Estrogen Replacement Therapy FAQs

Frederick R. Jelovsek MD

• Estrogen deficiency or systemic lupus (SLE) symptoms
• On estrogen, do persistent deficiency symptoms mean no bone or heart protection?
• Still having excess hair growth on ERT after ovaries removed for PCOD
• Converting from progesterone cream to estrogen with testosterone
• Difficulty getting to the right estrogen dose
• Can Tylenol® decrease estrogen levels?
• Breast tenderness upon starting estrogen therapy
• Too much, too little estrogen
• ?Viagra® for libido
• How long for breast cancer to appear if it's related to ERT?
• Why is testosterone added to estrogen replacement therapy?

Complement and white blood cell count (WBC) levels don't change with menopause that I know of. I agree that symptoms are often the best judge of hormone levels most of time.

The Estratest and Estratab you are taking won't show up on serum estradiol levels. The only way to tell between the SLE and menopause is to go high enough in your estrogens until there is no more symptom improvement or until you start getting estrogen excess symptoms (breast soreness, stomach upset).

On estrogen, do persistant deficiency symptoms mean no bone or heart protection?

How do you know whether the bones and circulatory system are protected in the woman who's symptoms are not controlled by .625 or even 1.25 of estrogen?

While lipids are not the total story in heart disease prevention, if your HDL (high density lipoprotein) levels are in normal or "good" range I would say you are on enough estrogen for circulatory system protection. If the levels are low, then you are not in the therapeutic ranges. I don't think I've seen low HDL levels on adequate HRT. Bone density is probably best checked by dual photon bone densitometry. Two measurements a year apart will tell if you are losing bone less fast, as fast, or faster as age matched women. There are some urinary tests that measure bone resorption and bone deposition. They are used with two measurements several months apart but their use is for before treatment with documented bone loss and then after treatment.

Still having excess hair growth on ERT after ovaries removed for PCOD

I was diagnosed with polycystic ovarian disease (PCOD after the birth of my first son at age 21. At that time I had one ovary removed due to an 8 pound dermoid cyst which had twisted. During the next few years I had wedge resection twice. I again developed large cysts and ultimately had a full hysterectomy at age 29. I am now 32 and taking 2.5 mg. Premarin daily My question is that I am still having problems with hot flashes, headaches, weight gain, as well as the excess hair. Since I was told that these symptoms would stop if there was an increase of estrogen, I am somewhat puzzled by the continuation. Do I need more to combat the "male" hormones? Are there methods to "undo" the PCOD symptoms, or why am I still having symptoms of PCOD if it is a disorder with the ovary production?

The continuation of "male hormone" signs of excess hair growth may be due to several causes. You may have a constitutional (hereditary) tendency toward excess hair growth. In this case your serum androgens would be normal. You may have an adrenal source of the androgens. The androstenedione or DHEA and 17-hydroxy progesterone may be elevated. There may also be peripheral conversion of estrogens to androgens by fat cells. Measuring serum androgens and 17-OH progesterone would be the next step.

The hot flashes are a different matter. 2.5 mg of Premarin should be enough to block hot flashes due to estrogen deficiency or at least most of them. It's hard to measure serum estrogens with Premarin since it has so many different estrogenic substances that won't show up on blood tests. It's possible that you are on too much estrogen and that can cause headaches. How did you get to that dose of Premarin?

Polycystic ovarian syndrome is also associated with insulin resistance, a tendency toward diabetes. This would be associated with weight gain in early stages. Sometimes it just happens with menopause, however. To tell, you need to have a glucose tolerance test and possibly a hemoglobin A1c. I don't know if the insulin resistance problem goes away with removal of the ovaries.

Converting from progesterone cream to estrogen with testosterone

I have a continuing struggle to get hormonally balanced since my TAH/BSO over a year ago. I am 37. I used nothing but natural progesterone cream up until one month ago. While it took away my hot flashes and night sweats, I am having increasing problems. Things were not too bad the first six months or so. After 3 months on ProGest@reg;, I actually started feeling great, losing weight without even trying and my energy was increasing, then about 8 months ago, being a little financially strapped and trying to make my ProGest® last, I thought things were going pretty well so I cut back to 1/2 tsp. 1x daily instead of the two times daily I was using it. It took about 2 months but then my hot flashes started returning and things just went downhill from there!

I did begin then in april taking it 2x daily (flashing and sweating went away again :o) But started having increasingly worsening problems with no libido, being very tired, weight gain, brain fog, depression and mysterious joint pains and body aches. You suggested I try Estratest HS® and Estratab®. My doctor only gave me a prescription for the Estratest® so I have been taking it now for 25 days, 1/2 tab daily. I am not noticing feeling any better, in fact I feel worse. I am due to go back to the doctor next month. she seems to be losing her patience with me, so I'm trying to formulate a plan before I go back.

My worst problems now are being very tired every day; the joint pains are worsening. For the last 4 months, I have been to the same doctor for unexplained mysteriously appearing-knee pain, elbow pain (they say I have tennis elbow), back pain, hip pain etc. My doctor in my opinion is not taking this seriously, she says its because I'm overweight and deconditioned. Both are true to some extent, but I've been overweight anywhere from 30 to 60 pounds since age 11. I am very distressed with all this and don't even know how to begin to sort it all out.

I always wanted to take natural(or as close as I can get) hormones. Many women at Sans Uteri are reporting success with naturally compounded hormones from Women's International Pharmacy. I called them last week and discussed my symptoms, they recommended a dosage of 0.625 estrogen, 100mg progesterone and 2.5 mg testosterone all in one capsule taken twice a day. What do you think of this plan?? Do you have any idea of what could be wrong with me, all these severe pains I am having? I feel so bloated, and......! since I started the Estratest®, I'm having mild hot flashes again! Please, help!!!!

Your estrogens are still too low. You are getting the equivalent of .625 conjugated estrogen and 1.25 testosterone. I think the original suggestion was Estratab® (0.625 CE) and Estratest HS®. which is one half of the Estratest®. That you are taking, but you aren't taking an additional 0.625CE. Apparently your doctor wouldn't go along with those dosages.

Your options now would be to take the full Estratest® you have or 1/2 tab twice a day. I think you would feel better than you do now. Ultimately (3 months or so), 2.5 mg of testosterone gets to be too much for many women so hence my original suggestion to use the combination to cut it down to 1.25 mg methyl testosterone.

A second option would be the compounding pharmacy you mentioned. While it has only 0.625 estrogen equivalent, the progesterone gets converted to estrogen so the practical dose is closer to 1.25. I still think the 2.5 testosterone is too much on a long term basis but you mentioned your weight is up so perhaps that won't give you increased hair growth at the 2.5 dose. If you wanted tor try this once a day it might work even though the testosterone is high. I think twice a day dosage is way too high with the testosterone.

P.S. I forgot to mention. I can't remember if your thyroid tests were recent. If not, that needs to be repeated. Also have them check your serum calcium level. Parathyroid disease is rare but you have a lot more bony pain than I would expect from just low estrogen levels.

Difficulty getting to the right estrogen dose

I had total hysterectomy 17 years ago. I'm now 41 and have: vaginal dryness w/atrophy, painful intercourse, no libido, frequent migraines, very dry skin, short term memory loss / foggy feeling, lethargy & fibrocystic breasts. My symptoms began in earnest about age 30. I have lost about 40% of my hair - no family history of female hair loss. My doctor increased Premarin® from 1.25 to 2.50 several yrs. ago to combat symtoms - stopped hot flashes but no other improvement. My mother, her mother, several aunts & cousins had / have breast cancer, so this concerns me, especially since my symptoms are no better. I believe the Premarin® has increased the frequency of my migraines. I saw two other doctors in recent years - all they say is keep taking Premarin®. Must I accept that this is as good as it gets????

An option would be to switch to an estradiol product orally and then get serum estradiol measurements to titrate to the best dose possible without getting estrogen excess symptoms. For example your optimal dose may be at 1.87 equivalent or even at 1.25. You can't know until you can measure serum levels and with Premarin, the serum measurements aren't accurate for biological levels.

The Estring is a vaginal ring that really helps vaginal dryness without putting any excess estrogen in your blood levels. If the dryness and pain were removed would you be more comfortable at the 1.25 level?

Can Tylenol® decrease estrogen levels?

I am a daily Tylenol® user - Do you suppose the use of acetaminophen with hormone replacement therapy (HRT) could cancel out or at least lower the estrogen? I read the article in your newsletter and thought that perhaps this might be the problem?

As I remember, you had the ovaries removed. The mechanism of Tylenol® was to decrease the ovulation hormones from the pituitary which in turn makes the ovary not produce estrogens through the normal ovulatory mechanism. Therefore without ovaries, I don't think this would lower estrogens. If you were younger and trying to get pregnant, heavy, regular Tylenol® use could affect fertility.

Breast tenderness upon starting estrogen therapy

I am still playing the "get the hormones right game". I have heard that many women stop hormone therapy because of breast tenderness and that it goes away with use. I have also heard that breast tenderness is a sign of too much estrogen. Who is right?

Both. When first starting or resuming estrogen therapy, the breasts can be sensitive and hurt. After about one or at the most two months, the breasts usually accommodate and the pain goes away. If it doesn't after 2 months, then the estrogen needs to be decreased. This is similar to how breast tenderness is worse in the early stages of pregnancy and then usually they get better over time. Pregnancy has whopping doses of estrogen.

Too much, too little estrogen

I had a TAH/BSO almost 4 months ago - I think some things are coming together or perhaps I'm just getting used to all this. However, the more I read, the more confused I get. I continue to have hot flushes each morning prior to taking 1 Estratab with 1 Estratest. I am also experiencing a slight burning sensation in the outer upper quadrant of my breasts. After taking the meds, the symptoms disappear. Does that seem strange to you?

If you are just getting the deficiency symptoms before your once-a-day dose and then get extrogen excess symptoms when taking your replacement all at once, I would suspect it may be a matter of just adjusting the dose. It has to do with the half life of the medications in your body. They are running out. Doctors see a fair number of women who have to split their doses to twice a day so there are no symptoms. You might try the Estratab® in the AM and Estratest® in the PM.

?Viagra® for libido

Instead of testosterone to improve libido, I would like to know if any of your patients have requested Viagra® and do you write prescriptions for it?

No. Ther are no scientific studies in women yet.

If you do, do you request testing such as blood flow, EKG, CBC, etc..first? I would love to have that spark back in my life and would be willing to participate in a study.

We're somewhat more conservative and don't want to be the first to try new regimens that might dangerous. This has worked for us. The only patients we had that developed the rare pulmonary hypertension on Phen Fen were ones that got it in Florida. I'm glad we didn't start using it.

As for the Viagra, I suppose I'll wait for all the studies - I am really a chicken at heart.

How long for breast cancer to appear if it's related to ERT?

Do you know how long it takes for breast cancer to appear if it's related to ERT?

Growth of breast cancer takes about 6 years to go from one cell to a 1 mm (BB size) nodule and 9 years to get to a 1 cm nodule (1/2 inch). Between 1 mm and 1 cm mammography can pick it up. At about 1 cm, 50% of examiners (women or physicians) can feel a cancer by palpation. It is not known whether estrogen speeds up this process, induces one cell in the first place, or actually has any effect at all. I suspect it does have some effect with long term use. Since the studies have never questioned less than five years of use (only longer times) I would take a pure guess that it doesn't hasten growth (because we would see more effect in 0-5 years in studies) but rather turns on a cell or so in women who have some other tendency to get breast cancer.

Also, during pregnancy, I understand the body is subjected to massive amounts of estrogen and progesterone. Would there be any harm in trying progesterone therapy along with the estrogen to protect the breasts?

The big nursing study shows no improvement (protection) from adding progestin). What you express about possibly being some protective progesterone effect was hoped for by many physicians until that recent study.

Why is testosterone added to estrogen replacement therapy?

I spoke with my OB last night and told him I thought I needed an increase in hormones, I told him when I came home from the hospital and approximately a month after I felt wonderful, full of energy, sexually responsive and a overall good feeling. I explained I felt I had an injection of hormones plus taking the .625 of Premarin that I am currently taking, he agreed without question. The question I have is he wanted to give me hormones with testosterone. The hormones are called Estratest®. I haven't picked them up yet since it was called in so late last night. What can you tell me about taking this combination? Why is this beneficial?

Testosterone added to estrogens can improve libido and general sense of well being. Studies have shown this but it is a much smaller improvement than the popular press would have you think. The downside is that after about 3 months, some women start getting testosterone side effects such as increased hair growth (hirsutism), acne, voice deepening and rarely some temporal balding. It's probably a function of how much testosterone your body is already making and how sensitive you are genetically. If 30% get improved libido and 30% get hirsutism is becomes a tradeoff so it's not for everybody.

I like the doses in Estratest H.S ®(half strength) rather than the full Estratest®. There tends to be less side effects. It really is a matter of trial and error though for your body. If you measure blood testosterone values, a women may be in the normal range but still get symptoms if she is genetically susceptible. So each woman has to be her own bioassay.