By Alicia Stanton, M.D., OBGYN
Chief Medical Officer

February 24, 2009

I know that there is a middle ground in the bioidentical hormone debate. Suzanne Somers is on one side of the debate. Pat Wingert and Barbara Kantrowitz appear to be on the other side. The focus of their criticism of “The Oprah Winfrey Show” was mainly on Suzanne Somers and her hormone regimen. Dr Streicher did a great job representing “mainstream medicine.” Her point that there are a few pharmaceutical bioidentical hormones available that mainstream physicians can prescribe is well taken. I was also originally trained in Ob/Gyn and practiced for 10 years before converting my practice solely to nutrition and bioidentical hormone therapy. I currently utilize both compounded and pharmaceutically available bioidentical hormones for my patients – each patient gets what works best for them.

In addition to my medical school training and my residency in Ob/Gyn, I have completed hundreds of subsequent hours of training in Functional Medicine, nutrition and bioidentical hormone therapy. There are many other physicians trained like I am – and, the number of physicians interested in this type of medicine is increasing every day. That being said, the criticism of Ms. Wingert and Ms. Kantrowitz is that these hormones are being prescribed by people who have no training and are not experts. I beg to differ. For the past 7 years, I have been studying bioidentical hormones with the American Academy of Anti-Aging and the Institute of Functional Medicine. During that time, I have developed a stronger understanding and appreciation of physiology and biochemistry than I ever had when I left medical school. I also believe that the current diet, stress levels and toxin exposure of our current population has changed the hormonal milieu to such an extent that most of what we learned in medical school no longer pertains to the patients we have sitting in front of us today. All doctors need extra training to really understand what we’re now seeing. Oprah had Dr. Christianne Northrup on as a guest for both of her shows on bioidentical hormones. Dr. Northrup is a well recognized expert in the field and her book, The Wisdom of Menopause, is brilliant. I’m sure that Dr. Streicher would not have been underlining many sentences in that book. As a matter of fact, Dr. Northrup and Dr. Streicher agreed on a number of points. However, they did disagree on the term “bioidentical.” Dr. Streicher described it as a “marketing term” of no biological significance while Dr. Northrup felt it simply meant “the exact same structure as what is produced in the body.” I agree with Dr. Northrup.

The studies that are being quoted regarding the dangers of hormone therapy are studies that utilize non-bioidentical hormones such as Premarin and Provera. It is impossible to directly compare Premarin (conjugated equine estrogen) with estradiol (our actual hormone) or Provera (medroxyprogesterone acetate) with progesterone (our actual hormone). The conclusions of these studies cannot be extrapolated to include all hormones. There are many studies that do demonstrate improved safety when hormones which are bioidentical to humans are used. Dr. Kent Holtorf just published an extensive study comparing bioidentical to non-bioidentical hormones and showed a reduced breast cancer risk with progesterone as opposed to Provera. That being said, hormone therapy is not for everyone. It remains a decision to be made by an informed patient with his or her highly trained and specialized physician. It is interesting to consider that breast cancer rates have fallen in the years since 2002 when hormone therapy had been less popular. Is that because the use of hormones in general is down, or is it because the use of Premarin and Provera is down? I believe it is the latter. There are studies that show Provera to be carcinogenic – especially when compared to progesterone. Also, it has been shown that Premarin preferentially metabolizes into the most dangerous metabolites, 4-hydroxyquinones. These two factors would lead you to think that reducing the use of Premarin and Provera would reduce the incidence of breast cancer. There is a great deal of controversy regarding Suzanne Somers and her use of hormones with a history of breast cancer. Again, those discussions need tooccur with a patient and her physician. However, there is some evidence that testosterone may be protective and it is important to realize that these patients may also have problems with their adrenals, thyroid and insulin levels. Thus, there may be ways that patients could alleviate some symptoms without using estrogen.

It is intriguing to me that “the decision to take supplemental progesterone despite her hysterectomy baffles mainstream doctors.” Dr. Nanette Santoro states, “There is no medical reason to use progesterone after a hysterectomy.” That is what I used to think. However, when you review biochemistry and hormone pathways, you realize that progesterone is an important building block for other hormones. Progesterone is also the hormone that balances estrogen. The main reason it became “medically necessary” only when there was still a uterus in place was that bleeding and endometrial cancer were the result of unopposed estrogen when the patient had a uterus. So, she was given Provera to keep her from developing irregular bleeding or endometrial cancer. Provera did work in that capacity. However, Provera is a progestin, not progesterone. So, the patient often didn’t get any other benefits from Provera – as a matter of fact, many women didn’t feel good on it. So, the main practice was to only give Provera when the patient had a uterus. That practice has distilled to “there is no medical reason to use progesterone after a hysterectomy.” Progesterone has over 400 functions in the body. In addition to balancing estrogen and being a building block for other hormones including cortisol and the sex hormones, it helps to rebuild bone, it is a natural calming agent, a diuretic and a sleep initiator. By giving women with no uterus estrogen only, we create a state of estrogen dominance that may lead to bloating, breast enlargement and tenderness, recurrent hot flushes as the estrogen receptors shut down and anxiety. Many women in my practice with significant perimenopausal and menopausal symptoms have great improvement utilizing ONLY progesterone.

Oprah never said that she was going to clear up the controversy regarding bioidentical hormones – she was going to start the conversation. When you start a conversation, you usually stir up all kinds of controversy. I applaud her ability to get people talking about it. Although it’s not for everyone, it is great to see that so many women (and men) are becoming aware that there are options. In the end, the main goal is to let everyone know that they have a choice. The one point of contention that I had with Oprah’s shows is that both of them focused on hormone protocols that were higher dosages than what many of us use. I would welcome another show with Dr. Streicher, Dr. Northrup and a few doctors who use the lower dose regimens and combinations of pharmaceutical and compounded prescriptions. Many of the physicians trained by the American Academy of Anti-Aging and the Institute of Functional Medicine practice in a more conservative manner than what was described on Oprah’s shows. Overall, I love the conversation and the fact that there are so many points of view. It gives everyone a chance to ask questions and learn more for themselves.