Estrogen – The One That Started it All
Estrogen restoration is the treatment that initiated the field of hormone replacement therapy. This hormone is responsible for a number of health benefits for women, but also in men. The loss of this hormone during menopause in women and with age in men has many negative and deleterious effects. These include an increased risk of heart disease, stroke, cholesterol abnormalities, Alzheimer’s disease, memory loss, osteoporosis, skin atrophy, depression, weight gain, vaginal atrophy (women), and urinary tract atrophy (women). These problems thus cause a significant burden on the health care system and increase costs astronomically due to polypharmacy (multiple drugs), ER visits and hospitalizations, surgeries (cardiac and orthopedic as examples), procedures (cardiac catheterizations and kyphoplasties), nursing home stays, and lost work days for caregivers. These are issues that may be easily avoided today and in the future with appropriate treatment including estrogen replacement (and progesterone for women).
Estrogen has been unjustly vilified in the medical community and by the press. The panic started after the Women’s Health Initiative (WHI) study. This study was completed using the synthetic forms of estrogen (Premarin) and progestins (Provera) and not the bio-identical equivalents of estradiol and progesterone. The study actually showed that the initiation of Premarin at menopause showed a reduced risk of heart disease and stroke. There was also no increased risk of breast cancer with Premarin alone. There was an increased risk of blood clots with Premarin. The bad actor in the study was the Provera. This synthetic progestin increased the risk of breast cancer and therefore was the culprit for the rise in this disease (not the Premarin). The Provera also further increased the risk of blood clots, pulmonary embolus (blood clot in the lungs), heart attack, and stroke. Subsequent studies have shown no increased risk for breast cancer, blood clot, stroke, or heart attack for the bio-identical hormones estradiol and progesterone. In fact, these hormones have been shown to be protective if started at menopause. Despite the data supporting the positive effects of bio-identical hormones and the negative and potentially dangerous effects of synthetic hormones, they (synthetic hormones) remain on the market. The pharmaceutical industry has again duped the public, and the medical community as a whole has bought into the lie without protest. Profits again are placed at a higher priority than the health of the population at large. The evidence-based scientific information is again ignored and harmful effects follow. This vicious cycle further fuels the drug industry to provide drugs to treat symptoms instead of providing cures. As noted in the aforementioned chapters, this seems to be a common theme and refrain from the status quo and a continuation of the medical industrial complex. It is thus our job (me as the physician and you as the patient) to break this cycle and trumpet facts over distortions and deceitful marketing.
Estrogen in men is incredibly important as it protects against many of the negative effects that also afflict women. These include cardiovascular disease, stroke, cholesterol abnormalities, osteoporosis, dementia, Alzheimer’s disease, increased visceral fat/weight gain, and skin thinning. Estrogen in men is produced by the aromatization (conversion) of testosterone to estrogen. These adverse effects may become particularly pronounced when either testosterone is diminished or estrogen conversion is blocked. The former may occur with age and the subsequent decrease in testosterone levels or with chemical castration via Lupron (decreases testosterone and estrogen production) and Casodex (block testosterone receptors) to treat prostate cancer. The treatment of testosterone loss due to age would be testosterone replacement. The treatment for prostate cancer would be to start oral estrogen as it provides two benefits. These would include improving symptoms of estrogen loss and treating the prostate cancer. The latter (estrogen blockade) is advocated by the bodybuilding community and some wellness organizations as a way to maximize the activity of testosterone. This action is commonly executed by the prescription medicine Arimidex which is an aromatase inhibitor that blocks the conversion of testosterone to estrogen. Intuitively, it seems to make sense that optimal testosterone is good, then having more must be better.
It also seems ideal to limit the production of the female hormone estrogen when the male hormone effects are trying to be maximized. Studies, however, have shown that blocking estrogen is a terrible idea and significantly increases side effects. These include heart attack, stroke, cholesterol abnormalities, vascular disease (narrowing of the arteries and veins), increased visceral fat, diabetes, hypertension, gynecomastia (man boobs), and low libido. These effects seem counterintuitive, but they have been borne out in multiple studies. If you look at estrogen levels in men in their teenage years and their twenties, they run in the 100-200 range as testosterone levels are optimal from endogenous production. At no time do we block estrogen in these age groups; yet, we would want to negatively affect it in these older populations when we attempt to maximize testosterone. It makes no sense, and thus we need to follow the science and not “bro science” (that purported in gyms and in online chat rooms to be true). All of these interventions (adding estrogen or testosterone) or lack thereof (not blocking estrogen) have been demonstrated to improve the overall well-being and longevity of the patient (you).