David Greenspan, ND
It is wonderful to see, as we have seen in so many places in medicine, that principles and practices of naturopathic medicine are becoming recognized as valid and safe when it comes to hormone balancing and hormone replacement therapy. As with many modalities in diagnosis and care, the fact that we NDs have been using bioidentical hormone replacement therapy (BHRT) for literally decades before the current wave of popularity hit, reminds us that our principles have always been sound. And, whether or not we gain notoriety for having brought forward and having preserved practices such as BHRT, we must engage in the forward momentum currently focusing on this modality and remember what it is that we contribute that is unique to our professional heritage.
The Basics
This article pertains mainly to age-related steroid hormone replacement therapy such as estrogen, progesterone and testosterone.
The use of hormone therapies dates back to the early 20th century (and perhaps earlier) when the use of extracts of glands from animals, or the glandular material itself, was used to treat certain ailments. Through the success of using glandular products, eventually hormones were discovered to be the “active component” that could be purified and used instead of the whole gland. Glandular therapy still exists and is available from numerous manufacturers. Be aware that in producing these products, the companies must extract all traces of hormones so the material in the resulting glandular products is presumably only the material that is used when the gland is actively making hormones and performing its functions in the body.
BHRT generally pertains to the care of menopausal women, although its scope is much broader. The “proper” use of the term BHRT includes any hormone that is used in therapy and that has the identical molecular structure to the hormones found in the body. As noted above, the estrogens, progesterone and testosterone are the hormones most widely used and these will be our focus.
Brief History of Synthetic Hormone Replacement Therapy
In the 1930s, after the use of whole glandular extracts yielded the discovery of hormones, it became necessary to find a cost-effective source of hormones. The hormone most in demand was estrogen. A pharmaceutical company found a way to produce large quantities of “estrogen” using concentrates from pregnant mares that were chemically modified in the laboratory to make them longer-lasting in the human body. These branded conjugated equine estrogens became the most widely prescribed pharmaceutical item for decades. During this time, a significant increase in uterine cancer was observed and this reduced the perceived safety of the branded conjugated equine estrogens and hormone replacement therapy (HRT). Interestingly, it is now known that there are over 200 steroidal/hormonal compounds in the conjugated equine estrogens such as the popular branded product.
For example, in 1938 an American biochemist, Russell E. Marker, manufactured progesterone in a laboratory by converting another substance, diosgenin, found in Dioscorea villosa into progesterone through a series of chemical changes. Also, the steroid substrate stigmasterol is taken from Glycine max and converted into progesterone. Soon after this breakthrough pharmaceutical companies then took progesterone and changed it further to give “synthetic” progestins, also called progestagens. These are compounds with actions similar in some respects to progesterone, but not naturally occurring and therefore patentable.
Since the 1940s G. max, Dioscorea and other plants from the tuber family have been used to make progesterone. It is very important to understand that G. max and Dioscorea DO NOT contain progesterone. Today progesterone is produced for pharmaceutical purposes in the laboratory with the aid of an enzyme. The vast majority of progesterone is sourced from G. max. And, interestingly, the major sources of bioidentical hormones are the pharmaceutical companies themselves. We simply purchase them for use at a manufacturing stage that they are familiar to the body and the pharmaceutical companies manufacture them further to produce unique hormones of their own propriety which they can patent and, at least for 17 years, have financial and manufacturing exclusivity for their “invention”.
For the record, the author understands that bioidentical estrogen is manufactured from G. max as well as from “calabar” beans, similar to fava. However, we are all aware of the three primary types of estrogens used in the BHRT arena. There has been a renewed interest and pursuit of natural hormones (BHRT), though there is some confusion about which ones to use and in what proportion. However, as I write this, I am informed that estriol has been successfully removed for availability to compounding pharmacies and their suppliers through legislative action. That means we will be adjusting our formulas dramatically as this hormone has comprised as much as 80% of standard BHRT formulas.
Once it was discovered that using synthetic progesterone (a progestin) along with the branded conjugated equine estrogens reduced the cancer incidence, or so they thought, the use of this form of HRT was resumed in full. While many women benefited from the use of a branded product consisting of conjugated estrogens/medroxyprogesterone acetate, it was finally revealed through the “Women’s Health Initiative” study that even this form of HRT leads to an increase in breast cancer, heart attack and stroke. In fact, both hormone products in these medicines are considered synthetic. In 2002, the flight away from conventional HRT and toward BHRT began.
BHRT gets “discovered”
As the concern about health problems led many women to question the use of, or to discontinue their synthetic HRT, they needed solutions and substitutes to their ongoing need for hormonal stability. Previous to the research news in 2002, the use of BHRT was loosely coined as “natural” hormones and enjoyed a relatively low usage, but was always in demand and slowly growing. I personally have used these “natural” hormones, now called bioidentical, beginning in 1988 when I was doing my clinical shifts in school. They were widely in use at that time in the naturopathic profession as they probably had been when their production from plant sources became economically cost-effective.
What is a “Naturopathic Approach” to Hormone Balancing?
I have carefully chosen not to write “hormone therapy” in the subtitle above because one of the things I believe our naturopathic principles and practices offer us is the versatility to use non-hormone approaches to balance hormones and bring up/normalize levels of depleted hormones. First we need to organize our approach to hormonally challenged patients. It is much easier to provide care when we know what our aim and ultimate goal are.
For that, we must depart from menopause as the primary focus and just look at the global phenomenon of hormone imbalance. This may include gonadal, adrenal, liver, fat, pituitary and thyroid, to name a few.
We can also look at this from a “systems” perspective, understanding that the endocrine system works in concert with the nervous system, the glycemic regulation system, lymphatics, hepatobiliary system and the immune system, among others.
Using both a “hormone balancing” basis rather than a “hormone replacement” basis, as well as using a systems approach to care, is in the author’s opinion what distinguishes the naturopathic approach to hormone balance.
Hormone balancing is a more general term that allows for many naturopathic modalities to be utilized in the process. We can easily include dietary nutrition, orthomolecular nutrition, botanical medicine, homeopathy, and psycho-emotional care (stress management), as well as directly effective modalities (bio-energetics, acupuncture, laser, etc). I often find myself offering the option of these modalities to complement low dose BHRT (ie, using hormone balancing can reduce the dosing needs of the patient) as most patients are very imbalanced and depleted when they are evaluated and simply using the modalities takes too long to produce results and patients sometimes get impatient.
The systems approach is a very individualized way of optimizing organ functions, again with the intention of minimizing dose needs for BHRT. This is a complex process beyond the scope of this article but I will offer one example to illustrate. When the body is continuously under a perceived “stress”, there is often a suppression of endogenous hormone output and a redistribution of hormones such as pregnenolone and progesterone toward the increased production of stress hormones.
As nature would have it, the liver perceives these regulatory changes and can actually increase hormone output, albeit not the desired hormones. This liver “compensation” manifests with extra androgen output and sometimes weight gain. The androgens also contribute to weight gain. One of the symptoms that can accompany this is irritability, impatience and a feeling of the need to push harder toward the goals the individual may have (ie, typical effects from excess testosterone). The patient may present with the testosterone/androgen symptoms when the real disorder is the suppression of the primary gland (gonad).
Effective treatment includes restoring hormone levels of the primary gland (oftentimes an initial low dose BHRT) with a balancing treatment to both sedate the liver’s overactivity but, more importantly, a treatment to restore the primary gland, if it is salvageable. In addition, improving the metabolism of these hormones through the liver is vitally important to a successful course of care.
Interfering Factors in Hormone Balance
We are all well aware that “removing the obstacles to cure” is a critical step in creating an optimal course of care. The most common disruptors are stressors of all kinds; toxicities (chronic from the distant past or current), infections (chronic or current), nutrient deficiencies, and disturbances in regulation (ie, blood sugar). To address this last issue, we see that blood sugar must be controlled closely in order to have adequate hormone regulation. When blood sugar is prone to dropping low, the body responds by producing stress hormones to make a quicker release of bioavialable sugars, often by breaking down muscle tissue. First, we see a change in body shape and tone as people age. Then, the cycle of liver compensation described above can possibly result, leading to hormonal imbalance.
Hormone Balancing Strategies
First, we must address dysregulation. Next, because many people are overloaded due to poor nutrition or congested hepatobiliary metabolism, we should inquire and treat the adequate function of bile flow through the liver and intestines. When excess hormones and waste materials are removed, the receptors for hormones in all organs of the body tend to be more responsive to the signaling that comes from normal blood levels of hormones. Receptor function is a key.
Finally, with the body systems being addressed and nutrients being replenished, we find that the patient can recover with minimal doses of HRT. This minimizes risk of cancer and cardiovascular problems, as well as revealing an optimized metabolism.
Putting it All Together
There are a few items I would like to share that I mix and match depending on the patient. These are Dong quai, Chamaelirium luteum, Leonurus cardiaca, Mitchella repens, Glycyrrhiza glabra, Dioscorea villosa, Vitex agnus castus, Arctium lappa, Taraxacum officinalis, Chionanthus virginicus, and Chelidonium majus. I like using tinctures when possible for the flexibility in formulation and dosing they offer. Nutrients that I consider to be most supportive in restoring hormone function are glandular extracts, B complex, vitamin E and Omega 6 EFAs. There are innumerable products with combinations of nutrients and you may have found some that bring about changes in symptoms, but you want to see sustained functional change in your patients.
I have used pre- and post-salivary hormone testing on these nutrient/glandular/herbal protocols and have been pleased to see that they bring about positive changes in hormone output when used in moderate doses and with the synergy of each other. As a clinician, I am primarily interested in providing a treatment that produces the results patients are seeking rather than pursuing a reductionistic protocol that is easier to assess effects of individual components, but less effective in producing clinical and improved lab test results.
As the attending physician, you must make yourself abreast of all risks and contraindications to HRT, whether the treatment is natural or conventional. Be sure to perform your due diligence in prescribing any HRT and know that BHRT is very safe in the context of issues addressed in this article and wherever else you might find information.
CONTRAINDICATIONS FOR HRT
Absolute Contraindications
- undiagnosed vaginal bleeding
- severe liver disease
- pregnancy
- coronary artery disease (CAD)
- venous thrombosis
- Well-differentiated and early endometrial cancer (once treatment for the malignancy is complete, it is no longer an absolute contraindication.) Progestins alone may relieve symptoms if the patient is unable to tolerate estrogens.
Relative Contraindications
- migraine headaches
- personal history of breast cancer
- history of uterine fibroids
- atypical ductal hyperplasia of the breast
- active gallbladder disease (cholangitis, cholecystitis)
Potential Side Effects
- headache
- upset stomach
- stomach cramps or bloating
- diarrhea
- appetite and weight changes
- changes in sex drive or performance
- nervousness
- brown or black patches on the skin
- acne
- edema of hands, feet, or lower legs
- changes in menstruation
- breast tenderness, enlargement, or discharge
- sudden difficulty wearing contact lenses
Uncommon Symptoms
- double vision
- severe abdominal pain
- yellowing of skin or eyes
- severe mental depression
- unusual bleeding
- loss of appetite
- rash
- extreme tiredness or lack of energy
- fever
- dark-colored urine
- light colored stool
David Greenspan, ND has served as President of the Oregon Association of Naturopathic Physicians, and is currently Vice-President of the Board of Directors at the National College of Naturopathic Medicine. www.greenspangoodhealth.com.
