In 2002, the Women’s Health Initiative contributed a study to The Journal of the American Medical Association on the “Risks and Benefits of Estrogen Plus Progestin in Healthy Post Menopausal Women.” Ten years later, there continues to be fall out from the original findings.
What the average woman may not know is that the hormone replacement therapy studies of 2002 were based on trials with the medications Premarin (estrogen alone) and Prempro (estrogen and progestin), derived from the urine of pregnant mares.
In writing a story about vaginal atrophy and dryness in menopausal women, I spoke to a range of experts with widely different opinions. I learned that there is nothing simple about this conversation. Side bar issues would repeatedly pop up. They included the agenda of pharmaceutical companies, women determining medical choices by insurance and financial considerations, even animal rights issues concerning the production of Premarin.
The goal of this article is to present material from diverse sources that will inform women, so that they can be proactive on behalf of their own well-being.
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Dr. Cheryl Perlis is a board certified gynecologist based in Illinois. After twenty-two years of practicing, she changed her approach by cutting down on the number of patients she saw daily so that she had sufficient time to converse with each person in detail. She has become a “huge advocate” of bioidentical hormone therapy (BHRT). “Women are living longer,” she told me. “Everyone should be on them. It’s the standard of care in Europe.” Perlis uses estrogen, progesterone, and testosterone to relieve vaginal dryness because “the condition is symptomatic of decreased hormone levels.” Perlis believes, “Nothing works for the vagina, vaginal walls and tissues like estrogen.” She said, “You can try “holistic remedies, but that they will not get of the core of the problem—which is the lack of hormones, particularly estrogen.” Perlis’s bottom line was, “You can’t get a better vagina without hormones.”
Perlis works with compounding pharmacies to create hormone medications tailored to the need of each person. She noted that these prescriptions are not FDA approved, but that they are legal and regulated. She suggested that conservative doctors would be less likely to use them, as they prefer to treat symptoms along “standard guidelines.” When I asked Perlis why these compounds couldn’t get FDA approval, she said, “Because no company is going to go after it in the United States. They are up against Big Pharma.”
Dr. Alyssa Dweck, board certified in Obstetrics & Gynecology and author of V is for Vagina, made clear that choices are “very individual.” First, she said, “you have to have the conversation—as it is not a one size fits all scenario.” She takes the time to thoroughly describe how bioidenticals are “molecularly identical to the hormones that women make in their bodies,” and are synthesized from plant elements such as yams and soy, making them different from a medication like Premarin. Dweck’s approach is to treat with the “lowest dose possible for the shortest amount of time.” She mentioned three specific products: the Femring, the Estring, and the vaginal tablet Vagifem—stating that the last two were very low in estradiol. The Estring is a flexible vaginal ring that is worn up inside the vagina for three months at a time. Vagifem is a small vaginal estrogen tablet that is inserted twice weekly into the vagina, after an initial “loading dose.” According to Dweck, they “both claim minimal absorption into the bloodstream,” yielding less risk. Bleeding is always a red flag, and Dweck advises a yearly transvaginal ultrasound to make sure that there is no thickening of the uterine lining.
Dweck concurred with Perlis that most Ob-Gyns tend to stay on the traditional path, set forth by the American College of Obstetricians and Gynecologists. Yet she insisted that was not an excuse for doctors to dismiss the concerns of vaginal atrophy or to short circuit describing all potential options. Dweck related, “There are plenty of women who don’t have any symptoms of vulvar or vaginal atrophy. However, for those who do, they don’t necessarily want aggressive treatment. What they do want is reassurance that they are normal.” She regularly fields questions about vaginal itching, burning, or repeated urinary tract infections. Dweck insists, “Any complaint should be taken seriously.” Then she asks her patients, “Are these problems severe enough that you want treatment?”
Dweck offers information about compounded lubricants to order (including one that contains Hyaluronic acid, Vitamin E, and aloe) or an over the counter product such as Replens. She mentioned that orgasms can help with secretions and maintaining vaginal tone. For Dweck, “It all comes down to risks and benefits.” She added, “We have to remove the taboo and embarrassment to make sure that women can have a candid dialogue with their doctors.”
Dr. Deborah Coady, co-author of Healing Painful Sex, evolved into caring specifically for women suffering from sexual and pelvic pain. She pointed to studies that estimate “50 to 75 percent of menopausal women undergo distress from vaginal changes,” yet half of that group revealed that they “learned to live with it.” Only 10 to 20 percent reported “their physicians ever asked them about the problem.” Coady contended, “Women have different phases of life. A doctor still heavily focused on obstetrics may not be the best solution for an older woman’s concerns.”
Coady was the only physician to speak to me about the “vaginal vestibule,” which is the opening of the vagina. Particularly vulnerable in menopausal women, it becomes delicate and raw when estrogen levels go down. Any plan for vaginal health should apply to both sexually active and non-sexually active women. She reiterated the maxim that using the lowest amounts of estrogen is always the optimum approach. Coady supports using a prescription topically and locally to treat the vestibule that won’t impact the bloodstream. She uses a custom compounded cream in a preservative free base without parabens and propylene glycol (she referenced the Women’s International Pharmacy as her source). Cody clarified that since vestibular tissue is “especially rich in hormone receptors,” when they lack the “optimal amounts of hormones, they atrophy or thin.” For intravaginal use, she recommends gel caps of Estriol and DHEA nightly for two weeks, before moving into a maintenance program of less frequent dosing. In Coady’s opinion, such a vaginally localized plan doesn’t necessitate a urine, saliva, or blood test.
Ann Louise Gittleman holds a PhD, is a Certified Nutrition Specialist, and has written extensively about the impact of nutrition in menopause. Her most incisive point to me was that nobody was connecting the dots for menopausal women. She gave the example of patients who were experiencing recurring urinary infections, even those who were not sexually active. She elucidated that the infections were the result of a “changing vaginal environment.” She said, “When the vaginal tissue atrophies, it makes the urethra more exposed and vulnerable.”
Gittleman has found the bioidentical cream Estriol to be especially effective, while still considered the weakest form of estrogen. She strongly supports getting a saliva test every two months to show what the balance between hormones is. “The key to what you need is in the test,” she said. Gittleman believes that the progesterone to estradiol ratio tells the most—as the two hormones should be in balance. She sees progesterone as being important because it stabilizes uterine lining cell growth. For Gittleman, “Balance is everything.”
For those women who prefer a strictly homeopathic approach, Gittleman recommends that they find a practitioner in that field, in order to obtain an individualized program tailored to their unique biochemical needs.
Dr. Laurie Steelsmith, a licensed naturopathic physician specializing in women’s health, fits that description. “It’s imperative that women maintain good vaginal and vulvar health throughout their lives, whether they are sexually active or not,” Steelsmith told me. She asserted that when women have good overall health, it is reflected in their vulvar area. In her opinion, not every woman needs to be on hormones. She prescribes vaginal suppositories from Earth’s Botanical Harvest that are comprised of black cohosh, wild yam, Vitamin E, and cocoa butter. She also suggests a DreamBrands vaginal and vulvar moisturizer made of 100 percent aloe, Vitamin E, and carrageenan that works both externally and internally for hydration. Steelsmith particularly likes that they have no harsh chemicals. If she uses Estriol for a patient, she has it prepared in an olive oil base with no other ingredients.
Steelsmith communicated her conviction that any woman who has had an estrogen related cancer (breast, ovarian, or uterine), should never use estrogen—even topically. She told me, “My patients who have had cancer have done fine with the alternative vulvar and vaginal moisturizers.” For Steelsmith, the key for a doctor and patient relationship is communication. “I work best with women who want to know what is going on with their bodies,” she said.
Internist Dr. Erika Schwartz is on a mission—and has written a series of books to inform the general public about her ideas. Her goal is to train “conventional” doctors about the benefits of systemic hormone therapy as a way to prevent “chronic illness and frailty,” I learned about her work from Perlis, who had trained with Schwartz. Previously the Director of Emergency Medicine at Westchester County Medical Center, Schwartz has presented her opinions at Harvard (2009). She is definitive in her point of view that doctors must look at the whole person. For women, that means not just treating the vagina. She contended, “You can not cure menopausal vaginal atrophy and dryness locally. You can only improve it.” Schwartz’s assertion is that when you “lose your hormones, you develop diseases of aging.” Depending on the preference of her patient, she prescribes FDA approved bioidenticals or those that are pharmacy compounded.
On the subject of self-advocacy, Schwartz said, “Women don’t have a choice. They have to learn to take control and understand what they need. Women have to make their own decisions, taking the fear and victim piece out of it.” Schwartz’s mantra is to do everything in an “individualized” manner. Her advice to women is to make sure that they work with a doctor that is on the same page as they are in terms of philosophy.
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There are many choices available to women. However, it’s not easy to push back against doctors and a medical establishment entrenched in a routinized way of handling patient concerns. Conversely, being armed with knowledge about your options and asking questions about how a course of treatment will impact you, is a smart place to start.
This article originally appeared on the Empowher website as a two-part series.
Image courtesy of RVR Associates.