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152 - Side Effects of Estradiol Part 1
BioBalance Healthcast — Dr. Kathy Maupin and Brett Newcomb
Recorded: October 6, 2013
One of the questions that comes up every time somebody looks at our podcast or contacts our office or comes in has to do with “why should I do this?” or “why should I not do this?” “How do I make a good decision?” Part of answering that question has to do with an assessment of side effects. In my business, people come in all the time and they come back “should I take antidepressants?” “Should I take anti-anxiety?” “Should I take mood stabilizers or regulators” and all of those have side effects. If I take them well I’d be better in this condition but worse in these conditions. I know that that is similar in what you do and so we thought we’d take some time today to talk about the concept of side effects for estrogen replacement therapy. Right. We’re going to start with estrogen. Talk about it in terms of it if you take it, if you take a replacement for the lost estrogen, what might be the side effects of what you take and what are the side effects or what are the conditions if you don’t take the replacement. You can get enough information that serves to think about what’s the best alternative for you. There’s a lot of ways to troubleshoot side effects, to preemptively strike at them in terms of looking at … well this patient probably from her history is going to have a side effect to estrogen of any type, the example of that is a woman who comes in and says, “I could not take the pill. The pill was horrible and then I tried the ring which is not oral, that’s transvaginal. I couldn’t use that either. It made me sick” or I have one person that said it gave her seizures, believe or not. I’m not sure how that works physiologically but because of that, that puts your doctor at the point of going, “Oh! I have to find the very safest estrogen and I have to preempt that side effect and how important is that side effect and how dangerous is that?” You play with minimal access like you’d start at the lowest possible dose or do you start at the mid-range dose that’s difficult for average people in your experience to gain the benefit that you want. How do you monitor dosage and the dosage questions? Because you… Preparing for this you’re saying that the under and over are generally worse than the medium. Right. In general we’re taught one size fits all, one dose of Premarin, one dose of Estrace, one dose of estrogen, estradiol, but in general what really works to solve all of the symptoms of estrogen loss is a medium dose and that in the medium there’s a range and within that, then that’s the kind of the art and science of figuring out what the patient needs. I look at lab tests. If someone has a high FSH and we talked about FSH before. It’s a hormone that stimulates from the pituitary to the ovary and it actually causes estrogen to be produced. If the FSH is elevated very high after menopause, that means somebody, this patient in front of me needs more estrogen than someone else. I would go to the high end of normal to start out with and then recheck her hormones. Basically when giving estrogen, it’s not the lowest possible dose. We’re going to talk about the symptoms. Let’s go over the symptoms that estrogen treats. It treats hot flashes. It treats dry vagina, stress incontinence which is like urine loss, irritable bladder. It treats painful intercourse and lots of times you get lichen scleroses which is very thin paper-like skin on the bottom, on your bottom, on a female bottom. Sometimes it affects skin. It makes skin wrinkle. It makes skin look dry and old and makes your hair fall out in the front, if you don’t have estrogen, in the front of your scalp. Those are all of the things that estrogen does prior to menopause and if you don’t take it, I’ve just described what are the side effects of no estrogen basically. What happens when you have no estrogen? Should you get some of those, should you get most of those, or you get all of those? If you get it, you mean those kind of symptoms? You don’t take estrogen, you don’t get it replaced, typically will most women who don’t take it have dry vaginas, painful intercourse, sclerotic bottom? Is that like psoriasis? No it just looks like paper. The skin’s so thin that it cracks up and … They get bleeding and soreness and it’s raw okay. It would be impossible to have intercourse with that. Bladder spasms, urine loss when you stand up. You lose all the tone to your bladder. Oh! Like when you sneeze, or if you laugh out loud, or you cough. Sometimes that’s anatomic dropping of the bladder and sometimes there’s just no support for the bladder and that support is improved with estrogen. Let me make this clear not everyone has all those symptoms. Most people have dry vagina. Most people have painful intercourse but not everyone has all of these symptoms. It depends on your genetics and your history and your child bearing. There are so many different things that can set you up for these symptoms but if you have those symptoms you know have them. You know which ones you have and then you know that that’s related. Now you know it’s related to estrogen and that estrogen replacement would be a good place to look for relief from that instead of taking five or six drugs for bladder spasms and that kind of thing. Dry vagina is in and of itself painful for intercourse but then you also mentioned painful intercourse. Is that a different situation? Dry vagina can be … it can be irritating when you wear blue jeans. It can be irritating when you wear clothing, underwear of the elastic that’s in underwear. It’s so thin and so dry that the vagina shrinks and so it’s even painful sometimes to urinate. It’s like having no defenses. Your whole bottom is just open to any bacteria or change in pH, or any kind of rubbing. That’s one problem but then for those who have intercourse who have that problem that makes it almost impossible. Intercourse is like having intercourse with sandpaper and it’s very painful for the woman. Sometimes you get tears and breaks in the skin. All of those things if you’ve the symptoms and take estrogen in the right form, those symptoms can go away. Okay. What are the forms for delivering estrogen? Well, the forms, you can have oral pills, which is what most prescriptions are. Most prescriptions are oral pills like Premarin or estradiol in the form of Estrace or Ogen. Those are all oral estrogens. Sometimes they come with a progestin with them. If you have the uterus you have take the combined but those are the forms of oral estrogens. Then there are transdermal estrogens which are the patches, the gels, the creams and those are also prescription or bio-identical. You can get them in either way. Put over your arm, put in your thigh or … The patch should be on your hip or your abdomen. The gels you can put on in the inside of your arm, inside of your thighs. Same with the cream which is Estrasorb. They come in little packets and you use one packet a day, and that can be used. None of those are bio-identical but you can have bio-identical versions of those made by a compounding pharmacy. If you’re using those gels, do you have to be really careful to make sure that your teenage daughter doesn’t handle them or that somebody else isn’t exposed to them? I know men sometimes take like Flomax and it says warning women shouldn’t handle these pills and if you’re pregnant especially don’t handle these pills. That has to do with testosterone and not estrogen. That’s in general another woman who is coming in contact with this, whether she be young or old, she’s not going to get enough estrogen to bother her. You don’t want to put it on the children that are younger than menopause or a young adult but if you rub up against them, it’s not going to cause any problem for that female. If somebody’s has put it in your dresser or something or … No that’s not going to have anything with it. The testosterone medications are important because they either block testosterone production when in women carrying children if they’re female or male they’ll be affected. You don’t want have anybody who could be pregnant touching or using Finasteride which is one of the things and the Flomax. Okay. So transdermal is a gel or a patch. Those are different hormones and then transvaginal can be a synthetic ring, they have an Estring which is like a ring which has estrogen in it and it lasts for three months which sounds kind of good except the fact that you would have to take it in and out for intercourse and it’s little bit of a hassle. Kind of the opposite of a diaphragm. You take it out at intercourse and you put it back in afterwards so you don’t want to expose your partner to the estrogen. That would be like Estring. If you’re using bio-identical, they don’t have anything in a ring but they do have creams that can be injected into the vagina and they also have little tablets that you can put into the vagina that will dissolve that have estrogen in them. Compounding can be done if you want a pure bio-identical hormone and they can and you can also get the synthetic type through your regular physician. What’s the difference between synthetic and bio-identical? Synthetic is made in the lab. It’s a chemical and bio-identical is made from plants and it looks exactly like your estrogen or my estrogen that I used to make. When they look for the chemical chain for the bio-identical, it is indistinguishable from the chemical chain of naturally produced estrogen. Right. It looks exactly the same but the synthetics don’t. They have to change them a little bit to get through the skin or to get through the stomach and so they are a little different. When we’re talking of side effects, side effects are divided by how you take your estrogen and also by whether they’re synthetic or bio-identical. In general, the side effects are lower from the bio-identical and higher for the synthetic but we haven’t even talked about the types of side effects so I’d like to go over that. I divide side effects into symptomatic meaning they bother you but they’re not going to cause you to be sick. They are not going to cause you to have a medical procedure. They’re just a hassle. So that’s symptomatic. Then medium severity of a side effect would be something that might cause you to go to the doctor, might cause you to have another symptom or a problem. Those are in the middle, those are moderate and then the medically severe or life-threatening ones are kind of a completely different category and we have to talk about them separately. The mild ones, most people know if they take estrogen usually oral, usually synthetic more often, they get breast tenderness. We also get it with pellets sometimes. Breast tenderness, water retention, excessive vaginal wetness which is a problem some people complain of, believe it or not, and then cellulite and fat collection under the skin, that’s what cellulite is, and it’s also kind of puckered so that happens often. Located mostly around the buttocks and thighs Thighs, right in the middle and then you can get irritability and PMS as well. Kind of PMS kind of symptoms because if you are not taking a progesterone then the estrogen causes you to feel that same imbalance that you felt before you were menopausal when you had too much estrogen or you were estrogen dominant. Not you but if a woman who is estrogen dominant and she is to have enough progesterone, yeah you have that. Yeah, you’ve got that from all sides. Those are the mild side effects. I’d like to go through each of them, each of the types or the severity and then go through what we do about them. There are ways to treat especially the mild ones and the moderate ones or troubleshoot so the patients don’t get that. We can fix these side effects. These are not side effects, these are like if you take an antidepressant, you may not have a sex life because you don’t have desire. That’s something it’s very hard to fix with antidepressants. Estrogen doesn’t have that type of side effect in general. The moderate ones are the dysfunctional uterine bleeding like you have abnormal bleeding. You might have to see the doctor to have your uterus ultrasounded. You may have to see if there is a fibroid or a polyp. Ultrasound to see if there’s something in it that’s causing it to bleed. That means a procedure going to the doctor but it doesn’t mean something lifethreatening. Then another one is weight gain. Now weight gain seems to be just a …. Okay. Can I ask you a question? Okay. Somebody takes estrogen then they start to have vaginal bleeding. They go and they get an ultrasound. The ultrasound is to see if there is a polyp or a tear that would … Polyp or a fibroid or a thickened lining on the inside of the uterus. … and if those would potentially be caused by taking the estrogen. Yeah. Estrogen cannot cause, it stimulates them to bleed. It makes fibroids grow. Absolutely. It doesn’t actually cause it. No, it just stimulates the fibroid or the polyp or the thick lining to bleed. One of those things raises its head and says “I’m here” then you treat that. We have to send for tests. You’ve to go to the doctor so that’s why I put this in the moderate category. You have to have it looked at, but it was something that was going to be there anyway. It’s something that’s every time we do this if we … we now do ultrasounds before we start estrogen therapy because I want to know what’s there. Yeah. If you have five polyps staying in there, you want to get those taken care of. Yeah, we want those out first and then we can give you estrogen because we know you’ll bleed from those polyps. In the very beginning I wasn’t trained to do ultrasounds to begin with, that just wasn’t part of the protocol and we had a few people who had their estrogen pellets and a few months later they started to bleed even though we gave them progesterone. You do those at your office or you send them out to their regular … We send them to their regular gynecologist. Just because they have ultrasounds in their office, I don’t. We sent these patients that were bleeding and one of them actually had a cancerous polyp. Now cancer doesn’t happen in two months. It happens over years inside the uterus and so our giving her the estrogen actually stimulated her to get an ultrasound to go to the doctor to get it treated, and she had a hysterectomy and she was cured. That’s amazing. That was life saving. Now we look for some of those things. Doctors change. Doctors change their protocols. Even though we’re taught to do one thing we often add blood tests, we add ultrasounds, and we add other tests so that we can be more careful and catch everything. Often times it seems tedious yet it’s because we want to protect you from one of the side effects and not have you find out when you start bleeding and go, “Oh.” I want to know ahead of time. There are ways to actually not necessarily prevent but troubleshoot it and keep you safe. Okay, let’s go to weight gain. That’s something everybody asks me. They have studies and studies that say estrogen of any type doesn’t cause you to gain weight, but honestly I don’t necessarily believe that. For estrogen … Anecdotally or in terms of the data that we have? Over the years when I’ve used oral estrogen, even if it is bio-identical oral estrogen, it makes estrone. Estrone makes belly fat. It’s just a common thing. Sometimes people taking the pill because it’s oral will get belly fat. Is that a weight gain or a body distribution change? It’s usually fat gain and fat in the middle but they don’t like take that off their thighs and put it on their stomach. It’s still on their thighs. They just … they … we women always usually when we were young we get it on our thighs and on our behinds and then as we get older we get that to hear that’s because of the hormone estrone and we’ll talk about that. This, the weight gain is something women hate and some of the studies say, “Oh, it doesn’t cause that” but I’ve seen this for years and years, maybe it’s all the just Midwest women. I take care of people from all over the world and if they’ve been on oral estrogen and I put them on pellets they don’t make estrone and their belly fat goes away. Yeah, you have treated clients from Australia and Germany, to get treated. Yeah, so it can’t be just be just Midwest women. When they switch the type of estrogen to something that’s not oral, they lose their belly fat. It’s just something that’s why the doctors call the practice of medicine. Because everything we do, we take in all this information about all the people we’ve seen and then we develop some, I guess, biases. When a study comes up and says no that’s not true, and I know my whole practice life, it’s been true, I go, “Hmm, what’s wrong with that study?” and I have to look at it. You assume you know they just haven’t found the right explanatory link yet. Right, they’re looking maybe at the wrong factor. The other moderate side effect is actually swelling or retention of salt and water. Okay and that’s more common in oral that is in non-oral, more common in synthetic than it is in bio-identical. Yeah we do. Actually, but in general, it’s better just to switch your estrogen to a bio-identical non-oral so that the swelling goes down. The bad news about the swelling is if you retain too much salt and water, then you can actually increase your blood pressure. If you have a lot of swelling in your lower extremities then you can make your veins work too hard to try to get rid of it and so your veins may get larger, varicose veins. It’s not good to have water in your lower extremities either. It could be … it’s all over from estrogen. Anyways, lastly … Well gravity pulls all of it down and your heart has to pump harder to try to get it back up and so we get stress and strain on the heart as well. Right but none of those are a direct a to b to a disease. They’re not just a hassle, they’re a little bit more than a hassle. I guess my grading system is such that you have to look at what does it lead to. Does it lead to nothing? Is that making you miserable? Well that’s sad but we can fix that. What are the treatments and how do they moderate it then as the various treatments or the intervention? Most of our interventions for estrogen, they make the estrogen worth taking. They’re not very expensive so we can make it so that a woman can take estradiol and feel normal. I think we are going to go into the severe side effects of estrogen on our next cast and we’ll through those and our troubleshooting that we do for estrogen. Troubleshooting meaning how do we stop the big things, how do we stop the middle things, and how do we stop the small things. When you say severe side effects, you’re talking about things that lead to major medical conditions or problems. If you’re interested in hearing about those and the troubleshooting process for discovering and treating those, then be sure that you come back for our next podcast. Thank you for listening today.

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