HRT
Dr. Nanette Santoro's POF FAQ

49. Should I take HRT?

The biggest single reason to treat you with estrogen would be to prevent osteoporosis. The second best reason would be for prevention of heart disease. Depending upon your lifestyle, whether or not you have had any children, and your blood chemistries, you may be at low or higher risk for these conditions. To make a good decision, a bone density test might be appropriate to guide you. If your bone density is very high, you may want to wait and do nothing. There are medications other than estrogen that you can take to prevent health risks later in life. These might need to be considered now, too.

50. HRT - what are the alternatives?

There are many books and articles discussing the different types of HRT and how one type might be better or worse for a particular person. A good place to start would be with some of the literature from the North American Menopause Society (NAMS). They have a lot of good resource material and can give you excellent reference guides. The information is also scientifically responsible. You will find that, as you ask these questions, there will be much information. Not all of it is accurate. A specialist in Menopause such as a Board Certified Reproductive Endocrinologist would be a good person to discuss this information with in detail. Also there are many Menopause Centers around the country and some provide outstanding educational resources for their patients.

51. Can you recommend a lower HRT replacement? My MD made a comment that she "would hope that I would not get pregnant" while taking HRT. What are the odds in your opinion?

I would generally recommend an estradiol patch in women who are hoping to conceive while on HRT. The patch gives you natural estradiol, identical to what your ovaries would make if they could. Doses of estradiol on the patch are about 1/4 of those in the pill. While this means your FSH will not be lowered by the patch, there is no reason in the world why your FSH needs to be lowered. Although package inserts of estrogens say loads of alarming things about fetal abnormalities, these are simply not believed to be even remotely realistic when you are taking these physiologic ranges of estradiol. Your doctor's concern might come from the package insert, or it might come from the worry that without suppressing your FSH you won't have a chance to ovulate. This is not true.

52. How long should it take for BCP/HRT to eliminate Hot Flashes?

Most women will feel a difference after the first pill. So I would expect you to be relieved of flashes within days.

53. What are "safe" levels of estrogen? Will it make me gain weight?

Estrogen can be given in a number of different ways. If given in the proper dose, it should not lead to weight gain. If it does, another form of estrogen can be tried. There are pills and patches that will provide comfortable replacement estrogen for most women.

54. How do I know if I'm still ovulating while on HRT?

When you are taking HRT you may note a rise in your basal body temperature. This could happen with Provera if you take it cyclically. If you are on combined continuous HRT, then a rise in your BBT could indicate ovulation.

55. My doctor wants me to take estrace. He says that some women can spontaneously ovulate while on this. Is there any proof that this can work?

There have been a few studies of giving estrogen to women with POF to see if it will 'jump start' the ovary and get ovulation to happen. When these studies have been done with the proper scientific standards, there is NO EVIDENCE that taking estrogen helps to bring on an ovulation. However, if you have other reasons to be taking estrogen (such as hot flashes) it will not harm your chances of ovulating and conceiving if that is going to happen. About 10% of women with POF get pregnant over a ten year period of time. This sounds pretty dismal, but if you get a baby, it's 100% yours!

56. What is the recommended HRT dosage for POF? Is it better to use HRT instead of BCP?

First of all, Birth Control Pills are fine to take. It is generally believed that women with POF do better with more than postmenopausal doses of estrogen. Premarin 1.25mg is appropriate if it helps your symptoms. If you feel like you are taking too much estrogen (and this is already less than what's in the birth control pill), then 0.625 or a patch doses of 50 micrograms can be given. 100 microgram patches can also be used when needed. There's no "correct" dose, use what controls symptoms and protect bone density. The minimum dose is 0.625mg Premarin or 50 microgram patches. Provera can be given in the usual fashion, 5-10mg a day for at least 12 days each month. Oral micronized progesterone is an alternative. The dosing of this at higher estrogen doses beyond 0.625mg Premarin or 50 microgram patch doses has not been well worked out. You would need some fine tuning to figure that out.

57. What level of estrogen I need to protect my heart and bones?

In general, if you are not getting periods, you should be on estrogens. If you are cycling and have osteopenia, you need a medical work up to rule out other causes of low bone density. Some of these can be reversible with proper diagnosis and treatment. If estrogen is the issue, it's been nicely worked out that the 'no brainer' therapeutic dose of estrogen is 0.625mg of Premarin, or 50 micrograms in patch form, or about 2mg of estrace tablets a day, and there are other equivalent compounds of estrogen that can be used. It is likely that lower doses than these can be effective, but the most women show the most benefit when at least this much is used. More is not necessarily better. You should have a follow up bone density to check the effectiveness of the treatment.

58. HRT- are these hormones safe for lengths of time?

Women with POF are in a special situation with regard to HRT. Since your body would normally be producing MORE estrogen than you are taking now if you didn't have POF (HRT estrogen doses are relatively low compared to those in normally cycling women) there may be no problem at all with continuing to take estrogens until you are menopausal aged, like about 50 years old. At age 50, then you would begin the same situation as any other newly menopausal woman, and ought to be 'handicapped' about your relative risks of several problems, such as heart disease, osteoporosis and Alzheimer's disease, as well as your risk of breast cancer. All of these risk assessments will allow you to make an informed decision about whether or not you want to continue with hormones. In the meantime, I think it reflects most of current thinking that you should probably STAY ON HRT. Negative publicity is not always based on scientific evidence.

Your question about the risks of long-term hormone use can be dealt with in two phases: for this part of your life, when you are a woman with ovarian failure too young to be menopausal (i.e., under the age of 40-45), there is not believed to be any risk to taking hormones, because if you didn't have POF your body would be making them anyway and they will prevent bone loss and probably reduce heart disease risk at this age. So it's a winner until you are in our mid-forties. By then, you will need to re-evaluate the risks and benefits of HRT depending upon your particular health risk factors and lifestyle, along with a lot of the new scientific information that will be available then about the long-term risks and benefits of HRT. So--you can wait to make that decision, but for now, I would advise you to take HRT.

59. I'm currently on HRT, Is there any hope that I will be able to wear my contacts again?

This is one of those little things that annoy patients a lot and that doctors don't pay a lot of attention to. My husband, who is an optometrist, is aware of female patients who complain of hormone related alterations in their contact lens fit. It's a well-known problem in pregnancy.

Your best bet is to consider having your contact lens fit re-checked. You may need more or less curve in the lens, and sometimes you are more sensitive to dirt, so the disposable lenses might work better. Some women have 2 pairs of lenses they keep around for 'bad contact lens days'

60. Would you prescribe HRT patches or tablets?

It's really a matter of personal preference. For many of my POF patients I like to try patches because they replace you with the most physiological estrogen.

61. Is estrogen really a carcinogen?

Your statement about estrogen as a 'carcinogen' makes me want to explain it a little more. Estrogen is not a direct cancer-causing agent to the breast. At worst, it's what called a 'promoter'. This refers to a substance that will facilitate the development of a cancer if the appropriate mutation occurs in the tissue that might lead it to grow abnormally. That's why women with estrogen dependent cancers should never taken estrogen and why you should have a negative mammogram and no abnormal bleeding before you ever go on estrogen. In your case, though, because you have POF, the philosophical argument is that your body would be making lots of estrogen if you didn't have POF, at this time in your life. SO the role of estrogen as a cancer-associated promoter in someone like yourself is very, very tenuous at best. Estrogen's role as a cancer 'promoter' has not even been well worked out in situations in which it is believed to play this role, as in breast cancer.

62. Is there a reliable source of information on alternative therapies?

There is very little information about alternative medicine in this area. When you are dealing with alternative medicines, you need to be aware that such medications are not held to standards of safety and efficacy like 'industrial' medications are. For many of these medications, if the cost is not great and they do not appear to be associated with unsafe side effects, there may be little harm in trying them, but you take them at your own risk. The manufacturer does not need to support any of the claims made about these chemicals promote your health.

63. I have read that an intake of soy maybe helpful. Any thoughts on the impact of diet?

There is not much known about the impact of soy or diet on POF. There is some environmental evidence that women who consume large amounts of dairy products might shorten their reproductive life spans by a couple of years (somewhat like smoking effects). Whether this is a cause of POF in some women is a subject of debate. I usually tell patients who are interested in modifying their diets to avoid dairy (and eat lots of calcium to make up for it!) and increase soy protein, but you to be careful about which forms of soy may help. Soy does not act directly on the ovary, but it may improve symptoms. Tempeh and miso are fermented soy products and they seem to have more of the active phytoestrogens and other agents that have the best effect. There are some kinds of soy milk that are also helpful in this regard, but I'm not sure which brands to recommend to you. Good luck with it!