NUTRITIONAL FACILITATION OF BIOIDENTICAL HRT
While a general consensus in Integrative Medicine supports the use of bioidentical hormone replacement therapy (BHRT) versus synthetic conventional hormone replacement therapy (CHRT), balancing sex hormone administration remains largely empiric and variably monitored in clinical practice. Many physicians have embraced the benefits of hormone replacement with estrogen, progesterone or testosterone that more closely resemble the types of hormones produced in pre-menopausal years. Popular healthcare literature on HRT claims better symptomatic control of menopausal symptoms, improved health outcomes and fewer side effects with BRHT compared with CHRT, but evidence to support these notions is unclear in peer-reviewed scientific literature.
Given the current level of scientific knowledge, it has become quite difficult to define indications for sex hormone therapy in post-menopausal women. The alarming side effects of CHRT in the Women’s health initiative studies in the U.S. and the one million Women studies have driven many mature females towards alternatives to HRT. That said, there are a number of benefits of sex hormone administration in mature females, providing that the treatment is applied in a selective, supervised manner with tailoring of management and close assessments of hormonal status. That said, clinical and laboratory methods for administration and monitoring sex hormone status possess disadvantages and limitations. An ideal management approach would involve real time assessment of hormonal status and its correction in a pulsatile manner that would be synchronous with biorhythms, but medical technology has not advanced to a level that would permit this kind of approach.
Medical acceptance that there are limitations in the application of both BHRT and CHRT has been slow to dawn on practitioners of both conventional and integrative medicine. There is increasing support for the utilization of services provided by compounding pharmacies that offer expertise in the mixing of sex hormones in efficient dispensation formats. Many modern pharmacists face two principle new challenges in healthcare consumer preferences for menopausal management. On the one hand, the art of compounding is not taught in a widespread manner among pharmacists, whereas on the other the modern pharmacist may not have had complete training in natural therapeutics, e.g. pharmacognosy.
The objective of this short article is to review the importance and application of nutritional or botanical support that can be utilized in the primary management of menopausal symptoms or health challenges and in the modulation or facilitation of exogenous sex hormone replacement. While the control of unpleasant symptoms in the peri-menopause or post-menopausal period is an important therapeutic target in many women, the major significance of the menopausal transition involves the onslaught of age-related diseases, such as cancer, osteoporosis, cardiovascular disease and cognitive decline. I propose that management of the menopause with HRT alone has been considered, at the expense of recognizing the importance of nutritional, herbal or botanical supplementation that has a clear evidence base to provide first-line or complementary management to facilitate the application of HRT. In brief, there are two principle approaches to the use of dietary supplements for menopause management. First, their must be a clear recognition of the importance of the nutritional factors that are obligatory for the efficient action, metabolism or function of sex hormones. Second, the application of several botanical or herbal extracts may provide beneficial options as adaptogens that can act primarily through sex hormone receptor sites, especially estrogen receptors.
THE CONCEPT OF HRT NUTRITIONAL COMPANIONS OR HELPERS
A large body of evidence supports the value of significant dietary change in the menopausal transition. Epidemiological information supports the value of phytonutrients with natural hormonal properties e.g. soy, fruit, vegetables, whole grains, nuts or plant lignans etc. Several isoflavonoids or lignans of vegetable origin are converted to phenolic compounds which can variably reduce vasomotor symptoms of the menopause, enhance vaginal secretion and prevent certain cancers, notably breast and colon cancer. These phytonutrients have been naively characterized in popular healthcare literature as simple “estrogens” or phytoestrogens. While the effects of these phytochemicals on estrogen receptors has been identified, their effects are both pro-estrogenic and anti-estrogenic, depending on prevailing hormonal dominance in the body-“an adaptogenic effect”.
Several individual or combined nutrient supplements have been demonstrated to be variably effective in suppressing unpleasant symptoms in the menopausal transition and providing other general health benefits. These studies, using single or combined nutrient supplementations, have led to the use of single or limited specific combinations of vitamins or minerals in dietary supplements that have been used, with variable success, to manage the peri-menopause and menopause.
These studies on the nutritional support of menopause have often attempted to explain a specific role for a single nutrient in the management of menopause, without explaining the beneficial effect of the nutritional intervention in terms of the ability of several nutrients to promote effective metabolism and actions of the nutrients on sex hormones. The reported variability in the efficacy of single nutrient supplements for the management of menopause is readily understood. Single nutrient studies are fundamentally flawed in their construction, largely because single nutrients never work alone. All body structures and functions involve complex cascades of metabolic events and such events are quite clear in the metabolism of estrogen in the complex metabolic pathways in the metabolism of estrogen and other sex steroids.
Dietary deficiencies in the menopausal woman are often underestimated. The modern menopausal female is often challenged by weight gain which results in attempts to limit overall calorie intake in the diet. While the standard American diet (SAD) is rich in calories it is often devoid of essential nutrients, such as minerals and vitamins. Therefore, limitation of calorie intake often results in selective nutrient deficiencies e.g. specific vitamins or minerals. Sex hormone metabolism requires many co-factors and therefore the facilitation of hormonal function may often depend upon adequate vitamin mineral intake. That said, there are certain nutrients that are particularly quite critical in supporting sex hormone metabolism and function. These nutrients of specific importance include Vitamin B6, C and E, with magnesium, zinc and essential fatty acids.
The importance of Vitamin E in the management of hot flashes or vaginal disorders has been recognized for more than 60 years. Many of these observations of the benefits of Vitamin E on menopause are dated and do not identify a specific benefit for one or other type of tocopherols. The biological function of Vitamin E has been most focused on its ability to act as an antioxidant that maintains the integrity of biological membranes. However, Vitamin E is known to regulate microsomal enzymes and membrane-associated enzyme systems, thereby acting as a key biological response modifier. In addition, it has a role in hormonal production, mytochondrial function and nucleic acid or protein metabolism.
The antioxidant functions of Vitamin E are believed to account for its benefit in cardiovascular disease, cancer prevention, cataract formation, maintenance of cognitive function and anti-aging properties. The antioxidant functions of Vitamin E is dependent upon nutritional co-factors including Omega-3 fatty acids, selenium, Vitamin C, beta-carotene and, to a lesser degree, iron and sulfur containing amino acids. Contemporary studies of Vitamin E supplementation in circumstances of dysmennorrhea, pre-menstrual syndrome and symptomatic menopause show benefits. In a prospective study of Vitamin E supplementation in breast cancer survivors, high dosage (800 iu per day) resulted in a significant reduction in hot flashes and other vasomotor symptoms, compared with placebo.
Supplementation with Omega-3 fatty acids, in there active form (fish oil with high concentrations of EPA and DHA) is advisable in all peri-menopausal and menopausal females because of protean health benefits. However, fish oil supplementation is best administered in enteric coated soft gels where the bioavailability of the active Omega-3 fatty acids may be enhanced up to 3 fold, resulting in superior therapeutic outcome, better patient tolerability and improved compliance. Regular fish oil capsules and liquids are becoming increasingly obsolete as scientific literature defines the need for relatively high dosages of active Omega-3 fatty acids to achieve treatment outcomes in a variety of disorders. Several studies have highlighted the importance of B complex vitamins in the management of pre-menstrual syndrome, menopause and adverse effects of hormone administration in birth control pills. Most interest has focused on Vitamin B6 which has been shown to be variably successful in alleviating symptoms of women with pre-menstrual syndrome and menopause. However, Vitamin B6 does not work in isolation and it requires the presence of Vitamin B2 and magnesium to be maximally effective.