Troubles Dealing With Hot Flashes

Your doctor’s approach is very sound. Because of the risk of breast cancer, it is good to see if non-hormonal preparations are sufficient for menopausal symptoms. If this is not enough, short term use of estrogen helps. The long-term goal should be to wean off estrogen eventually, or arrive at the lowest dose possible to control symptoms. Your doctor has suggested Activella, which contains oral estradiol, a bio-identical estrogen, and norethindrone, an artificial progestin (a progesterone-like drug). When you take estrogen, if you have not had a hysterectomy, you need to take a form of progesterone with the estrogen to prevent uterine cancer. There is some debate about the best form of progesterone. Provera, a common progestin, has been linked to breast cancer. Many physicians prefer the natural form of progesterone to artificial progestins, as natural progesterone has calming effects on the mood and perhaps other beneficial effects. There is not enough hard evidence to claim in a clear-cut way that natural progesterone has better effects on the breast than norethindrone.

In my gynecologic practice, I prefer the estradiol patch to oral estradiol, because the estrogen goes directly into the bloodstream and tissues, and does not pass through the liver, which creates other estrogen metabolites. Also, estradiol patches come in many different doses. This allows you to start with an effective dose of estrogen, and more easily reduce the dose every two or three months to wean down to the lowest dose possible, minimizing symptoms. I also would prescribe natural progesterone, in oral form (Prometrium is the common brand name) or progesterone vaginal capsules, available at Kubat pharmacy in Omaha. If you were able over time to wean down to a very low dose of estrogen, it is possible at some point that you could switch over to progesterone cream (also from a compounding pharmacist such as Kubat). Progesterone in a cream form is not strong enough to prevent the uterine effects of estrogen, except perhaps in the very lowest doses if one were close to discontinuing the estrogen altogether.

Dr. Mary Davenport