[Ed.- Jonathan Wright, M.D., is a world renowned expert in hormones, particularly in what is referred to as bio-identical hormones, or natural hormones. Estrogens are one of the world’s most prescribed treatments, and often referred to as hormone replacement therapy or HRT. Although it is hard to believe, the majority of the estrogens (and progesterones) that are prescribed around the world today are actually derived from animals, particularly horses. Dr. Wright has pointed out these facts in his best selling book, “Natural hormone replacement therapy, don’t let your doctor give you horse urine!” Accordingly, Dr. Wright has coined the phrase Bio-identical Hormone Replacement Therapy (BHRT) to differentiate the new approach to hormone replacement as opposed to the old (and still existing) methods. This article examines some of the ideas, dosages and methods behind the use of BHRT for women].

"To stay healthy, observe and follow nature." Physicians and master healers have made this statement for literally thousands of years, in many languages and variations. It remains as true today. None of us has to be a rocket scientist; we simply have to mimic nature.

For this reason, some question the basic concept of Hormone Replacement Therapy (HRT) during or after menopause, rightly pointing out that hormones naturally decline with age, although relatively abruptly at menopause for women.

So how can it be "natural" to replace hormones at a time of life when they're naturally not there? The answer to this criticism is conditioned by the circumstances of the late 20th and the early 21st centuries, definitely not a "state of nature" time for the human race. To stay as "natural" as possible, we must work on it. In our era, being natural doesn't happen naturally!

So if a woman at menopause;

• Had a mother who ate only whole, natural food with a full complement of nutrients during her pregnancies.

• Had (herself) no in-utero exposures to chlorination, fluoridation, pesticides, herbicides, artificial colors, flavors or other artificial chemicals, or any artificially generated electromagnetic fields.

• Was born without exposure to anesthetics.

• Was nursed until at least one year of age with no other food intake until at least 10 to 12 months of age.

• Grew up on that same whole, natural food diet, without any of the exposures noted above.

• Got lots of sunshine and exercise while growing up.

• Continued with the same diet, exercise, sunshine exposure, and none of the un-natural exposures noted above throughout the rest of her life.

• And in addition, if that same woman has no family history of osteoporosis, heart attack or arteriosclerosis, Alzheimer's disease or senile dementia.

Then she very likely doesn't need to think about hormone replacement therapy at the menopause!

Fortunately, there are some women who, despite not having been able to live a perfectly natural lifestyle, are able to live into their 90's in good health, having used no hormone replacement. However, if you're not in the "all-natural" category or have one or more risk factors noted above, or wish to use hormone replacement for anti-aging purposes, then it's obviously best to use hormone replacement that duplicates what was naturally there before menopause.

The average woman’s estrogen production is 90-7-3

In healthy, normally-cycling women under age 40 taking no medications, recent research at Meridian Valley Laboratories, (for whom I consult) has shown that 90% of serum, (the "clear" fraction of the bloodstream) estrogens are estriol, 7% are estradiol and 3% are estrone. (Of course these are "average" percentages- but the individual variations were not found to be wide).

Noting that estrone is pro-carcinogenic (as is estradiol; estriol is generally considered to be anti-carcinogenic), some natural medicine practitioners recommend the use of a combination of estradiol and estriol only. (It's not clear why no one has yet recommended eliminating estradiol and using a combination of estrone and estriol only, since estradiol is likely to be more pro-carcinogenic than estrone).

Following the "observe and follow nature" principle stated at the outset, my recommendation is still to use all three estrogens in their naturally occurring proportions. (Certainly if science can prove incontrovertibly that nature has been wrong, all along, I'll change my opinion!)

Estrogen timing

It's also best to duplicate nature's timing of those hormones. Remember, the hormones are not just sent from the ovaries on this schedule, they are also received by specific “hormone receptors” on the same schedule. Although this fact may seem obvious and perhaps not worth mentioning, it’s quite important to pay attention to the post menopause if we are using hormone replacement therapy. (For example, animal studies show that estriol is almost always anti-carcinogenic, except when it's given in very high doses, or when it's given every day without any pauses).

If the hormone receptors have been conditioned for a woman's entire menstrual years to receive hormones of a specific type on a specific schedule, it's more likely that some sort of malfunction will occur, if either the type of hormone or the timing is persistently altered. In addition to types of hormones and their timing, correct quantities are equally important. On this point, there's a bit of a debate among natural medicine practitioners.

Following another basic principle of "prescribe the least amount necessary to do the job," the majority of natural medicine practitioners currently recommend sufficient hormones to provide protection against osteoporosis, heart and blood vessel problems, senile dementia and Alzheimer's disease, but not enough to produce a monthly menstrual period. (These amounts usually result in "low-normal" serum or urine hormone levels).

Most women prefer this approach, generally agreeing, (when asked) that they'd rather not have menstrual periods until age 96 or so. However, a few practitioners recommend larger quantities, enough to produce monthly menstrual bleeding. These practitioners argue that it's probably better to "flush" the uterus on a regular basis. One particular study, (Moyer DL, de Lignieres B, Driguez P, Pez JP. Prevention of endometrial hyperplasia by progesterone during long-term estradiol replacement: influence of bleeding pattern and secretory changes. Fertil Steril. 1993 May;59(5):992-7), set out to answer that question regarding bleedings for postmenopausal women seeking treatment for menopause. Perhaps unsurprisingly, they discovered that high doses of estrogen and progesterone lead to more frequent bleedings than lower doses. However, the study did conclude that there did not seem to be any additional benefits from large doses, plus noted that relatively low doses of progesterone do help to reduce the risk of bleeding.

Estrogen dosing

I've prescribed true estrogen replacement during and after the menopause since 1982 using an older formula of 80% estriol, 10% estradiol, 10% estrone. Over the years, a 2.5mg total quantity of that formulation worked best for hundreds of women.

Using the formula derived from the latest research (the "90-7-3" percentages noted previously), I'd presently recommend (for technical reasons) a somewhat higher starting quantity of total estrogens, 3.5mg daily, used on days 1 through 25 of each month, and not used on days 25 through 30 of each month. (Certainly, not all months are 30 long, and the majority of women did not have exactly 30-day menstrual cycles. One woman with whom I work takes her hormones according to the lunar calendar, which has 28-day months. However, most women find it simpler and more practical to work with the "regular" calendar. The last five days, one is allowing the estrogen receptors to "rest" as they have been accustomed to do.

Progesterone

As explained in previous articles [Ed.- see References below], progesterone is an important addition when undertaking estrogen therapy, and the late John Lee, M.D., highlighted many of the progesterone issues with his work and publications.

A reasonable quantity of progesterone is 25mg to 30mg, used starting on days 10 to 15 and taken through day 25.

The starting date is varied according to the timing of each woman's ovulation when she was cycling. If this timing isn't known, a starting date from day 10 to 15 is arbitrarily chosen. Once again, the last five days with no progesterone allow the progesterone receptors to have their accustomed "rest."

DHEA

Since many women metabolize DHEA, (another valuable hormone to replace after ages 40 to 50) into testosterone, I usually delay considering testosterone replacement until tests are done to see if a woman's testosterone levels are raised by her supplemental DHEA. If they're not, a reasonable quantity of testosterone is 0.5mg daily, taken (and not taken) on the same days as the estrogens.

DHEA is an adrenal hormone, secreted every day by our adrenal glands. Therefore, when replacing it, an every day schedule is also recommended. For women, 15mg daily is generally a reasonable quantity. Follow-up testing shows a need for up to 30mg for a minority of women. It's been my observation that DHEA replacement therapy is essential to maintaining optimal immune function and reducing somewhat the risk of cancer. Testosterone replacement, either directly or metabolized from DHEA, is essential in enabling women to maintain good muscle mass, even when "elderly".

Conclusions

Summarizing hormone timing in graphic form: A very few women need to increase estrogen quantities towards the 5mg to 10mg range to control hot flashes, irritability, insomnia and other symptoms of the menopause. These quantities are not as “scary” as they seem; 5mg of natural Estrogen combinations are roughly equivalent to 0.9mg to 1.25mg of horse urine estrogen such as Premarin®.

If bleeding occurs with ANY starting quantity, the amount should be cut back. But if bleeding persists it is important to consult a doctor. Usually no problem is found, but rarely a pre-cancerous or even cancerous condition may exist.

Paradoxically, too much of the estrogens can cause bleeding, but for some women, too little can cause bleeding too! (It can be confusing for doctors too...especially us male doctors!) All in all, it's best to check in with your doctor again for advice on what to do if bleeding happens while taking natural estrogens...unless of course you and your doctor are following the "enough hormones to have periods every month, indefinitely" theory.

A small minority of women (5% or less), who start natural estrogens find that even the largest quantities don't relieve symptoms. Nearly all of these women have previously taken horse urine estrogen (Premarin®), or another synthetic form of estrogen and/or progesterone (such as Provera®). These “hormones” that are not identical-to–natural, somehow interfere with the ability of some women's bodies to use the identical-to-natural hormones.

For symptom relief, a few women "retreat" to using horse hormones or synthetics again, unfortunately raising their risk of adverse effects in the process. Fortunately, most women in this situation can re-establish their bodies' ability to use identical-to-natural hormones by working with their doctors to improve liver function.

Nearly all of these women are excessively metabolizing estrogens, a condition technically termed “hyperexcretion”. Estrogen hyperexcretion can be corrected with physiologic quantities of cobalt, but this question is best left to a practitioner skilled and knowledgeable in BHRT.

Fortunately, the overwhelming majority of women are able to use natural hormones from the outset without these complications. Please remember that no hormone replacement, horse-urine, synthetic, or natural is entirely risk-free, although identical-to-natural hormones are less likely to cause problems.

When taking estrogens, there is an extremely small risk of depression and blood clots. To help cut down on even these extremely small risks, it's wisest to include B-complex vitamins, (the amounts found in a good "megavitamin multiple" are usually sufficient), vitamin E (400 IU of mixed tocopherols), a source of omega-3 fatty acids such as cod-liver oil or flax oil (1 tablespoon daily), and iodine (one or two kelp tablets daily).

[Ed.- An excellent nutritional base for daily use is Beyond Chelation Improved, which contains all the above factors and more besides].

The types and quantities of supplements here are recommendations I make in routine circumstances. Your circumstances may vary, so please ensure you check with your own health care advisor.

As always, when working with a subject as complicated as replacement hormones, it's best to work with a physician skilled and knowledgeable in their use. It's the intention of this article (and my hope) to provide a little further detail on the practicalities of natural hormone replacement for women.

References

Adapted from “Natural Triple Estrogen and Progesterone for Women” by Jonathan Wright, M.D. To view other articles written by Dr. Wright, along with all clinical references, please follow the link to:
Natural Triple Estrogen and Progesterone for Women” by Jonathan Wright, M.D.