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Special Topic: Hormone Replacement

by Kathryn Petras
(Note: for more on HRT, click here for a listing of available forms of HRT)

Hormone replacement therapy is confusing enough, but it sometimes gets even more so when you’re faced with an array of different products -- natural estrogen, equine estrogen, progestin, natural progesterone gel, patches, pills, and so on and so on. . . . all with different names, claims, positives and negatives.

Probably one of the more confusing aspects of HRT is when people talk about synthetic versus natural HRT. You’ve heard the terms being used -- but what do they really mean? What’s natural and what’s synthetic, what’s the difference......and what works best?

It can seem complicated, without a doubt, but it’s not as difficult to understand as you might think. Here’s a quick look at this issue to help you better take charge of your health care:

What are Synthetic Forms of HRT?

This is the type of HRT that has been most widely prescribed for years -- estrogens like Premarin and progestins like Provera, as well as low-dose birth control pills.

Synthetics refer to manmade hormones, as you’d expect -- hormones that are made from chemical sources that approximate the hormones the human body makes. But it also refers to Premarin (and its offshoots) which, although made from a natural source (horse urine), isn’t exactly the same as the estrogen which is made in your body.

So synthetic HRT is similar to that which the body makes; it helps relieve symptoms and prevent long term risks, but isn’t identical to what your body made. In fact, some synthetic estrogens (such as ethinyl estradiol, found in many birth control pills, and the equine estrogens in both Cenestin and Premarin) are stronger than human estrogens. This may cause your liver to work harder than with the bio-identical estrogens. On the plus side, however, synthetic conjugated estrogens (as in Premarin) is the most widely studied form of estrogen -- so there has been much more research on its effects in the human body. It’s been shown to eliminate menopause symptoms and help prevent bone loss. In addition, it may help protect against cardiovascular disease.

As for progesterone, until very recently, the only easily available choice for progesterone replacement was progestin -- synthetic progesterone. Progestin isn’t exactly like progesterone, but has many of the same attributes and opposes estrogen in your body like natural progesterone. On the negative side, since it’s not exactly the same as human progesterone, it may cause side effects similar to PMS in some women.

What are Natural Forms of HRT?

As used here on the site and in my book, as well as by most people discussing HRT, natural refers to estrogens and progesterone that are often manmade, but from natural plant sources. But most important, most of them are naturally occurring and bio-identical to the hormones your body makes.

In other words, they don’t approximate your hormones; they have the same exact chemical structure as the hormones made by your ovaries. Because they are the same as what we make, our bodies can often work better with them. We can more easily metabolize them and break them down so our livers and kidneys can excrete them once they’ve done their work. Given this, they don’t accumulate in the body and cause side effects. As with synthetic estrogen, natural estrogens eliminate the symptoms of menopause, prevent bone loss and may help protect against cardiovascular disease. In addition, some people report fewer side effects with natural estrogens.

Okay, seems pretty straightforward, right? But there is one recent exception to this clear-cut definition: Cenestin is a conjugated estrogen that was recently made available. It’s natural in that it’s made from plant sources, but it’s not bio-identical to human estrogens. Instead, as a conjugated estrogen, it’s the plant-based copy of Premarin. It’s not horse urine, like estrogen, but the estrogens in it are copies of equine estrogens.

As for progesterones, until recently the only game in town were progestins -- synthetic progesterone. But over the past few years, natural prescription progesterone has become available. As with natural estrogen, it’s plant-based and identical to the progesterone we make. Because of this, it reportedly causes fewer side effects and -- one big plus -- may actually help build bone as opposed to only preventing bone loss.

What about Phytoestrogens? Aren’t they considered Natural HRT?

Yes and no. (How’s that for straightforward!) Some people do call phytoestrogens -- like soy isoflavones and flaxseed -- natural HRT, but generally it’s considered a substitute or addition to HRT. Generally speaking, HRT refers to prescribed hormones that replace those your body used to make.

That said, phytoestrogens can have an important role to play in managing your early menopause. They can minimize symptoms and offer other health benefits as well -- they can help build bones, fight heart disease and cancer, and more. So they’re often a good choice even if you’re on HRT. If you’re not on HRT, you can use them to raise your estrogen levels -- even though they’re much less potent than prescription estrogen. At the most, they’re only about 2 percent of the strength of estradiol. But they produce an estrogenic reaction in your body. In fact, they can both raise your levels of estrogen if its low by binding to receptor sites and lower it if its high by blocking the stronger estrogen. So they act as a balancing agent where your estrogen is concerned, can help protect you against stronger estrogens (which may help reduce cancer risks and other side effects), and can also boost your estrogen levels if you need it -- which can relieve menopausal symptoms like hot flashes, night sweats and more.

  • Phytoestrogens include: Lignans (found in sources including cereals and vegetables; especially high in flaxseed); Isoflavones (found in legumes; especially high in soy); Coumestans (found in red clover, such as Promensil; and alfalfa sprouts. The most potent phytoestrogen, although still about 200 times weaker than human estrogen).

Natural Versus Synthetic: What’s Best for You?

There’s no clear-cut answer to this question. It’s one of those cases where it’s up to you to decide what you’d prefer.

In general, where the synthetic versus natural debate is concerned, it may make more sense to opt for a natural progesterone than a synthetic because of its effect on bones. Since we in premature menopause are at such a high risk for osteoporosis, this may be a good choice. In addition, there are fewer side effects associated with natural progesterone versus synthetic.

Beyond that, however, it really boils down to a personal decision. While many doctors claim that naturally occurring forms of estrogen are a better choice because they are exactly the same as the hormones your ovaries produce, others feel more comfortable prescribing Premarin because it has been studied more extensively.

Ask yourself: What argument to you agree with? What do you feel comfortable taking? What works for you? There are many ethical, political and practical opinions floating around about HRT and its different forms, but I’m a believer in taking whatever works for you as an individual. Some women feel uncomfortable taking hormones made of horse urine and talk about the mistreatment of the horses used in the preparation. This is a legitimate concern on their part, and I agree that they shouldn’t take Premarin since the concept bothers them. Others however don’t feel this is a problem -- and feel comfortable taking Premarin because it has been so widely studied. This too seems to be a legitimate decision. In honesty, I think the different views are all valid. When it comes to health risks, you’ll note that some forms of hormones do appear to be associated with a higher risk than others -- but, in fairness, nothing has been unequivocally established.

The bottom line, then: HRT is such a personal decision, you shouldn’t allow yourself to be bullied into anything. Remember that everyone is different and what doesn’t work for one person may work well for another. For example, I opted against Premarin and Provera, having read about the possible side effects and having a personal preference for taking natural HRT. Moreover, my risk of osteoporosis is high since I have a family history of it, so natural progesterone seemed to be a better choice for me than synthetic. So I chose to take a natural estrogen and progesterone (in my case, Estrace and Crinone) based on my attitudes and health concerns. However, I know a number of women who are taking Premarin and Provera and are very happy with the results. Many have no side effects at all; others have side effects, but don’t feel that they’re a major issue. They are as pleased with their choice as I am with mine.

So listen to your body! Don’t be afraid to try different forms of HRT until you find the one that works best for you. Remember: there’s no "one size fits all" prescription when it comes to HRT.