Don’t Become a Victim of All-Too-Common Errors in Bioidentical Hormone Replacement Therapy

by Jonathan V. Wright, MD

As many readers may already know, comprehensive bioidentical hormone replacement therapy (BHRT) got its start here in North America at the Tahoma Clinic in the early 1980s. However, if you’ve read Stay Young and Sexy with Bio-Identical Hormones: the Science Explained by Lane Lenard, PhD, and me, you know that BHRT really got its start in China in the 11th century, where it continued to be used and improved until the 19th century! (You also read that Chinese BHRT was even more comprehensive than what we have now, but that’s a discussion for another time.)

From the very start, BHRT has had dual goals: effectiveness and safety. Copying, as closely as possible, what Nature has been doing for hundreds of thousands of years is the most likely way to be both as effective and as safe as possible. This is true not only with BHRT, but with any approach to health care. That’s why patent medicines (the vast majority of “prescription drugs”) are so far off the mark for health care. You see, if it’s a patented molecule, by definition it can’t be found in Nature, and if isn’t found in Nature, it’s extremely likely it will have adverse effects in human bodies.

Researchers have confirmed time and time again that copying Nature is best. That’s why I’m so surprised that there are still so-called authorities on BHRT who haven’t yet learned that unless there’s solid research that says it’s not necessary, copying Nature is always the best approach

While teaching part of a BHRT seminar in earlier this year, several participants told me that they had attended another BHRT seminar recently during which they were advised that women should swallow their daily estrogen replacement. Even worse, they were told it should be swallowed every day with no monthly breaks. Another attendee said she had attended a seminar where she was told that the only estrogen needed in BHRT is estradiol, as it’s the most potent bioidentical estrogen, and “can be turned into all the other estrogens.”

Frankly, I found it nearly impossible to believe that anyone could actually be teaching those three fundamental BHRT errors in 2013. Surely the attendees must simply have misunderstood the instructors, right? But when I expressed my doubts that these risk-increasing practices were actually being taught, other seminar attendees assured me that they had heard the same things.

Fundamental BHRT Error #1: Swallowing Estrogen

From the “copy Nature” point of view, all three errors are glaringly obvious. But let’s start with the concept of swallowing estrogen (of any kind) first. During menstrual cycling years, the vast majority of estrogen originates in the ovaries, is secreted into the veins of the pelvis, and then it is transported to the heart. The heart then pumps it to every cell in a woman’s body, including a small amount that goes to the liver. The liver excretes some of that estrogen via the bowels, and another small amount is routed to the kidneys for excretion. Most importantly, every organ – the brain, heart, bones, lungs, and so on – and every cell in a woman’s body receives some unaltered, unmetabolized estrogen, and uses it as Nature intended.

By contrast, when a woman swallows estrogen, all of it goes straight into the stomach and intestines. All the blood vessels from the intestines flow to the liver, not the heart, so the liver receives 100% of the estrogen. The liver naturally does what it is designed to do: it tries to rid the body of it through the intestines and the kidneys. This phenomenon is so well known that it’s been given a name: “first-pass” metabolism. While first-pass metabolism is obviously normal for food and food components, the only way that it could possibly be normal for estrogens would be if a woman’s ovaries were located by Nature and Creation on the inner surface of her intestines!

Research has already proved that swallowing estrogen is a very bad idea for several reasons. Swallowing the hormone can lead to liver inflammation, and raises your risk of thrombosis (i.e., blood clots) and strokes. In fact, the proof of this is so abundant that I’m not even going to bother with footnotes. While rubbing estrogen into a “mucous membrane” (preferred) or skin surface, is not exactly what Nature and Creation have designed, it still mimics Nature in that it allows the estrogen to flow with the bloodstream to the woman’s heart first – not her liver – and, as a result it reaches every cell in the body, just as happens to estrogen that originates in the ovaries.

Fundamental BHRT Error #2: Never Taking a Monthly

‘Break’

Which brings us to the fundamental BHRT error number 2: using estrogen every single day (along with progesterone and for many, testosterone, commonly known as “continuous combined” treatment) of every month increases a woman’s cancer risk. Nature and Creation certainly don’t supply a woman’s body with the same quantities of these two hormones every day from her teens through to her 40s or 50s. Everyone knows that there is a significant drop in these two hormones – and testosterone, too – that occurs approximately once a month during the menstrual years except during pregnancy, and even then “continuous daily hormones” are normal for only nine months.

Similarly, the receptors for these hormones are accustomed (you could even say “programmed”) to that monthly break from all but a small amount of estrogen (and progesterone). If, instead, estrogen and progesterone receptors are stimulated every day for years, even decades, that clearly deviates from “Nature’s plan” by a very significant margin, and quite predictably, something can and will go wrong.

In 2011, researchers confirmed that Nature (and Creation’s) plan for “taking a break” from these hormones approximately every month is the safer way to go.¹ In a review of data from over 130,000 postmenopausal women during 1,153,447 person-years, it was found that “continuous combined regimens conferred a 43% greater risk compared with sequential regimens.” That 43% greater risk refers to breast cancer! And, as you likely have already guessed, “sequential regimens” are the ones that take a break every month.

Fundamental BHRT Error #3:

Not

Using

Estriol with Estradiol

Now about that third fundamental BHRT error, recommending estradiol as the only estrogen to be used in BHRT … you may be wondering why I insist that estriol always be included, and in greater amounts than estradiol. From the “copy Nature” point of view, it’s because the majority of women have more estriol in their urine tests than estradiol. (Urine testing is used instead of blood testing because estriol has a very short “half-life” in blood, so testing blood levels of estriol is quite unreliable.²)

Henry Lemon, MD, was a gynecologic oncologist at the University of Nebraska who published from the 1960s through the 1990s. Dr. Lemon showed us that estriol – even though a much weaker estrogen than estradiol – is an anticarcinogenic estrogen.

Subsequently, researchers have reported that estriol stimulates only “estrogen receptor beta” (ERβ), a receptor that maintains normal structure and function of estrogen responsive cells. Other researchers have reported that estriol stimulation of ERβ in a woman’s brain is responsible for helping to maintain mood and attitude and normal function in areas of the brain responsible for emotions. By contrast, estradiol stimulates both “estrogen receptor alpha” (ERα) and ERβ, so although it’s the estrogen most responsible for breast and hip development, and reproductive functions in the brain, it can be procarcinogenic and must be offset by the entirely anticarcinogenic estriol.

In the 1970s, Dr. John Myers taught many physicians – including me – that fibrocystic breast disease can always be eliminated with iodine, when properly applied. (For details, see the January 2005 issue of my newsletter Nutrition & Healing.) Many women being treated for this problem at Tahoma Clinic had before-and-after urine tests performed for estrogens, including estrone (E1), estradiol (E2), and estriol (E3).

Dr. Lemon had previously established that levels of estriol higher than the combined levels of estrone and estradiol (technically E3 > E2+E1) were protective against cancer and cancer progression. An unusually high percentage of women being treated for fibrocystic breast disease at Tahoma Clinic had the opposite result before treatment, lower levels of estriol than the combined levels of estrone and estradiol (technically E3 < E2 + E1). But after treatment, nearly all these women’s tests had “flipped” to greater levels of estriol (E3 > E2 + E1). Hundreds of similar observations over the last 35 years have established that both iodine and iodide help the vast majority of women’s bodies make more of the anticarcinogenic estriol.

So if a woman’s body can make more estriol, why do I insist that estriol must be in any BHRT prescriptions? Primarily, it’s for safety, because so many women (and men and children too) have lifelong suboptimal iodine/iodide intake, and secondarily because over the years I’ve observed that a very small minority of women’s bodies can’t synthesize enough estriol no matter much iodine and/or iodide they take. For these few women, it’s likely a genetic problem, and without specific testing for every woman, there’s no way to know which ones have this problem. Since estriol is anticarcinogenic, is beneficial for mood and attitude, and can’t hurt except in enormous overdose, it should be included as the major estrogen in all women’s BHRT prescriptions.

Men Can Be Victims of BHRT Errors, Too

Also in 2013, two excellent magazines which focus on anti-aging and a primarily natural approach to health care published articles suggesting that the same basic kind of error can be made almost automatically in prescribing testosterone for men. With differing degrees of emphasis, both magazines suggested that “aromatase inhibitors” (the patent medicine Arimidex and the botanical compound chrysin) be prescribed right along with the very first testosterone prescribed for any man.

Aromatase is the name of the enzyme present in female and male bodies that transforms testosterone into estrogen in one step. Aromatase obviously normally functions more rapidly in women than men, but with age, some men’s aromatase enzyme becomes increasingly active or, in technical terms, their aromatase enzyme is induced. Have you ever been on the beach and seen an older man with what appear to be breasts? That’s a man whose aromatase enzyme activity has been way overactive for way too long!

One-Third of Us Have a Genetic

Tendency for Type

2 Diabetes

But that’s an “end stage” problem of overactive aromatase. Unfortunately, approximately one-third of all men develop aromatase overactivity, a few as early as their late 30s, the majority in their 40s and 50s, and a lesser number at older ages. The reason why so many men have this problem may surprise you. It’s because approximately the same proportion of all of us – one-third of both men and women – have the genetic tendency to develop type 2 diabetes.

Decades ago, it was discovered that people who have this genetic tendency respond to sugar and refined carbohydrates with significantly greater insulin output than those who don’t have it. Over the years, a diet high in sugar and refined carbohydrates causes persistently higher insulin levels leading to our bodies developing insulin resistance.

To overcome that resistance, insulin secretion goes higher, causing even more insulin resistance. To overcome the increased resistance, insulin secretion goes even higher, causing the resistance to increase again, and on and on the upward spiral continues, until the insulin resistance is so strong that even very high levels of insulin can’t break through to efficiently help transfer sugar (glucose) from the bloodstream into the cells, to be burned for energy.

When that stage of insulin resistance is reached, the concentration of sugar in the blood starts to increase – remember it’s not getting into the cells because of that very strong insulin resistance – and we’re diagnosed with type 2 diabetes.

It’s the ever-increasing insulin signal that activates the aromatase enzyme, making more and more testosterone turn into estrogen. That ever-increasing insulin signal can also stimulate the production of more cholesterol and triglycerides, increase blood pressure, and contribute to the accumulation of abdominal obesity.

None of this information is new. This grouping of symptoms, and the increasingly high insulin signal that causes them, were first called “syndrome X,” a name that has since evolved into the interchangeable terms insulin resistance, metabolic syndrome, and prediabetes. As I mentioned earlier, the genetic tendency toward type 2 diabetes and all of these “precursor” problems is shared by one-third of all of us, including one-third of all men.

This means that approximately two-thirds of all men do not need a natural or patented aromatase inhibitor. For the one-third of men who may need one to lower the testosterone-to-estrogen transformation rate, an aromatase inhibitor automatically prescribed with testosterone does nothing at all to reduce the increasingly high insulin signal, so those men continue down the metabolic path toward type 2 diabetes.

That’s the problem with automatically prescribing aromatase inhibitors along with testosterone prescriptions. It often delays a potential diagnosis of insulin resistance until it becomes type 2 diabetes! A physician’s responsibility is to dig deeper, do a physical exam looking for high blood pressure (even “just a little”), abdominal obesity, “skin tags” (80% risk of future type 2 diabetes if they’re present), osteoarthritis (another 80% risk of future type 2 diabetes, even higher risk if the individual is in his 40s or early 50s, based in four published research reports and one as-yet unpublished report from Tahoma Clinic), and to ask about any family history of type 2 diabetes or any of these individual signs or symptoms.

If enough of these signs or symptoms add up, then it’s the physician’s responsibility to recommend very specific insulin resistance testing, which I’ve named the “Kraft test” after its originator.³ If the Kraft test is positive, then an over-all program of diet (Paleo diet), exercise (interval training), and supplementation (featuring adequate quantities of chromium, biotin, magnesium, vitamin D, and the botanical berberine) will progressively reduce the excess insulin signal and accompanying insulin resistance toward normal.⁴ Not only that, it will also go a long way toward bringing down elevated blood lipids and blood pressure, reducing weight (particularly that “central obesity”), and gradually reducing the excess testosterone to estrogen transformation, which is only a small part of the overall metabolic disruption, and not a problem of its own.

If the insulin resistance test is positive, this program will prevent type 2 diabetes! Yes, this reversal of type 2 diabetes or prediabetes takes time, and a temporary recommendation for an aromatase inhibitor is then justified only until the overall program does the job. But blindly prescribing aromatase inhibitors to go with testosterone without bothering to check for insulin resistance – the cause of the problem – is totally unnecessary for approximately two thirds of all men with low testosterone, and irresponsibly incomplete for the rest.

Reprinted with permission from Dr. Jonathan V. Wright’s Nutrition & Healing newsletter.

For more information on Dr. Wright’s natural therapies, please go to www.wrightnewsletter.com.

© 2008 Healthier News LLC.

Notes

1. Bakken K, Fournier A, et al. Menopausal hormone therapy and breast cancer risk: impact of different treatments. The European Prospective Investigation into Cancer and Nutrition. Int J Cancer. 2011 Jan 1;128(1):144–156.

2. Longcope C. Estriol production and metabolism in normal women. J Steroid Biochem. 1984 Apr;20(4B):959–962.

3. Kraft JR. Detection of diabetes mellitus in situ (occult diabetes). Lab Med. 1975;6:10–22. A reformatted but verbatim version can be downloaded for free from http://meridianvalleylab.com/wp-content/uploads/2012/08/GITT-Article-Re-type1.pdf.

4.A summary of how to interpret the test can be downloaded (also for free) from

http://meridianvalleylab.com/glucose-insulin-tolerance-test.