Answers to Commonly Asked Questions ( 30 - 39 )

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30. What about heart health?

The estrogen that dominates women's lives during the reproductive years also protects us from heart disease. After the loss of estrogen there is an increase in heart disease. Data from the Nurses' Health Study found that women who went through surgical menopause (removal of the uterus and the ovaries) before the age of 35 have two to seven times the risk of heart attack; the risk is also high in women who go through a natural POF.

31. How long should I take HRT?

Because women with POF face many more years than normal without estrogen it is recommended that they take HRT until age 51 and then make a "menopause" decision about continuing HRT.

32. Why isn't progesterone necessary if I've had a hysterectomy?

For women with a uterus, the combination of estrogen and progesterone is effective in preventing endometrial cancer. If you've had a hysterectomy, endometrial cancer isn't a risk. In addition, we know that progesterone can negate some of the cardiovascular benefits of estrogen so in general, women who've had a hysterectomy don't take progesterone.

33. My mother and I are both on HRT! Can you believe it! Why does she take Premarin 0.625 mg and I take 1.25 mg?

One of our members calls the HRT her "granny pills." It is really hard to be taking this "medicine" at such a young age. Generally a higher dose is needed: to control the hot flashes and other symptoms, to provide the vagina with enough estrogen, and to compensate for the deprivation of estrogen at a time in life when the ovaries produce most of the body's estrogen. The levels of hormones that are produced by the body during the reproductive years are much higher than those given through HRT at the dose recommended for the "menopausal woman."

34. How should young women with Premature Ovarian Failure replace the estrogen that their ovaries don't supply to them?

The National Institutes of Health provided this information: "When the ovaries stop working in young women one could argue that the natural human hormone should be replaced just as natural human insulin can be replaced in people who have diabetes. It makes sense to try to replace exactly what the ovaries make and supply it in a way as similar to the way nature provides as possible. This means using the natural human hormone estradiol. This is the major hormone that human ovaries make. It also means giving the estradiol in a way that goes into the body through the veins (the normal human ovary doesn't provide estradiol through the mouth, it provides estradiol by putting it into the ovarian vein). Well, you say, we obviously can't give estradiol by putting it into the ovarian vein, now can we! True, but we can give it through veins in the skin by using a patch. This is what we recommend you do until we have better scientific information."

Another benefit of the patch is that it releases estrogen continuously, rather than all at once like the tablet. This way the delivery of estrogen more closely resembles your body's own estrogen production. However, not all women can use the patch because of skin irritation. And some women don't like the idea of "telling the world" they're on HRT by wearing a patch. So don't feel badly if a patch is not the ideal medication for you. The oral estrogens have worked effectively for years.

35. What about progesterone?

You asked about progesterone but I'm going to start off by giving you some information on the combination of estrogen and progesterone! We know that estrogen alone is the most effective in increasing the good lipids (HDL) and decreasing the bad lipids (LDL). When a progestin is added to estrogen the positive effects of estrogen is decreased. However, as we stated above, progestin is necessary to protect against uterine cancer and should be taken unless you've had a hysterectomy.

Provera (medroxyprogesterone acetate) is often recommended as the progesterone substitute. It has been around for a long time and its benefits have been proven.

Another choice is micronized progesterone. The findings of the PEPI (Postmenopausal Estrogen/Progesterone Intervention) Trial confirmed that the levels of the good lipids were highest in women taking estrogen alone but they were almost as high for women who took estrogen and a micronized form of the natural hormone progesterone.

The PEPI trial was a 3-year study of nearly 900 women on various forms of HRT. This was a study of postmenopausal women. Their ages ranged from 45 to 64 (there are no HRT studies on women with POF although NIH is getting ready to do one). One of the outcomes of this study was that potentially pre-cancerous lesions developed in one-third of the women with a uterus who only took estrogen! Also, the estrogen effect on the lipids is only one aspect of cardiovascular health. Look for more studies!

Micronized means finely ground. That it's been broken down into very tiny particles. It allows for a steady, even absorption of the medication. Natural means many things to many people but here we mean chemically identical to the hormones produced in your body. It doesn't mean that it's an organic product like you'd find in a health food store.

The dose used in the PEPI Trial was 200 mg of natural micronized progesterone for 12 days per month.

Until just a few months ago the only way to purchase micronized progesterone was through a compounding pharmacy. Micronized progesterone was sold as a bulk powder to pharmacies that specially prepare or "compound" the powder in capsules or tablets. Now you can have your HCP write a prescription and take it to your local pharmacy just as you do for your estrogen.

36. What are the side effects of estrogen and progesterone?

Side effects of estrogen include: breast tenderness, headache, blood clots, worsening of astigmatism, intolerance to contact lenses, nausea, vomiting, diarrhea, bloating, weight changes, acne, decreased absorption of folic acid and increased gallstones.

Side effects of progesterone include headache, irritability, depression, nausea and vomiting.
Several women state that they have fewer side effects on micronized progesterone than on Provera. Micronized progesterone should be taken at night because it often causes sleepiness.

37. Should I take continuous or cyclical HRT?

Generally, cyclical HRT is recommended. Again, from NIH: "Our feeling is that having a regular period helps to make young women with POF feel more normal, like every other young woman having monthly bleeding. Also, should you spontaneously ovulate and conceive, which does sometimes happen, you will miss a period, know to have a pregnancy test, and stop the hormones if pregnant."

38. I had a blood clot. Should I take HRT?

No, women who've had blood clots should not take HRT.

39. What can I do instead?

If you cannot use HRT there are alternative therapies available. A healthy diet, an exercise plan, and stress/symptom management can protect the heart, bones and relieve the symptoms of POF. In truth, those of us on HRT can benefit from alternative therapies also.

Diet:

If you are used to eating the typical American diet (lots of fats, sugar, salts and artificial chemicals) you might consider making a change! A switch to a diet that more mimics the Asian diet appears to help to alleviate menopausal symptoms and protect your heart. Their diet emphasizes: whole grains, beans/legumes, fruits and vegetables, foods that contain essential oils and fish.

More specifically this means soybean-based products. Soybeans contain phytoestrogens. In addition to helping reduce hot flashes they also may have an anti-cancer effect. Japanese women have a lower incidence of breast cancer.

Unlike saturated fats, essential oils are not primarily used by the body for energy. Fatty acids help to provide moisture, softness and smooth texture to the skin. They are also a main structural component of all cell membranes. Sources of essential oils include: sesame and sunflower seeds, walnuts, trout, salmon, and green leafy vegetables.

There are also some vitamins and minerals that can be helpful. A daily supplement (as we stated above in the osteoporosis area) can be helpful. However, it is not enough to take a supplement while continuing an unhealthy diet! Vitamin E at 800 mg per day may help relieve hot flashes, night sweats and vaginal dryness. Vitamin B complex helps in several ways. They help regulate estrogen levels by promoting healthy liver function. They play an important role in the function of the nervous system.
Herbs that are beneficial include chamomile. Yes, like in the sleepy-time teas you may see at the store! Chamomile is a good source of tryptophan, which may help to provide a restful sleep and so it may be helpful if you have insomnia. If you do have insomnia, you may need to make the tea stronger than normal. Start with one tea bag and increase to two or three until you find the amount that works best for you.

Exercise plan:

Look back at the osteoporosis section for exercise suggestions for healthy bones. These need to be done regularly, a minimum of three times per week. To strengthen the muscles of the urinary tract, vagina and anus, Kegel exercises can help. These can help to make sex more pleasurable and to prevent leaking of urine that can occur when you sneeze, cough or laugh. They are simple to do. First, you want to find where these muscles are. The easiest way to do this is while you're urinating. While you're urinating, stop the flow of urine. The muscle that stopped the flow is what we're looking for. However, now that you've "found the place" do not do this exercise by stopping the flow of urine because it can lead to bladder infections. Contract the muscle, hold for a count of 5, relax for a count of 5 and repeat this 20 times. Do at least 10 sets of 20 every day. The nice thing about this exercise (this exercise may be unlike any you've ever done before!) is that it can be done anywhere. They can be done as you stop your car at a red light, while brushing your teeth, putting on make-up. You get the idea.

Stress reduction and relaxation exercises:

These can help with the both the physical and emotional components. Some of the changes that are occurring are due to the lability of the hormones and some are due to the feelings of loss you may be experiencing due to infertility. Again, all women with POF can benefit from these. Stress reduction and relaxation exercises include abdominal breathing, visualization, and meditation. Some women find that acupuncture, acupressure or yoga are helpful.

A book could be written just on alternatives, and they have been! So, we would recommend that you buy at least one book that addresses alternatives to HRT. See Resources.

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