Download Calm Your Hormones or Everything You Should Know About

11/11/2015
Jill Earl CNM,CRNP
Calm Your Hormones!
OR EVERYTHING YOU SHOULD KNOW ABOUT HORMONE
THERAPIES
Hormone Production &Utilization
LITTLE PACKAGES WITH A BIG IMPACT
Key Components of Overall Health
Chemical substances produced in the body that
control and regulate the activity of certain cells or
organs.
They are powerful molecules
They interact with each other.
They can interact with the cells on the surface at
receptor sites OR
Enter directly into the cell and interact inside the
nucleus
The action can be direct or indirect
The interface and result can be a single direction,
or can form a cascade of action
Women’s Health
• Your sex hormones interact with cortisol
(stress hormone) and insulin (glucose
regulator)
• They are made by pregnenolone, the
memory hormone
• They interact with thyroid hormones
(metabolism)
• Hormone levels influence each other and
change over time
• Environment, diet, toxins and life stage are all
factors
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A few good hormones
ALSO KNOWN AS THE SEX HORMONES
Estrogen
•
•
•
Estrone (E1)
Estradiol (E2)
Estriol (E3)
Progesterone
Testosterone
• stor
Estrogen
NAMED FOR THE OESTRUS CYCLE
• The primary female sex hormone
• Develops secondary sex characteristics
breast development
thickens endometrium
part of cycle regulation
• FSH and LH regulate the production in
ovulating women
• Circulating estrogen will decrease FSH and
LH
• Presence in the first 14d of cycle inhibits
ovulation
Estrogen
con’t
• Produced primarily in the ovaries, corpus
luteum and placenta
• All three estrogens are produced from
androgens through enzyme action
• E2 produced from testosterone and
• E1produced from androstenedione
• Androstenedione is made in the theca interna
cells (in the ovary) from cholesterol
• Your body has receptor sites everywhere!
• There are more than 400 known functions
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Low estrogen levels
• Smokers
• Low Fat Diets
• Common symptoms:
Acne
Anxiety
Arthritis
decrease in libido
infertility
Chronic fatigue Decrease in memory
Depression
panic attacks
vulvodynia
PCOS
thinner skin
palpitations
vaginal dryness
osteoporosis/osteopenia
incontinence
Thin endometrial stripe
High estrogen
ESTROGEN EXCESS / ESTROGEN DOMINANCE
• Includes most women with estrogen
imbalance
• Over production of estrogen
• Progesterone/estrogen ratio imbalance
• Xenoestrogens(environmental bombardment)
• Common symptoms:
bloating
fatigue
cervical dysplasia
heavy periods
panic attacks
ESTRONE
decreased libido
hypothyroidism insomnia
mood swings
fibroids
edema
headaches
irritability
weight gain
(E1)
Derived from E2
Main estrogen post menopause
Reserve source of estrogen
Converted to E2 in ovaries
Routine alcohol consumption
increases ovarian E1
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ESTRADIOL (E2)
Strongest form of estrogen
Main estrogen in the body
before menopause
Mostly made in the ovaries
High levels associated with
increased risk of breast &
uterine cancer
ESTRIOL (E3)
Less stimulating to breast &
uterine lining
Does not promote breast
cancer
It is an adaptogen, adapting
to the specific environment
Does not protect bone, heart
or brain like E2
Does help bone a little and ↓
cholesterol
There are two types of receptors
ER ALPHA AND ER BETA
• ERα increases cell growth, proliferation
• ERβ decreases cell growth, helps prevent
breast cancer
• E2 equally activates both receptors
• E1 activates ERα selectively 5:1
• E3 activates ERβ selectively 3:1
• E3 has 20-30% affinity for ERs compared to
E2, therefore cleared rapidly from the cell
• E3 at concentration is equivalent to E2
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ERα and ERβ
con’t
• Receptors ERα and ERβ are similar and
respond in comparable ways.
• Phytoestrogens have a greater affinity to
ERβ.
The regulatory domains differ between the
receptors and is beyond the scope of this
talk.
Synthetic estrogen
MOST COMMONLY RX’D HT IN THE USA
Premarin is a mixture of estrone,
sodium equilin sulfate, and
components such as 17-alphadihydroequilin,17 alpha-estradiol,
and 17 beta-dihydroequilin.
Equilin and equilenin are horse
estrogens. There are other additives
and coatings.
Synthetic estrogens contain many
estrogens that do not fit into human
receptors, and it is unknown what
happens to them.
Synthetic estrogen
CON’T
The estradiol your body makes is eliminated
from your body through urine within a day.
Equilin, derived from the urine of horses, has
been shown to persist in the body for 13 weeks.
Human enzymes are designed to metabolize
human estrogen, not horse’s.
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On to Progesterone!
BEST KNOWN AS THE PREGNANCY HORMONE
Important in menstruation,
pregnancy and the formation
of embryos.
Made in the ovaries until
menopause.
Performs many functions in
the body!
Balances estrogen helps sleep
Helps build bone prevents anxiety
Helps bladder function
Relaxes smooth muscle in the gut
and blood vessels
Signs of progesterone imbalance
YOU CAN HAVE TOO MUCH OR TOO LITTLE
• High P4
• Only happens if taking too much or too much
pregnenolone
•
leaky bladder
•
ligaments relax
•
backaches
•
Leg aches
•
hip pain
Progesterone deficiency
• Many causes:
low LH
increased saturated fats
stress
high sugar intake
decreased thyroid hormone
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Synthetic progesterone
PROGESTIN
• Does not have the same structure as the
body makes
• Does not reproduce actipons of ‘natural’
progesterone
does not balance estrogen
interferes with body’s production of progesterone
• Attaches to multiple receptor sites, nopt just
PR
• Stops the protective effects estrogen has on
heart and causes spasms of arteries
Synthetic P4
CON’T
•
Studies have shown progestin increase risk of breast CA by
800% when compared to estrogen alone
•
An article in JAMA discussed the risk of developing breast
CA was predicted to rise by 80% after 10 yr of using
estrogen &/or progestin
•
Cardiologist Stephen Sinatra MD,FACC has found
progestins cause cardiac SEs including SOB, fatigue, chest
pain and HTN
“Menopausal estrogen-progestin replacement treatment and
breast cancer risk” JAMA, 2000;283:485-491
progestin
THE GOOD, THE BAD
The good:
does help build bone
helps thyroid function
protects against fibrocystic disease
normalizes zinc and copper levels
proects the uterus from cancer
The bad:
acne increased appetite and wt gain
depression
hair loss
decreased libido
increased LDL breast tenderness
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Natural progesterone
• Same chemical structure as the body makes
• Made from yams or soy
• Disogenin, a plant steroid, can be turned into an exact
duplicate of human progesterone
• Has all the important good effects of progesterone and
no serious SEs.
• Most common SEs:
– Dizziness
– Fatigue
– nausea
Effects of Progesterone
• Balances estrogen & fluids in cells
• Decreases rate of cancer on all PR
• Does not change the good effects of estrogen
on blood flow
• Enhances thyroid
• Calming
• Cycle regulation
• Messages body to maintain conception
More good stuff
PROGESTERONE RULES!
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•
•
•
•
•
•
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Short half life
Lowers BP, relaxes smpooth muscle
Normalizes/improves libido
Natural antidepressant
Increases metabolic rate & scalp hair as well
Anti-inflammatory
Prevents menstrual migraines
Promotes myelination and protects nerves from injury
Lowers cholesterol
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Natural progesterone
DOSING TIDBITS…
Can be taken orally or
transdermal
SL is a form of transdermal
For insomnia take the oral
Prometrium is micronized in
a base of peanut oil
Absorption rate for oral
increases with age
Adrenaline blocks
progesterone receptors
Transdermal progesterone
• Hormones are all lipophilic
• Subcu receptors get loaded over time, so rotate sites
• If commercial cream, not compounded, be sure label
says USP progesterone or it may lack enzyme for
conversion
• If exact dosing is required, do SL or injectible
Testosterone
THE MASCULINE HORMONE
• An androgen, usually seen
as the male hormone b/c it
stimulates male secondary
sex characteristic
• Estrogen stands in
opposition- a balancing act
• Made in the adrenal glands
and ovaries
• Production decreases with
age
• Only 1% of circulating
testosterone is free and
bioavailable, the rest is
bound to SHBG
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testosterone
CON’T
• Inhibits bone catabolism
• Decreases body fat, increases muscle mass
• Increases libido
• Elevates norepinephrine in the brain
Testosterone imbalance
• Androgen dominance is the most common hormonal
disorder in women
• PCOS
• Signs and symptoms:
anger agitation
insulin resistance
fluid retention hirsutism
infertility
irregular menses
Testing and Dosing
SOME QUICK FACTS
• Serum progesterone WNL:
before ovulating/after menopause – 1ng/ml
mid cycle- 5-20ng/ml
pregnant- 1st 11.2-90 ng.ml
2nd 25.6-89.4
3rd 48.4-42.5
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Estrogen levels (E2)
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During menses 45 ng/ml
Ovulation peaks near 400pg.ml
Pregnancy- up to 100x higher
After menopause 10-20 pg/ml
(optimal is 40-50 pg/ml)
Testosterone levels
• Females 12-16 yr
•
19 yr+
<7-75 ng/ml
8-60 ng/ml
• Average adult male 270-1,070 ng/ml
• Average adult female 15-70 ng/ml
Dosing
QUICK AND DIRTY….
Remember dosing can be
‘usual amounts’ but will
always be evaluated
individually in the patient !
Bioidentical preparations are
compounded by the
compounding pharmacist
according to your orders.
These can be shipped to
patient.
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Beginning dosages for common
problems:
• Menstrual migraines d 22-25
• Endometriosis
rec’d salivary testing to determine E2 dominance
Progesterone 200mg-400mg ½ troche BID
Menopause Syndrome
Biest 1-2mg/Progesterone 200mg
½ troche SL BID daily or cyclic
• PPD
• PP insomnia
Progesterone 400mg SL daily
Fibroids
progesterone 200mg qd or cyclic
PCOS
progesterone 200mg ½ troche BID cyclic
• Premature Ovarian Decline
• Premature Ovarian Failure
No menses, FSH >20 mlU/ml
Needs Biest 0.5mg/Progesterone 200mg cyclic
+heat + TCM herbs
Many women can achieve menstruation and
ovulation
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• Luteal phase infertility
progesterone 200mg ½ troche SL BID
on day 14-28 of cycle
Patient should have been monitoring ovulation
to insure correct timing
The 3 P’s
• PCOS
metformin
progesterone 200mg ½ troche SL BID cyclic
• PMDD usually progesterone 200-400mg SL qd or cyclic
day 12-24
Look at testosterone levels and estrogen levels, can be low
• PMS
progesterone 200mg troche ½ SL BID
d 12-24 of cycle
A little more about PMS
SOME WOMEN HAVE LOW E2, NORMAL P4
• If the progesterone is not effect give
phytoestrogens and/or herbs:
Angelical sinensis (Dong Quai)
Borage oil
EPO
Ginko
Black Cohosh
Vitex agnus castus
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A few good resources
Clinical Gynecologic Endocrinology and Infertility 2010
by Marc A. Fritz MD and Leon Speroff MD
What You Must Know About Women’s Hormones
By Pamela W Smith, MD,MPH
http://discovery.lifemapsc.com/library/review-of-medicalembryology
http://e.hormone.tulane.edu/learning/estrogens.html
Thank you for attending!
Any Questions?
My contact info:
[email protected]
Wellspan Family Health Georgetown
(717)806-3800
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