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From conventional gynecologists to women’s health experts in the Paleo community, the word tends to be the same: A woman after menopause should try to avoid hormone therapy. If absolutely necessary, she should take the least amount of hormones for the least amount of time possible. Two lines of argument attempt to justify that caution, but let’s see if they hold water. Because if you ask most women who are taking bioidentical hormone therapy, they want to know it’s safe—and they want to keep taking it!

First, it has been argued that, “respecting evolution,” we know that Paleolithic women didn’t have post-menopausal hormone therapy and they were “fine,” so why should we need this therapy? While there is some evidence that cultural milieu has an effect on the severity of hormone symptoms, we are each faced with the cultural milieu in which we find ourselves. I am not moving to Japan (where there are fewer menopausal symptoms) or going back in time to hunt mastodons. In my cultural milieu, menopausal symptoms abound.

Women suffer from hot flashes for 10 or more years, disrupting sleep and thereby wreaking havoc on mood and mental clarity. Osteoporosis affects both women and men. Vaginal dryness from lowered hormone levels causes discomfort during sex, and for some women, discomfort just walking and sitting! Not to mention, those same lowered hormone levels raise a woman’s risk of urinary incontinence and infections, which can lead to courses of antibiotics or possibly sepsis if not properly diagnosed.

More importantly when it comes to the Paleo community, let’s talk about what it means to respect evolution. It makes a lot of sense, in terms of evolution and selective advantage, for women to forego the physiologically costly process of reproduction when they pass a certain age. I am more valuable as a grandmother and more likely to be a liability to my “tribe” should I become pregnant after the age of 50. Once a person, male or female, is no longer capable of promoting the survival of the species, we are past the concern of evolution, which is all about reproduction and species survival.

So it behooves me personally, and the species generally, for me to be as healthy as possible after menopause, even if I take some twists and turns that aren’t exactly Paleo—such as reading articles on the Paleo Magazine website and taking bioidentical hormones, for as long as they are helpful. In my personal and professional opinion, that would be for the duration—for life.

The other arguments buys into the hype surrounding the 2002 Women’s Health Initiative study. This huge study caused mass media headlines when it was interrupted because of an increased risk of breast cancer in the women taking the experimental protocol. Of interest, there was also an increased risk of stroke and heart disease, but the women on the protocol also had less colon cancer and osteoporosis.

In the WHI study, the treatment intervention was a combination drug that included Premarin (estrogen from pregnant horses, quite unlike the human estrogen estradiol) and Provera (a synthetic progestin that shares only one physiological effect with progesterone, the human hormone). I would agree that this is a deadly combination; a woman taking PremPro or Provera alone is at increased risk for depression and breast cancer. Just say no!

But I like to say that WHI is the gift that keeps on giving: There has been a wealth of calculations made from the original data, and new research inspired by the questions raised by the WHI data. The truth, when you look at the whole story, is a bit different.

  1. Estrogen on its own, whether human or equine, appears to be neutral or protective against breast cancer. Many factors contribute to breast cancer, and adopting a Paleo lifestyle will confer many protections. Get good sleep, eat a balanced diet, stay active, get outside—these are all important in preventing breast cancer. I would add to the general Paleo routine, in this regard, to eat lots of cruciferous vegetables (broccoli, cauliflower, Brussels sprouts, cabbage) and limit yourself to one alcoholic beverage a day.
  2. In terms of heart disease, human estrogen appears safer than equine, in part because it can be applied topically, which eliminates the tendency of oral estrogen to increase blood clots, heart disease and strokes. When you take estrogen as a cream or a transdermal patch, you avoid the hazards of taking estrogen as a pill (which is another reason birth control pills shouldn’t be used for post-menopausal HRT).
  3. Studies comparing progestin (Provera from the WHI) to progesterone (the hormone made by women’s ovaries and duplicated in bioidentical progesterone) demonstrate a clear emotional benefit for progesterone over progestin. Furthermore, studies from Europe (we can count those, right?) show a neutral or protective effect on the risk of breast cancer!
  4. Estrogen receptors in the brain respond only to estradiol (the bioidentical human hormone, different from Premarin), yielding at least two effects. Estradiol works as an antidepressant in the brain and seems to have a role in scavenging the amyloid beta protein that leads to Alzheimer’s disease (AD). Women have higher rates of AD than men do, presumably due to their suddenly lowered estrogen levels. Men’s estrogen levels usually go up in later life, parallel to their beer belly; very fit Paleo men might want to check that they have at least a bare minimum estrogen level, as estrogen is key to maintaining strong bones, for both men and women.

Bioidentical hormone therapy can provide the perfect situation for a great interactive relationship between patient and doctor. When I prescribe hormones to a woman, we make the best guess of the right dose for her, something not predictable based on her size, but more likely based on the health of her liver, which is much harder to assess, as well as her menopausal symptoms. Hormones for a menopausal woman consist of estradiol (with or without estriol) applied to the skin, balanced by oral progesterone (orally to help with sleep), as well as topical testosterone (helps with mood, bone strength and libido) and vaginal estriol.

I feel so strongly about vaginal estriol that I think it should be mandatory for all women in menopause! It’s the best estrogen to maintain the health of the mucous membranes of the genitourinary tract, not only reducing vaginal dryness and discomfort, but improving urinary function on many levels: reducing incontinence, night-time urination, and urinary tract infections.

All the hormones require a doctor’s prescription. Estradiol and progesterone are available through conventional pharmacies; testosterone and estriol must be compounded. (Alternatively, vaginal estradiol is available through conventional pharmacies, but may be inferior to estriol in my experience.)

My patient is the first judge of the accuracy of the dose: How does it feel? Once we find a dose that she feels is right for her, I order blood tests to see if I’m comfortable with the blood levels of the hormones. Too low, and she won’t reap any of the benefits of hormones; too high, and I think she will eventually “feel” the hormones or resume her menstrual cycle. A mismatch between progesterone and estrogen can cause physical discomfort or post-menopausal bleeding. Once she’s happy and the blood tests are good, our work is still not done.

I order a special lab test, a urine panel that evaluates how well her body breaks down the estrogen as it passes through her liver. Liver detoxification of hormones consists of two phases, and both are important. If either phase is sluggish, estrogen metabolites can accumulate and cause a risk to that woman. Sluggish action of the liver can be boosted through proper foods (cruciferous vegetables, leafy greens and organ meats) or supplements (indole-3-carbinol, folate and methyl B12.)

If the process sounds complicated, perhaps it is, but it is not unlike the way I would approach any prescription. If you have scary-high blood pressure, you’re getting a drug today—but we’re also mounting a search to find out why, and then to identify which lifestyle modification will remedy the problem. In the case of menopause, no lifestyle modifications offer the full range of benefits conferred by bioidentical HRT.

What is the natural lifespan we can expect, given that our lives have not been as pristine as we might wish? At some point in our lives, we’ve all eaten too much tofu or cotton candy, swigged water from plastic bottles, and spent too much time online or in traffic lines, all of which lessen the lifespan we would enjoy if our lifestyle were more attuned to our evolutionary legacy. The environmental stresses and toxins alone might suggest we would live shorter lives than our Paleolithic ancestors.

Yet we don’t live in a Paleo world anymore. We live surrounded by a medical system that’s skilled at life-saving interventions. If we live to the age of 60, it’s likely that we will make it to 80, with a little help from our medical friends. I would suggest that for women looking forward to many years after the sunset of their reproductive years, properly prescribed bioidentical therapy can be a boon to both the length and quality of life, and needn’t be parsimoniously reserved only for those with the greatest levels of suffering.