CBS

Information on Menopause

Posted on Nov 16, 2011 05:20am

Dr. Maria Oquendo


"Unless there's a history or very high ris­k of breast cancer, heart attack or stroke, there's no reason for a woman to suffer needlessly through a difficult menopause. The key to hormone therapy is balance: using the lowest effective dose for the shortest necessary time."­­
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-Interview with Dr. Isaac Schiff, Joe Vincent Meigs Professor of Gynecology at Harvard Medical School and Chief of the Vincent Obstetrics and Gynecology Service at the Massachusetts General Hospital.

"Strong evidence suggests that declining estrogen levels (during menopause) appear to be associated with...a gradual weight increase."

-A Personal Perspective from Dr.Wulf Utian, Founder and Executive Director of the North American Menopause Society and Consultant Gynecologist, The Cleveland Clinic.

"There's not one medication or one practice that suits all. Women are not all albino rats from the same litter reacting predictably to the same medications."

-Interview with Dr. Bernadine Healy, Physician, Cardiologist, Professor, former Director of the National Institutes of Health and former President of the American Red Cross.


"I think we're in the beginning of what I call Westernized Talibanism of women. There is an invasion of women's sacred property--their estrogen. Our society wants to take estrogen away from women and make them foggy, depressed and unproductive."

-Interview with Dr. Uzzi Reiss, Beverly Hills gynecologist, obstetrician and specialist in Anti-Aging Medicine.




WHY MENOPAUSE?
Well, to begin with, there are 111 million adult women in the United States, almost all of whom watch the CBS Television Network in a typical week and all of whom will or have experienced the inevitable transition of menopause.

In addition, the landmark Women's Health Initiative Study concluded that there was an increased risk of breast cancer and stroke in women taking a combination of synthetic estrogen and synthetic progesterone (progestin). This triggered considerable confusion and fear among many women about the overall risks of hormone therapy.

So, we thought that, by embracing this cause and interviewing top experts, we could help clarify some of the confusing and frightening information...hopefully impacting the lives of many CBS viewers in a positive way. We couldn't think of a better reason for a Television Network to take on a cause.

CBS Cares conducted considerable research to identify a gynecologist in the U.S. who brought the utmost credibility and expertise to the issues. The name of Dr. Isaac Schiff, Joe Vincent Meigs Professor of Gynecology at Harvard Medical School and Chief of the Vincent Obstetrics and Gynecology Service at the Massachusetts General Hospital, came up repeatedly. We were therefore thrilled when he agreed to be extensively interviewed for this website.

We also approached Dr. Bernadine Healy, a distinguished cardiologist and women's health expert who, as former head of the National Institutes of Health, initiated the landmark Women's Health Initiative Study, which triggered much of the recent concern about hormone therapy. Her perspectives on the study she launched and various other issues related to menopause and hormone therapy are very important.

In wanting to provide a complete and balanced discussion of the issues, we also interviewed Dr. Uzzi Reiss, a prominent Beverly Hills Gynecologist, who prescribes bio-identical/natural hormones. Dr. Reiss has very strong and passionate convictions on bio identical hormone therapy and related women's health issues.

So, we invite you to read the transcripts and sit in on our interviews with these leading experts. We hope that you'll find them informative and that they will facilitate the dialogue between you and your health care provider on important issues directly impacting your health.

Interview with Dr. Isaac Schiff:  Joe Vincent Meigs Professor of Gynecology at Harvard Medical School and Chief of the Vincent Obstetrics and Gynecology Service at the Massachusetts General Hospital

CBS Cares:  What is perimenopause and how is it different from menopause?

DR. SCHIFF:  Perimenopause is that time in a woman's life, before menopause, when she starts to run out of eggs and skip periods. So, it's basically a time when her ovaries stop being responsive to pituitary gland stimulation.  For perimenopause, she has to skip at least one period, but not 12 or more consecutive periods.  Also, in perimenopause, periods and the intervals between periods may get longer or shorter.

Menopause is a permanent end of periods for a woman and occurs when her ovaries run out of eggs and stop producing hormones called estrogens.  You're in menopause when you skip at least 12 or more consecutive periods.  So, it's menopause if you have no periods for a year.

CBS Cares:  How are perimenopause and menopause, respectively, diagnosed?

DR. SCHIFF: Basically by listening.  If a woman is 47 and has skipped periods, then I would say to her, "It sounds like you're perimenopausal, and you may start to go through menopause at some point."  But even if you skip a period at 47, they could resume and you could have regular periods for years.

A diagnosis of menopause is made through exclusion; in other words, a year of no menstrual flow.  If someone skips a period at age 47, you could measure a hormone called FSH (follicle stimulating hormone) and it would be elevated at menopause.  If someone skips a period for a month, and is not using contraception, you have to consider pregnancy as a possibility.  I wouldn't encourage too much testing; I'd rely on what's happening to the woman.  If a woman of 47 skips a period or two and is having hot flashes, the diagnosis is likely to be perimenopause.

CBS Cares:  What is the average age that women experience perimenopause, and what are the typical symptoms?

DR. SCHIFF:  The average age in the U.S. for perimenopause is about 47 years. Usually, it happens about four years before menopause. Some physicians may not be aware that perimenopause may be accompanied by hot flashes, which can actually be more severe than the hot flashes during menopause. There can also be mood changes.

CBS Cares: For women in their thirties, are there any subtle hormonal changes?

DR. SCHIFF:  For these women, the bigger issue is decreasing fertility.  There is a slight change in periods in the 30s but not much.  However, I wouldn't want a woman in her thirties to think, "Oh my God, I'm going through menopause!" just because she skipped a period. Pregnancy is a more likely diagnosis at that age.

CBS Cares:  What exactly causes hot flashes?  What causes some women to experience worse hot flashes than others?

DR. SCHIFF:  It is thought that the decline in estrogen leads to a change in the set point of the woman's temperature control mechanism. In other words, the body is trying to cool off. So, blood is brought from her organs that produce heat, such as the liver, and they come to the periphery; namely, to her skin over the face and upper body. Her blood vessels expand, allowing for more blood and thus more heat to come to these areas. The woman will now feel very warm and will start to sweat. There will be a loss of heat by radiation, and then, she'll start to feel cold because of the heat loss.

It's thought that the woman who undergoes menopause because of surgery or chemotherapy is the one who has the most severe hot flashes. 

CBS Cares:  Is hormone therapy used as short-term treatment for perimenopausal symptoms?

DR. SCHIFF:  Yes.  If a woman is experiencing symptoms of perimenopause and has no contraindications, her doctor might prescribe a low-dose birth control pill, which contains estrogen and a progesterone-like agent.  This would give her regular periods and reduce or eliminate hot flashes.  If the woman doesn't want to use the birth control pill, another option is a low-dose estrogen skin patch or pill, with just enough hormones to get rid of the hot flashes. 

 But, women with an intact uterus would need progesterone as well, to protect against endometrial cancer, or cancer of the lining of the uterus.

CBS Cares:  Do any non-hormonal treatments exist for perimenopausal treatments?

DR. SCHIFF:  Yes.  There's a body of literature developing that a class of anti-depressants known as selective serotonin reuptake inhibitors (SSRI's) might reduce hot flashes.  They've been used in studies of women who have had breast cancer and therefore estrogens are contraindicated but the women have severe hot flashes. 

The drug Bellergal was used in the past and was effective.  However, it could be addictive and leads to dry mouth and is not necessarily safe.  Another group of agents that were used included drugs like Clonidine. Clonidine is traditionally used for high blood pressure.  However, if you used enough Clonidine to rid the hot flashes, the patient would feel very tired. 

CBS Cares:  Do diet, exercise and a healthy lifestyle help relieve symptoms?

DR. SCHIFF:  It's thought that caffeine, alcohol, hot liquids and spicy foods can make hot flashes worse, so you should avoid consuming these.

In general, you should have a healthy diet that is low in fat and, while I'm not a dietician, you should have the usual balance of carbohydrates and fat.  Don't smoke, don't overeat, and get enough exercise. 

CBS Cares: You mention the importance of diet on a general level, but a lot of women think they should be taking soy and eating yams as a way of boosting estrogen levels. Do you recommend that?

DR. SCHIFF: We don't have data to say that soy and yams, which both contain estrogen-like substances called phytoestrogens, are good. We have evidence indirectly that the traditional Asian diet that has a lot of soy in it may be a contributing factor to why those women have less incidence of breast cancer. But we don't have the flip side-we don't know if North American women start eating more soy whether they will have reduced the risk for breast cancer. In fact, the one study that did suggest that soy reduces the risk for breast cancer comes from Singapore, but it showed that you've got to start eating soy before puberty. That's probably because it affects breast development. So it's a little late by the time a woman goes to see her doctor about menopausal symptoms.

CBS Cares:  Let's turn to the subject of menopause. You explained earlier how it's defined, but at what age does it usually start?

DR. SCHIFF:  Menopause usually occurs between the ages of 45 and 55, with the average age in the U.S. being 51, but it can occur earlier or later.

CBS Cares:  Do women generally go through menopause at the same age that their mothers did?

DR. SCHIFF:  There's not a good relation between a mother's age of menopause and her daughter's age of menopause.  However, there are certain genetic situations in which the mother has an alteration in the X chromosome, causing an early menopause, and this alteration might be passed on to a daughter. Such situations are rare, though.

CBS Cares: If a woman wants to know, can she have tests to determine if she has that X chromosome alteration and is likely to have an earlier menopause?

DR. SCHIFF: Yes, a woman could have genetic counseling and a chromosome analysis to see if she has, for example, inherited a deletion in the long arm of the X chromosome, which could lead to premature ovarian failure. And Turner's syndrome, also the result of a genetic defect, leads to primary amenorrhea, or absence of periods.  Thus, if it happens in a family, one can do genetic testing. 

CBS Cares: Is there anything women can do to delay the onset of menopause?

DR. SCHIFF: While it might not be possible to delay menopause, multiple studies show that cigarette smoking triggers early menopause. Women who smoke generally experience menopause about two years earlier than non-smokers.

CBS Cares:  What are the typical symptoms of menopause itself?

DR. SCHIFF:  Well, every woman is different, and symptoms can even differ according to nationality. For example, Asian women complain more of joint pain than of hot flashes. 

In the U.S., women can experience some or many of the following range of symptoms: hot flashes, insomnia, fatigue, anxiety, irritability, problems focusing.  There's also usually vaginal atrophy and dryness because of the loss of estrogen.  Some women's skin may become drier and less elastic, because lower estrogen levels result in less collagen production, and collagen is what keeps the skin elastic and supple.  Though hair loss could have a genetic component, it may be associated with menopause.

CBS Cares:  That's quite a litany of potential symptoms. Anything else for women in the U.S.?

DR. SCHIFF:  Yes.  After menopause some women, especially if they have had children, have trouble with bladder control.  The muscles around the bladder become weaker.  Thus, if a woman coughs and increases the pressure in her abdomen, and it gets transmitted to the bladder, the urine will be forced out of the bladder. If there is not adequate muscle contraction around the urethra to prevent that, urine will be lost.  Kegel exercises, which involve contracting and releasing pelvic floor muscles, can strengthen those muscles and improve bladder control. 

There can also be an increase in urinary tract infections. Drinking cranberry juice can help reduce urinary tract infections. 

In addition, many women may experience a decreased libido; the cause of which can be complicated.

CBS Cares:  Well, why can the cause of a decreased libido be complicated?

DR. SCHIFF:  Well, vaginal atrophy and decreased lubrication can cause sexual relations to become painful instead of being pleasurable.  This can certainly contribute to a lack of desire.  Or, a menopausal woman may need more time to reach orgasm, while men don't have as much time on their side. Decreased libido can also be caused by anti-depressants in the SSRI category. Of course, if a woman is in a bad relationship, that, too, is a factor. In addition, there are lower levels of testosterone, the hormone responsible for sex drive, apparent at menopause, which can certainly decrease libido. So, it's multi-factorial. 

CBS Cares:  When typically is the peak testosterone production in a woman?

DR. SCHIFF:  Peak production for a woman's testosterone is around age 20, and it falls by 50 percent by age 40.  So, testosterone is falling long before menopause.  And, if you remove the ovaries, there will be a further reduction in testosterone.  Some people think that the post-menopausal ovaries produce testosterone, and others don't. 

CBS Cares:  Can testosterone replacement, such as in patches or cream, help restore a woman's libido just as it can for men?

DR. SCHIFF:  Yes, in fact testosterone replacement can help with libido.  The initial studies were done in women who had their ovaries removed and were given estrogens and still had decreased libido. They continued to receive estrogens and were prescribed either a testosterone patch or a placebo patch. The women who received the testosterone patch had an improvement in their libido.  More recently, testosterone patches were used for menopausal women with decreased libido who still had their ovaries, and it was found that they had increased frequency of relations compared with the women who received placebo. However the FDA has asked for more long-term safety data before considering approval of it.  

CBS Cares:  Are there other ways to treat a woman's decreased libido?

DR. SCHIFF:  Well, to the extent that vaginal atrophy reduces libido, regular sexual intercourse is thought to help with vaginal lubrication...making sexual intercourse more enjoyable.

CBS Cares:  Does menopause cause weight gain?

DR. SCHIFF:  There is definitely a tendency to gain weight in menopause years and some evidence to suggest that menopause could in part be directly responsible.  But, there is still some debate on the subject and more research needs to be done to definitely resolve this issue.  I should add that weight gain is also age-related.  Over time, metabolism slows and gravity weighs us down.  There’s more fat deposition and less lean muscle mass, and the development of fat in the abdomen and the buttocks.  Whether weight gain is linked to menopause itself and/or age, the important thing is that a clinical trial has shown that weight gain in menopause years can be prevented by diet and exercise. 

CBS CaresWell, does menopause cause weight redistribution as opposed to weight gain?

DR. SCHIFF:  Yes, there is very compelling evidence to that effect.  Women’s waists tend to get wider, hips narrower in menopause and there can be central accumulation of weight.  Again, this can be helped, even prevented, by a healthy lifestyle … essentially exercise and diet.  In fact, because central accumulation of weight increases heart attack risks, exercise and a healthy diet are essential.

CBS Cares:  Does hormone therapy itself cause weight gain?

DR. SCHIFF:  Hormone therapy does not cause weight gain when given to postmenopausal women.  Weight gain, loss of lean body mass and central redistribution of body fat is a nearly universal occurrence throughout adult life.  This can be modified by exercise. Long-term control of blood sugar is not adversely affected by hormone therapy. 

CBS Cares:  Thanks.  Turning to the subject of headaches …. do peri-menopause or menopause cause these?

DR. SCHIFF:  There was a study in England where it was shown that women can get migraine headaches a few days before their periods start, because of a big decline in estrogens.  And, if you give them a small amount of estrogen in a patch and avoid major fluctuations in hormones, you could avoid migraines.  And the migraines would therefore tend to decrease in menopause, because – if the woman is not taking hormones – you don’t have those fluctuations.

CBS Cares:  So, a menopausal woman on hormone therapy who has severe migraines should speak to her doctor about the dosage of hormone therapy, because it might explain her migraines?

DR. SCHIFF:  Yes, it could well explain them and hormone dosage adjustment may be appropriate if the headaches are severe or frequent.

CBS Cares:  Is it fair to say that going back 50 years ago, a lot of women going through menopause were misdiagnosed as having psychological problems?

DR. SCHIFF:  Yes. There used to be a diagnosis of melancholia, or melancholy of menopause. Up until 20 or 30 years ago, there was that whole concept that menopause was associated with depression. And there weren't many antidepressants around, so these women were likely to be treated with electroshock therapy. But you've touched on an important point that needs to be emphasized: we have no evidence that there is a chronic depressive syndrome at menopause.

CBS Cares: Besides potential symptoms, are there any increased health risks associated with menopause?

DR. SCHIFF:  Yes. While menopause itself is not a disease or health risk, postmenopausal women, due largely to loss of estrogens, are more vulnerable to osteoporosis.

CBS Cares: Do other parts of the body continue to make estrogen after the ovaries have stopped or are removed?

DR. SCHIFF: That's the whole basis for why women who have had breast cancer have their ovaries removed. Even after the ovaries are removed the adrenal glands continue to make androgens or male-like hormones. These male like hormones go to the liver or fat-like tissue and are converted by the enzyme aromatase into estrogen. That is why a woman who has had breast cancer and has her ovaries out may be given Tamoxifen, which blocks the receptors for estrogen. But, we know Tamoxifen only works for about five years and then has a counterproductive effect. After the five years they would be switched to an aromatase inhibitor, which essentially reduces any estrogen production at all.

CBS Cares:  Can we turn now to the much debated subject of hormone replacement therapy?

DR. SCHIFF:  Sure.  Actually, conventional hormone therapy is no longer called hormone replacement therapy because we now understand that these hormones are not replacing lost hormones, but rather, using just enough hormones to treat symptoms.  Both hormone therapy and estrogen therapy are used to treat women.  Hormone therapy describes estrogen and progesterone, while estrogen therapy uses estrogen only.  As I touched on earlier, women who have had a hysterectomy receive estrogen therapy only, because the progesterone component in hormone therapy protects against endometrial cancer, or cancer of the lining of the uterus, and women who have had hysterectomies are not at risk for endometrial cancer.

CBS Cares:  What percentage of menopausal women require hormone treatment?

DR. SCHIFF:  About 20 percent of women experience symptoms that require hormone treatment.  And then there are some women who glide through menopause without ever experiencing a single symptom.

CBS Cares:  When and why should a woman opt for hormone therapy?  What is the profile of women who should not take hormone therapy?

DR. SCHIFF:  Menopausal women who experience hot flashes, vaginal dryness, sexual problems or other symptoms, and who have no contraindications should consider hormone therapy to feel better.  Contraindications would include any history of heart attack, stroke or an estrogen-sensitive cancer, like breast cancer or endometrial cancer. Also, women with a history of phlebitis or liver problems should not take hormones orally.

Women who smoke should definitely not take low dose birth control pills as the combination increases the risks of blood clots and strokes and heart attacks. The reason given is with the birth control pill you are trying to prevent the ovaries from functioning and thus you are using a significantly high dose to take over that role. With hormone therapy, the dose is much lower and thus the effects of smoking are not apparent. 

CBS Cares:  When you advise a patient, do you provide information about the benefits and risks of hormone therapy, and then let her decide?

DR. SCHIFF:  Yes, exactly. It's always ultimately the patient's decision, with input from me, based on my knowledge of her medical condition and her personal risk factors. It is essential for a woman to be as informed as possible.

 I feel very strongly that every woman should have a partnership with her health care provider. If your health care provider is not your partner and doesn't have time to answer your questions, you should change your health care provider.

CBS Cares:  So you're basically a proponent of hormone therapy for women with difficult menopausal symptoms?

DR. SCHIFF: Yes, and I am basically a proponent of discussing it. Unless there's a history or very high risk of breast cancer, heart attack or stroke, there's no reason for a woman to suffer needlessly through a difficult menopause. The key to hormone therapy is balance: using the lowest effective dose for the shortest necessary time.

CBS Cares:  What is the most widely used hormone therapy for menopausal women in the U.S.?

DR. SCHIFF:  The most commonly prescribed hormone in the U.S. is Premarin, which is comprised of conjugated estrogens derived from pregnant mare urine.

CBS Cares:  Are the hormones that women produce really similar to those found in the urine of pregnant mares?

DR. SCHIFF:  No, this is a substance that differs from what women produce and is actually a combination of a number of different conjugated estrogens.  However, although this is a substance that is not natural for women, but rather, natural for horses, it is an effective therapy for menopausal symptoms. And because it has been around for 60 years, it is also the most studied therapy and we have the most information about it, versus other treatments.  Premarin is also found in Prempro, which is a combination of Premarin and Provera, which is a synthetic progesterone known as progestin.

CBS Cares:  With its heritage and decades of use, it sounds like Premarin is figuratively and literally the work "horse" of hormone therapy! What gave scientists the idea to experiment with urine from pregnant mares?

DR. SCHIFF:  It was in the early 20s that Edgar Allan and Edward Doisy first isolated estrogen from pig ovaries.  Doisy was able to isolate estrone from the urine of pregnant women in 1929 and estradiol from sow ovaries.  However, they were unable to get large amounts.  In the 30s the Ayerst Company in Canada (now Wyeth) was extracting estrogens from urine of pregnant women but not very successfully. They had problems because it was tough to get, the activity was very low and it had an odor and a bad taste. 

Thus they decided to do so from horses, the result being Premarin. Premarin was prescribed in Canada and in the United States in the early 40s for the treatment of menopausal symptoms, and was found to be effective.

CBS Cares: Wouldn't estrogen activity in the urine of pregnant women more closely resemble estrogen that menopausal women used to make? If so, why not use modern technology to try and solve the problems they encountered in the 1930’s and develop a drug from this rather than from horses?

DR. SCHIFF:  Yes, estrogen in pregnant women's urine was closer.  But one of the other issues with the estrogen in pregnant women’s urine is that it is predominantly estriol, which is not especially effective.

CBS Cares:  Well, which scientifically proven effective hormone is the closest to what a woman naturally produces before menopause?

DR. SCHIFF:  The most natural, effective hormone for menopausal symptoms is a hormone that the ovary used to produce, which is estradiol.  Estradiol is the most potent estrogen produced by the ovary, while estrone and estriol are weaker estrogens also made by the ovaries.

CBS Cares:  If estradiol is so potent, what's the best way for a woman to take it to maximize safety, while maintaining efficacy?  Specifically, is it best taken by mouth or by a patch or cream applied and absorbed through the skin?

DR. SCHIFF:  If you take estradiol by mouth it gets converted by the liver after passing through the stomach and small intestine into another estrogen called estrone. Estrone is natural also, but not the predominant estrogen of younger women.  If you want to get the exact hormone that your ovaries used to produce, you want to use estradiol as a cream that you rub on the body or a skin patch or a pill placed in the vagina or a vaginal ring. It goes right through the skin, directly into the blood.  This avoids the stomach and liver, which means less risk of blood clots or phlebitis.  You would have to take higher doses of oral estradiol to equal the effect of estradiol that is absorbed through the skin.

CBS Cares:  Why then don't all women on hormone or estrogen therapy just use an estrogen cream or patch instead of taking the hormones by mouth?

DR. SCHIFF: Women in the United States apparently prefer to take oral medications.  Women in France preferred to use the patch or cream.  About 70% of the women in France used the latter while in the United States only about 10-20 %. 

CBS Cares:  You said earlier that the estrogen in Premarin differs from what a woman would naturally produce. Despite these differences, do Premarin and Prempro still mimic a woman's natural hormone functions, or do they essentially act as a drug to just relieve peripheral symptoms?

DR. SCHIFF:  Premarin is an estrogen-like agent, and it will mimic what a woman's cycle did pre-menopause, which was to make estrogen the first two weeks of the month.  It functions very similarly to the natural hormone estradiol.  Provera, which is synthetic progesterone (progestin) and functions very similarly to progesterone made by the body.

Prempro, on the other hand, is a combination of estrogen and progesterone taken throughout the month, which is different from the way the ovary used to work.  In the reproductive woman, the first two weeks prior to ovulation, only estrogen was produced.  After two weeks, then the body produced estrogen and progesterone.  And if the woman didn't get pregnant, she had a period.  Remember, the ovulating woman makes estrogen initially, then estrogen and progesterone.  But with Prempro, a woman is getting estrogen with progesterone every day of the month instead of just the last two weeks.

CBS Cares:  Why would a woman take estrogen and progesterone every day of the month, which, from what you've just described, is different from the way her ovaries used to naturally work? 

DR. SCHIFF:  The major reason for taking the two hormones together every day of the month, or what is known as continuous combined therapy, is to avoid having a period.  So, instead of thinking of continuous combined therapy as duplicating natural hormones' functions, the best way to think of it is as a therapy to relieve symptoms. 

When a woman makes estrogen for two weeks and then estrogen along with progesterone for the next two weeks, the lining of the uterus undergoes various changes, from proliferation initially, to more glandular formation when the progesterone is made.  This prepares the lining of the uterus for a fertilized egg.  If the woman does not conceive, the two hormone levels decline and the lining of the uterus comes out in the form of a period.  It was theorized that if one tries to mimic pregnancy, namely, when the body is making lots of estrogen and progesterone and in that case the lining of the uterus does not grow.  

Thus, in the pseudo-pregnancy state, it was thought that endometriosis, where the normal lining of the uterus is outside its traditional site, would atrophy and shrink, and that similarly, the lining of the uterus would not undergo stimulation and thus there would not be monthly periods.  This is the thrust behind using estrogen and progesterone together.  It was first done with the birth control pill when the two were used together and then taken every day of the month instead of stopping. 

CBS Cares: So, if a woman takes hormones the way her ovaries used to produce them, by taking estrogen the first two weeks of her cycle, and then estrogen along with progesterone the last two weeks, she will have a period again?

DR. SCHIFF:  Right, she will experience monthly withdrawal bleeding even though her body has no more eggs left and she can't get pregnant.

CBS Cares:  Will women who take hormones in this cycling manner also experience a return of premenstrual syndrome (PMS) symptoms?

DR. SCHIFF:  Yes, they will. I think there is no question that hormone therapy can reproduce premenstrual syndrome.  It appears that women who had PMS premenopausally and who are then given hormone therapy may have similar symptoms.  That is why some women cannot tolerate having progesterone at all.  When they take progesterone, they become irritable and may have fluid retention, difficulty sleeping and all the other symptoms we tend to associate with PMS. 

CBS Cares: What are your views on the theory that continuous combined hormone therapy, which simulates a permanent state of pregnancy, could lead to the same medical problems caused by continuous pregnancies (e.g. diabetes, insulin resistance, stroke, blood clots, etc.)?

DR. SCHIFF:  There is no evidence that continuous-combined therapy has more risks because it can create a pseudo-pregnancy state.

CBS Cares:  What exactly is the significance of the landmark Women's Health Initiative Study?

DR. SCHIFF:  The background for The Women's Health Initiative is as follows:  Estrogens were utilized in the 1960s for alleviation of symptoms.  In the 70s, we learned that estrogens used in unopposed fashion could cause endometrial cancer.  Thus, by the late 70s, we learned that if we added progesterone you did not have to worry about the development of endometrial cancer.  It prevented it. 

Then in the 80s, we learned that estrogens prevent osteoporosis.  A number of observational studies at that time started to suggest that estrogens might in fact even prevent heart disease.  We should keep in mind that the estrogens tended to be given to healthier women who sought out treatment because they were health-conscious, and they were started soon after menopause.  All the studies were on estrogens taken in a cyclic fashion, that is, estrogens alone or estrogens in combination with progesterone for about no more than two weeks out of the month. 

In the 1990s, there was an effort to have estrogens approved for the prevention of heart disease by the FDA.  The FDA initially said yes and then said no, and thus was born the Women's Health Initiative (WHI) of the National Institutes of Health (NIH) to answer the questions.  The Women's Health Initiative used two drugs to compare with placebo among its many arms.  For Prempro, there were few data even in observational studies that it was effective. The other drug was Premarin, for which there was observational data.   

The thrust behind the Women's Health Initiative was not to see if estrogens provide symptomatic relief—that was a given. There were so many observational studies in the early 90s about estrogens preventing Alzheimer’s and heart disease, etc., that investigators wanted to design a study to see if they could prove that estrogen prevents all of these chronic diseases. You want to study a population that is at risk for the disease you are trying to prevent. It is important to show that if many people are at risk, that the intervention can make a difference, and you have got to have enough participants for it to be statistically significant. In order to prevent these chronic diseases, they said, we don't want to study symptomatic women, because then the women who got estrogens will know they got estrogens because they will have relief from their symptoms (knowing whether they received estrogens or placebo could bias results). So they deliberately chose asymptomatic women, which automatically bumped the age up. Then you're going to see if you get placebo and there's no prevention, while if you get the active drug there is prevention. If that happens, you can easily show a positive effect while the opposite outcome would be a negative effect.

The study found that there was an increase in stroke and breast cancer with the Prempro (negative effect). The Women's Health Initiative is an important study in that thousands of women were evaluated in a very careful way.  The major problem with it is that the hormones used were not used in the traditional way that physicians prescribe them. They studied hormones on a preventative basis in a kind of paradigm where the hormones were not used before.

Thus, there are still questions as to whether if one starts hormones at a younger age, you would see more benefits.  At this point, it is not reasonable to take estrogens to prevent heart disease.  However, it is certainly reasonable to take hormones for alleviation of symptoms. 

With respect to the progesterone component, there was a thought that maybe it was the Provera in Prempro that led to the increased risk for breast cancer, which was not seen in the estrogen-only arm.  There are other studies with estrogen only that show an increased risk, but along with progesterone the risk may be even more.  I do not know whether it is the continuous combined hormones that cause all the problems.  Remember, we have very little observational data on continuous-combined.  In addition, the estrogen-only arm had better outcomes.  However, in the estrogen-only arm, the women may have had their ovaries removed and this may be an explanation for their decrease in risk. I fully agree that, again, if hormones are started at age 70, and the woman has not seen hormones for ten years, it can be harmful. 

CBS Cares: What follow-up studies are being done in light of the WHI study?

DR. SCHIFF: One of the most important ones is the Kronos Study. The lead doctor is S. Mitchell Harman, who used to be at the National Institute of Aging. As I mentioned, the WHI dealt with an older population, one in which we don't traditionally begin treatment. Women in their early 50s who just went through menopause are usually the ones who start taking hormones. So, this is one of the major criticisms of the WHI... that it dealt with an older population. The average woman in the study was actually in her early 60s. So, a follow-up study, not part of the WHI, is looking at younger women who go through menopause and then go on hormone therapy right away to see if it actually prevents heart disease.

CBS Cares: Is it going to explore the breast cancer risk as well?

DR. SCHIFF: Not as a primary motivation, because there may not be enough patients.  And in the WHI, they are still doing follow-ups on the patients, and there are other WHI studies just dealing with intervention such as diet, the outcomes of which we have not seen yet.

CBS Cares:  What are the short- and long-term benefits and risks of hormone therapy?

DR. SCHIFF:  Short-term benefits are alleviation of symptoms and then prevention of osteoporosis. The risks of hormone therapy are stroke, heart disease, phlebitis and breast cancer.

CBS Cares:  There seems to be a lot of confusion about the risks of hormone therapy.  Can you clarify the situation for women visiting this website?

DR. SCHIFF:  The risks of hormone therapy are complex.  Estrogen increases the risk for endometrial cancer, but adding progesterone is thought to protect against this type of cancer. This is why, as I've already touched on, Prempro is prescribed for women with an intact uterus, while Premarin may be prescribed for women who have had hysterectomies.  It is thought that the longer you remain on hormone or estrogen therapy, the higher the risks for breast cancer. They also increase the risk for stroke, as well as venous thromboembolic phenomenon. This refers to an increased tendency to develop clots in the vascular system, which can lead to heart attack, stroke or phlebitis.  The major risks appear to be estrogen related.  As always, it is important to discuss the benefits and risks with your physician.

CBS Cares:  Is there anything that can be done to decrease these risks?  How long is it safe for women to remain on these therapies?

DR. SCHIFF:  Ideally, the lowest possible dose of estrogen should be used for the shortest possible period of time.  It's thought that the longer you remain on hormone or estrogen therapy, the higher the risks.  Each year, I ask the patient if she wants to continue on hormone therapy and I describe the benefits and risks. If she is not committed to hormone therapy, I might suggest that we stop and see how she does. 

The health risks probably start to go up in as soon as two to three years.  But the moment you stop the hormones, the risks go away soon after.  For symptomatic relief, a patient may remain on hormone therapy or estrogen therapy for as long as she needs to, as long as she understands the risks. What we need to do is get better at finding out who is at increased risk when they take hormones.

CBS Cares: Is it fair to say that, paradoxically, estrogen taken early upon onset of menopause may be protective against Alzheimer's, whereas taken much later may cause the death of brain cells?

DR. SCHIFF: Yes, that is precisely the concern with Alzheimer's disease: On the one hand, some observational studies suggest that estrogens prevent Alzheimer's disease in women who start estrogens soon into menopause.  And, there are other studies that have shown that women who have surgical menopause and are given estrogens immediately might have better results on a test for recall of numbers.  But on the other hand, it's thought that when you start hormones later in life, as was the case in the WHI, there is already disease in the blood vessels and this creates a hypercoagulable state where you are prone to little clots or strokes. 

CBS Cares: Would that mean that even women without symptoms might benefit by taking low doses of estrogens early on?

DR. SCHIFF: Yes.

CBS Cares: At this time, would you recommend HT or ET for menopausal women without symptoms to protect against Alzheimer's and osteoporosis?

DR. SCHIFF: There is not enough data to recommend it for prevention of Alzheimer’s disease but it can be used for osteoporosis if the patient understands that benefit: risk profile and she has been made aware of other agents available for her.

CBS Cares:  Does estrogen therapy increase the risk of developing breast cancer or does it essentially accelerate a pre-existing cancer? 

DR. SCHIFF:  There is ample evidence to support the conclusions that women who take hormone therapy are more likely to develop breast cancer than women who do not.  Whether it accelerates an existing cancer or causes development of a new cancer, is not known. 

The size of the increase per year of hormone use is the same as that associated with delayed menopause (meaning that women were exposed to their own estrogen longer than those who went through menopause earlier) by year.  Based on a meta-analysis of 51 studies as well as the WHI, there would be 20 extra cases per 10,000 women after taking hormone therapy for five years, 60 cases after ten years and 120 after 15 years of use.  As I mentioned before, once hormones are stopped, the risk disappears. 

Hormone therapy does increase the incidence of breast cancer with the best evidence for estrogen plus progestin.  Although observational studies suggest a small increase in breast cancer risk for women with hysterectomies taking unopposed estrogen, the WHI study did not.  Keep in mind that the WHI was a randomized trial. They looked at all the aspects. In other words, the WHI women who got placebo versus women who got the hormone intervention, at baseline, had the same risk factors. There were no differences, and that's one of the advantages of the WHI.  When you deal with thousands of patients and you randomize them, essentially the risk factors will be the same for the intervention group as for the women who receive the placebo. I was not surprised by the Prempro data because I think this was known for some time.  The Nurses Health Study over ten years ago suggested an increased risk with Premarin only. 

CBS Cares:  Some recent studies suggest that progesterone may be the culprit in accelerating breast cancer, not estrogen.  What are your comments about those studies?

DR. SCHIFF:  While it's starting to look more and more like the progesterone component could be a culprit, there are still enough studies out there involving the use of estrogen only that show it can increase breast cancer risk, at least when used for an extended time. 

Women who take estrogen alone have had hysterectomies, which means that usually (not always) their ovaries were removed. That, in and of itself, may alter a woman's risk for breast cancer, because her exposure to estrogen has been reduced.  So I wouldn't remove the progesterone component of hormone therapy in women who have a uterus.  It does protect against endometrial cancer.

CBS Cares: So, both estrogen and progesterone may increase breast cancer risks to some extent?

DR. SCHIFF: Progesterone may increase it even further, but I don't think we should say it is all progesterone. However, there are many excellent studies where there is no increased risk of breast cancer with estrogen. So, it is not like cigarette smoking, where the data show that if you smoke, you are at a marked increased risk for lung cancer. It's not as dramatic as that, but the change is big enough that we can say there is a small increased risk of breast cancer with the use of estrogen.

CBS Cares:  Can someone who has had a hysterectomy and is taking only estrogen remain on estrogen therapy for life?

DR. SCHIFF:  Yes, as long as they're aware of the potential risks. We do not know how long the safety window is. It depends on which study you use to answer the question. Thus, it is important to be familiar with all of the studies and to say that the data about the five years came from the Nurses Health Study. The WHI did not have the same findings.  So, we try to do our best for our patients by describing the various studies and pointing out which one may be the most relevant for the individual woman.

CBS Cares: Does it concern you that, as we speak, women are still ingesting or absorbing synthetic or natural hormones without any definitive idea of just how safe and effective they are?

DR. SCHIFF: Well, any time I prescribe anything I worry about it. All drugs have side effects and risks. If I prescribe penicillin for a patient, I hope they don't have a penicillin reaction, which may have serious consequences. With any medication you prescribe as a physician or health care provider, you have to wonder, what is it going to do to the patient? If someone takes a lot of acetaminophen, you have to wonder what it's doing to their liver. If they take aspirin or ibuprofen for joint pain, are they going to bleed from an ulcer in their stomach? You worry about everything when you prescribe a medication including, of course, whether it is going to be effective for the indication you have selected.

Along those lines, in terms of estrogen, it's is a very high profile medication. Any risks get a lot of publicity, but there are infinitely more drugs that have significantly more dangers involved. This is a very emotional agent and I share all of the benefits and risks with the patient, but frankly, I prescribe a lot of estrogen and I make it very clear to my patients what the risks are.

Now, of course, I see a self-selected group of women who want to see me because they want me to prescribe the hormones for them. But I have never been on the estrogen bandwagon in the sense of aggressively prescribing it. Even in the late 80's and early 90's, before the WHI data came out, I always believed that the data to suggest that estrogen prevents heart disease was way over done. I used to say in my lectures that the suggested benefits to the heart are exaggerated and we have better agents to prevent heart disease, like the statins, to lower cholesterol.

So, I've never been a strong proponent of hormone therapy, but I've prescribed a lot of it and I can tell you that, when I prescribe it, I worry about breast cancer and blood clots. But there are other drugs that I've prescribed that I've worried about a lot more.

CBS Cares: Do you think that some women and even some doctors may have overreacted to the results of the WHI study, or are the risks such that women should try to avoid these hormones if possible?

DR. SCHIFF:  If a woman has no contraindications and she's having bad hot flashes, and/or sexual symptoms, she should try to relieve those symptoms to improve her quality of life.  Hormones can relieve these symptoms.  But women see a newspaper with a screaming headline, "Women who take hormones have a 33 percent increased risk for breast cancer," and they decide to stay away from hormones, and continue to suffer.

The average listener, viewer or reader will assume that if they take hormones, they have a 33 percent chance of getting breast cancer.  That's not the case. The reality is that, if you took 1,200 women aged 55 to 59, not on hormones, in the next 12 months, three out of 1,200 will get breast cancer.  If they were on hormones for more than five years, four out of 1,200 will get breast cancer.

When you go from three women in 1,200 getting breast cancer to four in 1,200, that's a 33 percent increase. So, the increased risk is there and needs to be disclosed to women. But the degree of risk is more easily understood when stated as the number of women likely to get breast cancer rather than as a high percentage that can easily be misinterpreted.

CBS Cares:  Prempro seems like an important drug, but it was developed 10 years ago and Premarin 50 years before that.  Have there been more recent breakthroughs in the development of new hormonal drugs?

DR. SCHIFF:  There has been. In my view, one of the major breakthroughs over the past twenty years has been the estrogen transdermal approach. I think the estrogen skin patch delivers estrogen in really the most physiologically similar form to how they would naturally be in the woman's body.  It's important to mention because it could be helpful for women if they have some kind of liver problem, or maybe a history of phlebitis, but again you still have to be careful in this situation.  And the main point is for the woman who theoretically believes she would like to have exactly what her ovaries made and to get it into her body that way, the patch or a cream is the simplest way to do so. 

CBS Cares: The transdermal patch seems like an important new method of delivering a prior drug.  But, are there any chemically new hormonal drugs that have been approved or look promising?

DR. SCHIFF:  Yes, there is a drug called Tibolone, which is not available yet in the United States, but is used in Europe, and is thought to have estrogen components and testosterone components and progesterone components all at once. It is said to help with hot flashes, to help with sex drive, to help with moods—really, to help with everything. But it is still not approved in the United States because it lowers HDL, which is the good cholesterol, and we worry ultimately about heart disease. The other concern about Tibolone is, in the Million Women's Study in the UK, it actually showed an increase in the risk of breast cancer.

CBS Cares:  What's the difference between "bio-identical hormone therapy" and conventional hormone or estrogen therapy?

DR. SCHIFF:  Bio-identical or natural hormone therapy is used to describe hormone treatment with individually compounded recipes of certain steroids in various doses. And, they are the ones occurring naturally in women and thus do not refer to phytoestrogens.  

The word "natural" implies that the substance is somehow safe and more effective than synthetic hormones, but what exactly is a natural hormone?  When administered orally, some of these natural hormones are altered in the gut.  If one wants the ideal hormone and to use what the body used to make, then one would consider using estradiol and avoid the gut by using it in either a patch or a cream. 

CBS Cares: What is the difference between FDA-approved bio-identical estradiol and prometrium (bio-identical progesterone), and the bio-identical estradiol and progesterone, respectively, that are developed by compounding pharmacies?

DR. SCHIFF: Well, estradiol is estradiol, whether it's made by a compounding pharmacy or a pharmaceutical company.  However, because bio-identical hormone prescriptions filled by compounding pharmacies are customized to individual patients' needs, there's not a consistency to the dosing.  While there are the Professional State Boards of Pharmacy and an International Academy of Compounding Pharmacists, the FDA is not involved in approving hormones synthesized by compounding pharmacies.

By contrast, the FDA has a much tighter control over the hormones in drugs that it approves. When you're getting a dose of an FDA-approved drug, you know it's got that exact amount.  With hormones made by a compounding pharmacy, on the other hand, there may not be the same stringent controls as are applied to drugs, and you don't know exactly what a compounding pharmacy is doing.  There have been studies that look at concentrations of hormones from different compounding pharmacies, with very different

results.

CBS Cares:  Are bio-identical hormones as effective as conventional hormones, and are they as safe or safer? 

DR. SCHIFF:  There is some anecdotal evidence suggesting efficacy, and there are women on bio-identicals who say that their symptoms have improved. But there's no scientific evidence that they're as safe, safer or as effective.  They just haven't been scientifically tested. Most of our current evidence-based knowledge of hormone therapy have been obtained with Premarin because it has been around the longest, or estradiol valerate, a different form of estrogen used in Europe and not available in the United States. 

While it does make sense that something bio-identical could be safer, a lack of controlled clinical trials, and the label "natural" cannot and must not be interpreted as evidence of its safety.  So, it appears that there is no proven advantage over conventional hormone therapy. 

CBS Cares:  Are there any advantages to taking a synthetic hormone versus a "natural" one?

DR. SCHIFF:  The most common synthetic estrogen is ethinyl estradiol, which is predominantly in the birth control pill.  Remember, estradiol, the natural hormone the ovary makes, gets converted to estrone when taken by mouth.  Not only that, but it leaves the system very quickly.  For a birth control pill, you want something that is going to last at least 24 hours until one takes the next pill, or else it's not going to function very well as a contraceptive.  And so if you add an ethinyl group, which is a kind of chemical, onto the estradiol, it prevents the liver from breaking it down rapidly.  And it persists in the body for some period of time.

The physician would usually prescribe conventional hormone therapy because we know more about conventional hormone therapy.  It's measured.  As we've discussed, we have no data to say bio-identical therapy is safer or effective.  So why not use the thing that we have the most information about?

CBS Cares:  Is prescribing bio-identical hormones a reasonable thing for some doctors to do?

DR. SCHIFF:  Oh, sure.  Prescribing bio-identical hormone therapy is not bad medicine.  These doctors are thinking theoretically that they're using the most natural form of hormones and that they may present a lower risk than conventional hormones.  They measure hormone levels in the blood to see what's too low or too high, and then prescribe doses that correlate to the "correct" hormone levels.  The main reason for taking hormones is symptom relief, so you want to make sure your individual "correct" levels provide enough hormones to feel better. There is no “correct” blood level. The lowest dose that relieves symptoms is appropriate.  

CBS Cares: What would you say to a woman who believes bio-identical hormones have lower risks than conventional hormones?

DR. SCHIFF:  I'd say to her that women who go through a later menopause and/or start having periods at an earlier age, and are therefore exposed to estrogen longer, have an increased risk for breast cancer. This is true even though the estrogen they're exposed to is the natural form, made by their own bodies. In fact, for every year that a woman continues to have periods, her risk for breast cancer continues to go up just as much as if she takes hormone therapy.

The point about bio-identicals is that theoretically, they are what the body made, but just because the body made it doesn't mean it's safe. So the idea that bio-identicals are better or safer is mostly theoretical since there are no scientific studies to prove safety or effectiveness. I think it's a fallacy to assume that a particular hormone is safer or riskier than the others. And the Million Women study showed that whatever hormone you were using, the risk for breast cancer went up. 

CBS Cares:  Why haven't bio-identical hormones been scientifically tested?

DR. SCHIFF:  They haven't been tested, because they cannot be patented and there's therefore no financial incentive for drug companies to incur the expenses in testing them.  The reason that bio-identical hormones cannot be patented is because they occur naturally and don't contain any patentable synthetic components.

The compounding pharmacies are all sort of independent and fragmented and they don't have the financial resources to prove or disprove efficacy or safety either way.

The FDA has approved bio-identicals—the estrogen skin patch with estradiol, oral estradiol, oral micronized progesterone, progesterone as a suppository. These are indeed bio-identicals.

CBS Cares: Is any research institution or government agency such as the NIH doing or considering doing a scientific study of bio-identical hormones?

DR. SCHIFF: Not that I'm aware of.

CBS Cares: Why is a clinical study on bio-identicals not considered necessary right now?

DR. SCHIFF: I think there has been enough comparative study to suggest that just because you're using the same estrogen that the ovary used to make, it shouldn't be any safer. I gave you some anecdotes: if you remove the ovaries of a woman who is at risk for breast cancer, her risk goes down. If she has a late menopause and she's making her very own hormones, her risk for breast cancer goes up. So, there's no reason to think that using a bio-identical hormone will decrease the risk.

If you follow the breast cancer literature, the newest form of treatment are drugs that interfere with the ability of the body to even make estrogens when the ovaries are removed. These drugs are believed to reduce the recurrence of breast cancer. So, a lot of what we know shows that you're trying to reduce the body's own ability to make estrogen, so why would you think that using something the body used to make would be safer and not increase that risk? Usually when you do a study you want to do good and you feel like it's going to make a major difference in the outcome.

CBS Cares: Do environmental factors affect menopausal symptoms?

DR. SCHIFF: There could be a lot of environmental factors as well. For example, Japanese women in Japan rarely get breast cancer until they immigrate to the United States.

CBS Cares: This question is for the men who are reading this interview or the women who care about them: is there a male equivalent of menopause?! How do men lose hormones as they age, compared to the way women lose hormones?

DR. SCHIFF: In women, menopause is a pretty abrupt event. She's having periods, her ovaries have eggs, and theoretically she can get pregnant any month that she matures an egg. Then it changes very quickly and the hormone levels decline very abruptly. A man, in contrast, could father a child in his eighties, because he is constantly producing sperm albeit not as much as when he was younger. So, "male menopause," or andropause, is not a comparable thing to menopause. Having said that, men are not spared the ravages of time: there is a decline in testosterone levels over time in men and some men may need testosterone therapy if their testosterone levels are consistently below normal. Andropause, however, has not been studied as well as menopause in women.

CBS Cares: What studies are not being done or contemplated which, in light of the findings by the WHI, you think are important?

DR. SCHIFF: Well, I think it's very important to answer the question of why the observational studies suggest a benefit in certain conditions, such as preventing Alzheimer's disease, if women start hormones soon into menopause. The problem with the observational studies is that they are not randomized. A woman goes to her doctor and says, "I have hot flashes," and some get treated and some don't. We are concerned that there may be a healthy user effect and you end up with a self-fulfilling prophecy. The healthiest patients get hormones and thus are most likely to do best. The other question is, who are the women who go to get treated? In the past, the women who go to get treated tend to be wealthier, better educated, and exercise more compared with the women who don't take hormones. So, that was the criticism of the observational studies.

CBS Cares: What study is Harvard contemplating now or doing as it relates to hormone therapy?

DR. SCHIFF: Well, many. There's the Nurses Health Study, which has been following nurses for over 25 years and learning more about estrogens and heart disease. It is trying to tease out why the observational studies show a benefit and the intervention trials don't. There is a study looking for alternative agents such as a selective estrogen receptor modulator, which is like an estrogen in some tissues and an anti-estrogen in other tissues.  Another investigator at Harvard, Dr. Joanne Manson, is involved in the Kronos study on heart disease, which we discussed earlier. There is a major study on the effects of testosterone on sexuality. So, there are many studies still being followed through.

CBS Cares:  What made you decide to go to medical school, and specifically become a gynecologist?

DR. SCHIFF: I went to medical school to become a psychiatrist, and while in medical school, I became a little disillusioned with psychiatry, but I still thought of pursuing it. I did 18 months of residency in Internal Medicine to provide me with more background. My worst fear was that I would be treating a person for depression when in reality perhaps their problem was abnormal thyroid function.  I then realized how much I was interested in women's health issues and thus completed a residency in Obstetrics and Gynecology and a Fellowship in Reproductive Endocrinology.  I tried to combine all that I learned in Internal Medicine, OB/GYN and Reproductive Endocrinology to help women pass through menopause.  

 

 

Interview with Dr. Bernadine Healy:  Physician, Cardiologist, Professor, former Director of the Institutes of Health and former president of the American Red Cross.

CBS CARES: Why do women have such different experiences with menopause?

Dr. Bernadine Healy: Each woman may experience it in different ways because their circulating hormones trail off at different rates.

CBS CARES: Are hormones still produced after menopause, even when the ovaries stop producing them?

Dr. Bernadine Healy: Yes. Natural hormones are still produced by their bodies outside the ovary by fat cells and adrenal glands. So, before a woman can even think about hormone therapy, the woman has to know how much circulating hormones she already has. There is a big variability there from woman to woman. Women who have more fat on their body versus those who have less fat are more apt to produce more natural circulating estrogen. That partly explains why some women have more symptoms during menopause while others go through menopause without any symptoms whatsoever.

CBS CARES: Are symptoms like mood swings or cognitive problems physiologically based, or are they side effects of poor sleep due to hot flashes and related night sweats?

Dr. Bernadine Healy: Well, first of all, there is huge variability among women. If you look at one study like the Women's Health Initiative's randomized group and the quality of life analysis, women who were neutral about hormone therapy when they went in claimed absolutely no difference in the quality of life on or off hormones. On the other hand, women who will not give up their hormones are women who will see that when they stop their hormones, they'll have mood swings or cognitive problems.

Having said that, there have been several studies that looked at mood swings or cognitive issues on the same woman on and off hormones. And what these studies have shown is that there is a direct cognitive effect. And some have said it's mainly due to problems sleeping. There's no question that the sleep problem is a real problem. I think the sleep, the hot flushes, the cognitive, and the mood issues are all things that may or may not be related. I've spoken to many women who have said after going off hormones they decided to go back on for mood reasons. These are pretty normal women. They just felt that emotionally they need to be back on it.

This is the situation where a woman can use her own body. You're not going to harm yourself by taking medication under a doctor's prescription.  See if it improves your sleep or not if that seems to be a major problem.

CBS CARES: What do you think of the use of  non-hormonal treatments, such as the SSRI class of antidepressants, to treat menopausal symptoms?

Dr. Bernadine Healy: I don't think it's very important to push SSRI'S as a treatment. I don't know that an anti-depressant is something that's beneficial during this period of hot flashes and mood swings. It's certainly not for all women.

CBS CARES: But it could be beneficial to some women?

Dr. Bernadine Healy:  Yes

CBS CARES: What about sleeping pills if a woman's main menopausal problem is with sleeping?

Dr. Bernadine Healy: Occasionally, maybe, but sleeping pills have side effects that I think are probably troublesome in and of themselves. Usually, sleep problems will go away over time. We know that as men and women age, their sleeping patterns change anyway. Their biological clock shifts. This is why they tend to get up earlier in the mornings naturally but teenagers can sleep through the alarm clock.

CBS CARES: Who should consider hormone therapy?

Dr. Bernadine Healy: It varies depending on the symptoms. The most troublesome symptoms are those that relate to the brain and cause sleeping problems and hot flushes or hot flashes, which can be incapacitating. Some women also have cognitive problems like short-term memory issues. It's variable. In certain subsets of women who have severe menopausal symptoms, hormone therapy can be very effective.

CBS CARES: Is there a movement toward using hormones that are closer to what a woman naturally produces before menopause?

Dr. Bernadine Healy: It's certainly my bias, and I think there is a growing bias, that the more the hormones are biologically similar to what a woman has naturally, the more sense it makes.

CBS CARES: But Premarin, Prempro and other so-called synthetic hormone treatments, continue to be the gold standard of hormone treatment?

Dr. Bernadine Healy: Premarin is really a mixture of various hormones, mostly estrogens. I think there are a couple of reasons it continues to be used. First of all, it's the most widely used hormone treatment over the past 50 years, and therefore is believed to be safe and effective. It's also inexpensive.

CBS CARES: When you headed the National Institutes of Health, you initiated the landmark Women's Health Initiative ("WHI") Study?

Dr. Bernadine Healy: Yes

CBS CARES:  What did the WHI study involve? 

Dr. Bernadine Healy: The Women's Health Initiative (WHI) of the National Institutes of Health was the first controlled study of any hormone therapy. That's the study I started. All of the data up until then was based mostly on observational studies. And those studies tended to include mostly the self-selective population. The NIH decided to first study the most commonly used estrogen. At the time it was a combination of Premarin, and for women who had intact uteruses, a combination of estrogen and progesterone in a low dose, which was Prempro.

CBS CARES: What was the profile of women who were part of the WHI study and what were the findings?

Dr. Bernadine Healy: The Women's Health Initiative included over 150,000 women in a controlled trial and an observational trial. The controlled trial included a population of women in their sixties and seventies who had not seen a hormone in years, and were now being put on hormone therapy. These women, who were in the part of the trial where it is a flip of the coin as to whether or not they would be in the group receiving hormones, were women who were completely indifferent to taking hormones. If they were on it, they really didn't care whether they were on it or not. That group also included women who had never had hormone therapy.

When women over the age of 50 were given hormones without any screening to determine if they actually needed hormone therapy, but instead as a sort of universal magic pill, it flunked. It didn't flunk in a major way, but a minor way, showing a slight increase in the number of strokes and heart attacks in a few per thousand. It also showed benefit to the bone. And, as expected, it showed a reduction in the incidence of colon cancer, but an increased risk of breast cancer after roughly five years of being on hormone therapy.

CBS Cares: What about the observational trial?

Dr. Bernadine Healy: Of the over 150,000 women, almost 100,000 of those women are women who were part of what I called the Framingham Study for Women. In this study the women signed up and followed up with regular blood testing that was set aside for all sorts of analyses including genetic studies.  They also filled out questionnaires. The observational trial women were the women who said, "I will not give up my hormones." They wanted to be part of the Women's Health Initiative but they didn't want to go into a trial in which they had a 50 percent chance of not having their hormones. The observational side of the study showed that the women on estrogen had less cardiovascular disease, which is consistent with earlier observational studies.

So, you can argue that they needed different groups of women, and maybe not  women whose own natural biological assay was believed to be physiologically better because they are the ones who also happen to have healthier lifestyles and are more health conscious. It could be the hormone therapy, but it might not be. What this means is that it could be a healthy user effect, meaning that the women on hormone therapy tend to have healthier lifestyles to begin with. I mean, they watch their weight, their diets, and in general are more health-conscious, and therefore they do very well cardiovascular wise. But it's not necessarily the hormones that are doing it, it's just their healthy lifestyles and they tend not to have any risks related to hormones.

CBS CARES: Or, it could be the hormones?

Dr. Bernadine Healy: Or, it could be there's a benefit to the hormones because those women are estrogen deprived or they are more estrogen deprived than other women who were indifferent about the hormones.

CBS CARES:  What can we learn from the study?

Dr. Bernadine Healy: What it showed was that hormone therapy is not for everyone. There was a presumed benefit on the heart, because in observational data, where you compared groups of women who were on hormone therapy to women who were not, the women who were on it had a much better outcome. All of the prevailing information at that time pointed in the direction of a very strong benefit to the heart as well as symptomatic relief. And, there was also a benefit to the bones, and the F.D.A. approved estrogen for the prevention of osteoporosis.

So, for the first time it was tested as it was being used, and it failed. But where it failed is that it was not a medicine for all. There's no universal magic bullet. Every drug comes with side effects. Skill and wisdom of benefit is required to decide what medicine is right for which patient.

But that was tossed out the window when people began to overreact and say, "Gee, hormone therapy is bad for every woman." In fact, estrogen is appropriate for some women. But now we're in a position, which is more difficult, because unfortunately the interpretation by some physicians and some people in the media has been that estrogen is for no women, and is somehow this horrible, dangerous medicine. So you go from one inappropriate extreme to the other.

CBS CARES: What is your opinion of recent studies suggesting that progesterone may be a catalyst to breast cancer?

Dr. Bernadine Healy: There are some studies that used a particular formulation of progesterone, given in a continuous low dose characteristic of Prempro. These formulations have specifically been the agent that accelerated the development of breast cancer. This is the biggest concern. The reason the WHI study was stopped prematurely in 2002 was because, there was a difference in breast cancer—not quite significant—but a difference in cancer risk between the women who had hysterectomies and received only estrogen verses the women who still had their uteruses and received both estrogen and progesterone in the widely used drug, Prempro. The latter women, who received Prempro, had a slightly increased risk of breast cancer.

CBS CARES: Is there a safe window within which to use synthetic hormone therapy?

Dr. Bernadine Healy: Oh, you know, everybody says to take it for the short term. Take it for the two years-period-when you're having symptoms. But the highest risk for heart attack and stroke is in that two year window, although it's one per thousand. So I've never quite understood that philosophy.

We need to get back to the question of the individual woman. I think that she has to look into her own health and symptoms. If she's having terrible menopausal symptoms and she wants to go on hormones and her doctor will work with her, she can do it, but she does have to realize that during the first two years she is on hormone therapy, there is a very slight increased risk of having a heart attack or stroke. We're talking about around one per thousand, but that is something she has to recognize.

CBS CARES:  But, if a woman takes steps to reduce the heart attack risk in this two year window, couldn't that further increase the stroke risk? For example, a lot of people take high doses of fish oil and/or low doses of aspirin to reduce their risk of a heart attack, but don't these thin the blood and increase the risk of a brain hemorrhage or stroke?

Dr. Bernadine Healy: You just pointed out something that's really, really important. There's a tendency to look at any of these drugs all by themselves. But you have to look at them interacting with other things. In fact, if you're taking low dose aspirin, and then you're also taking fish oil, and Vitamin E, because you're interested in the cardiovascular benefits of fish oil and Vitamin E, you have definitely increased the chance of having a hemorrhagic stroke. That is why I say it all has to be individualized. 

CBS CARES: How have the findings of the Women's Health Initiative changed the way women and physicians think about hormone therapy?

Dr. Bernadine Healy: Well, first of all, we were in this sort of very simple rosy world in which hormone therapy was perfect for everyone. It had been felt that there were almost no risks except if you had breast cancer. If you were going to get mammograms every year, there was a low risk. It was a very simplistic approach.

I think that we tend to suffer from trying to oversimplify both our bodies' chemistry, of which hormones are one part, as well as what we put in our mouths or on our skin. You know, hormones are powerful agents that affect various parts of our bodies. There are hormone receptors for estrogen on your brain, on your heart, in your knuckles, skin, your uterus, and ovaries. To think that hormone therapy is all good or all bad is a wrong perception that I think is, unfortunately, continuing.

CBS CARES: Have the drugs themselves changed or evolved in say the past decade?

Dr. Bernadine Healy:  What's happening now is that there's variability among hormone therapy preparations. It's not just a question of formulations, but whether it's natural progesterone or a natural estrogen. Also as important is whether you take it orally or transdermally. If you take hormones orally, you tend to get a very, very high level initially. There's a lot of processing that goes on in the liver. If you take hormones transdermally, you tend to get a continuous, more physiologically normal level of hormones without stressing the liver.

CBS CARES: So when hormones are absorbed transdermally, such as through a skin patch or cream applied to the skin, they are closer to what the body would have naturally produced?

Dr. Bernadine Healy: Yes, it's a more natural preparation and you don't get the stress on the liver. And so, I think that those need to be studied more.

CBS CARES: What about bio-identicals? Are you a proponent of them?

Dr. Bernadine Healy: I think that the more you can take something, which is bio-identical, the better. It makes a lot of sense. Now, what is the negative side? There has not been a controlled study of the different hormone preparations-both the bio-identical versus something like Premarin, which is the old mainstay, or transdermal versus oral preparations. We just don't have that kind of information. And quite honestly, they should be done very soon.

CBS CARES: Who should be doing these tests?

Dr. Bernadine Healy: I think it should be the NIH

CBS CARES: Why have controlled studies of natural hormones not been done when there seems to be much at stake for women's health?

Dr. Bernadine Healy: It's simple. They're hard to do. They're expensive. And it's a question of priorities. The Women's Health Initiative was never done before 1991 because some people thought it was too expensive. It was almost a billion dollars over 15 years. I don't happen to think that's expensive. When you look at it over 15 years, the NIH has a 30 billion dollar budget. But it has to be a high priority. You have to have an agency like NIH involved and at least partly supporting it to get it going. Comparing synthetics vs. bio-identicals is not a high priority. I think it is part of a neglect of women's health research.

And by the way, this is not just a woman's issue. We're seeing a really big increase of men taking testosterone. I think that as men live longer, the number of men taking hormones is going to continue to grow. Testosterone is thought to produce benefits in men, like cognitive benefits, mood benefits including less depression as men get older, and musculoskeletal benefits. So before we get carried away with testosterone patches for men, we ought to be doing that study as well.

CBS CARES: If there have been no scientific studies of natural, bio- identical hormones, on what basis do some doctors say that are safe and effective...or at least, safer and more effective than synthetic hormones?

Dr. Bernadine Healy: I don't have the answer. But, it's probably their assumption that natural is better. I think one of the problems with some of the bio-identicals is that you're not quite sure about the dose. Even with something like soy, we don't know what impact soy estrogen has on the uterus, how long to take it, and how much. There has been no long-term study on the taking of soy and how much soy could actually get you into potentially negative territory.

CBS CARES: Do the levels of estrogen and progesterone in blood correlate to safety and efficacy of hormone therapy?

Dr. Bernadine Healy: The problem is that blood tests don't always tell you what's happening at the organ site, because a lot of the conversions of bio-active estrogen happens in the organ, for example, in the brain. So what's circulating in the blood is not always representative of what's going on in the organs.

So, if you look at the medical literature, you'll find that there really isn't much information correlating the level of hormones in the blood with, for example, something like the development of breast cancer. That is because that correlation hasn't always been done. But, secondly, when it has been done, it hasn't been conclusive, unlike cholesterol, which studies show is always associated with negative effects at certain levels.

CBS CARES: Are there any uniform standards that guide physicians who recommend or prescribe bio-identical hormones?

Dr. Bernadine Healy: There really isn't much clinical guidance for physicians. I mean, it doesn't exist. I think that's one of the unfortunate dilemmas today, that doctors don't have that guidance. Instead, it's a little bit of trial and error for an individual woman. One cannot diminish the importance of the woman's own analysis of this.

The internet has made a lot of information readily available. I think that individual women are going to have to be part of the decision of whether or not they wish to take hormone therapy, and if so, what they want to try.  A woman could try one and she may not like it. We're not talking about an irreversible decision, which I think is another important thing to remember.

CBS CARES: It seems that, until more studies are done to resolve some lingering issues, some points will remain open to debate. But, are there any clear cut answers right now?

Dr. Bernadine Healy: Yes, there are some clear-cut answers. I think if you're a woman over the age of 60 and you went through menopause without any problems, didn't use any hormones and you feel perfectly fine, stay away from hormones. Don't let any doctor talk you into taking them, period. And if there are issues about bone loss and osteoporosis, for which estrogen might be useful, there are alternatives.

As I mentioned earlier, women are not all the same. What is a beneficial medicine in one woman could be either neutral or even harmful in another. Take a woman who has a very strong family history of osteoporosis. She and her doctor might look very differently at hormone therapy than someone who has a very strong family history of breast cancer.

CBS CARES: Do you anticipate, in the foreseeable future, any more studies being done on hormone therapy?

Dr. Bernadine Healy: They'll only be done if women continue to put pressure on the NIH and CDC. These are not strictly pharmaceutical studies, so NIH and CDC need to drive these studies.

CBS CARES: If NIH or CDC were to undertake these studies, which ones do you think are the priorities?

Dr. Bernadine Healy:  The study that absolutely must be done, should have been started right after the Women's Health Initiative came out with its findings, and should be started tomorrow is a comparison of the different hormone formulations. In other words studying Premarin as well as plant formulations, looking at oral versus transdermal, natural versus synthetics, etcetera. Remember that even natural hormones like estradiol are different from the phytoestrogens you'll find in soy/plants like wild yams. And then you also need to look at dosages. There needs to be some science placed into the area of natural hormones, which has not been done.

CBS CARES: Do homeopathic and other alternative therapies have potential?

Dr. Bernadine Healy:  Yes, they should definitely be explored and tested. I have to give Senator Harkins credit for his idea to look at alternative therapies to see if they provided any kind of benefit or even sometimes caused harm. A lot of the multivitamins and therapies like acupuncture fell into that class. Senator Harkins kept putting pressure on NIH and started an office of alternative therapy that's now grown into a center for alternative therapy. It has a modest budget. But that should really be the place where research is done on some of these promising but still not very well understood treatments out there. If people are consuming lots of soy with the hope of helping their health, or taking these over-the-counter hormones, or raiding the shelves of nutraceutical shops, it seems that we have an obligation to research those treatments, which have every bit as much impact on people's lives and well-being as an approved drug from the FDA.

CBS CARES: What is the most important thing that you want women and the men who care about them to take away from this interview?

Dr. Bernadine Healy: That medicine must be personal. This makes it harder for women, but this is also reality based. Women have to understand that their health and well-being is affected and determined by personal choices. That includes personal medical choices. There's not one medication or one practice that suits all. Women are not all albino rats from the same litter reacting predictably to the same medications.

Rather than being discouraged, women should be liberated by the fact that they are not all the same. It's more complicated, but it's real.

CBS CARES: What should a woman look for in choosing a doctor to help her through menopause and post menopause?

I think it's important to get a doctor who is going to spend time with a woman to inform her and answer all her questions. And someone who is open-minded about these issues. The individual doctor needs to deal with the patient as an individual. Don't choose a doctor because you say, oh this is a doctor who loves hormones, or this is a doctor who likes the natural stuff, or this is a doctor who won't even consider a pharmaceutical product. Open-minded doctors who will treat patients as individuals are out there in your community, but you might have to go through a little trial and error in asking around to find such a person.

 

 

Interview with Dr. Uzzi Reiss:  Beverly Hills gynecologist, obstetrician and specialist in Anti-Aging Medicine

CBS Cares: What would you say to doctors and scientists out there who might say to you, "There's no scientific proof of the efficacy or safety of bio-identical hormone therapy"? Why do you, and many other doctors, prescribe them even though they have yet to be scientifically tested?

Dr. Uzzi Reiss: You don't need any tests. It's biochemistry. We have three estrogens in our bodies: one called estradiol, one called estrone and one called estriol. And we have progesterone.

What you're asking me about right now is the most tragic event. You have to prove your viability. I have to prove that my own body is functioning normally. Do you understand? I don't have to prove anymore that birth control pills are safe and effective. I don't have to prove anymore that I could take two drugs that will work better than our own hormones. Why do we need to prove it? I'll tell you why.

Remember, pregnancy is the most protective moment in the cycle of livelihood of a mammal, okay? During pregnancy, one estrogen goes up a thousand times. The two other estrogens go up ten times. Progesterone goes up a hundred times. With each full term pregnancy, there's a seven percent less risk of breast cancer. I want to see one drug you can increase by as much as those hormones go up during pregnancy and the person will stay alive. And not only stay alive, but they'll live better.

Now, here's another way to look at it. Do you know anybody who reaches menopause and says that her life has improved so significantly because all those horrible hormones have left her body? I see women who at this stage of life are starting to lose the fruits of all the hard work they put into their social advancement. I see women from all classes, women who run huge corporations of 20,000 people and are totally falling apart because their estrogen has been taken away from them. Because they are told that their own hormones are bad for them. And they have a choice to either be drugged and be totally dysfunctional and numb, or to be depressed, foggy, uninspired, not social, angry, unable to sleep, and lose their sensuality and sexuality, and start to gain weight like a balloon. No one will come and tell me that there is anything great about menopause. It's not great.

CBS Cares: So you feel that symptoms like difficulty sleeping, mood changes, and memory problems are directly related to hormone levels declining? Or, are they the result of poor sleep caused by hot flashes constantly waking women?

Dr. Uzzi Reiss: Let's say that everyday, I give you a potato to eat. And everyday, you eat this potato. One day, I take this potato away from you. And you stop sleeping well. You stop dreaming. You feel foggy. You have body pain. You feel as if you have arthritis. You feel dizzy. You lose your sensuality and your sexuality. Your vagina starts to dry. Your breasts are drooping. Wouldn't I correlate what happened with the fact that something was taken away from you?

You know, we can drug women left and right. There are so many sleeping pills around. But why don't sleeping pills solve any one of their problems? On the other hand, if you give them estrogen, suddenly they sleep. Suddenly they dream. With the drugs, they don't dream, they sleep in a superficial and unrested way.

It's all the decline of the estrogen.

CBS Cares: Some recent studies suggest that progesterone, not estrogen, is the hormone that could accelerate cancer. Do you have any comments?

Dr. Uzzi Reiss: It's the drug progestin (synthetic progesterone), not the natural progesterone, that does that. Every study on progesterone shows its significant benefit. There's a Belgian study in which they biopsied the breast, wrapped it in progesterone and then did the biopsy again. The result was that the cells replicated much less. Now there are some major studies that show clearly how progestin increases breast cancer (not progesterone). The more progestin you give, the more breast cancer people have.

Progesterone, on the other hand, is the most protective breast hormone. At an infertility clinic at Johns Hopkins, Linda Cowan published a study in the early 1980's. She followed two groups of women for more than 20 years. There aren't many studies like this. What's unique about these women is that one group had blocked fallopian tubes, and the other group had progesterone deficiency. The only long-term health effect the women with blocked tubes had was the inability to get pregnant. But more than 20 years later, the group with progesterone deficiency had tenfold more cancer.

How could this be? Very easily. Progesterone does a few things:

It increases the activity of a gene called P53, which protects us from cancer. It also down regulates and decreases the function of BCL2, a gene that causes cancer. Progesterone prevents cells from replicating it. Progesterone causes adhesion in the cell. There are many other detailed functions of progesterone that decrease cancer in the body. It also moves estrogen from a strong state to a less strong state. Medroxy progesterone acetate (progestin), on the other hand, does the opposite.

CBS Cares: A lot of menopausal women say they have headaches. Do headaches indicate there's an imbalance of progesterone?

Dr. Uzzi Reiss: Ninety percent of them will tell you their headaches come before their period, when the estrogen is low, and disappears the second week of the cycle. Eighty-five percent of women with migraines will need no medication if treated by the hormones and the nutrient they lack. But migraines and headaches are caused by a combination of melatonin deficiency, magnesium deficiency, and estrogen deficiency.

CBS Cares: In your opinion, is it better to take hormones in a continuous combined manner, where estrogen and progesterone are taken throughout the month, or in a sequential combined therapy, in which estrogen is taken alone for the first two weeks, and then along with progesterone the last two weeks of a woman's cycle?

Dr. Uzzi Reiss:  I don't believe in sequential, which is the result of the last hundred years of modern society. Up until a hundred years ago, women never had periods. They were always pregnant and breast feeding, starting at age 16.

Two weeks on, two weeks off violates the biggest principle: you don't leave estrogen alone. You always balance it with the proper amount of progesterone. Some claim that if you use progesterone all the time, you get diabetes. Well, first of all, I haven't seen that in 20 years, and I've given close to 50,000 women progesterone. Secondly, it has been scientifically shown that diabetes is not the result of taking progesterone, but progestin.

CBS Cares: Is it true that if too much progesterone cream is used regularly-in other words, a dose more than 1/16 of a teaspoon-that the progesterone can accumulate and interfere with adrenal function?

Dr. Uzzi Reiss: Progesterone is a very misunderstood hormone because many times, it doesn't work exactly as you hear it works. It doesn't always make all women calm and relaxed, or help them sleep, or decrease their craving for sweets, and it doesn't always behave like a diuretic. Many times, it functions in the total opposite way. In those times when people are under significant stress, the body will take the progesterone, and rather than only use it to support a pregnancy, it will be used to support the adrenal glands.

So, when you give those women progesterone, rather than becoming calm, they can get more energetic and edgy. But it's not because progesterone affects the adrenals negatively. The body chose to use it to support the adrenal glands.

CBS Cares: What's the difference between FDA-approved bio-identical hormones, and bio-identical hormones synthesized from plants by a compounding pharmacy?

Dr. Uzzi Reiss: Today, you can buy a lot of hormones approved by the FDA that are basically bio-identical. All the estradiol patches and now two estradiol creams are bio-identical. Bio-identical progesterone is available in a cream and also a skin patch.

I think the problem with some FDA-approved products like estradiol and Prometrium has a fixed dose.  Maybe women in their late 60's to 70's with a very even lifestyle have hormone levels that don't change much, it’s okay for them, but younger women with PMS, women in perimenopause, and women in the first ten or 15 years of menopause have hormone levels that are constantly changing. When a person is stressed, their hormones simply don't go into the cell. As a result, you don't feel as good. You need more hormones. When you do a lot of physical work, you also deplete hormones and need more. When you do a lot of mental work, you need more. When hormone levels change, our hormonal needs change. So instead of the dose controlling you, you should be able to control the dose. I like to give women hormones in such a way that they can go up and down within a range, and be adjusted according to a woman's changing hormonal needs.

So, the difference between FDA-approved bio-identical hormones and bio-identical hormones made by compounding pharmacies is that the compounding pharmacies can customize the dose to the individual needs of a woman.

Another difference is that none of the FDA-approved pharmaceutical products contain estriol. This is an extremely weak estrogen, but it's there. When women are pregnant, estriol goes up a thousandfold. Estrone and estradiol go up tenfold. But none of the drug companies make estriol.

CBS Cares: What are "biest" and "triest", and what are the advantages and disadvantages of taking those instead of just estradiol?

Dr. Uzzi Reiss: In triest, you have all three estrogens: estrone, estradiol, and estriol. In biest, you have only estradiol and estrone. And this is completely unscientific, but people that prescribe bio-identical hormones claim that estrone is bad. Well, estrone is not bad. We can't have anything in our body that's bad, okay? Even if something has some bad aspect, it's good in another aspect. When you take estradiol orally, it turns into estrone. After our body uses the estrone, the estrone goes in three directions.

In one direction is two hydroxyestrone, which decreases breast cancer. In another direction, we have 16 hydroxyestrone, which builds bone and increases breast cancer. This is why the stronger a woman's bone is, the more likely she'll have breast cancer.

And in the third direction is four hydroxyestrone, which increases breast cancer. But in order for it to do that, you must have a specific gene defect in a specific site in the liver. About 40 percent of women have this. So, by identifying all three, we can modify it. If you have more of the one you don't need, biologically we can decrease it. And I think that should be done to every woman.

You know, estrone, estradiol-there's no bad, there's no good. Usually, there's a balance between estrone and estradiol of about 50/50. Whenever you take estrogen by mouth, because it gets converted to estrone by the liver, you'll have a huge level of estrone compared to estradiol. So there's really no reason to give estradiol by mouth. I think taking estradiol in a cream is superior because it bypasses the liver, and you'll have slightly more estradiol than estrone. The cream I use really is based on these physiological changes.

CBS Cares: So in your opinion, it doesn't make sense for a doctor to give a menopausal woman one estrogen hormone like estradiol instead of the combination in triest?

Dr. Uzzi Reiss: In our bodies, estradiol doesn’t exist alone.  We have a whole rainbow of hormones that work together and can counteract each other in the body.  I think we should use the whole combination. And when you give the whole rainbow of hormones, you can give much less.  But you know what? There's no science about it, unfortunately. The science about estriol is from 20, 30 years ago, showing that the higher the level of estriol in your body, the less breast cancer there is.

By cream, I use triest. In my triest, there's more estrone and three times more estradiol.  The dominant hormone is estriol.  So I kind of create the balance in one to one, then people take it. With a drug, there's absolutely no science about how it should be.

CBS Cares: Is it your view that women should start bio-identical hormone therapy as early as possible after menopause?

Dr. Uzzi Reiss: I think we need to replace things in our bodies the minute we lose something. Do you think that the minute you don't see well you should start to wear glasses, or wait to go blind before doing something about it? I think hormones are part of a system that gives us life, brains, mood, motivation, sensuality, sexuality, physical and mental energy, and the wish to grow, learn and excel.  Hormones are not in our body by mistake. And they're not in our bodies for just 20 or 30 years. They're there to allow us to function well and enjoy the universe given to us.

CBS Cares: Do all your patients tell you that their symptoms improve when they go on natural hormones?

Dr. Uzzi Reiss:  Yes, except if it's started too late and their bodies will not accept it. You take an 80-year-old, get her on estrogen, and she'll have the most minimal breast tenderness and freak out and won't take it. The point is, you can't wait.

CBS Cares: Would you say that even women who don't experience troublesome, or any, menopausal symptoms should also take bio-identical hormones?

Dr. Uzzi Reiss: You know what? That's a great question. And I don't know the absolute answer. I always ask myself when patients come to me, Does this person need bio-identical hormone therapy?

What I can tell you is that there is a small percentage of women who have totally different mechanisms and might have more estrogen in their cells.

And, at least 50 to 75 percent of women who come to me and say, "Great, what can you offer me?" need HGH, or human growth hormone. It's their thyroid.

CBS Cares: How did you get interested in natural hormones?

Dr. Uzzi Reiss: It was luck. I was trained in Israel, where it was like a big government HMO. When I came to Albert Einstein in New York, I had to do the same training again from the very beginning. It was totally the opposite of anything they taught me in Israel. What was great about the department in Einstein was that there were four full time professors who hated each other. Each of them wanted to promote his own idea. So this helped me grow my own philosophy about health care.

I was always interested in mind and body. And because some people learn to do something in one way and no other way, like a monkey, I wanted to think differently and try to do different things. And I listen, you know? When somebody tells me that five days before her period she gets depressed, she doesn't sleep, she feels foggy and angry, but that when she finishes her period, she feels great, I ask: "What happened? Hey, here your estrogen went up, and here, your estrogen went down."

You know, we are the best medical textbooks on the planet. When somebody tells you, "I have pain," they have pain. So you don't go and say, "You don't have anything." You don't say, "Well, you're depressed. Take this anti-depressant." You try to understand why it's happening. And when you do that, you slowly come to the conclusion that something is deficient. Our bodies don't have a deficiency of Prozac, of antibiotics, of sleeping pills, of anti-anxiety medication. Our bodies have failures in a few or some of the systems that we have had from the very beginning. Until we spend more time finding the failure that causes the problem, we are not going to correct the problem.

CBS Cares: Is there anything we haven't asked you which you think is really important for us to communicate to CBS viewers and readers of this website?

Dr. Uzzi Reiss: I think we're in the beginning of what I call Westernized Talibanism of women. There is an invasion of women's sacred property-their estrogen. Our society wants to take estrogen away from women, and make them foggy, depressed, and unproductive. The moment they should collect the fruits of 25 or 30 years of hard work, they're collapsing because their own hormones are taken away from them because of fear.

That's the point I wanted to make. All these women think that their own hormones are going to kill them. It's a tragedy.