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Adam S. Levine, M.D. recently finished his fellowship in reproductive endocrinology and infertility within the department of gynecology and obstetrics at the Johns Hopkins University School of Medicine. His areas of expertise include reproductive endocrinology, infertility, assisted reproductive technology, reproductive surgery, pediatric and adolescent gynecology, and menopause.

 

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menopause & hormone replacement

Q:     I am 23 years old and my ovaries, fallopian tubes and breasts did not develop.  I do have a uterus and have been told that I need to be on hormones to prevent such things as osteoporosis and heart disease.  Right now I have two options.  The first is to take birth control pills which will cause me to have monthly menses and the second is to take the same hormones women take when they reach menopause.  Do you feel either of these is what my body needs?  Would you recommend one over the other?  I know my case is very rare.  I am sure there are other women who can benefit from getting information about the importance of certain hormones for our bodies.  Thank you for your time.	A:     There are three basic types of hormones present in a woman’s body:  estrogens, progestogens and androgens.  Estrogens are female hormones that perform a variety of functions including breast development.  Progestogens are neutral hormones that counteract the actions of other hormones.  For example, estrogens cause the lining of the uterus to grow and progestogens cause it to stop growing ultimately resulting in menses.  Androgens are male hormones that are involved several functions including hair growth and libido.       Given the information that you have provided you may have one of several problems.  In most all cases it would be important for you to take some form of estrogen and progestogen replacement either in the form of oral contraceptives or as hormone replacement therapy.  The major difference between oral contraceptives and typical hormone replacement therapy is the strength of the medications.  Oral contraceptives are approximately 3 times as strong as typical hormone replacement therapy.  Younger women will benefit from higher doses of estrogen than older women.  For your case, you should seek a consultation with a Reproductive Endocrinologist.  A Reproductive Endocrinologist is a sub-specialized Obstetrician-Gynecologist who deals with hormone replacement issues.
Q:     I'm approaching menopause and would like to know about estrogen from plant sources. I have read stories about how the pregnant mares and their foals are treated, and would prefer not to use Premarin. Are the plant-based hormones comparable and effective?	A:   At the present time, plant-based hormones (like soy beans) are neither comparable to acceptable pharmaceutical preparations, nor are they effective. These plant-based hormones are similar to other mineral, vitamin and plant supplements, so unfortunately they are not regulated by the U. S. Food and Drug Administration. This means that their labeling may not be accurate. I do not recommend plant-based hormones at this time, because there is no scientific evidence that they do anything. However, I do recommend pharmaceutical estrogen preparations (including Premarin), because there is a great deal of well-accepted scientific evidence that they are of benefit.    Pharmaceutical estrogens (administered as a pill, patch, injection, implant or vaginal cream) are reported to effect numerous body systems. These include: the central nervous system (estrogen improves memory in patients with Alzheimer's Disease and may effect libido and sense of well being), skin (estrogen decreases acne and may reduce wrinkles), skeletal system (estrogen promotes bone production and decreases bone loss), cardiovascular system (estrogen improves blood flow to the heart and has a beneficial effect on blood cholesterol levels), urinary system (estrogen improves the supportive tissue around the bladder and urethra and may improve some types of urinary leakage), and genital system (estrogen maintains the caliber of the vaginal vault and keeps the vaginal lining healthy).    Estrogen causes the uterine lining (endometrium) to grow in women who have a uterus. Some women who used estrogen over an extended period without progesterone (the hormone that stops endometrial growth and causes menses) developed endometrial cancer. Because of this, women with a uterus are generally given estrogen in combination with another hormone (progesterone) to prevent unopposed endometrial growth.    Currently, there is a great deal of controversy regarding estrogen and breast cancer. Unfortunately there is no clear-cut answer. However, when all the studies are examined together, there does not appear to be an increased risk of breast cancer with estrogen use. In fact, some patients with breast cancer are using estrogen under the care of their physician.    Estrogens have been used worldwide for more than 30 years, with only rare side-effects or complications. Premarin is the estrogen preparation that has been available for the longest time and is considered the gold standard by which others are compared. It is manufactured from the urine of pregnant mares. Unfortunately, there is a great deal of misinformation from some of the animal rights groups. In reality, the stables where these mares are kept are carefully monitored by Canadian and United States veterinary authorities. Both groups have reported that there is no evidence of abuse or neglect at these stables.
Q:     I'm approaching menopause and would like to know about estrogen from plant sources. I have read stories about how the pregnant mares and their foals are treated, and would prefer not to use Premarin. Are the plant-based hormones comparable and effective?	A:   At the present time, plant-based hormones (like soy beans) are neither comparable to acceptable pharmaceutical preparations, nor are they effective. These plant-based hormones are similar to other mineral, vitamin and plant supplements, so unfortunately they are not regulated by the U. S. Food and Drug Administration. This means that their labeling may not be accurate. I do not recommend plant-based hormones at this time, because there is no scientific evidence that they do anything. However, I do recommend pharmaceutical estrogen preparations (including Premarin), because there is a great deal of well-accepted scientific evidence that they are of benefit.    Pharmaceutical estrogens (administered as a pill, patch, injection, implant or vaginal cream) are reported to effect numerous body systems. These include: the central nervous system (estrogen improves memory in patients with Alzheimer's Disease and may effect libido and sense of well being), skin (estrogen decreases acne and may reduce wrinkles), skeletal system (estrogen promotes bone production and decreases bone loss), cardiovascular system (estrogen improves blood flow to the heart and has a beneficial effect on blood cholesterol levels), urinary system (estrogen improves the supportive tissue around the bladder and urethra and may improve some types of urinary leakage), and genital system (estrogen maintains the caliber of the vaginal vault and keeps the vaginal lining healthy).    Estrogen causes the uterine lining (endometrium) to grow in women who have a uterus. Some women who used estrogen over an extended period without progesterone (the hormone that stops endometrial growth and causes menses) developed endometrial cancer. Because of this, women with a uterus are generally given estrogen in combination with another hormone (progesterone) to prevent unopposed endometrial growth.    Currently, there is a great deal of controversy regarding estrogen and breast cancer. Unfortunately there is no clear-cut answer. However, when all the studies are examined together, there does not appear to be an increased risk of breast cancer with estrogen use. In fact, some patients with breast cancer are using estrogen under the care of their physician.    Estrogens have been used worldwide for more than 30 years, with only rare side-effects or complications. Premarin is the estrogen preparation that has been available for the longest time and is considered the gold standard by which others are compared. It is manufactured from the urine of pregnant mares. Unfortunately, there is a great deal of misinformation from some of the animal rights groups. In reality, the stables where these mares are kept are carefully monitored by Canadian and United States veterinary authorities. Both groups have reported that there is no evidence of abuse or neglect at these stables.
Q:   Is there any data on the correlation between estrogen replacement and asthma? My asthma began with estrogen replacement therapy, and the coughing stops when I stop estrogen. However, then the menopausal symptoms return. I have tried all types of estrogen -- oral, patch and injection.	A:   There is no direct evidence that estrogen replacement therapy causes new cases of asthma or coughing. However, there are a few reports of allergic type reactions to estrogen replacement therapy. These reports are generally associated with specific estrogen replacement preparations. It is very unusual to have a reaction to all the available types (oral, patch and injection), because they are all fairly different compounds. While there are alternatives to estrogen replacement that will help alleviate some bothersome symptoms (like hot flushes), none of the alternatives will prevent cardiovascular disease or bone loss. Since there are so many benefits to estrogen replacement such as: improving memory, improving skin tone and collagen content, decreasing risk of cardiovascular disease, decreasing bone loss, preventing some types of urinary incontinence, preventing hot flushes, etc., and there are so few risks (potential increase in breast cancer risk and an increase in uterine cancer if progesterone is not used), it may be useful to consult with a gynecologist or reproductive endocrinologist that specializes in hormone replacement therapy.
Q:   Why would a doctor request a prolactin blood level test for a woman with irregular menstrual cycles?	A:   Women may have irregular menstrual cycles for a variety of reasons. An elevated prolactin level may be one potential reason for irregular menses. Prolactin is a normal hormone that is associated with milk production following pregnancy. Prolactin is made in the anterior pituitary gland in the brain and is normally produced in very low levels. In addition to pregnancy however, there are several different things that may cause prolactin production to increase, including benign growths called pituitary micro or macro adenomas, and some medications such as anti-depressants.    Prolactin may be measured from a blood test. In cases where the level is elevated, the blood test should be repeated. If the blood test is high enough, the physician may want to continue the evaluation with an MRI of the pituitary gland. If the prolactin level is high, and there are no other problems, there are medications available which will decrease the blood prolactin concentration, frequently resulting in normal menstrual cycles.
Q:   What are the differences and similarities between estrogen/progesterone taken as an oral contraceptive and that taken as hormone replacement therapy? Does HRT function as a means of birth control during menopause?	A:   The types of estrogen and progesterone used for birth control and hormone replacement therapy in menopausal and peri-menopausal women are similar. However, the dosages used are different. The amount of estrogen and progesterone in standard birth control regimens is at least three to five times greater than the amount used for hormone replacement therapy. The amount of estrogen and progesterone used for hormone replacement therapy will not prevent a woman from becoming pregnant!    Hormone replacement therapy should be used for women who no longer ovulate, and therefore no longer have menses. One alternative for peri-menopausal women, those women having less frequent menses with less flow, is using a low-dose oral contraceptive. Low dose oral contraceptives will safely prevent pregnancy with minimal side effects and will provide their users with all the benefits of hormone replacement therapy, including protection against cardiovascular disease and osteoporosis.
Q:    My wife has been on estrogen therapy for 14 years, following surgery for a complete hysterectomy. Eight years ago she was diagnosed with low white blood count. Could the Estrace (1 mg) she takes be a side effect that lowered her white blood cell count?	A:   Estrace (estradiol) is manufactured by Bristol-Myers Squibb Co. It is a natural estrogen commonly used for hormone replacement therapy. It is indicated for the treatment of: hot flushes, vaginal thinning and dryness, low estrogen due to ovarian failure, palliative therapy for some types of breast or prostate cancer and the prevention of osteoporosis. There are a variety of side effects that have been reported in association with its use including: vaginal bleeding, breast tenderness, skin rashes, headache, weight changes and changes in libido. Although in some limited cases, estrogens have been implicated in changes in red blood cells, I am not aware of any reports where estrogen causes a low white blood cell count. In this case, consultation with your physician may be helpful. It might be reasonable to stop using the Estrace for a short period of time, and then recheck the white blood cell count.
Q:   Do estrogens cause any adverse side affects?	A:   Estrogens are hormones that are naturally produced by women. Production increases after the onset of puberty and declines in peri-menopause and menopause. Estrogens, both endogenous (produced within a woman's body) and exogenous (medication administered as a pill, patch, injection, implant or vaginal cream) are reported to effect numerous body systems. These include the central nervous system (estrogen improves memory in patients with Alzheimer's Disease and also may effect libido); skin (estrogen decreases acne); skeletal system (estrogen promotes bone production and decreases bone loss); cardiovascular system (estrogen improves blood flow to the heart and has a beneficial effect on blood cholesterol levels); breasts (estrogen promotes growth and development and may contribute to the development of breast cancer); urinary system (estrogen improves the supportive tissue around the bladder and urethra and may improve some types of urinary incontinence); and genital system (estrogen maintains the vaginal caliber of the vaginal vault and keeps the vaginal lining healthy).    Estrogen causes the uterine lining (endometrium) to grow in women who retain their uterus. Some women who used estrogen over an extended period of time without progesterone (the hormone that stops endometrial growth and causes menses) developed endometrial cancer. Because of this, women with a uterus are generally given estrogen in combination with another hormone (progesterone) to prevent unopposed endometrial growth.    Currently, there is a great deal of controversy regarding estrogen and breast cancer. Unfortunately, there is no clear-cut answer. However, when all the studies are examined together, there does not appear to be an increased risk of breast cancer with estrogen use. In fact, some patients with breast cancer are using estrogen under the care of their physician.    There are a number of adverse reactions associated with estrogen that have been reported to the United States Food and Drug Administration. These include central nervous system effects (headache, migraine, dizziness and depression); skin effects (increased hair growth or hair loss, or rashes); breasts (enlargement, discharge or tenderness); gastrointestinal effects (nausea, bloating, cramping, vomiting, gall bladder and liver problems); genitourinary effects (irregular menses, breakthrough bleeding, pelvic pain, fibroid growth and vaginal yeast infections); and systemic effects (weight loss or gain, swelling and change in libido).    Estrogens have been used worldwide for over 30 years. The vast majority of women use exogenous estrogen with either minimal or no side effects. Many of the adverse effects are limited to the duration of estrogen use. Estrogen should be used while under the care of a physician. The risks associated with use should be balanced by the benefits of its use.
Q:   I understand it is now possible to use a blood test to predict the onset of menopause, and perhaps the severity of onset. Is this the case? Which test is used, and what data is relevant?	A:   Menopause is technically defined as the cessation of menstrual flow for 12 consecutive months. The average age for the onset of menopause in the United States is approximately 51 years. There is no accurate way to predict when an individual woman will undergo menopause or how severe her symptoms will be. However, there is a loose association between when an individual woman's mother became menopausal and when she will undergo menopause. Smoking will also result in an earlier menopause.    Menopause is usually a gradual change and may be diagnosed by a variety of complaints and findings. Women will commonly have hot flushes (also called "hot flashes"). Hot flushes usually begin on the chest and slowly rise over the neck and face to the forehead. They may begin at night and cause sleep disturbances. Women may also notice vaginal dryness and possibly an increase in irritability or moodiness. Objectively, menopause may be diagnosed by a physical examination--the lining of the vagina appears thin--or by a blood test.    The most common blood test used to diagnose menopause is an FSH (follicle stimulating hormone) level.    In some cases, physicians will check other blood hormone levels to either assess current treatment or the need for further treatment. These hormone levels may include estrogens (estradiol) or androgens (testosterone). An important fact, however, is that blood hormone levels are effected by diet, stress and other factors and fluctuate widely. A single FSH may not be able to accurately diagnose menopause. Rather than waiting for 12 consecutive months without menstrual flow, menopause may be diagnosed based on an individual's subjective complaints, objective findings during a physical examination, and perhaps a blood FSH level.
Q:   I am obese, and would like to know if obesity can cause a low estrogen level. I am 29-years-old and have been told that my estrogen level is in the menopausal range.	A:   Obesity is associated with many health risks. Obese women commonly have alterations of their normal hormone levels. These hormonal alterations result in a wide spectrum of disorders that are usually treatable. In many cases, the actual estrogen concentration is elevated, but the available (useful) amount of estrogen is too low. Many of these disorders fall into the diagnosis of polycystic ovarian syndrome (PCOS). Women with PCOS may have difficulty becoming pregnant, and may also experience irregular menstrual cycles and abnormal hair growth (beard, chest hair, etc.). A subset of women with PCOS have hormonal problems that can result in diabetes. Some women with PCOS who do not have menstrual cycles are also at increased risk for endometrial (uterine) cancer.    In addition to disorders specifically associated with obesity, obese women may also have other medical problems which could result in low estrogen levels. For example, premature menopause (menopause before 40 years of age) occurs in as many as 10 percent of obese women. In most cases, obese women benefit from a complete gynecologic evaluation. Further, consultation with a reproductive endocrinologist is helpful for any woman diagnosed with possible premature menopause.
Q:    I had my cervix and uterus removed 10 years ago. I'm now 42-years-old. How will I know when I've started menopause?	A:   Menopause is technically defined as the cessation of menstrual flow for 12 consecutive months. Women who have had a hysterectomy (generally, the removal of the uterus and cervix) do not have menstrual flow. For these women, the diagnosis of menopause depends on the occurrence of certain symptoms, a physical examination and, in some cases, a laboratory test.    The most common symptoms of menopause include: 1) Hot flushes (also called hot flashes) which usually begin on the chest and slowly rise over the neck and face to the forehead. They may begin at night and disturb sleep. 2) Vaginal dryness, which can make sexual intercourse painful. 3) Emotional changes, including increased irritability or moodiness. In addition, during a physical examination, the clinician may find that the tissue of the vagina appears thin. A common blood test used to diagnose menopause is an FSH (follicle stimulating hormone) level which is elevated during menopause.    Perimenopause is a period of time (not well defined) that precedes menopause. There is evidence that during this time a woman's bone density begins to decrease. There is also evidence that during this time a woman's cardiovascular risk factors begin to increase. In most cases, the risks of hormone replacement therapy are outweighed by their benefits. It is therefore reasonable to begin using hormone replacement when menopause or perimenopause is suspected. All women will benefit from annual gynecologic examinations and a discussion with their provider about menopause (or perimenopause) and hormone replacement therapy.
Q:   Although I have been post-menopausal for the past nine years, I was just given hormones this year. Will this nine-year time-lag affect any benefits I might gain from hormone treatment?	A:   Hormone replacement therapy generally involves using two naturally-occurring hormones. The first type of hormones are estrogens ("female" hormones), which are responsible for a wide variety of functions, including: improvement in cardiovascular function, prevention of osteoporosis, improvement in memory, prevention of wrinkles, reduction of acne and facial hair growth and maintaining vaginal lubrication. The second component of hormone replacement therapy is a progestogen. Progestogens are "neutral" hormones used to prevent overgrowth of the uterine lining (endometrium). These hormones are used because, in the past, women with a uterus who used estrogen alone had an increased risk of developing uterine cancer due to the unopposed growth of the endometrium. This risk is removed by the addition of a progestogen.    The major health risks to women in peri-menopause and menopause result from bone loss and subsequent development of osteoporosis and an increase in cardiovascular risk. Recent studies suggest that up to 20 percent of all bone lost is actually lost in the peri-menopause (when a woman may still be having regular menstrual cycles). The first few years immediately following menopause are marked by accelerated bone loss. After this time, however, the rate of bone loss is slowed.    Osteoporosis is a slowly evolving disease that may take as long as 20 to 30 years before a fracture develops. Starting hormone replacement therapy at any time in peri-menopause or menopause is probably beneficial since bone is a dynamic structure that undergoes continuous breakdown and rebuilding. Estrogen will decrease bone breakdown and increase rebuilding.    Estrogen exerts two major effects on cardiovascular fitness. Over the long term, it alters the amount and type of cholesterol in the blood. Estrogen increases the concentrations of "good" cholesterol and decreases concentrations of the "bad" cholesterol. The second effect is more immediate. Estrogen causes the blood vessels in the heart to dilate (relax) and increases blood flow (oxygen and nutrients) to the heart. Hormone replacement therapy at any time may improve cardiovascular status.    Ideally, hormones should begin in peri-menopause. However, there are many women who are already menopausal and are not yet using hormone replacement therapy. Since there do not appear to be any major risks associated with hormone replacement therapy in appropriately selected women, I recommend beginning hormone replacement therapy, regardless of how long ago menopause began.
Q:   My wife was taking Premarin--dosage .625 mg. We would like to know the equivalent dosage of esterified estrogen as in Estratest. Also, what is the difference between conjugated estrogens and esterified estrogens? We appreciate this opportunity for information.	A:   Premarin and Estratest are two different medications used by post-menopausal women for hormone replacement therapy. Both contain estrogens ("female hormones") which are responsible for a wide variety of bodily functions including: improvement in cardiovascular function, prevention of osteoporosis, improvement in memory, prevention of wrinkles, reduced acne and facial hair growth and maintenance of vaginal lubrication. Estratest also contains methyl-testosterone. Testosterone is a "male hormone" which may be taken by post-menopausal women to help improve libido and, in some women, a sense of well being.    Premarin, manufactured by Wyeth-Ayerst Laboratories, is also referred to as conjugated equine estrogens. Premarin is composed of more than 20 different compounds which are purified from the urine of pregnant mares. Premarin has been available longer than any other medication used for hormone replacement and is the gold standard to which other medications are compared. There are several commercially-available dosages available. For most women, 0.625 mg is the minimum effective dose that is demonstrated to prevent osteoporosis and improve cardiovascular function.    Estratest, manufactured by Solvay Pharmaceuticals, contains two different types of compounds. The first are esterified estrogens, which are purified from the urine of pregnant mares. The second is methyl-testosterone, which is synthesized from testosterone. Estratest is available in two strengths: Estratest contains 1.25 mg of esterified equine estrogens and 2.5 mg of methyl-testosterone; and Estratest HS contains 0.625 mg of esterified equine estrogens and 1.25 mg of methyl-testosterone.    In general terms, to remove a hormone from the body, the liver chemically alters the hormone by "conjugation" or "esterification." The resulting hormone is then referred to as conjugated or esterified. Therefore, both Premarin and Estratest are similar. It is, however, difficult to determine which dose of Estratest is comparable to Premarin 0.625 mg. This is because each contains different ratios of their component parts. Both medications are excellent choices for hormone replacement therapy. In most cases, I would use the least amount of medication necessary which has been proven to have an effect. I use Estratest or Estratest HS if Premarin is not effective in alleviating menopausal symptoms (such as hot flushes) or if there is a desire to improve libido. Many of these issues will benefit from a discussion with a gynecologist.
Q:   I have developed an allergy to sun and I think it is because I am on hormone therapy replacement. I discontinued the hormones and the allergy has decreased. Is this common among the users of hormones? If so, what should I do? Shall I continue taking them or not? The allergy can be very bad, on my face and neck, especially.	A:   Hormone replacement therapy generally involves the use of two naturally occurring hormones. The first is an estrogen. Estrogens are "female" hormones that are responsible for a wide variety of bodily functions including: improvement in cardiovascular function; preventing osteoporosis; improving memory; preventing of wrinkles; decreasing acne and facial hair growth; and maintaining vaginal lubrication. The second component of hormone replacement therapy is a progestogen. Progestogens are "neutral" hormones that are used to prevent overgrowth of the uterine lining (endometrium) in women that are using estrogens. This is because in the past, women with a uterus who used estrogen alone had an increased risk of developing uterine cancer. This risk is removed by the addition of a progestogen.    There are a number of commonly used substances (prescription and over-the-counter) that may increase an individuals sensitivity to sun exposure (photosensitivity). For example, sulfa drugs such as bactrim are associated with an increase in photosensitivity. However, none of the medications (estrogen or progestogen) currently used for hormone replacement therapy are reported to either increase or cause photosensitivity reactions. Individuals with new-onset photosensitivity reactions or persistent rashes should contact their physician for further evaluation.