Hormone Replacement Therapy and the Estrogen Dilemma

Walk into any health food store and you’ll see shelves packed with natural alternatives to hormone replacement therapy (HRT). And as evidence of the risks of HRT continues to pile up—namely, heart disease, breast cancer, and stroke—the market for these products should only expand. If they’re natural they must be safer, the thinking goes.
But are they?

There’s reason to believe at least one of the most popular alternatives, soy, may not be so safe after all—at least when you get the high quantities needed to ease hot flashes. (As part of a balanced diet, soy has protein and bone-building properties you don’t want to pass up.) But there’s also encouraging news about a hot flash tamer that turns out to be safer than we thought—as well as other HRT alternatives to consider.

First, here’s how soy works and why it’s problematic. The reason it may ease hot flashes is that it’s a phytoestrogen, or plant-based estrogen, which means it behaves in the body much the same way synthetic estrogen does. Specifically, its isoflavones park in the same cellular spot the body reserves for estrogen. So when a woman’s natural estrogen levels dwindle during menopause, causing those famously uncomfortable overheated moments, soy’s isoflavones offer the body an estrogen fix that may cool the fire.

But the very fact that soy is a powerful phytoestrogen complicates the picture. The reason HRT raises breast cancer risk is that too much estrogen is thought to stimulate breast cell growth, which can lead to cancer. Because soy isoflavones behave like estrogen in a woman’s body, the concern is that they may have the same cell-stimulating effect. And the problem is, scientists don’t know how much is too much.

“We know that the phytoestrogens in soy are somewhat weaker than the estrogens in HRT,” says Colleen Piersen, a researcher at the Center for Botanical Dietary Supplements Research at the University of Illinois, at Chicago. “But we just don’t know if they’re safer.”

Ounce for ounce, soy supplements may be even chancier than soy foods. “A lot of these supplements aren’t just crude extracts,” says Piersen. “They’ve been purified to further concentrate the active ingredient, which is where the potential danger lies.”

The bottom line? “Women at high risk for breast cancer shouldn’t take soy supplements,” says Piersen. As for soy foods, she’s reluctant to make specific recommendations, but she says the best approach is to eat them as part of a regular diet and not load up on them disproportionately. Several factors can put a woman into a high-risk category, including having a first-degree relative (a mother, sister, or daughter) who had the disease, particularly before menopause. Other red flags include having already had breast cancer, early menstruation, and late onset of menopause.

And what about women who aren’t at high risk? The problem is that it’s not easy to say who will develop cancer and who won’t. Keep in mind that only a small proportion of women fall into a high-risk category, which means that the majority who develop the disease will do so for reasons that are not known. And there’s no way to assure any particular woman, high risk or not, that she won’t be one of those cases.

For that reason, it’s probably wise to look elsewhere for hot flash relief. Luckily, there are several options that appear to be safer than soy.

For instance, scientists recently discovered that black cohosh, which was once thought to contain phytoestrogens, does not. They don’t know exactly how the herb works, but many now believe that components of it, called triterpene glycosides, ease menopausal symptoms by attaching to serotonin receptors in the brain.

The discovery that black cohosh sidesteps the estrogen pathway makes it a favorite among women’s health practitioners. “Right now, black cohosh is the most promising alternative to HRT for women with mild hot flashes,” says JoAnn Pinkerton, a spokesperson for the North American Menopause Society and medical director of the Women’s Place/Midlife Health Center at the University of Virginia Health System.

So far, studies haven’t turned up any risks, including increased odds of breast cancer—except one. If you’re recovering from or being treated for breast cancer, check with your doctor before swallowing the herb. Animal studies suggest that black cohosh can cause already established breast cancer cells to spread. It also may interfere with the breast cancer drug tamoxifen.

Some women get hot flash relief from topical progesterone creams, which are available over-the-counter or in stronger, prescription-only versions. Progesterone, the other hormone in HRT, was originally added to the mix just to balance estrogen, which can raise the risk of uterine cancer. But now some experts think it has its own ability to ease symptoms.

Finally, many experts think taking HRT short term is a viable option for women with unrelenting symptoms. Yes, HRT raises a woman’s breast cancer risk, but not until she’s been taking it for about five years—and the average woman is troubled by hot flashes for less than two. (Keep in mind that risks for heart disease and stroke go up within the first year, but experts say that’s mainly a concern for women who are already at high risk for heart trouble—a very small group at that age.)

Vaginal synthetic estrogen products, such as creams, rings, and suppositories, are also considered safe, though they don’t help with hot flashes; they’re used to treat the vaginal dryness, itching, and pain during intercourse that some women experience.

The bottom line? Keep eating those tofu burgers and edamame (in moderation), but for hot flash relief, you’re better off depending on something other than soy.

User’s Guide: HRT Alternatives

Black cohosh: For best results, try Remifemin, the brand most commonly used in clinical trials, and take two 20-milligram tablets a day with meals. An upset stomach is one of the herb’s few potential side effects.

Progesterone cream: Over-the-counter natural progesterone creams are available at health food stores, and while research on their effectiveness is mixed, some women with hot flashes do report getting relief. If OTC creams don’t do the trick, you may want to try the prescription-strength variety, which must be mixed in a pharmacy according to a doctor’s instructions. High-dose natural progesterone is also available in pill form and tends to cause fewer side effects, including breast pain, bloating, and headaches, than synthetic versions.

For the OTC creams, look for a product with at least 400 mg of progesterone per ounce, and rub half a teaspoon into your wrists, inner thighs, or chest twice a day (check with your doctor for dosages on the prescription variety). If you no longer menstruate, lay off the cream one week a month. If you still have menses, stop using the cream during your period.