HORMONE REPLACEMENT THERAPY AND HEALTHY BONES: SORTING THROUGH JUST WHAT HORMONES “HRT” MEANS FOR YOU
Several types and forms of estrogen are available (with and without several varieties of progestins or progesterone), in a variety of doses. There are no hard-and-fast rules about which way of taking estrogen is right for who, and you may have to experiment a bit to figure out what works best for you. Your needs may change as time goes on; what works, say, during your transition to menopause may not be the best thing for you a few years later, when a much smaller dose will probably do.Estrogen comes in pills, patches, creams, and now even a ring that is placed inside the vagina. It can be synthetic or natural. Different forms may help some problems and symptoms more effectively than others. Pills and patches have FDA approval for osteoporosis prevention (give appropriate dosages— see below), but creams and the ring are localized and come in extremely low doses, so they are more targeted to specific issues and won’t benefit bones as much. For that same reason, they are less likely to increase your risk of breast cancer. That won’t do your bones any good, but may still allow you to relieve some menopausal symptoms.Another of the twists and turns on the road to making decisions about using estrogen is that the more you take and the longer you take it, the more your risk of breast cancer goes up. The trick is to get enough estrogen to receive the benefits, but not so much that side effects become too risky or too unpleasant. For protection of bone in the hip and spine, the standard daily dose is .625 mg of “conjugated estrogen” (the kind made from horse urine, brand name Premarin), which is the most common prescription. For “micronized estradiol” (pill form, brand name Es-trace) the usual dose is .5-2 mg, which is proven to protect the spine, with less clear results at the hip. For estradiol in a patch(brand name Climara, Estraderm, Vivelle), .05-1 mg daily is the usual dose and is protective of both the back and hip. And 0.625 mg a day of estrone sulfate protects the spine but not necessarily the hip. Estropipate (Ogen and Ortho-Est) requires .625-3 mg to work in the vertebrae, but 1.25 mg to help in the hip. Ethinyl estradiol (Estinyl) is usually prescribed at .03-. 1 mg a day for the spine, and “esterified estrogens” (Estratab) at .3-2.5 mg, though in both cases the results at the hip are unknown.Heavy women may be able to use smaller doses because estrogen is made and stored in body fat, so their own supplies may be higher. Thin women and smokers, on the other hand, may need higher doses to realize all the benefits to their bones. Smokers should try the patches, as transdermal estrogen may be more effective for them than pills.Take the smallest doses that work for you in order to limit side effects large and small. Taking calcium supplements will help you reap the full benefits of HRT even at lower doses. We know low doses can help your bones in part because of the effects on bone density seen in patients who have taken oral contraceptives for years. Birth control pills are estrogen based and use much smaller amounts than HRT. Even so, women get increased bone density as a side benefit.No matter what hormones you are taking (or not taking), you should be following the other guidelines in this book to maximize the benefits and minimize any risks. Be sure to get enough calcium, magnesium, and vitamin D, as well as all the other nutrients described in Chapter 8, so your bones have enough of what they need to create healthy bone even as the rate of loss is slowing. Women taking (and absorbing) calcium and other supplements may be able to use half the dose of estrogen and still get the full benefit. That’s good news for anyone who experiences side effects from the hormones (and might not at lower doses), and may also lessen the increase (if any) in breast cancer risk.*137\228\2*
