For any of you who have read any of my books on Somersizing, you know the important role Dr. Schwarzbein plays in my life. She is an awesome doctor, cutting-edge, and the first doctor I met who truly understands menopause and its ramifications. As an endocrinologist, her specialty is the chemical makeup of the body. As I struggled to find a doctor who really understood what my body was going through in menopause (before I found the wonderful doctors I have interviewed for this book), it was Dr. Schwarzbein who was finally able to help me find relief. She understands the importance of replacing the hormones lost in the aging process with natural hormones that are exact replicas (bioidentical) of the ones we make in our own bodies. Because of Dr. Schwarzbein, I am enjoying my menopause more than any other passage so far. Here is our conversation.
SS (Suzanne Somers): First of all, I appreciate your giving me time to do this. I know how swamped you are at the office.
Every woman is looking for answers during this confusing passage, and you have made menopause a specialty. So let me first ask you: Because menopause is confusing not only to women but also to most doctors, how did you figure it out?
DS (Dr. Diana Schwarzbein): Most of what I know about hormone replacement therapy in menopause I did not learn in medical school, or in medical training. It was when I was in private practice. I had four years of medical school, three years of internal medicine, then two years of endocrinology, but in nine years of training no one said, This is menopause, this is what you need to be doing.
SS: What made you pay attention?
DS: I started treating diabetic patients back in 1991, and I was noticing that a subset of my diabetic patients who happened to be menopausal women, who were following the exact same diet and exercise program as all the other diabetic patients, were not responding with the same good results. In other words, their sugars were not budging. It was startling. They were eating the same way, doing the same kinds of exercises, but their blood sugars were staying at 300, whereas the men and the premenopausal women had blood sugar levels that were coming down.
SS: What were you missing?
DS: It started to dawn on me that maybe the sex hormones were playing a role in their problem. But initially I made a lot of mistakes.
SS: For instance?
DS: If someone said to you, you can have all the benefits of hormone replacement therapy with or without a period, everyone would probably say, "Oh, without a period, please."
SS: Very understandable. I mean, who wants to have a period if they don't have to?
DS: I agree, and at that point I bought into the current standard of care that believed you could have the benefits of hormones without a period. But I found that when you give hormones that way [continuously combining an estrogen with a progestin on a daily basis], you make the patient more insulin resistant.
SS: But isn't a woman her healthiest when she is pregnant, because her body is making estrogen and progesterone simultaneously?
DS: Actually, no. Pregnancy is not the healthiest state for a woman to be in. In fact, pregnancy is one of the times when you are more insulin resistant. If you are pregnant back to back and you have many children, I guarantee you're going to end up with type 2 diabetes or another form of insulin resistance such as obesity, abnormal cholesterol levels, and/or high blood pressure. Also, we now realize that pregnant women have a higher risk of breast cancer.
SS: Why is that?
DS: I am not sure that anybody really knows, but I'm going to say I think it's because of insulin resistance. Because high insulin levels have been linked to breast cancer. For instance, women with type 2 diabetes have one of the highest risks of developing breast cancer. So do women with metabolic syndrome [an insulin-resistant problem].
SS: Okay, but why would pregnancy make you insulin resistant?
DS: It's complex, but to simplify, physiologically you have many hormonal changes in pregnancy that block the action of insulin. One of them is the high progesterone levels.
SS: But people always think of pregnancy as a high estrogen state.
DS: Actually, pregnancy produces high estrogen levels but much higher daily progesterone levels, and the progesterone blocks the action of estrogen every day. The result of this is a low estrogen effect in the body.
SS: So let's get back to how you started treating your diabetic menopausal patients.
DS: I started treating women with diabetes in 1991, and I prescribed Prempro to those who were in menopause. Luckily, I noticed right away that their blood sugar control worsened. This was a group of patients who were not improving despite how hard they were working at eating well and exercising. In fact, some of them were getting worse. That's when I realized Prempro was the problem. Then I switched these women to estradiol and progesterone, thinking the bioidentical hormones would be the answer. However, I still prescribed them in a continuous combined way (no periods), and their blood sugars remained elevated.
Then I thought about the four rules that I use for the replacement of any missing hormone:
1. Don't take a hormone that's not low or missing.
2. Take only bioidentical hormones.
3. Mimic normal physiology as much as possible.
4. Track the hormone levels and their effects.
Starting with rule number one-in menopause you are low in estradiol and progesterone. Rule number two, give back the same hormone in its bioidentical form. I realized that Premarin was being substituted for estradiol, and Provera was being substituted for progesterone, and this was not the right thing to do. So I prescribed bioidentical estradiol for estradiol and bioidentical progesterone for progesterone.
Then, because of rule number three, I realized that continuous combined therapy was not the way the body made these hormones. To mimic normal physiology as much as possible, these hormones would have to be taken in a cyclical manner, and then women would have to have withdrawal menses [monthly period] again.
Then, rule number four, I followed my patients by tracking their hormone levels through blood work and the effects of these bioidentical hormones.
When I followed my four rules of hormone replacement that I used in treating all types of hormone deficiencies, the blood sugars of the women with diabetes improved and their hormone levels came back into balance. Finally, these women felt well again.
I realized the mistake I was making [ten years ago] treating menopausal women with type 2 diabetes was in giving them continuous combined HRT. Remember, as diabetics they were already insulin resistant, and they became more insulin resistant on continuous combined HRT. Unfortunately, many doctors today still don't understand the link between continuous combined therapy and insulin resistance and are still making the same mistake today that I did all those years ago.
In my opinion, the harm of continuous combined therapy was confirmed in July 2002, when the first results of the Women's Health Initiative was published. There were three groups of women in this study:
1. The observational group. These women were in menopause but were given only a placebo. They were "observed" to check for heart disease, breast cancer, stroke, blood clots, type 2 diabetes, and so forth.
2. Two treatment groups: subdivided by whether the woman had a uterus or did not because of a hysterectomy.
If the woman had a uterus, she was given Prempro, a synthetic drug hormone comprising an estrogen, Premarin, and a progestin, Provera. Progestins block the effect of estrogen, so the women on Prempro did not get a period. In other words, if you take an estrogen and then block the action of it with a progestin, you end up with a low estrogen effect in the body. Hence, no bleeding.
If she didn't have a uterus, she was given Premarin alone. [Premarin is a drug that contains many different estrogens, most of which are not found or made in the human body.] Taking Premarin alone would lead to a higher estrogen effect in the body.
SS: Interesting. And when you have a low estrogen effect because of continuous combined HRT [no period], are you subject to disease?
DS: That's what the WHI study showed. It was going to be an eight-plus-year study. They wanted to compare the outcome of the treatment groups with those of the observational group.
But at 5.2 years, the Prempro study was stopped early.
SS: Why?
DS: They started noticing that the women on Prempro [continuous combined therapy-no period] were having more heart attacks, more strokes, more blood clots, and more breast cancer than the group taking the placebo.
SS: What about the women who were taking Premarin?
DS: They haven't found the same kind of increased risk for disease with Premarin alone; therefore, that part of the WHI study is still ongoing. It is slated to be finished and reported in 2005 after eight years plus.
Last year when the news broke out about Prempro, the initial reaction was to get all women off all HRT, and to this day that is what most physicians are recommending.
SS: Why was the Women's Health Initiative done in the first place?
DS: The idea was to do a long-term prospective study on the possible benefits versus risks of the most commonly used HRT. They studied Premarin and Prempro because these are the most commonly prescribed therapies.
SS: So, when a woman takes these drug hormones, is she getting any good out of it at all, or would she be better off not taking anything?
DS: The WHI concluded that Prempro is worse than not taking anything, and I agree with the conclusion.
SS: That's a pretty strong statement.
DS: Yes, but that's what the study concluded.
As far as Premarin goes, I do not like it because it is not a bioidentical estrogen. However, it hasn't been shown to be more harmful than not taking anything at all. But this part of the study is still ongoing. It's important to know that Premarin has not yet been shown to be of much benefit, either. When it first came on the market, it was only supposed to be used in the short term to treat hot flashes, but then its use got extended (without any studies, I might add) to long-term hormone replacement therapy for menopause. As far as I am concerned, one of the uses of HRT after menopause should be for protection against heart disease. Premarin does not protect against heart disease.
SS: Well, all I know is I am feeling so wonderful that I am going to take bioidentical [natural] hormones for life, or as long as I choose to do so.
DS: And I believe it is safe for you to take bioidentical hormones for the rest of your life as long as we keep monitoring the effects of these hormones and we keep adjusting the amount to match your ever-changing lifestyle.
SS: Now what about Prempro or Premarin? Would a gynecologist put a woman on these drugs for life?
DS: I know many women who have been on these drugs for too long. There are two paralleling concepts going on: One is don't substitute a drug for a hormone; they do not do the same thing in the body. Two, do not think that you are going to come up with a better way to give these drugs than to match the physiology that already exists, as in natural bioidentical hormones.
I learned from my own studies and my treatment of menopausal women that you can approach menopause in two ways: symptomatic relief therapy or bioidentical HRT following the four rules mentioned earlier. Most gynecologists have been approaching it from the symptomatic side. They feel that as long as a woman is not having hot flashes, she is being treated properly. That is not true.
Furthermore, in my experience most gynecologists treat the uterus as the most important organ in the human body. As such, they feel their role is to keep harm from coming to your uterus. The medical literature in gynecology is filled with studies on the amount of progestin needed to protect the uterus from developing cancer. In trying to save the uterus and prescribing continuous combined therapy, gynecologists have increased the risk of breast cancer, heart attacks, and strokes in once-healthy women! Unfortunately, by messing with Mother Nature and giving drug hormones without restoring menstrual bleeding, we have done more harm than good.
SS: Okay, here we are again at having a period.
DS: You have to have a period, because this mimics normal! The normal state is not pregnancy! Prempro mimics pregnancy, so continuous combined therapy is not normal. Having a monthly period is normal. At one point gynecologists understood this concept. Prior to the last ten to fifteen years, most doctors did prescribe Premarin and Provera in a cycling way. That was the standard of care for quite some time.
SS: Then what happened?
DS: Primarily, women weren't feeling good on Premarin and Provera. They were complaining of bloating and irritability and on top of it were getting their period again! Then many women stopped taking HRT because they felt so poorly on it. Instead of treating women with bioidentical hormones, gynecologists tried different ways to give Provera to protect against uterine cancer and came up with continuous combined therapy without thinking about or studying the long-term consequences.
SS: Quite a dilemma. So if rule number three is to mimic normal physiology as much as possible, that would mean having a period, but is having a period all your life normal?
DS: Medically we are altering natural phenomena everywhere. There is nothing natural about immunizations, or open heart surgery, or hip replacement surgery. We have to decide as a society whether we are all going to honor aging or not. If we are, then I would say don't give hormone replacement therapy. But if as a society we choose to alter natural phenomena medically, we have to be consistent. Taking HRT after menopause is not natural, but neither is performing open heart surgery.
SS: Let's talk more about rule number four-tracking.
DS: Tracking means monitoring the effect of the hormone a woman is taking. It is done through assessing hormone levels, assessing how the woman feels on hormones, when and how much bleeding she has on a monthly basis, assessing bones and cholesterol, and evaluating her uterine lining with yearly ultrasounds. It also entails following specific issues pertinent to the woman's personal health history such as blood pressure, insulin, and blood sugar levels.
Menopause is a serious condition. In other words, I don't just prescribe hormones and say, "Have a nice life, call me if you get a hot flash." Menopause needs to be followed just like any other hormone replacement therapy. Dosages of hormones may need to be continuously adjusted around a woman's aging and her changing lifestyle.
SS: What about self-medicating, as in today my breasts are a little more tender, I think I'll take a little more estrogen cream?
DS: I don't feel very comfortable with women self-medicating around symptoms. For instance, let's take breast tenderness . . . it could be from too little estrogen or too much estrogen. So how would a woman know what to do?
I'll tell you something else about estrogen: It can act like an antidepressant, and women can end up taking too much of it if left to determine how much they should be on in relation to how they feel. Then you get into the complications of high hormone effect in the system.
And then there is progesterone. Women cannot tell if they're taking too much progesterone because it is a stimulant and can initially make one feel better. It isn't until later that they can start feeling depressed or gain weight from too much progesterone, and by then they may not realize it's the progesterone because of how long it took before the symptoms occurred.
SS: Oh, so that is why you don't like women to self-adjust their hormones.
DS: Right, you have to be very careful. You do not want too much or too little. It has to be just right, and the only way to do that is through tracking.
SS: Should women and men go only to an endocrinologist who specializes in bioidentical HRT to get their sex hormones balanced?
DS: As an endocrinologist, I have chosen to specialize in sex hormones. But not every endocrinologist has the same training. I wish I could say, "Go to your local endocrinologist and everything will be okay." Unfortunately each person must find the right endocrinologist or doctor for him- or herself. It will require interviewing the doctor to see if he or she has made sex hormones a specialty.
SS: When you do get your hormones in balance (as you have helped me balance mine), life is blissful. It's worth a trip or a drive to another city to get on track. After all, it is a three-hour drive for me to see you, but you are worth it.
DS: Well, thank you. Now that you and I have worked together for all these years, you know that hormone replacement therapy can be complex.
SS: And this is where the concept of synthetic pharmaceutical hormones is screwy to me. How can one pill fit all?
DS: Exactly. Even though we all share the same physiology, we don't all share the same metabolism rate of different hormones. I mean, you and I have completely different body types. Let's look in the mirror at ourselves: Who has more estrogen . . . you or me?
SS: Old friendly me. Curvy body . . . you get to have a long, lean body and slim hips (I hate you, by the way). But I get your point. Every "body" has different needs.
DS: It's also genetics. It's about ratios among different hormones.
SS: Right now the ratio, the match, you have prescribed for me feels good. I'm feeling fantastic.
DS: Great. But it's sometimes a very difficult thing to find the perfect match for women. It takes patience and focus.
SS: How difficult?
DS: Well, it depends on their lifestyle and what is going on.
SS: So if a woman lived by a river and didn't work and didn't have a telephone or a television set and wasn't constantly thinking, Oh, my God, I have to juggle a million things . . .
DS: It would be easier to find a match for that woman. She could probably get away with much less estrogen, because estrogen is the multitasking hormone. But if this same woman smoked, it would make the body rid itself of the estradiol faster.
Another example is you, Suzanne, when you were going through that period where you were so stressed. Your hormone needs kept going up, so I had to keep changing your doses, yet your hormone levels stayed the same, because you were using it up so much. And then abruptly your stress stopped and the dose of your hormones was too much for you. All of a sudden you had a high estrogen effect.
SS: Right, and that was excessive bleeding . . .
DS: Yes, you called me and I decreased your doses and things got on track and in balance again.
SS: What's interesting to me as the patient who has been doing this for several years is that I have become very sensitive to when the doses are not correct. I find this an incredible way to work with you as my doctor. We are doing this in concert together, and it helps me to feel that I am in control of my health and my body.
DS: Yes, and as you recall when we first started working together, I was very clear about the fact that this is a pain in the butt. A "one pill fits all" would be a lot easier, but the rewards of doing it this way, from a health standpoint, a quality-of-life standpoint, and a longevity standpoint, are indisputable.
And it's not just about the hormones. It's about eating well and stress management, and tapering off sugar and other chemicals, and doing the right kinds of exercise. All hormones talk to one another. So you can't take estradiol and progesterone and expect to find balance if your insulin and adrenaline levels are going crazy from poor nutrition and lifestyle habits. Every hormone has to be in balance with the other hormones.
SS: That makes a lot of sense. A woman has to have better habits after menopause to keep her hormones in balance to help keep her prescribed hormones in balance, too. How do you feel about gynecologists giving antidepressants to quell menopausal symptoms?
DS: I think it's a tragedy. We are one of the first generations of women to fully experience this passage. We have much higher stress levels and more anxiety in our lives than ever before, and we are seeing menopause at earlier ages. And all this accelerated aging is due to bad lifestyle and dietary habits! Giving a woman an antidepressant to deal with the suffering of menopause does nothing to replace the hormones she has lost in the aging process. Antidepressants take away the vibration of living and create a host of other problems. Menopause is natural, but dying is natural also! Today we have ways of dealing effectively with menopause or delaying death; why wouldn't we want to take correct advantage of that? Antidepressants are not the answer.
SS: So what is the answer?
DS: Remember this concept . . . she who keeps her hormone levels highest the longest wins. That's the race, dear!
It's got to start with good nutrition. People don't realize that if they want to be busy and run around like a crazy person, and they don't eat well, then they will literally eat themselves!
If a woman of childbearing age wants to make a baby but is under any type of stress, she can end up dealing with infertility. Eggs are dispensable. This is not the time to make a baby, because she needs to use whatever she would use to make an egg for energy instead to fight off the stress.
We have advanced medically so that women no longer need to die prematurely from childbirth or from infectious diseases as they did before we had antibiotics. Women also used to die in perimenopause from infections before proper medicine was available, because we are more susceptible to infections during this phase. Women are their healthiest and strongest during their childbearing years, when they are making a full complement of hormones. The loss of hormones makes you weak.
SS: So the theory is that if I keep my hormones balanced and I continue to eat right, I can expect to stay strong and most likely avoid the diseases of aging?
DS: Right, and we now know that it's not just about menopause. It's about nutrition and stress management and sleep and exercise, and hormone replacement, if needed.
SS: Are we baby boomers the guinea pigs?
DS: I think the women who have been given the chemicals are the bigger guinea pigs. Come on, giving drugs to replace a hormone? These chemicals will cause you to lose the hormones that protect you from heart disease, namely estradiol. Real hormones provide protection from heart disease if given in bioidentical form [exact replicas of the hormones we make in our own bodies]. This was confirmed by the Howard Hodis study at theUniversity of Southern California. He showed that estradiol-not Premarin, not synthetic hormones, not drugs, but the bioidentical estradiol found in human ovaries-will protect a woman against heart disease.
SS: Okay, Dr. Schwarzbein, we're sold, but where am I going to send women to find this kind of excellence and understanding relative to this passage? Women are barraged with bad medical advice and are highly influenced by the drug companies, so where do they go, and what should they ask their own doctor? For instance, the woman says, "I am in menopause, I am having hot flashes, I am irritable, and I am bloating."
DS: First thing to ask your doctor is to get baseline hormone levels through lab work. You want to have your estradiol, progesterone, and follicle-stimulating-hormone levels tested. If you are in menopause, you proceed to rule two.
Tell your doctor that you want to be prescribed bioidentical estradiol and progesterone. You can get the best form of these hormones from a good compounding pharmacy. Next, ask your doctor if he or she knows or works with a good compounding pharmacy. If not, or if you don't have one in your area, have them check the reference guide you have provided in the back of this book. However, some doctors won't know how to use the compounding pharmacy, so ask them to prescribe an estradiol preparation such as Estrace or Gynodiol found in the local pharmacies. There is also a noncompounded form of bioidentical progesterone known as Prometrium.
SS: How would someone know how much to take?
DS: You always want to take the lowest dose and taper up slowly.
SS: And see how you feel?
DS: Yes, and take the estradiol hormone twice a day. Estradiol is in and out of the body very quickly, so you really need to take smaller amounts more frequently to achieve the best balance. Take it twice a day about twelve hours apart, because you want to mimic a steady stream, as if your own body is still making it. The progesterone may be taken once a day or sometimes twice a day if needed.
SS: Okay, they have their estradiol and progesterone preparations. Now what?
DS: They will need to take them in a cycling manner. Take the estradiol every day of the month twice a day and add in one pill of progesterone for fourteen days out of each month. The easiest way to do this is on calendar days one through fourteen of every month.
SS: What dosage should they take?
DS: Start with about 0.5 mg of estradiol twice a day and with 100 mg of progesterone a day, and then track symptoms and levels to determine if a higher or lower dose is needed.
SS: What happens after the fourteenth day of progesterone? Is that when a woman should expect to have her period?
DS: Yes, they are supposed to be having a regular menstrual flow around the end of the progesterone or just after it is finished. . . . If they break through early [bleeding], then they are taking either too much progesterone or not enough estradiol.
SS: How will they know?
DS: They will need to have their blood levels checked to see which one it is.
Now, we are not taking into account that some people would like to be on progesterone 50 mg twice a day, not 100 mg once a day. Unfortunately, we don't have a 50 mg at every drugstore. We only have 100 mg. You have to try to work with it. But if you are able to work with a compounding pharmacy, they will be able to work it out to fit your needs more specifically.
SS: This will be a big help to women who are frustrated and do not live in an area that has an informed endocrinologist or gynecologist. As women, we have to be proactive about our health and our hormonal needs, because there is so much misinformation and lack of understanding about this passage. That is the point of this book, to empower women and men (and believe me, they also lose their hormones) to find quality health care and information about hormones for themselves.
DS: We are in a crisis as far as menopause is concerned. Doctors are going to have to learn something new, because we can't keep allowing women to suffer and become ill due to the lack of understanding that exists.
SS: So what is the future? I agree with you that menopause is a crisis at this time with this lack of understanding among women and doctors, but another generation is coming up right after us, and everyone is still in a state of confusion and frustration. Women my age are suffering, their marriages are falling apart, the divorce rate is going up, men are remarrying young girls to get the fun back in their lives, so what is going to happen? What are your hopes?
DS: Menopausal women have to demand answers. We also have to get them over their fear of breast cancer and of estrogen. One of my hopes is that the right information gets out. Women have to know that the risk of breast cancer is much less than the risk of dying from not taking hormones, or the risk of getting a heart attack or a debilitating stroke.
Let me state that insulin is a much bigger hormone relative to breast cancer than estrogen will ever be, because insulin is a major growth hormone. Insulin is a major growth hormone and estradiol is a minor growth hormone. Breast cancer is not caused because you took estradiol. Breast cancer comes from damage to DNA from the environment and damage caused by unhealthy lifestyle and dietary habits.
SS: Like . . .
DS: Stress, smoking, too much caffeine, high daily doses of progestins, lots of artificial sugar, anything that you put in your body that shouldn't be there. If you damage an area of the DNA that promotes a tumor, then that tumor is going to start to grow. Estradiol is a growth factor for normal breast tissue. So if you have normal breast tissue, but now the DNA of that normal breast tissue gets damaged, estradiol is still going to make it grow, but it didn't cause the damage.
In fact, I am going to stick my neck out and say that when we finally get around to studying bioidentical estradiol, it is going to be shown to be protective against cancers because it is an antioxidant in the human body.
Again, though, it is not about too much or too little of a hormone. The balance has to be just right.
SS: Thank you so much.
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