Hormonal Management

Our body has many different Endocrine glands which make even more different Hormones. Hormones are powerful substances that help to regulate many physiological functions. They are not only powerful in their activities but have widespread actions throughout the body. And while each individual hormone has specific functions, it is a very appropriate analogy to look at hormones as different instruments in an orchestra. Some work in concert with other similar, though slightly different, hormones, and some have quite different functions but all work together for the overall harmonious running of the body. When functioning optimally they keep us in tune and create emotionally enriching and uplifting performances. When functioning poorly they create jangling discordant chaos.
Most of the endocrine glands throughout the body are under the control of stimulating hormones produced in the pituitary gland in the brain, the grand conductor. The pituitary in turn takes direction from the Hypothalamus, the composer. This system is one of biofeedback which is nuanced by the brains emotional state.

Hormones work like keys in a lock. Their structure defines their affinity to the hormone binding proteins embedded in cellular membranes and nuclear membranes. Once attached to the binding protein, the hormone changes its shape and causes the hormone function to be engendered in the cell. Some hormones have several different receptors that they bind with in different tissues with different functions. This applies to Estrogen and Progesterone.

Hormones can become dysfunctional due to various reasons including chronic stress effects, nutritional deficiencies, environmental toxic chemicals, and the relationship of each of these with our individual genetic controls.
Treatment of Hormonal dysregulation can be with nutritional supplements, herbal supplements or with hormonal treatment itself. Hormonal treatment can be with one of three main forms.

1    Glandular extracts are natural and are extracted in pharmaceutical conditions from specific organically farmed animals, either porcine from pigs or bovine from cattle. These are the most “natural” but have obvious issues for vegetarians. They have been used traditionally for centuries but are currently a small part of the market. They are not funded by the PBS system and are frowned upon by endocrinologists. They are typically used for thyroid and adrenal hormone therapy.

2    Bio-identical Hormones are hormones which are, as their name suggests, identical in structure and thus function to the hormones found naturally in the body. They are, however, not natural as such, to the extent that they are not extracted from animals, nor found in plants. They are made in laboratories. They remain significantly different from pharmaceutical synthetic hormones, in that they are the exact same form that is naturally found in people. 

Our bodies’ natural hormones are extensively well studied and understood. They are not, however, patentable and so the large pharmaceutical companies are not interested in Bio-Identical Hormonal Replacement Therapy (BHRT). Some endocrinologists are happy to use BHRT, many are not. They are typically used for sex hormone use including managing the menopause.

3    Synthetic hormones are man-made chemicals which have a structure that is similar to but different from the bodies’ natural hormones. Their different structure means that they act differently to the natural hormones. In many instances they are actually more potent than the natural hormones, but in some instances their action on some of the binding receptors does not work and actually blocks function. This is the case with the synthetic Progestogens which are stronger than natural progesterone in their action on the uterus but have a negative impact on the progesterone receptors elsewhere in the body.

Sex Hormones

Female sex hormones have a normal monthly cycle which can be unbalanced causing problems with irregular or heavy periods and premenstrual symptoms. Such dysregulation can be controlled by a variety of means including nutritional and herbal, as well as sometimes with hormones themselves.

Menopause is defined by the cessation of periods and is caused by ovarian failure. For several years before menopause, the premenopausal time, during the change itself, the peri menopausal time, and once the hormones have stabilised, the post menopausal time, there are a variety of symptoms that can develop. These include hot flushes, sleep disturbances, moods either more flat or irritable, loss of libido, loss of mental sharpness, skin and hair dryness, and vaginal dryness. There is large variability in how many of these symptoms each woman may get and for how long.

Hormone replacement therapy (HRT) refers to managing the symptoms of any hormonal deficiency by providing various hormones. Strictly speaking it can be used to describe any hormone whether ovarian, thyroid or adrenal, and either synthetic or bio-identical, although in common usage HRT usually is used to mean the use of synthetic hormones to treat menopausal symptoms. 

In the 1980’s and 1990’s synthetic HRT was thought to be potentially useful to reduce the risk of cardiovascular disease and so a large trial called the Women’s Health Initiative ( WHI ) trial was set up to prove that theory. Unfortunately the trial showed the opposite with a small but significant increase in the risk of women having heart attacks and strokes. It also showed a small but significant increase in the risk of breast cancer. This result gave HRT a bad name and its use was drastically reduced ever since then.

Subsequent further analysis of the same WHI study statistics have led to a more nuanced view by orthodox practitioners. There was no increase risk of any deleterious outcomes for at least 2 years and so, if menopausal symptoms are severe, it is recommended to use HRT for up to 2 years only. There is even a further school of thought that says the increased risks were only in women in the study who began the HRT in their 70’s and that those women who began treatment in their 50’s did not show the same adverse events. This school of thought allows standard HRT begun in the 50’s to continue longer term.

What the study did show was that women who were given only estrogen, because they had a prior hysterectomy and thus did not require the progestogen, did not have increased risks of cardiovascular disease or of breast cancers, both being fairly neutral. It was the women who were given the progestogen Provera who had the increased risk of both breast cancer and cardiovascular events. This is because the protective effect that natural progesterone has on the breast and cardiovascular system is blocked by the synthetic progestogens effects on the progesterone receptors outside of the uterus.

Studies have been done which show that bio-identical progesterone has a mildly reducing effect upon both the risk of breast cancer and cardiovascular disease. Other studies have also indicated that testosterone replacement as part of hormone therapy for menopausal women have further reduction of risk of both breast cancer and cardiovascular events.
Bio-identical hormones are used in doses that are tailored to the individual patient based on their clinical symptoms, genetic factors, and their measured hormonal status, both before treatment commences, and in monitoring its ongoing management. Because this tailor made dose variation is so different to orthodox medical treatment, including of HRT, and has not been applicable to an enormous study such as the WHI study, many gynaecologists and endocrinologists have a negative bias against the use of BHRT. While such sentiments may have a well meaning core concern, the reality is that there are in fact double bind crossover drug trials that prove the relative safety of Bio-identical hormone therapy, supplementing the very robust physiological studies showing the greater safety of BHRT. Furthermore there is a very large body of clinical experience in the use of BHRT in hundreds of thousands of women over decades which confirm this safety.

So to be clear, current medical orthodoxy allows the use of standard HRT for up to 2 years for any woman who has significant menopausal symptoms. The use of standard HRT for more than 2 years may have a slight increase risk of breast cancer and cardiovascular disease. Bio-identical HRT is more effective in controlling the full spectrum of symptoms of the menopause and may be safely used indefinitely when its use is clinically and pathologically monitored. Women who use BHRT as well as those who use no hormone therapy at all still have some risk of breast cancer and cardiovascular events.

Thyroid Hormones

Thyroid hormones are important for basal metabolic rate. Low thyroid function causes low energy physically, mentally and emotionally, as well as often causing dry skin and lifeless hair, hair loss, constipation and cold intolerance.

Thyroid Stimulating Hormone (TSH) is produced in the pituitary gland and causes the thyroid gland to make Thyroxine or T4. This acts as a reservoir hormone, not being particularly active in itself, and is converted in the liver into the active thyroid hormone T3, and a lesser amount into the blocking hormone reverse T3.

Abnormal thyroid hormones are the commonest form of endocrine disorder in humans (excluding sex hormone issues) Underactive thyroid disease or hypothyroidism is far commoner than overactive thyroid disease or hyperthyroidism. Thyroid disease is usually caused by either autoimmune antibody production against the thyroid, eg Hashimoto's disease, or an inflammatory thyroiditis due to a viral infection. An enlarge thyroid gland or Goitre, may or may not be associated with abnormal thyroid function. The thyroid gland is intrinsically a cystic structure and is prone to the development of cystic disease and nodules. These are usually benign but thyroid cancer does occur.

Treating Hypothyroidism usually involves requiring some form of thyroid hormone replacement therapy. It may be possible in the early stages of thyroid disease to reverse the process with dietary changes and nutritional and herbal supplements, but usually once the condition is established hormone therapy is required.

Thyroxine, also known as T4, is the commonest form of thyroid hormone therapy. It is cheap, easy to use, is actually bio-identical and usually effective. It is, however, not universally ideal. It is a good reservoir hormone but in itself is not at all active. It is converted, primarily in the liver, into T3, also a bio-identical hormone, which is the active thyroid hormone. T3 is available as the pharmaceutical medication Tertroxin. While it may seem more logical to take T3, the active hormone, unfortunately T3 has a very short duration of action and so needs to be taken three or four times a day. There is a slow release form of T3 which can be compounded which does partially overcome this obstacle. 
While Thyroxin is perfectly adequate for many people, there is a fairly common issue that when taken as a medication, the first pass effect on the liver causes a high level of reverse T3 to be formed which blocks the effect of T3. This effect is aggravated by high stress hormones. For such people it is far better to have treatment with a predominantly T3 form of therapy. 

Predominant T3 forms of therapy include simple T3, slow release T3, and also thyroid glandular extracts. The advantage of the thyroid glandular extracts (porcine) is that they provide predominant T3 but in a naturally slow release form, as well as some T4 as a reservoir but low enough to not stoke reverse T3 formation. Thyroid extract is usually required once a day, sometimes twice a day. It is not covered by the PBS.