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Celebrity Suzanne Somers has taken menopause by storm in her book released in 2020. Over 50, menopausal women find hope in the message of sexy aging. Ms Somer’s spotlights the term “bio-identical hormones” and makes it hot on the lips of every woman (and man) coming to grips with the aging process. Now we can expand the term “natural” with “bio identical”, giving everyone a new appreciation for hormone replacement.

A major issue in the book has made women apprehensive; some are even scared enough to avoid hormone replacement. Ms Somers claims that cycling (creating a period every month) is recommended and natural. She implies that we menstruate while we are “young” and it is advantageous and natural to continue to menstruate forever (if you take hormones).

What is cycling? It is the fall of hormones in a woman that results in menstruation. Therefore, if a woman stops the progesterone for a few days every month she will cycle and bleed. This is possible even if you have been years without a period, unless of course, you have had a hysterectomy.

MENOPAUSAL WOMEN DO NOT NEED TO MENSTRUATE – Taking hormones does NOT necessitate cycling!

First: hormone replacement therapy does not put one in a state of pregnancy. During pregnancy, the levels of estrogen might be in the thousands. On estrogen replacement, ideal estradiol levels are typically 50-100 mg/dl.

Second: the reason a woman menstruates is to clean the uterus in preparation for the eventual implantation of a fertilized egg. If one is not interested in becoming pregnant, there is no physiologic reason or benefit from menstruation!

A recent article in the obstetric/gynecological literature claimed that unexpected vaginal bleeding was the most common reason woman stopped taking hormone replacement therapy (HRT). The cessation of periods was one thing women welcomed with menopause. The medical literature often addresses how to stop and prevent post menopausal vaginal bleeding so that women will be comfortable in continuing HRT. Progesterone is used to reduce the growth of the uterine lining to prevent bleeding (i.e. cycling). With the appropriate balancing of estrogen and progesterone, women should not bleed and will be more satisfied with continuous HRT.

For years, woman have been treated with birth control pills taken continuously and not cycled to control PMS. It is the fall of women’s hormones that takes place right before their periods that causes the symptoms of PMS. By taking birth control pills continuously, a woman can avoid this drop of hormones and the symptoms of PMS. The pharmaceutical industry has now caught onto this and promotes a new birth control pill that is cycled for bleeding every four months instead of monthly. The researchers claim that while no menstruation is necessary, the cycling allows women to menstruate every four months to make them feel more “normal”. We now realize that even pre-menopausal women do not need to menstruate, let alone post-menopausal women! Remember, cycling involves stopping the progesterone for a few days.

Another reason not to cycle is the loss of protection that takes place when the progesterone is not present. Bioidentical progesterone protects the breasts and uterus against cancer.

It is obvious and well accepted that progesterone protects against uterine cancer. The bleeding that takes place with menstruation is NOT what protects the uterus against cancer; it is the DIRECT effect of progesterone on the uterus that protects it. Stopping progesterone for a week means that the body is without the protective benefits of progesterone for those days. It makes no sense to lose the important protective benefits of progesterone for even a few days every month.

Recent studies have shown that Provera (medroxy-progesterone) increases the risk of breast cancer and increases the thickening of breast tissue. Provera does this by direct stimulation (termed, up regulation) of estrogen receptor sites in the breast. Once study showed that Provera increased breast stimulation by 400% over baseline (those not on Provera). The same study showed that bioidentical progesterone (not synthetic progestin, Provera) does not stimulate breast tissue as it down regulates receptor sites in the breast (i.e. progesterone is protective). Why lose the protective effect of progesterone by stopping it for a few days every month?

There is a condition known as “endometrial hyperplasia”; the condition causes increased thickening (or growth) of the uterine lining (the uterine lining is termed ‘uterine stripe’) – this growth is a precursor to cancer. This condition must be treated to avoid the development of cancer. The treatment is high dose progesterone (unfortunately, Provera by conventional physicians) to shrink this tissue. If repeat ultrasound does not show a decrease in the endometrial lining, then the dose of progesterone is doubled. The shrinkage of the endometrial tissue is a result of the direct stimulation by the hormones. Protection from uterine cancer is NOT occur because of the shedding of the uterine lining. A constant sufficient dose of progesterone is the better protection against cancer.

In summary, women on hormone replacement therapy do NOT need to cycle (stop the progesterone) and bleed on a periodic basis. There is no substantiated benefit to the body to regularly bleed. This fact certainly makes hormone replacement therapy and its many protective benefits a more attractive and convenient regimen for women.

Daniel S Bennett, MD

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