HERBS AREN’T FOOD … THEY’RE DRUGS!
As you peruse the aisles at the vitamin shop in search of a natural remedy for your postreproductive problem, be aware of some basic facts about the herbal industry, and some potential pitfalls. Though it’s true that herbs and other natural products have provided the raw material for countless modern medications, there’s a great deal that’s simply not known.
In most cases, the effectiveness and proper doses are not very well established.
Both the benefits and the potential risks are often unclear. Herbs and supplements may have widely variable production standards, which can make it hard to pinpoint the dose entering your body. Safety is an issue. Serious side effects are quite possible, and the regulatory status of these substances is often poorly defined. Especially if you have a history of breast cancer, uterine cancer, or abnormal blood clotting, consult with your doctor before taking an estrogenlike herb. As with hormone pills and patches, certain estrogen precautions may apply.
Herbs mixed with some medications can, on rare occasion, create dangerous cocktails that can even be life-threatening. Be sure to check with your doctor before starting something new.
Watch the sugar content if you’re diabetic, and the salt content if you have high blood pressure. And if you’re pregnant, absolutely, positively never take these products without your doctor’s permission.
Stick with brands recommended by your doctor or pharmacist, and avoid products that make outrageous or overly broad claims. If it sounds too good to be true, it almost certainly is.
ESTROGEN AND OTHER HORMONES IN THEIR MANY MEDICAL FORMS
In July 2002, the medical world was rattled with some surprising news. According to a study of more than sixteen thousand postmenopausal women taking part in the Women’s Health Initiative, the use of combined conjugated equine estrogen and progestin (marketed as Prempro) caused more harm than benefit with respect to heart disease, strokes, and venous blood clots (a potentially dangerous condition) as compared with women taking a placebo pill. Although combined hormone therapy appeared to reduce hip fractures and colorectal cancer, these benefits were clearly outweighed by the increased cardiovascular risk. As a result, this portion of the Women’s Health Initiative was halted, and women on this type of combined hormone replacement are discontinuing their long-term use of this therapy in great numbers. At the very least, any woman taking this particular hormone replacement on a long-term basis should review the best approach for prevention with her doctor, in light of this most recent data.
TYPES OF ESTROGEN THERAPY
Type #1: Systemic Estrogen—Pills and Patches
Systemic medications are those that enter your bloodstream and travel throughout your whole body. For estrogen, this refers to pills or skin patches, prescribed either with the short-term goal of relieving symptoms like hot flashes or insomnia; or, more commonly, the long-term protection against heart disease and weakening of bones (osteoporosis). Other potential benefits around the body may exist, from the skin to the brain, but at this point, they are not fully understood.
Pills (Premarin, Estratab, Estrace, Ogen, femhrt, Activella, Ortho-Prefest). This is the most commonly prescribed form of systemic hormone replacement, used with the intent of providing protection against heart disease and osteoporosis. Although some of the estrogen that enters the bloodstream through these pills will eventually reach the vagina and pelvic tissues, it’s most often not enough to fully relieve symptomatic atrophy.
EMPOWERING PATIENTS: THE POWER OF HIGH-QUALITY RESEARCH
The Women’s Health Initiative provided a few important lessons. First, that one particular type of combined hormone replacement (Premarin with Provera) was not the preventive panacea it had hoped to be—a surprise ending for a long chapter in women’s health. Second, the Women’s Health Initiative emphasized the power of carefully performed research. A single randomized placebo-controlled study had more scientific impact than dozens of less well-designed studies that had come before it. With the results of one good trial, several decades of debate were abruptly settled, to the benefit of millions of women. Wouldn’t it be nice to see randomized trials looking at other questions in women’s health—for instance, determining the best labor strategies and pushing positions? High-quality research trials are expensive indeed, but as we’ve learned from the Women’s Health Initiative, they’re worth their weight in gold.
Patches (Estraderm, Climara, Alora, Vivelle, FemPatch, Esclim). These are the second most common form of synthetic estrogen. Medicated stickers applied to the trunk, buttocks, or abdomen, they are changed once or twice weekly. The available patches deliver estradiol, the most potent type of estrogen, and may reduce the odds of side effects caused by pills. Newer patches are thin, strong, and barely visible.
Is Systemic Estrogen Right for You?
Whether or not to begin using systemic (pill or patch) estrogen replacement therapy has proven to be a perplexing medical decision for many women. Are the symptoms of menopause pathological conditions that should be treated with medications, or natural transitions that should be met with simple changes to diet and lifestyle? Is hormone therapy an unnecessary manipulation of a natural event, or an example of preventive medicine at its finest—right up there with childhood vaccinations and Pap smears, increasing your odds for an increasingly long and healthy life? The basic biological dilemma revolves around the fact that estrogen affects the whole body, in both desirable locations (heart, bone, brain tissue, muscle, and fat) and undesirable ones (breast and uterus). While estrogen (when not combined with certain progestins) may offer some protection against osteoporosis and perhaps heart disease, it may also increase the risk of breast cancer. The ongoing estogen-only portion of the Women’s Health Initiative will hopefully provide answers to these questions in the coming years. In the meantime, does it suit your health goals to take this medication today, accepting its potential risks, to possibly prevent certain diseases decades from now? The pros and cons of taking systemic hormones after menopause remain central questions in women’s health and are the subject of an ongoing debate that’s worth discussing with your doctor.
Our questions regarding systemic hormone therapy are much more limited in scope. Can estrogen in the form of a pill or patch provide relief of incontinence, pelvic prolapse, sexual dysfunction, or any other postreproductive problems? If estrogen pills and patches do help to improve the bladder symptoms of urinary incontinence, the benefit is probably subtle. Some studies have found mild benefits to bladder control. Another study on hormone usage (the HERS trial)—as an aside to the main analysis concerning cardiovascular effects—raised concern that taking oral estrogen along with progesterone may even worsen incontinence for some women.
What about sexual function? For reasons both physical and psychological, systemic hormone replacement will provide benefit to some women. But in most cases, little improvement will be seen in the way of vaginal atrophy, often the biggest culprit leading to sexual troubles. Local estrogen therapy (vaginal creams and vaginal tablets) are the more effective route in this respect, and they can be used right along with oral estrogen for women whose vaginal atrophy is causing sexual, urinary, or other pelvic problems.
THE MANY FACES OF MEDICAL ESTROGEN
Though the term estrogen may sound like it refers to just one chemical, it’s a family of hormones derived from several different sources and consisting of several different types.
Conjugated equine estrogens (Premarin). Extracted from the urine of pregnant horses, containing several estrogen types.
Estradiol (Estrace). The most potent estrogen type, mirroring the estrogen produced most abundantly by your ovaries before menopause. The estradiol contained in Estrace is derived from plant sources.
Plant-derived estrogens (Cenestin, Gynodiol, Estratab, Menest).
Raloxifene (Evista). The breakthrough designer estrogen that has attracted enormous attention over the past several years. Belonging to the SERM (selective estrogen r
eceptor modulator) family of medications, it was developed with the hope of selectively providing all the benefits of estrogen while avoiding any increased risk of breast and uterine cancer. While raloxifene seems to offer protection for the heart and bones, it’s unclear whether its urogenital benefits—in other words, the prevention of atrophy in the vagina and bladder—are as potent as standard estrogen’s. Ongoing research trials should provide this answer in the near future.
Type #2: Local Estrogen Therapy—Creams, Gels, Tablets, and Rings
Local hormone replacement refers to creams, tablets, and devices that deliver estrogen straight to the target areas in your pelvis. Unlike systemic pills and patches, they tend not to enter the bloodstream very much, but by targeting symptoms of atrophy right at the source, they may provide even more relief. For instance, regularly using vaginal cream results in bloodstream levels of estrogen that are only a quarter of those reached with oral estrogens. This means that much higher doses can be delivered directly to the urogenital area, with far less chance of an undesirable effect elsewhere. If your vaginal, urethral, and bladder tissues have become thin, pale, or dry from atrophy, you may benefit from local estrogen therapy in one of a few available forms.
Vaginal estrogen creams (Estrace, Premarin, Ortho-Dienestrol, Ogen). Vaginal estrogen cream is a very effective treatment for vaginal and urinary symptoms resulting from atrophy. It’s inserted at bedtime with a measured applicator. Estrogen cream slowly but surely makes atrophic tissues thicker, better lubricated, and less prone to infection. Like all forms of local estrogen therapy, full effects may take six to twelve months to achieve. Estrogen cream comes in two forms in the United States: Premarin (conjugated equine estrogens) and Estrace (micronized estradiol). Estrogen gel exists in Europe, but it has not been FDA-approved in the United States. When used once or twice weekly, these creams raise blood estrogen levels minimally, which means that no protection can be expected for the heart or bones. On the other hand, if taken in high enough doses, estrogen in the vagina can enter the bloodstream in significant quantity and will carry risks similar to estrogen taken as a pill or patch.
Insert the cream at bedtime to minimize leakage while you’re upright and active.
Load the applicator by screwing it onto the opening of the tube. Fill the tube with the dose prescribed by your doctor.
Lie on your back and fold up your knees; or stand with one foot on a chair.
Insert the loaded applicator slowly, like a tampon, and press in the plunger. Don’t insert any farther than is comfortable.
Applicators are rinsed with warm water (not hot or boiling) and reused.
Vaginal tablets. Some women may prefer inserting a tablet, rather than cream, into the vagina. Similar local estrogen effects can be achieved.
Vagifem tablets come in preloaded disposable applicators.
Oral estrogen tablets can also be used for vaginal insertion, with your doctor’s guidance regarding the correct dosage.
Estrogen rings (Estring). This small Silastic ring has been designed for insertion into the vagina, like a small diaphragm, releasing estrogen over a span of three months at a very low but continuous dose. Every three months, it’s removed and replaced with a new ring. Great for women seeking the most hands-off approach to local estrogen therapy.
Local estrogen therapy might improve the following problems:
Overactive bladder and urge incontinence. Several clinical trials have shown that estrogen applied directly to the genital area can improve urinary urgency, daytime urinary frequency, and nighttime voiding. Although several studies have tried to show an effect of estrogen therapy on reducing the amount of actual urine leakage, the results have been mixed and inconclusive.
Stress incontinence. Vaginal estrogen treatment can help to improve stress incontinence by improving blood flow and making tissues around the urethra and vagina thicker and healthier. Although only one in ten of mild stress incontinence cases will be cured with estrogen therapy alone, at least 30 percent of them will be improved.
Urinary tract infections. Estrogen can help to prevent bladder infections in some women with signs of vaginal atrophy due to low estrogen levels, since the same changes associated with decreased estrogen (thinning and drying) tend to also affect the urethra, increasing its susceptibility to bacterial infection. Intravaginal estrogen in particular has been shown to decrease recurrent infections among postmenopausal women.
Painful intercourse. Vaginal atrophy is a major cause of painful intercourse after menopause, or dyspareunia, due to poorly lubricated and irritable vaginal skin. Estrogen replacement is a common remedy.
Pelvic prolapse. One 1995 study from the University of Southern California concluded that vaginal estrogen can decrease the need for surgery to repair prolapse by strengthening the vaginal skin and its connective-tissue components. We cannot conclude on this one study, however, that local estrogens help with mild prolapse.
WILL VAGINAL ESTROGEN CAUSE SIDE EFFECTS?
Low doses of vaginal estrogen are unlikely to cause any serious side effects; however, occasional breast pain or enlargement, vaginal itching, headaches, or nausea can occur. Higher doses may cause vaginal bleeding, a symptom that’s extremely important to report to your doctor. With the doses typically used, most women notice no side effects whatsoever—one major reason why vaginal estrogen therapy is a great preventive strategy.
SYSTEMIC VERSUS LOCAL HORMONES
The increasing array of local estrogens in today’s pharmacy allows women to treat their urogenital symptoms while minimizing the entry of estrogen into the bloodstream. Local replacement is free from most of the risks and side effects of estrogen therapy and is often the most potent form used in urogynecology. Before taking the leap into hormone therapy, take time to discuss your goals with a doctor, and assure yourself that you’re choosing the type and dosage that best suit your needs.
THE “OTHER” HORMONE: PROGESTERONE
When taken alone, estrogen causes the inner lining of the uterus to become overgrown, and over time, this can lead to malformed or even cancerous cells. If you still have a uterus and begin estrogen therapy, taking a progestin (synthetic progesterone) keeps the uterine lining in normal condition and nullifies the risk of uterine cancer. Unfortunately, progestins quite often cause side effects, including mood changes, weight gain or fluid retention, and breast tenderness. For better or worse, they should have no noticeable effect on the postreproductive problems that we’ve discussed.
Medroxyprogesterone acetate (Provera, Cycrin). The most commonly used progestin for hormone replacement. Very effective but likely to cause side effects.
Micronized natural progesterone (Prometrium). Natural progesterone in the form of tiny particles engineered for even absorption into the bloodstream.
Norethindrone acetate (Aygestin, Micronor), norgestimate (Ortho-Prefest). Mild synthetic progestins common in oral contraceptives; also useful for hormone replacement, especially if other progestins have caused bothersome side effects.
Vaginal cream or gel (Crinone). Yet another alternative for women who develop side effects to oral progestins.
Single combination packs (Prempro, Premphase, CombiPatch, femhrt, Ortho-Prefest). A number of HRT products include both an estrogen and progestin. As with all hormone therapy, their use over the short term and long run should be carefully discussed with your doctor.
OPTIMIZING PREVENTION AND IMPROVING YOUR FUNCTION AT ANY AGE
Whether you’re thirty-five or sixty-five, there are always opportunities to explore connections between your pelvic-floor symptoms and other aspects of your health and lifestyle. Minimizing your gynecologic problems, understanding the occasional link between general medical ailments and pelvic-floor symptoms, and managing menopause masterfully all may have an impact on your postreproductive symptoms. As you sort through pelvic-floor symptoms for the first time, keep these important connections in mind.
Seeing the Doctor
WHERE TO GO, WHAT TO EXPECT,
HOW TO PREPARE
Of the 10 million Americans with urinary incontinence, more than half have had no evaluation or treatment.
—National Institutes of Health, 1988 consensus conference
I consider my problem to be quite severe. It’s affected all my activities, even intercourse, ever since I had a baby. I’m too young to be going through this!
—Thirty-two-year-old, during her first office visit
So, now you have a new understanding of the likely roots of your problem, and you’ve decided, despite all the tips for getting started on your own, that it would be best to see a doctor. Good job. By the time most women seek medical help for incontinence, it’s after an average of seven years of leaking. Very frustrating years, without a doubt. Those with sexual dysfunction or prolapse will also endure years with symptoms, detracting from what should be active stages of their lives. Unfortunate but totally understandable. These are personal problems, after all—ones that just about anyone would prefer not to discuss. Many women simply find excuses: “This happens to everyone after having kids. What gives me the right to complain?” “As long as I don’t jog or play tennis, I’m fine. I’ll just become a walker.” “This is way too embarrassing—I’m going to cancel that appointment again.” According to national data, only one in five women with the symptoms we’ve discussed will see a specialist.
Ever Since I Had My Baby Page 28