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From the Townsend Letter
February / March 2019

Hormone Therapies to Cure Female-Related Disorders: Practical Tips
by Thierry Hertoghe, MD
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Polymenorrhea, spaniomenorrhea, and irregular menstrual cycles: How to restore a 28-day menstrual cycle. Short (26 or less days), prolonged (30 or more days), and irregular (mixing of short and long) menstrual cycles are mainly due to estrogen deficiency. To treat them, a higher estrogen dose is useful (e.g., 2-4 mg/day of transdermal estradiol with a moderate 100 mg/day dose of progesterone given in premenopausal and postmenopausal women on the same days of the menstrual cycle or month, respectively) as suggested above.
      
In some premenopausal women with short menstrual cycles, progesterone deficiency symptoms, and not symptoms of estrogen deficit, predominate with severe premenstrual syndrome and tension, mastalgia, etc. In this case, I recommend treating with slightly lower doses of transdermal estradiol (1.5 - 3 mg/day) and higher doses of progesterone 150 to 200 mg/day.
      
Tip: Recommend the patient eat sufficient animal protein-rich foods (> 200 g/day) to support female hormone production and avoid whole grain foods to avoid hormone loss in the stools. There is a fivefold higher risk of irregular menstrual cycles in women regularly eating whole grain bread.
      
Spasmodic dysmenorrhea, menstrual migraine, and hot flushes: How to get rid of severe cramps, hot flushes and migraines. Heavy cramps in the lower abdomen alternated with pain-free periods during the day and hot flushes in premenopausal women occur generally during menstruation when estrogen levels are at their lowest levels. As for menstrual migraine, these menstrual abdominal cramps are due to estrogen deficiency and relieved by estrogen supplementation. In case one of these three complaints is the only bothersome complaint, the estrogen deficiency is probably only present during menstruation and 0.75 to 1 mg/day of transdermal estradiol during the first four days of the menstrual cycle may be sufficient as a therapy.
      
When a patient suffers from other estrogen deficiency complaints appearing at other times of the menstrual cycle, then a typical premenopausal female hormone treatment is required to relieve the patient from all her symptoms. It typically consists of 2-4 mg/day of transdermal estradiol gel from the 5th to the 25th day of the menstrual cycle with progesterone from the 15th or 18th day to the 25th day. If some spasmodic dysmenorrhea would persist, add a smaller (0.75 to 1 mg/day) dose of transdermal estradiol during the first 4 days of the menstrual cycle.
      
Tip: Avoid smoking and caffeinated beverages because even if they may help relieve some of the spasmodic dysmenorrhea or migraine, they usually accelerate the upcoming next painful period and increase its intensity. Note that for migraines, thyroid therapy may help, too, as it eliminates the myxedema, which compresses brain structures inside the non-extendable skull. Thyroid therapy also increases estrogen production, another way by which it can reduce migraine.
      
Ovulatory pains, constant dysmenorrhea, and premenstrual migraine: All three symptoms are due to progesterone deficiency and require progesterone for treatment during the luteal phase, the second part of the menstrual cycle. To prevent ovulatory pains, progesterone treatment should start at a smaller dose of 50 mg/day before the normal time of ovulation (from the 10th to the 14th day of the cycle), usually from the 10th to the 14th day of the menstrual cycle, and then continue at higher doses of 100 to 200 mg/day from the 15th or 18th day to the 25th day of the cycle as there are usually many other complaints of progesterone deficiency when ovulatory pains occur.
      
When a patient suffers from permanent lower abdominal pain and recurrent migraine in the premenstrual period, starting progesterone from the 15th or 18th day of the menstrual cycle to the 25th day of the cycle may suffice and deliver the patient from her pain. However, frequently estrogen deficiency complaints may also be found in these premenopausal women and require small (not high) doses of 0.75-2 mg transdermal estradiol from the 5th to the 25th day of the menstrual cycle. Whatever the case, a relatively higher progesterone dose than the estrogen dose should be given when constant dysmenorrhea and premenstrual migraine are the predominant complaints, otherwise there is a risk of aggravating these stressful complaints with estrogen supplementation.
      
Tip: Check for hypothyroidism whenever progesterone deficiency complaints predominate, particularly in young women (below age 30). The ovaries in hypothyroid women produce insufficient amounts of progesterone because of a lack of thyroid hormone stimulation. In young women, thyroid therapy usually restores ovulation and progesterone levels and may make the complaints of progesterone deficiency disappear on their own without exogenous female hormone supplements. In hypothyroid women above age 35-40, the number of functional oocytes has dropped to levels that are too low, and progesterone supplementation is almost always necessary next to thyroid therapy.
      
Vaginal dryness and dyspareunia: The dryness and atrophy of the vaginal mucosa and its almost inevitable consequence of pain at penis penetration during intercourse are due to estrogen deficiency.
      
In most women, correcting the underlying estrogen deficiency with a typical pre- or postmenopausal treatment consisting of transdermal estradiol and oral or vaginal progesterone such as explained above is efficient. In some women, the vagina has remained in estrogen deficiency for too long a time and addition of a vaginal gel or tablets of estriol is necessary the first six months to make the symptoms completely disappear. In rare cases, the adjuvant vaginal estriol treatment should be continued for a longer time, perhaps indefinitely.

Female-Related Disorders That Need Months and (for some) 1-2 Years for Correction
Breast cysts: How to make breast cysts disappear naturally. It takes approximately six to 15 months to make cysts totally disappear in women, regardless of the age or severity of the breast cyst, even in Reclus disease. The main treatment here is not hormonal but nutritional: iodine. One to three drops per breast of a 5% iodine-containing Lugol's solution daily applied (no interruption) on the area overlapping the breast cysts permits 12% penetration of the iodine into the skin and cysts. The solution stains the skin yellow-brown, but this is transitory. After 20 to 30 minutes almost all iodine that has remained on the skin has outgassed into the atmosphere. Iodine blocks proliferation of tumor cells so that in the cysts drenched with iodine no new cells appear while the old cells die and disappear one after the other. In severe fibrocystic breast disease, I recommend reinforcing the efficacy of the topical iodine treatment by having the patient take an additional 3-5 drops/day orally of the same Lugol's solution mixed with water to reach cystic areas within the breast that are poorly accessible topically. As progesterone also helps to prevent and reduce breast cysts, I also prescribe the patient a progesterone gel 1% to apply daily on the breast before placing the iodine solution.
      
Tip: Recommend the patient avoid drinking coffee, tea, and alcohol as the caffeine or ethanol these drinks contain promotes breast cysts formation. Make them also take progesterone orally or vaginally in the second phase of the menstrual cycle in case the breasts swell painfully.
      
Small breasts: How to stimulate underdeveloped breasts (micromastia) to grow to a normal adult size. In young women using female hormone treatment, it takes about 12 to 15 months to fully develop breasts from one of the lower Tanner puberty stages (stages 2 to 4) to a full adult stage 5 breast development. The typical treatment consists of administering upon awakening 2 to 4 mg/day of a transdermal estradiol gel from the 5th to the 25th day of the menstrual cycle and at bedtime 100 to 150 mg/day of progesterone from the 15th to the 25th day of the cycle. The higher the estradiol levels are, the bigger the breasts become.
      
In older peri- and postmenopausal women, growth hormone therapy may be necessary in addition to estrogens (and progesterone) to make the breasts grow.
      
Tip: Breast enlargement requires sufficient animal protein intake. Suggest the patient eat at least 200 grams/day of meat, fish, or chicken.
      
Enlarged breasts: How to prevent and treat over-sized breasts. Prevention of over-sized breasts is simple: Treat any progesterone deficiency as soon as possible as it is long-term progesterone deficiency that allows excessive mammary cell proliferation to make the breasts too big. In general, the treatment consists of administering 100 to 200 mg/day of micronized progesterone from the 15th or 18th day to the 25th day of the menstrual cycle.
      
Once the breasts have become excessively enlarged (macromastia), further enlargement can be hindered by administering progesterone alone in the same manner and at the same doses used for prevention of breast enlargement. Reduction of breast size is usually not very efficient with progesterone or other hormone therapies without surgery, and if so, it results in breast ptosis rather than breast reduction.
      
Tip: Avoid coffee, tea and alcohol as they increase breast epithelial cell proliferation.

Ovarian cysts, polycystic ovarian syndrome, and hirsutism: How to make ovarian cysts disappear. Ovarian cysts are facilitated by one of the following deficiencies: iodine, thyroid, cortisol, or progesterone deficiencies. Toxins (chlorine, etc.) may facilitate the development of cysts, but it is usually by producing one or more of these four deficiencies. Correction of one or two of these deficits is generally sufficient to correct the problem.
      
BioDisruptIn case of iodine deficiency, 3 to 5 drops a day of a 5% Lugol's solution may be sufficient to make the ovarian cysts disappear in 3-6 months. Hypothyroidism is, in my experience, best corrected with 30 to 150 mg/day of desiccated thyroid extracts from pork origin as they contain not only T4 (thyroxine, four iodine atoms), but also T3 (three iodine atoms, by far the most active thyroid hormone), T2 (two iodine atoms), T1 (one iodine atom), and T0 (zero iodine atoms), which all may have some additional benefit. These different T0 to T4 hormones are delivered by thyroid extracts imbedded in a big thyroglobulin protein. Absorption and digestion of this protein is slow and progressive, permitting progressive release of the different thyroid hormones out of this long protein. In this way, a more persistent 24-hour thyroid activity is achieved and, thus, better correction of the hypothyroidism than treatments containing only purified T4 or T3.
      
Cortisol deficiency is best corrected by hydrocortisone (bioidentical cortisol) 10 to 15 mg in the morning and 10 mg at midday. Remember to always supplement DHEA in equivalent doses (15 to 25 mg/day) whenever cortisol is given as the DHEA protects against any excessive catabolic effects of cortisol.
      
In polycystic ovarian syndrome with typical hyperandrogenism and hirsutism, the treatment is more complex as, in my experience, all of the aforementioned thyroid, cortisol, and progesterone deficiencies exist simultaneously with some degree of estrogen deficiency. These deficits trigger a compensatory increase in production of testosterone and adrenal androgens. Correction of these aforementioned deficiencies usually reduces and normalizes the androgen excesses and associated hirsutism, although slowly. After confirmation of the deficiencies by laboratory tests, administer to your patient hydrocortisone, desiccated thyroid, and a combination of 2-4 mg/day of transdermal estradiol from the 5th to the 25th day of the menstrual cycle and a maximum of 100 mg/day (not too high) of oral progesterone from the 15th to the 25th day of the cycle.
      
How do these hormones reduce hirsutism? The hydrocortisone reduces the secretion of ACTH, the pituitary hormone that stimulates the adrenal cortex to produce cortisol and adrenal androgens, thereby reducing the secretion of DHEA, androstenedione, and other adrenal androgens. In case of severe adrenal hyperandrogenism with important hirsutism, correct in the first six to nine months the cortisol deficiency with a potent synthetic derivative such as 0.25 to 0.35 mg/day of dexamethasone, which lowers the adrenal androgen levels more than the bioidentical cortisol. However, it is important not to lower the adrenal androgens too much, so regular control of the 17-ketosteroids, the metabolites of the adrenal androgens, in a 24-hour urine collection is recommended every six months. If a hirsute patient wishes only to take bioidentical hormones, then provide hydrocortisone in four divided doses of 5 mg taken at regular four-to-five-hour intervals: upon awakening, at lunch, at 4 PM, and before bedtime. The spreading of the dose permits better suppression of excessive adrenal androgen production. Thyroid therapy increases the conversion of testosterone into estradiol rather than into the masculinizing dihydrotestosterone. Estradiol blocks the masculinizing effects of androgens and progesterone amongst others by inhibiting the conversion of the harmless testosterone into the body hair-promoting dihydrotestosterone.
      
Without aesthetic hair removal, it takes 2-4 years after normalization of androgen levels for slow disappearance of the excessive body hair. For this reason, I suggest women with hirsutism get their excess body hair removed. After hair removal, the hirsutism should not grow back if all hormone levels are in the meantime normalized.

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