Estrogen is made in the ovaries but is also made in the corpus luteum, adrenal glands, and fat cells. Once the ovaries stop producing estrogen on a regular basis, the adrenal glands become the main source of estrogen (primarily as E1).
Estrogen is actually available in 3 forms – estrone (E1), estradiol (E2), and estriol (E3). The production of the various forms of estrogen and estrogen metabolism depends on your age, cycle, genetics, and other factors. Suffice it to say that the various estrogens have different potencies and effects.
In menopause, the absolute levels of estrogen and progesterone are affected, but it is also important to consider the relative levels of estrogen as it relates to progesterone (i.e. estrogen dominance vs estrogen deficiency). Failure to attend to the proper balance of estrogen to progesterone can lead to worsening symptoms.
Estrogen, progesterone, and testosterone do not act in a vacuum but intimately interact with other hormone systems such as the thyroid and adrenals (cortisol). Hormones must be considered a web with rather complex interconnections that must be properly monitored and adjusted as needed. Remembering that systems such as the methylation system are intimately involved in the detoxification system reminds us that it is important to consider hormone use in the context of a systems approach rather than to treat hormone therapy as an isolated therapy.
Proper monitoring and management of menopause hormone therapy is paramount.
Estrogen is metabolized into substances that may increase the risk of breast cancer (if not properly identified and managed). If you are currently on hormone therapy (or even if you are not) you should be aware if your metabolic products of estrogen metabolism are within a safe range (easily measured with a urinary estrogen metabolite test). Sadly, monitoring such data is not the norm. Equally important is the status of your detoxification systems, your toxin exposures (even if unwittingly) and so on.
Adding estrogen (hormone therapy) when your estrogen is being metabolized in such a way as to increase your breast cancer risk is obviously something that should not be done – but if you are not assessing and addressing your estrogen metabolism, how will you even know you are at risk?
Thus, it is important to identify and correct any questions about proper estrogen metabolism and detoxification sufficiency prior to (or concurrently with) adding estrogen therapy. Focusing solely on hormone implementation is not recommended – patients are strongly advised to make sure you are being treated and appropriately monitored by a properly trained physician.
Not all hormones are alike. Bioidentical hormones are, well…. identical to the hormones your body produces. This seems to be an appropriate approach (and it is the one that we strictly adhere to – using only bioidentical hormones) but many are still being treated with hormones that are not bioidentical (such as Premarin – derived from horse urine, and medroxyprogesterone – Provera – a chemical analog of progesterone that is absolutely NOT the same as your own progesterone).
The Women’s Health Initiative study showed the risks involved with artificial progesterone (Provera), and artificial estrogen (Premarin).
In addition, hormones should be used within their physiologic ranges to minimize risk. There is very little data available concerning the risks of using long-term higher-dosed hormones.
It is our contention that symptomatic improvement without the excess risk (seen with non-bioidentical hormone treatment) is attainable but is complex and requires proper monitoring of multiple factors as outlined.
We feel that it is important to appreciate that BHRT (bioidentical hormone replacement therapy) needs to be properly integrated into a comprehensive approach. There are multiple metabolic systems that interrelate with hormones and influence their levels, potential toxicities and effects.