There are three human estrogens:  Estradiol, Estrone, and Estriol.  Estradiol is the strongest and some of it converts into Estrone.  Estrone has a mid-range strength, but is felt by some authorities to have more cancer causing attributes than Estradiol.  Estriol is the weakest estrogen and is more water soluble than the others.  It has the least propensity for cancer stimulation and some experts feel that it decreases breast cancer risk.  It used to be thought that Estriol was produced only during pregnancy but recent studies show it is produced at high levels throughout the menstrual cycle. 

Testosterone is produced in women and men.  Men produce ten times more than women and thus it is usually called a male hormone.  Testosterone is anti-inflammatory and vital for men and women.  I do not believe that Testosterone is the cause of prostate cancer.  Prostate cancer is related to elevated systemic inflammatory change and the increased conversion of  Testosterone into Estradiol by the aromatase enzymes found in excess visceral fat (especially beer/wheat belly).  Testosterone is responsible for muscle mass, ambition, sex drive, and positive outlook, for example.  

Following childbirth some women lose some of their Testosterone production from the interstitial cells of the ovary.  Most hormonal contraception causes suppression of Testosterone.  This can lead to fatigue, depression, and decreased sex drive.  The usual explanation for these symptoms is stress and depression related to child rearing, marriage, work etc.  The most common treatment suggested is counseling or antidepressant therapy with meds that can often cause more sexual dysfunction, weight gain, and fatigue.  While stress issues are very real in our society, testosterone deficiency (and hypothyroidism) is very real and should be evaluated before blaming stress.  

In my next blog, I will discuss how I use these “Tres Amigos” to treat perimenopausal and menopausal  women who suffer from symptoms of hormonal imbalance.

As women enter the perimenopause (around the age of 35), their Progesterone production begins to decline.  This is due to anovulatory cycles and inadequate luteal phase progesterone production causing an increase in fertility problems as women age.  Perimenopausal women become Progesterone deficient ( Estrogen dominant).  Estrogen production in the perimenopause becomes erratic with both higher and lower levels during the cycle.  These changes cause the common perimenopausal symptoms such as weight gain, fatigue, decreased sex drive, abnormal bleeding, and cyclic moods (PMS).  Estrogen dominance is also an issue in uterine fibroids and endometriosis.   Remember, Dr. Katharina Dalton, the inventor of the term PMS, recommended progesterone suppositories for the treatment of PMS.  I spent a week with Dr. Dalton inLondon in 1985 learning about her theories.  She came to Columbia and presented two talks.  One was a private talk for physicians only.  Two doctors attended; myself and a family physician no longer in private practice.  The other presentation was for the general public and was at the Ramada Inn.  Well over 500 attended and many were turned away for lack of room. 

Check back for the continuation of Volume 2 of Dr Trumbower’s Hormone Diaries where he discusses more about the “Tres Amigos” and what happens to estrogen production at menopause.

                There are many different combination birth control pills.  They all have similar composition with estrogen and a type of progesterone.  The progesterone component and the dose of hormone varies between pills and accounts for why some pills work better for some people than for others.

                The pill is often prescribed for problems with menstruation.  Taking birth control decreases the amount of blood lost each month and decreases cramps better than any other medication.  It makes the menstrual cycle more predictable and more manageable for many women.  Taking the pill continuously or using a 24 day pill is often used to treat PMS symptoms as well.  Another problem for some women is menstrual migraines.  These are often treated using a special formulation that adds back estrogen during a women’s period to decrease the frequency and severity of headaches.

                Hormonal imbalances are also treated using the pill.  The hormones in the pill lead to changes in the production of proteins in the blood that bind testosterone and other compounds.  This change results in lowered effects from testosterone and decreases acne and dark hair growth some women have on their faces and chests.

                Other uses for the pill include the treatment of gynecologic disorders, such as uterine fibroids and pelvic pain.  Many women with endometriosis are treated successfully using the pill, as are women with recurrent ovarian cysts.

                As with any medication you need to consider the benefits taking it compared to the risks.  For many women with menstrual or gynecologic problems the pill remains a great resource.

There have been many observational studies over the years trying to determine the effect of using OCs on overall cancer risk.  When all types of cancer are combined there is a decrease in the overall cancer risk in women who have ever used OCs.  This decrease is likely due to a substantial decrease in uterine and ovarian cancer in women who take the pill.  Studies have consistently shown that using OCs decreases the risk of ovarian cancer.  Overall the risk is one-third less for women who currently use or have used OCs in the past.  What is most impressive is that the protection lasts for up to 30 years after stopping the pill and all doses of the pill provide the same protection.  Uterine cancer is also decreased in women on OCs, the risk of uterine cancer while on the pill is almost half of what it would be off.  The relative protection can last up to 15 years in some studies.

The effect of the pill on the risk of breast and cervical cancer is more controversial. 

There may be an increase in cervical cancer in women who have taken OCs. Many studies show an increase in cervical cancer that continues as long as the pill is continued.  When the pill is stopped, the risk returns to baseline levels.  Interestingly, women who are negative for HPV (the virus most often associated with cervical cancer) do not have an increase in the risk when using OCs, leading to the conclusion that the pill may interact with the growth of HPV already present.

There have been several studies on the risk of breast cancer in OC users and the results are conflicting.  Several population studies have been done and show no increase in the risk of breast cancer later in life for women who have taken OCs.  The only study that showed an increase looked at women who took high dose OCs (in the 1970’s) AND had a strong family history of breast cancer.  This may indicate that for women of average risk there is no significant increase, but in women who carry the BRCA1 or BRCA2 gene (or who have a strong family history-a mother or sister affected) the risk increases.

Overall, these risks and benefits likely balance out for women of average risk.  In women with a family history of breast or ovarian cancer the circumstances may need to be discussed in more depth with a provider.  It is important to remember that all these risks estimates are pretty low, not doubling or tripling risk.  Another thing to keep in mind is that we increase and decrease our risks of cancer and other chronic diseases everyday, not just in medication choices, but in lifestyle choices as well. 

As the reasons for giving the pill have changed, so has the way they are taken.  For years, gynecologists have been having women ‘skip periods’ for medical reasons by rearranging the way they take their regular birth control.  In the past few years the pharmaceutical companies have jumped onto this wagon and started packaging pills for this specific purpose leading women to wonder, “Is it safe to skip my period?”

When talking about the way birth control pills work most  people are referring to a combination pill, one that contains both an estrogen and progesterone component.  These pills mimic the normal hormones produced by the ovary and suppress ovulation to prevent pregnancy.  They also contain less estrogen then most women normally produce and a low but stable amount of progesterone unlike the variation seen in the natural cycle.  This combination of hormones makes it possible to suppress ovarian function while keeping the lining of the uterus thin and healthy. 

Women who are not on a birth control pill do need to have a menstrual cycle at least four times each year to prevent abnormal growth of the lining of the uterus.  Women who are on birth control are keeping the lining thin and healthy by taking the medication and have no medical need to have a period. 

There are now several pills out that lengthen the time between periods (such as Seasonale), or try to eliminate periods altogether (Lybrel).  Newer formulations are meant to shorten the period to 1-2 days but frequently result in no noticeable bleeding at all.  The biggest side effect seen in women taking extended cycle pills is spotting that typically resolves with time.  The good news is that a woman can use any low-dose pill to skip periods after consulting with her physician.

When birth control pills were first introduced it took several years for women to accept them as safe and effective.  Now the next step is for women to accept the manipulation and even elimination of the menstrual cycle is a safe alternative and even added benefit of the pill.

This is the first in a two part series.  Check back for “Part Two: Birth Control Pills and the Risk of Cancer.”

Listeria monocytogenes is a bacteria that can be found in soil, water, sewage plants and food.  It is considered an important public health problem due to the fact that infection with this bacteria most often occurs in people with a weakened immune system- such as pregnant women, newborns, the elderly and people on chemotherapy.  In this population the infection can have severe consequences. 

Symptoms of infection with Listeria usually include diarrhea or other gastrointestinal symptom followed by fever, body and muscle aches.  The symptoms usually develop one to a few days after eating the contaminated food.  It is diagnosed by blood testing.  Treatment with antibiotics cures the infection and can prevent pregnancy complications so it is important to contact your physician if you develop these symptoms or have consumed food known to be contaminated

The actual risk of contracting Listeria in the United States is quite low.  The incidence given by the CDC is 3 per 1,000,000 (.3/100,000).  Reported cases were down 38% in 2010.  Of the cases reported, 16% occurred in pregnant women.  Of those pregnant women 28% were Hispanic.  This leads many to believe that the most common source of infection is soft, non-pasteurized Mexican cheeses like queso fresco and queso blanco.

As with any bacteria that is naturally present in our environment, it is impossible to completely eliminate the risk of infection.  There have been reports of Listeria isolated from many types of food including contaminated vegetables, hummus, even milk contaminated after pasteurization. (In other countries it has been isolated from soft serve ice-cream, but not in the US).  Common sense food safety guidelines and avoiding high-risk foods are the best ways to avoid infection.

Food safety guidelines include washing all utensils and surfaces used in preparation of raw meats and storing uncooked meats separately from vegetables and cooked foods. 

Foods considered high-risk include unpasteurized soft cheeses, such as brie, feta, or queso blanco.  Cold deli meats and uncooked hotdogs are also considered to be high risk unless they are cooked before eating.  All hard cheese (like cheddar), semi-soft cheese (like mozzarella) and pasteurized cheeses are completely safe.

Most feta and brie that is made in the United States has undergone the pasteurization process- just check the label.

 The great news is that most nachos are made with monterey  jack or cheddar.  If there is any doubt, just ask the cook.  Now you can just sit back and enjoy your meal.

There is a lot of talk about bioidentical hormone therapy.  Bioidentical hormones (BH) are hormones that are molecularly identical to the ones produced by the human body.  BH differ from synthetic hormones which have different structures than the ones made in your body.  Most hormone products made by pharmaceutical companies are at least partially synthetic so that they can be patented to increase profits.   BH have advantages over synthetics in that they fit your cell receptors perfectly, and thus cause the same effects as your own hormones. As a result, they are also much easier for your body to eliminate after their effect is completed.  Based on these characteristics, in my opinion, BH is a safer product than synthetic hormones.

An example of a synthetic product is Prempro, a combination of horse-derived estrogens, Premarin (pregnant mare’s urine) and Provera a synthetic progestin.  The Women’s Health Initiative (WHI) study in 2001 showed that Prempro increased heart attacks, strokes, blood clots and cancer. 

Examples of BH include Estradiol, Estriol, Testosterone and Progesterone.  These hormones are all made naturally by women (men also make their own bioidentical hormones—more in a later blog) and are the ones that are usually used in Bioidentical Hormone Therapy (BHT).  

There has been little hormone research in this country since the WHI study.  Most research is funded by government grants or by pharmaceutical companies.  It is possible that the drug companies do not want to test their synthetic products as the results may mirror the WHI study findings.  However, the French have done large studies on BHT.  The French Cohort study was published in Maturitas, an international medical journal.  It reported a 10year study looking at BHT (the French rarely used synthetic HT).  The results showed no increase in heart attacks, strokes, or blood clots and a slight decrease in breast cancer rates compared with the national averages.  

Not all menopausal women need hormone therapy, but many women suffer from incapacitating hot flashes, mood swings, vaginal dryness, and decreased sex drive symptoms that are not relieved by over the counter or herbal remedies.  BHT may be a reasonable option for many such women.   BHT requires a prescription and is often compounded by a pharmacy.   Routes of administration can be oral, transdermal, sublingual, injectable, or subcutaneous pellets.  The dosage level can be monitored by saliva or blood tests as well as by clinical symptoms.

Volume 2 of The Hormone Diaries will cover more about bioidentical hormones, including a brief history of how I became interested in BHT.  For those persons who want to learn more, the best starting books are those written by Dr. John Lee:  What Your Doctor May Not Tell You About Premenopause, What Your Doctor May Not Tell You About Menopause, and What Your Doctor May Not Tell You About Breast Cancer.

A perfect example of a condition that can be controlled by diet is polycystic ovarian syndrome or PCOS.  PCOS is a disorder of metabolism in women that is primarily due to insulin resistance.  Women with PCOS may have any combination of: irregular or absent periods, increased hair growth on face/chest, acne, dark skin patches on neck/underarms and  difficulty with weight gain.  If left untreated it can lead to diabetes, high triglyceride levels and increased risks of heart disease and uterine cancer.

There are many medications that women can take to treat the symptoms of PCOS, but the most effective one targets the body’s sensitivity to insulin.  Increasing insulin sensitivity can be readily accomplished with changes in diet and exercise.  We are seeing more studies everyday that show the insulin resistance in PCOS can be reversed by a low-carbohydrate diet combined with weight bearing exercise.  Multiple studies show that reversing the insulin resistance leads to decreases in the levels of hormones that cause abnormal hair growth and acne.  These studies also show that correcting the insulin resistance can restore ovulation, this means normal periods and improved fertility for women who are desiring pregnancy.

There are so many diets out there that it is overwhelming.  I like to think of this as a very necessary lifestyle change.  Just as a diabetic has to change her eating habits forever, a woman with PCOS should as well.  When deciding to embark on a low-carb lifestyle there are a few sweeping changes that make a big difference. First get rid of all the processed simple carbohydrates.  Its amazing how much of this we eat without knowing it. This includes white bread, pasta, rice, cereal, chips, cookies, cakes and candy.  Bummer.  It sounds really hard and it is- at first.  Once your palate becomes accustomed to more fresh vegetables you really don’t miss all the bad stuff.  A common mistake people make when trying to lower their carbohydrate intake is not eating enough calories so they feel hungry constantly and fail.  Eating a salad as a meal is great, but it needs to be a big salad with lots of veggies and protein to give you enough calories to make it through your day.  Make sure that you vary  what you are eating.  Another important change is to make certain you eat a protein rich breakfast before you really get your day going.  We are addicted to empty carbohydrate rich granola bars and muffins that are really bad for metabolism.  Starting your day out with at least 20g of protein in the morning sets your metabolism for the whole day.

Sometimes having a plan to follow is helpful and there are a lot of different plans you could choose- south beach, sugar busters, glycemic index, atkins, nutrisystem are some examples.  The main point of all these is the same.  Limited carbohydrates.  Once you find one that works you can try adding back in some whole grain carbs very slowly and carefully watching to see how it effects you.  Some women tolerate a moderate amount of carbohydrates from fruit or whole grains and some don’t.

A second very important part of reversing insulin resistance is regular weight bearing exercise to build muscle and increase metabolism.  We all need aerobic exercise for cardiac health, but we also need to pump some iron to build muscle.  Get some weights, a kettle bell, do some push-ups or join a gym.  You will see a difference.  It won’t make you look bigger to lift weights, muscle burns fat so you will become smaller.

This is a big change in the way you live your life so enlist the help of family or friends.  If you can, change what you buy at the store so there is no temptation in you pantry.  I also think you should have a day every couple of weeks when you treat yourself.  Knowing that you can have a cupcake or some lasagna next week seems a lot better than trying to never have any ever again.  It makes the change more sustainable.  Don’t get discouraged if you fall off the wagon.  Its easy to start over.  Like the commercial says: Just Do It.

                While some women may be apprehensive to do anything strenuous during pregnancy, for a majority of women, exercise is just fine and actually beneficial during pregnancy.  If you are used to exercising when you are not pregnant, there is a very good chance you can exercise during pregnancy as well.  While it may not be the best time to make the jump to train for a marathon, most women can continue what they were doing prior to pregnancy.  If you aren’t used to exercising prior to pregnancy, you can still start, just take it slow and steady. 

                The American Congress of Obstetrics and Gynecology supports doing 30 minutes or more of moderate exercise during pregnancy in the absence of obstetric complications.  There is also data to suggest regular exercise during pregnancy can reduce the risk of gestational diabetes and postpartum depression.  The primary modification I tell patients to focus on is to avoid any sport where you are more likely to get hurt (downhill skiing, rugby, soccer, etc) and to pay attention to their bodies.  During pregnancy, your exercise tolerance is lower so you will probably have to adjust the intensity you are used to.  Instead of pushing yourself to go that extra ten minutes when you feel fatigued, you should probably slow it down.  It is also important to remember that your center of gravity changes quickly during pregnancy which will affect your balance (important to keep in mind for yoga fans).  

                While there are very few reasons not to exercise, there are some individuals who need to talk with their doctor prior to starting a routine.  If you have a history of preterm labor, seizures, heart disease, lung disease, high blood pressure, vaginal bleeding or concern you’re leaking amniotic fluid, it is a good idea to have a discussion with your doctor first.  However, for most people, you have just as much reason to enjoy the warm weather as the next person.