In health, hormone levels in the body are basically controlled by the
pituitary gland, using “negative feedback loops.” An example of such a
loop is making a left hand turn while driving. As you turn the wheel to
the left, the car turns. Seeing that your effort is working, you turn
the wheel in the opposite way (hence the term “negative.”) If you did
not “correct” your initial action, the car would simply turn in a circle.

An example in the body (simplified) is the control of the ovarian hormone,
estrogen (in actuality there are several estrogenic compounds made by
the ovaries.) As the menstrual cycle is ending, the pituitary secretes
follicle stimulating hormone (FSH) which causes the ovarian follicles
to make estrogen and to “ripen” an egg. The uterus, stimulated by estrogen
secretion, builds up a lining with which to support the growth of a fertilized
egg. If the egg is not fertilized, FSH secretion diminishes, and as estrogen
levels fall the lining of the uterus, having lost it’s estrogenic support,
sloughs off (causing the menstrual flow). The cycle then begins again.

By taking supplemental hormones, this cycle is interrupted. For example,
by taking the birth control pill, which contain estrogen, the pituitary
“thinks” that the ovary is working, and does not secrete FSH, which in
turn means that the ovary is not stimulated to produce an egg. The uterus
continues to respond to the estrogens in the pill, so there is a menstrual
cycle. But the ovaries are, in effect, “turned off.” This is why some
women, when going off the pill, do not get their menstrual periods back
right away. In menopause, as the ovaries stop producing eggs (ovarian
“senescence”) pituitary FSH levels rise to levels quite a bit higher than
previously seen. This stimulates the production of estrogenic compounds
by the adrenal glands and the body fat. These compounds, though not an
identical mix to those produced by the ovaries, do provide the basic functions
of ovarian estrogens. In health, the transition is fairly seamless — symptoms
such as hot flashes, moodiness, fatigue, are minor if at all present.
A menopause accompanied by distressing symptoms indicates that the body
is not functioning properly.

One approach to remediate this is to “substitute” the hormones the body
is not making properly. However, by doing this, as in the example above,
the “normal” functioning of the body is disrupted. The adrenal do not
have to function under the stimulation of pituitary FSH. No fundamental
improvement in body function is achieved — rather only a substitution
for what the body should be doing. Another problem, to my way of thinking,
with substitution is that it assumes that enhanced pituitary FSH in menopause
does not serve any other function than to stimulate the adrenals and body
fat to produce estrogen. It is probably safe to assume that we don’t yet
know all the reasons the body functions in the way that it does, and that
long-term health is more likely to be achieved by helping the body to
do what it should do than by substituting for it’s shortcomings.

Menopause is not a state of disease — it is rather a normal phase in
a woman’s life. As I said above, in health it should not be a period of
significant symptoms and distress. It does not automatically lead to osteoporosis,
Alzheimer’s disease, heart disease, etc.

The latest assessment of the efficacy of estrogen replacement therapy
on heart disease is discouraging. No benefit has been found in the latest
two large studies performed, the Estrogen Replacement and Atherosclerosis
(ERA) trial or the previous 1998 Heart and Estrogen/Progestin Replacement
Study (HERS). The HERS study actually found an increased number of heart
attacks in the first year in the group using hormone replacement. A third
study, reported in the Family Practice News, April 15, 2000, showed no
reduction of heart attack risk in diabetic women.

Estrogen also appears to not slow the course of Alzheimer’s disease in
older women already diagnosed with that condition.

Another hormone that is popular to replace is Melatonin,
made by the pineal gland, with many important functions. It is said that
Melatonin production diminishes with age, giving rise to the idea that
increasing Melatonin levels (through supplementation) is a good idea.
If the decrease in Melatonin secretion is unhealthy, then increasing it
may not be a good idea. If the decrease is a function of poor health (or,
very likely, sleep deprivation) then it makes sense to correct the problems
leading to the low secretion, as discussed above.

Another problem with hormone supplementation is that the body makes hormones
in very small amounts, almost continuously, increasing or decreasing secretion
according to need. This system, a very elegant and efficient one, cannot
be duplicated by any external delivery system. (The one artificial possibility
on the horizon is an “artificial pancreas,” with a computer-chip functioning
as a blood-sugar tester and controlling the release of stored insulin.)
Trans-dermal systems do provide a more continuous delivery of hormone,
but not according to need. Oral supplementation is obviously the least
elegant alternative.

There is a body of work pertaining to “Bio-identical hormone” therapy. I am investigating this, as it has helped some of my patients, who have only partially benefited from other treatments that I’ve used for them.  I’ll write more on this as I learn more.