To Replace, Or Not Replace Hormones…That is The Question!

“What do you think I should do, Randy?”, Yolanda asked, her voice a mixture of trust, hope and worry. “Do you think I should really consider hormone replacement in light of all I have been through?”

Yolanda had come to A Mind For All Seasons with a complaint of ‘brain fog’. If you have experienced brain fog, you know exactly how disconcerting it can be! Like most people in her situation, Yolanda was not suffering enough that her daily life was upended by cognitive challenges, but she lacked the mental crispness she had always enjoyed. She harbored a private, incessant worry that her diminished memory, trouble focusing, difficulty finding words and mental sluggishness would deteriorate into dementia like it had for others in her world. As my associates and I coached her through The Enhance Protocol®, we learned that Yolanda had a history of a cancerous mass: a stage-0, high grade, estrogen and progesterone receptor-negative, ductal carcinoma in situ (DCIS) in the right breast. Fortunately, the mass was caught early enough that lumpectomy and radiation were the only recommended treatments.

In the years since her brush with cancer, Yolanda struggled with the typical menopausal symptoms of hot flashes, night sweats, depression, anxiety, insomnia, fatigue, and yep… brain fog! As is customary in our current medical climate, her healthcare provider warned her against the evils of hormone replacement.

Now, I found myself sitting opposite a woman who desperately wanted two good things, both of which seemed on the surface to be at odds with each other: the goal to eliminate her brain fog and the desire to avoid future showdowns with cancer.

Hundreds of similar conversations flashed through my mind as I thought of the challenging situation post-menopausal women- especially those who have had cancer- go through every day when they meet with their healthcare providers to consider the devastating effects of hormone loss and the competing desire of preventing a life-threatening cancer. Neither option seems acceptable, and there was a time I would have never hesitated to recommend avoiding hormone therapy. Better to err on the side of caution, right? But at what cost- especially considering all I had learned about the crucial role hormones play in brain functioning- let alone energy, bone health, mood, sleep and sense of wellbeing.

Experiences with many of my menopausal clients cause me to reflect on the challenges common to women with a hormone deficiency who also struggle with early symptoms of Alzheimer’s. That adds a whole new dynamic because there IS such a thing as a hormone-deficiency (particularly estradiol) that can lead to Alzheimer’s. The brilliant work of Dr. Dale Bredesen has changed the way astute practitioners look at Alzheimer’s disease. In a study published in the Journal of Aging, 2015, Dale Bredesen dissected Alzheimer’s into specific disease sub-types based on certain metabolic profiling particularly to each subtype. Categorically, Dr. Bredesen classified them into Dementia Type I- inflammatory, Dementia Type II- atrophic (this is the dementia most associated with menopause), and Dementia Type III- toxic[i]. If you are female, menopausal, or you had an early hysterectomy, then listen up. This blog is for you!

Though the extent to which menopause (or an early hysterectomy) contributes to Alzheimer’s dementia is not completely understood[ii], a clear relationship has been suggested[iii]. Over a decade of clinical findings, observational evidence, and basic scientific research suggests that estrogen administration during a woman’s menopausal transition provides beneficial effects on cognition and can decrease a woman’s risk of developing Alzheimer’s disease (AD) later in life[iv]. Early hormone replacement in women has been shown to positively impact neuromodulation, provide neuroprotection, and optimize cerebravascular regulation[v]. In Wharton et al. estradiol was shown to be beneficial in at least one cognitive-related domain in 14/21 studies, with no studies suggesting a harmful impact of estradiol on cognitive function.

Notwithstanding the controversy associated with hormone replacement, I am unashamed to state that most people who participate in The Enhance Protocol® will be asked to consider some form of hormone replacement if they are categorized within the atrophic subtype of Alzheimer’s dementia. I never intend to step on the toes of my clients’ other providers, and I do not insist that all who may benefit from hormone replacement participate. Our approach at A Mind For All Seasons is to educate our clients, work with their providers, and help everyone involved make a fully informed decision. Yolanda’s case illustrates our approach.

When we started to work through The Enhance Protocol, Yolanda completed a comprehensive set of labs used to identify potential triggers and contributors to dementia. Alzheimer’s disease is often at work for 10 to 20 years before dementia symptoms show up, so we do not take complaints of brain fog lying down. Yolanda’s follicle stimulating hormone (FSH) level was 68, her estradiol level was 12, her progesterone was < 0.1 and her total testosterone was 17. While it is beyond the scope of this blogpost to interpret these labs, suffice it to say that this is a very typical hormone presentation for a menopausal woman. 

In early stages of Alzheimer’s Dementia Type II, individuals often express the brain fog so commonly associated with menopause, but there is more. Their lab work also demonstrates sub-optimal levels of other hormones, including DHEA, pregnenolone, testosterone, progesterone, thyroid, and cortisol, and sub-optimal levels of essential nutrients such as B-vitamins, magnesium, vitamin D, vitamin E, etc. The combined impact of these suboptimal hormones and nutrients reduces neurogenesis and neuroplasticity- the brain’s ability to grow and thrive. Yolanda showed deficiencies in many of these nutrients and hormones. So how should I handle her situation? Would I dare recommend hormone replacement in the historical context of a breast cancer? What about in women who have taken estrogen blockers at the encouragement of their physicians?

I am certain that the mere suggestion of hormone replacement in this context would cause apoplectic shock in many of my colleagues. So, I take the high road and I neither recommend nor discourage hormone optimization. But I do take a considerable amount of time educating my clients about the risks of either decision and I no longer believe the decision to withhold hormones is as simple as I used to think. 

I am the first to suggest that hormone replacement in menopausal women is not without controversy or risk, regardless of their personal or family history of cancer. Many health practitioners are quick to jump on the ‘research’ that hormone replacement therapy (HRT) increases the risk of blood clots, DVT’s and/or cardiovascular disease. The controversy and risk may be amplified when women have a history of breast cancer. In fact, those participants of The Enhance Protocol who choose to participate in hormone replacement are asked to review and sign an informed consent before starting replacement, regardless of whether we prescribe the therapy or it comes from another health care provider we are consulting with. We believe in full disclosure and we don’t twist arms!

We also believe that if a woman has a moderately high risk of cognitive decline based on her current health or family history, but only a relative risk of a cancer, blood clots, or worsening cardiovascular disease with hormone replacement, then treatment may not just be beneficial, it may be brain-protective! Said another way, how much benefit is there in cancer prevention if a woman develops Alzheimer’s in her 60’s? Seems kind of absurd to be so vigilant about cancer prevention and yet oblivious about Alzheimer’s risk, doesn’t it?

Consistent with our values, we offered a broad array of educational articles to Yolanda. My answer to her question, “What do you think I should do?”, was to take the time to walk through the risks and benefits of hormone replacement therapy and leave her with the offer to help if she felt it was in her own best interest.

A few months went by before I heard from Yolanda again. This time, she emailed the following (redactions inserted to protect privacy):

From: XXXXXXXX <[email protected]>
Sent: Tuesday, March 10, 2020 11:12:05 AM
To: Randy Vawdrey <[email protected]>
Subject: hormones for XXXXXXXX

Hi Randy,

I wanted you to know that I read the book Estrogen Matters and also read several articles from www.hormonebalance.org such as the Top 10 myths about testosterone use in women, Beneficial effects of testosterone therapy in women, and Testosterone therapy in women.

I would like to pursue hormone replacement because of all I read there are so many benefits for the brain, and I want to do everything I can to prevent dementia. Testosterone is essential for women’s physical and mental health. I was also happy to read that Testosterone is breast protective and does not increase the risk of breast cancer. Also reading that estrogen improves women’s well-being and lengthen their lives.

Please let me know if you are able to put me on the hormone replacement.

Thanks,
XXXXXXXX

That is an interesting email, isn’t it? Does it sound like I twisted her arm into taking HRT? Isn’t her level of investigation impressive? She did her own research. She read books, articles, studies and opinion papers from many talented physicians. Did I mention that fact that the book she referenced, Estrogen Matters, was written by an oncologist? Check it out; it may shift your long-held opinion about the potential benefits of hormone replacement in women struggling through menopause, particularly brain fog! After a little guidance, my client came to her own conclusions and I supported her decision by writing her a prescription for HRT.

I am the first to suggest that hormone replacement is not for everyone, but I do suggest that it may be  less problematic than many practitioners choose to believe. I know, I know… there are doctors out there in cyberspace that will send me hate mail, load up my inbox with studies and references that support their argument (that estradiol or other forms of hormone replacement) is evil, kills women, and that I am doing a great disservice for suggesting otherwise. Trust me, I’ve received the hate mail, and the doctor that read this before you already sent me a negative study.

In conclusion, I don’t want to be cavalier or insensitive, but my response to these arguments is that Alzheimer’s disease also kills! Alzheimer’s is evil! I have often felt that it is a great disservice to watch women fade into cognitive oblivion in the attempt to protect them from a potential side effect! How many times has your doctor written a prescription for a medication that had the potential to cause a side effect, but you proceeded because you felt the benefits of the medicine overwhelmed the risk of, or the potential for, an adverse effect? That is the same argument when we consider responsible hormone replacement in the context of Type II Alzheimer’s dementia.

Hormone replacement therapy is a treatment option that can strengthen a woman’s cognitive function, calm her nerves, improve her sleep, enhance her mood, moderate her challenges with chronic UTI’s, and improve her overall sense of wellbeing. In that context, doesn’t hormone replacement feel less evil? I support the perspective that both sides of the argument need to be discussed. When HRT is understood and viewed in the context of progressive dementia, the understanding can strengthen a woman’s decision making about the appropriate use of hormone replacement. To replace or not replace… that is the question!

As for Yolanda, she has very successfully applied all the treatments and therapies of The Enhance Protocol in her life, including a bioidentical hormone cream, and recently commented about how much clearer her thinking is and how much more energy she has. Her story and hundreds of others like it keep me motivated to continue working to change lives…one brain at a time!

[i] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4586104/
[ii] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4586104/
[iii] https://curealz.org/news-and-events/increased-alzheimers-risk-during-menopause-transition/
[iv] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2776312/
[v] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2776312/