They're back: Estrogen supplements and hormone replacement therapies that women rejected en masse a decade ago when a major study reported significant health risks among subjects given estrogen, are returning to the arsenals of health professionals.
And the attitude shift is, to some extent, gender neutral. Testosterone replacement is also gaining acceptance as a useful therapy when natural levels of this hormone decline, producing symptoms that used to be synonymous with aging.
"There's a Boomer generation now getting to mid-life that doesn't want to go into decline when they turn 60," says one pharmacist actively involved in hormone replacement therapy. "If they find that they don't feel good, can't sleep, gain weight, grow forgetful, they're saying: 'This is not working for me.' It's not only about sexuality. It's about vitality and energy and cognition -- especially with the large number of professional women in this generation who want to continue their careers into their 60s and 70s."
Men and women both produce estrogen and testosterone, with gender differences in the normal range levels of each hormone. Ample medical data demonstrates that men and women both suffer significant negative health effects without them, including possible depression, sleep disturbances and mood swings, muscle and bone loss (osteoporosis), cardiovascular disease, decline in brain function and loss of sexual and overall vitality.
"I'm not trying to put everyone on hormones, but I do want to present them with the data that we now have, and show them what hormones can do for them, especially women suffering from perimenopause," says Dr. Peter Koshland, one of several hundred compounding pharmacists across the country pioneering a re-examination of such therapies. "There's no reason to suffer. I don't think it's beneficial in any way."
Koshland is a champion for those who are not up for going gentle into the good night. "Very few men will talk about testosterone deficiency to each other," he says. "But what I'm seeing in my practice is that if a man's wife is taking hormones, and he sees how she's benefiting, a lot of these people will come in to see how hormone therapy might also help them."
But the campaign to restore the good name of hormone replacement therapy is about more than alleviating some temporary midlife discomforts like hot flashes, says Susan Podolsky, an Ob/Gyn who prescribes it to "many happy patients" at the Women to Women Medical Group in Riverbank, CA. She says the health effects of estrogen loss are every bit as serious, if not more so, than the risks associated with estrogen supplements.
For example, calcium levels in a woman's bones begin to diminish toward the end of her fertile years and drop dramatically in just a few years after menopause, no matter how good her nutritional regime. "Once a woman in her 60s breaks her hip, she has a 25 percent greater chance of dying within the year," Dr. Podolosky says. "You need your bones. You need your calcium. Estrogen helps women maintain healthier bones, and that's just one benefit."
Hormone therapies fell out of favor in the wake of the Women's Health Initiative (WHI) study, launched in 1991, which looked at major health problems of older women, including cardiovascular disease, cancer and osteoporosis.
Two separate, randomized studies compared the health outcomes of women who took a placebo with women who took estrogen alone, or estrogen plus progestin. The women on estrogen showed increased risk of stroke and blood clots; those on estrogen plus progestin had similar outcomes, along with a higher risk of heart attack, stroke and breast cancer.
But critics have since pointed out flaws in the research and its conclusions. The form of estrogen used in the study was the conventional pharmaceutical Premarin, derived from the urine of pregnant mares. Prempro, an oral estrogen with synthetic progestin, which was also prescribed in the study, "had all these terrible outcomes," said Koshland. "Basically across the board, except for bone-strengthening, it had worse outcomes than the placebo. It just freaked everybody out."
Giving synthetic compounded estrogen orally to women over 70 who had not taken any hormones earlier in life, had predictable negative effects, says Dr. Ricki Pollycove, who with Koshland organized a recent summit on best practices in hormone replacement therapy in San Francisco.
"There was a higher incidence of health risks for women over 70, using that particular test product," Pollycove says. "But for younger women, those in their 40s, 50s, 60s, there were always other options."
Those options include newer forms of hormone therapies, called bioidentical hormones. These are derived from plants or animals, but chemically modified in labs to be molecularly identical to those produced by the human body, improving their reception.
Hormone replacement is also getting a second look because the therapies are now administered through topical creams or patches, which allow for lower doses and less interference by other bodily functions, which occurs with oral doses.
A third trend is a higher standard of medical care. The best quality of bio-identicals are not mass produced, Pollycove says, but rather individually prescribed and produced in small batches by specialists called compounding pharmacists like Koshland.
Pollycove cautions that patients are not getting the same quality from large, mail-order 'compounding' pharmacies. The safest products are prescribed based on lab tests in collaboration with the patient's doctor, who ideally monitors the effects of the regimen on each individual patient, she explained.
Dr. Podolosky, who resumed prescribing bio-identical hormone replacement regiments about five or six years ago, agrees. "What I can do as a doctor is to take a good history of each patient, identify risk factors, and customize the prescription according to symptoms and responses," she adds. "The results in my practice have been very good."
A California woman who prefers to be identified only as "B," described her experience: "When the WHI study came out, I really panicked. I spoke about this with my gynecologist, who strongly encouraged me to stay on my [estradiol] hormones, believing that the study was seriously flawed in multiple areas and that the benefits of HRT outweigh its risks. He gave me lots of articles from medical journals that also helped me to decide to stay on the hormones," she said.
B, now 65 and still married, remains on the regimen to this day. The benefits, she claims, are "a happy libido and great sex. I am much more lovable to others."
Koshland, an adjunct professor of pharmacology at the University of California San Francisco (UCSF) who runs the small Koshland Pharmacy in San Francisco, says pharmacists like himself can be a bridge between patients and doctors. He is a member of the Professional Compounding Centers of America (PCCA), which work with doctors to discuss the science, the symptoms, the tests, the results, the interpretation of those results.
"I'd like to see the mainstream doctors get more on board with this, but I believe that in a decade or so, this will become absolute standard care. The evidence and the rational is so solid, and we will receive more and more of it," he says. "What I hear most often from women under treatment is, 'You gave me my life back.' "
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