Endometriosis and Hormonal Therapy

Endometriosis and Hormonal Therapy

Hormones are chemicals produced by glands of the endocrine system which travel through the bloodstream and interact with specific target cells. These cells have receptor sites where the hormones bind like a lock and key mechanism. Many hormones are interactive and interdependent (1), making the endocrine system extremely complex and difficult to fully understand.

As it is widely recognized that estrogen affects the growth of endometriosis, conventional treatment often includes hormonal management to suppress estrogen function (2). Hormonal therapy is also used to treat post-menopausal symptoms (3).

Since the Women's Health Initiative (WHI) Study was published in 2002 (4), there has been significant debate within the medical community about which types of hormones should be available for patients. Much of the argument centers around safety and efficacy questions concerning the use of pharmacy-compounded bioidentical hormones (BIH) versus traditionally-used pharmaceuticals (5).

Synthetic Hormones

Progestins and gonadotropin-releasing hormone agonists (GnRH) are frequently used to stop menstruation (2). These compounds are synthetic (man-made) drugs, whose chemical structure differs from hormones made in the body (5). Use of these drugs can cause significant side effects which some patients may find difficult to tolerate (5).

Progestins and animal-based estrogens have been used for many years for hormone replacement therapy (HRT) in menopausal women (4). However, since the WHI Study revealed an increased risk of breast cancer, cardiovascular disease and stroke in women taking these compounds, use of these products has declined sharply (3).

Bioidentical Hormones

Some doctors advocate the use of bioidentical hormones over conventional preparations, claiming they carry less risk of side effects (5,6). These hormones are defined as having the same chemical structure as hormones made in the body (6). Bioidentical hormones can be prescribed in several forms including pharmacy-compounded transdermal creams and subdermal pellets as well as pharmaceutical preparations of oral pills/capsules and transdermal patches (3).

Bioidentical hormones are widely used for post-menopausal HRT (3) and in some cases, have also been used to stop menstruation in the same way synthetic progestins are used (7).

Personal Commentary

In doing our own research, we've encountered strong opinions on both sides of this argument. On one extreme there are doctors who advocate high levels of bioidentical hormones in a cycling regimen with the goal of inducing a menopausal woman to start cycling again. On the other extreme, there are doctors who insist that the FDA-approved synthetic drug with well-documented side effects is really safer than the bioidentical hormone which is chemically identical to the molecule made by the ovaries. (The particularly shrill tone of the Position Statement released by The Endocrine Society defending the molecular structure of medroxyprogesterone, makes one think their primary concern might not be patient safety.) As with any topic where politics and money are involved, there is a lot to gain and a lot to lose for both sides and the patient is left to sort out for themselves, the truth from the hype.

While some of the patients we've corresponded with have had success on synthetic hormonal drugs, others reported adverse side effects and/or continuing collapses. Speaking from our own experience, Lori had severe bleeding and developed anemia and hypertension following use of these drugs, as well as a blocked renal artery which led to the loss of her kidney. Was that the result of her progestin use? We don't know for sure, but blood clots can be a side effect. What we do know, is that we've done well on bioidentical hormones for several years now, and do experience fewer menopausal symptoms than we did without HRT. We have also received a good report from one patient whose collapses stopped (as well as her monthly chest pain) after she began receiving bioidentical subdermal pellets to balance her hormones.

The bottom line about hormones is that there is a lot of information out there, some of which is complicated and much of which is conflicting. Each patient must educate themselves the best they can so they can have an intelligent conversation with their doctor about these issues.

Useful Links and References

Endometriosis.org (Information about pharmaceutical hormonal drugs)

The Endocrine Society (Strongly critical of bioidentical hormones)

Women's International Pharmacy (Advocate of bioidentical hormones)

John Carr MD (Advocate of bioidentical hormones; web site features videos about BIH hormone use)

Jeffrey Dach MD (Advocate of bioidentical hormones; web site features articles about BIH hormone debate)

What Your Doctor May Not Tell You About Pre-menopause, Balance Your Hormones and Your Life from Thirty to Fifty, John Lee, MD Dr. John Lee, MD (Advocate of bioidentical hormones)

There is an excellent resource for information and support for women who have experienced or are considering a hysterectomy. The site includes a wide variety of hysterectomy information, including pre-op and post-op issues, hormone replacement therapy, anemia and hysterectomy recovery. Hyster Sisters.com and their related web site The Hormone Jungle.com

(1) Human Physiology. Stuart Ira Fox, WCB/McGraw-Hill Companies, Inc. 1999; pgs 290-292

(2) Endometriosis - Morphology, clinical presentations and molecular pathology. Agarwal N, Subramanian A. J Lab Physicians [serial online] 2010 [cited 2012 Jan 21];2:1-9, HERS Research Group. JAMA. 2002 Jul 3;288(1):49-57

(3) Bioidentical Hormone Therapy. Files JA, Ko MG, Pruthi S. Mayo Clin Proc. 2011;86(7):673-680

(4) Risks and Benefits of Estrogen Plus Progestin in Healthy Postmenopausal Women: Principal Results from the Women's Health Initiative Randomized Controlled Trial. Rossouw J, et al, Writing Group for the Women's Health Initiative Investigators. JAMA. 2002 Jul 17;288(3):321-333

(5) The bioidentical hormone debate: are bioidentical hormones (estradiol, estriol, and progesterone) safer or more efficacious than commonly used synthetic versions in hormone replacement therapy? Holtorf K. Postgrad Med. 2009 Jan;121(1):73-85

(6) Effectiveness of Compounded Bioidentical Hormone Replacement Therapy: An Observational Cohort Study Ruiz AD, Daniels KR, Barner JC, Carson JJ, Frei CR. BMC Women's Health. 2011;11:27

(7) Jerilynn Prior, MD, The Centre for Menstrual Cycle and Ovulation Research (CeMCOR)

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	Endometriosis and Hormonal Therapy Hormones are chemicals produced by glands of the endocrine system which travel through the bloodstream and interact with specific target cells. These cells have receptor sites where the hormones bind like a lock and key mechanism. Many hormones are interactive and interdependent (1), making the endocrine system extremely complex and difficult to fully understand. As it is widely recognized that estrogen affects the growth of endometriosis, conventional treatment often includes hormonal management to suppress estrogen function (2). Hormonal therapy is also used to treat post-menopausal symptoms (3). Since the Women's Health Initiative (WHI) Study was published in 2002 (4), there has been significant debate within the medical community about which types of hormones should be available for patients. Much of the argument centers around safety and efficacy questions concerning the use of pharmacy-compounded bioidentical hormones (BIH) versus traditionally-used pharmaceuticals (5). Synthetic Hormones Progestins and gonadotropin-releasing hormone agonists (GnRH) are frequently used to stop menstruation (2). These compounds are synthetic (man-made) drugs, whose chemical structure differs from hormones made in the body (5). Use of these drugs can cause significant side effects which some patients may find difficult to tolerate (5). Progestins and animal-based estrogens have been used for many years for hormone replacement therapy (HRT) in menopausal women (4). However, since the WHI Study revealed an increased risk of breast cancer, cardiovascular disease and stroke in women taking these compounds, use of these products has declined sharply (3). Bioidentical Hormones Some doctors advocate the use of bioidentical hormones over conventional preparations, claiming they carry less risk of side effects (5,6). These hormones are defined as having the same chemical structure as hormones made in the body (6). Bioidentical hormones can be prescribed in several forms including pharmacy-compounded transdermal creams and subdermal pellets as well as pharmaceutical preparations of oral pills/capsules and transdermal patches (3). Bioidentical hormones are widely used for post-menopausal HRT (3) and in some cases, have also been used to stop menstruation in the same way synthetic progestins are used (7). Personal Commentary In doing our own research, we've encountered strong opinions on both sides of this argument. On one extreme there are doctors who advocate high levels of bioidentical hormones in a cycling regimen with the goal of inducing a menopausal woman to start cycling again. On the other extreme, there are doctors who insist that the FDA-approved synthetic drug with well-documented side effects is really safer than the bioidentical hormone which is chemically identical to the molecule made by the ovaries. (The particularly shrill tone of the Position Statement released by The Endocrine Society defending the molecular structure of medroxyprogesterone, makes one think their primary concern might not be patient safety.) As with any topic where politics and money are involved, there is a lot to gain and a lot to lose for both sides and the patient is left to sort out for themselves, the truth from the hype. While some of the patients we've corresponded with have had success on synthetic hormonal drugs, others reported adverse side effects and/or continuing collapses. Speaking from our own experience, Lori had severe bleeding and developed anemia and hypertension following use of these drugs, as well as a blocked renal artery which led to the loss of her kidney. Was that the result of her progestin use? We don't know for sure, but blood clots can be a side effect. What we do know, is that we've done well on bioidentical hormones for several years now, and do experience fewer menopausal symptoms than we did without HRT. We have also received a good report from one patient whose collapses stopped (as well as her monthly chest pain) after she began receiving bioidentical subdermal pellets to balance her hormones. The bottom line about hormones is that there is a lot of information out there, some of which is complicated and much of which is conflicting. Each patient must educate themselves the best they can so they can have an intelligent conversation with their doctor about these issues. Useful Links and References Endometriosis.org (Information about pharmaceutical hormonal drugs) The Endocrine Society (Strongly critical of bioidentical hormones) Women's International Pharmacy (Advocate of bioidentical hormones) John Carr MD (Advocate of bioidentical hormones; web site features videos about BIH hormone use) Jeffrey Dach MD (Advocate of bioidentical hormones; web site features articles about BIH hormone debate) What Your Doctor May Not Tell You About Pre-menopause, Balance Your Hormones and Your Life from Thirty to Fifty, John Lee, MD Dr. John Lee, MD (Advocate of bioidentical hormones) There is an excellent resource for information and support for women who have experienced or are considering a hysterectomy. The site includes a wide variety of hysterectomy information, including pre-op and post-op issues, hormone replacement therapy, anemia and hysterectomy recovery. Hyster Sisters.com and their related web site The Hormone Jungle.com (1) Human Physiology. Stuart Ira Fox, WCB/McGraw-Hill Companies, Inc. 1999; pgs 290-292 (2) Endometriosis - Morphology, clinical presentations and molecular pathology. Agarwal N, Subramanian A. J Lab Physicians [serial online] 2010 [cited 2012 Jan 21];2:1-9, HERS Research Group. JAMA. 2002 Jul 3;288(1):49-57 (3) Bioidentical Hormone Therapy. Files JA, Ko MG, Pruthi S. Mayo Clin Proc. 2011;86(7):673-680 (4) Risks and Benefits of Estrogen Plus Progestin in Healthy Postmenopausal Women: Principal Results from the Women's Health Initiative Randomized Controlled Trial. Rossouw J, et al, Writing Group for the Women's Health Initiative Investigators. JAMA. 2002 Jul 17;288(3):321-333 (5) The bioidentical hormone debate: are bioidentical hormones (estradiol, estriol, and progesterone) safer or more efficacious than commonly used synthetic versions in hormone replacement therapy? Holtorf K. Postgrad Med. 2009 Jan;121(1):73-85 (6) Effectiveness of Compounded Bioidentical Hormone Replacement Therapy: An Observational Cohort Study Ruiz AD, Daniels KR, Barner JC, Carson JJ, Frei CR. BMC Women's Health. 2011;11:27 (7) Jerilynn Prior, MD, The Centre for Menstrual Cycle and Ovulation Research (CeMCOR) Copyright 2008. catamenial-pneumothorax.com. All rights reserved.