and Bones

Another common symptom of menopause is the growing risk of osteoporosis. Osteoporosis is a sadly neglected problem and much more prevalent and starts at a much younger age than anyone realises. In the UK, the National Institute of Clinical Excellence (NICE) guidelines for doctors say that osteoporosis occurs in 5 out of 12 women over age 50, but it’s not worth screening before age 65! I like to start screening my patients in their 40s. Instead of x-ray screening, I use a Sahara ultrasound. It has been compared to the more-accepted DEXA bone density screening and correlates well.”

Bone mass loss starts in most women by the time they reach age 40, due to a drop-off in progesterone production. If a woman isn’t ovulating, then she’s not producing progesterone – and progesterone stimulates osteoblast cells which build new bone.  Giving progesterone cream almost invariably increases bone mass density. But there’s no point in checking for increased bone mass density on an x-ray or ultrasound, because it won’t show up immediately. You have to wait a year. You can check after three months with a deoxypyridinoline (DPD) test, which is a urine test that tells you if bone is being lost. If progesterone doesn’t reverse bone loss, then something else is going on. Weight bearing exercise – such as walking, jogging, climbing stairs and weight training – is also important for boosting and maintaining bone mass.

Alternatives to HRT
Doctors are now advised not to prescribe HRT for osteoporosis prevention. That’s because it’s only effective with long-term use (and even then, not as effective as progesterone), and the risk for breast cancer with long-term use just isn’t worth it. Many doctors now prescribe Fosamax, which is a bisphosphonate that slows the breakdown of bone by suppressing osteoclasts. But it only works when you take it, and it can have digestive side effects.

Some doctors recommend tibolone (Livial) which is a steroid drug, but it has side effects. I’m not a fan.

The Inside Story on Oestrogen
Oestrogen is not one hormone, but a family of three – namely estradiol, estriol and estrone. There are also other substances – both natural and artificial – with oestrogen-like properties.

• Estradiol is the strongest, and the one most often used in conventional HRT preparations. It’s also the form of oestrogen most associated with side effects, including increased risk of breast and uterine cancers.

• Estriol is available by itself as a cream and in tablets. The cream is excellent for vaginal dryness, while the tablets often help women with hot flushes – with a fraction of the risk associated with estradiol. Estriol is best given together with progesterone cream.

• Some HRT preparations contain all three forms of oestrogen. These preparations are more balanced for your body, since they provide what your body produces. For post-menopausal women with low oestrogen and progesterone levels, this type of preparation – taken together with progesterone cream – is a more logical way to restore hormone balance.

• Phyto-oestrogens are weak plant-based oestrogens that are classified as ‘adaptogens’. This means if your oestrogen is low, they will boost your levels, and if it’s high, they will compete with what’s circulating to reduce any negative effects.

• Xeno-oestrogens are environmental chemicals that mimic oestrogen. They can also attach to oestrogen-receptor sites, but they trigger a growth message – an excess of which can lead to hormonal cancers. Xeno-oestrogens are found in plastics and some detergents (eg anything ending in ‘phenols’), industrial pollutants (eg PCBs and dioxins), and pesticides and herbicides.

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Comments 3
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Paul J. Molinaro, M.D.,J.D. | 5:50 am, May 8th, 2014

AnnA Rushton… thanks for the comment… of course, Fosamax (now generic) and like prescriptions do have a role in preventing bone disease – and they have likely prevented many women from serious debilities – but, each patient is different, and thus, should have a personalized discussion with her physician to weigh the benefits and the risks – and that includes the risks that drug makers may not willingly reveal.
– Paul

AnnA Rushton | 10:23 am, April 23rd, 2014

Certainly bioidentical doctors will agree with you Paul as natural progesterone offers the best chance of healthily building bone and dealing with osteoporosis without the side effects associate with drugs such as Fosamax.

Paul J. Molinaro, M.D., J.D. | 9:17 pm, April 22nd, 2014

The prescription drug Fosamax (the generic is alendronate sodium) is a medication which has been prescribed to hundreds of thousands of postmenopausal women to treat osteoporosis and help increase bone mass thereby reducing the chance of spinal or non-spinal fractures. Fosamax has also been prescribed to increase bone mass in men with osteoporosis. Brand name Fosamax is manufactured in the United States by Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc. In about 2008-2009, Fosamax became widely available in its generic form (alendronate sodium).

Side effects of Fosamax may include the following:
1. Esophagus problems including irritation, inflammation, or ulcers
2. Low blood calcium levels (hypocalcemia) which may lead to muscle spasms, twitches, or cramps as well as numbness or tingling in the face, fingers, toes, and around the mouth
3. Severe jaw bone problems (osteonecrosis of the jaw often abbreviated as “ONJ”)
4. Bone, joint, or muscle pain
5. Unusual femur (thigh bone) fractures

ABC News ran a story on May 10, 2012 about the dangers of “bone drugs” stating, “In a report published in the New England Journal of Medicine on Wednesday, the U.S. Food and Drug Administration raised concerns about the potential for some serious side effects in women taking bone-building drugs called bisphosphonates, specifically Fosamax, Actonel and Reclast. The published findings are not new. In 2011, the agency voiced concerns that taking the drugs long-term may actually make bones weaker and increase the risk of rare but serious side effects such as atypical fractures of the thigh bone, esophageal cancer and osteonecrosis of the jaw, a rare but painful condition in which the jaw bone crumbles. To investigate, the FDA reviewed data from women who had taken the drugs for six to 10 years.” Underscoring just how commonly these medications are prescribed, ABC News commented, “According to the FDA, doctors wrote more than 150 million prescriptions for bisphosphonates between 2005 and 2009.”

At the end of 2013, Merck settled with about 1,200 plaintiffs alleging that Fosamax caused them to suffer osteonecrosis of the jaw (“ONJ”). ONJ is a rare condition in which the patient suffers degeneration and deterioration of the jaw and often necessitates surgical repair with bone grafting. This recent settlement requires a total of about $27.7 million to be paid by Merck. Before anyone feels bad for Merck, he or she should also know that some researchers estimate that Merck “earned” about $3 billion (with a “b”) in 2007 from Fosamax. There are still many unsettled suits.

While alendronate sodium does have some appropriate indications, there are serious side effects which can occur. Most of the lawsuits focus on one of two harms – femur fractures or osteonecrosis of the jaw. Each is treated differently by many of the lawyers handling these cases. If someone has taken brand name Fosamax and suffered either of these harms, he or she should immediately consult with his or her physician and then consult with an attorney who is experienced in handling such a matter.

– Paul

Paul J. Molinaro, M.D., J.D.
Attorney at Law, Physician

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