Dr. Lisa Esposito
Chair of Philosophy & Religion Department
Associate Professor of Philosophy & Religion
Phone: (417) 873-7229
Fax: (417) 873-7435
lesposit@drury.edu
Hormone Replacement Therapy: Herbal Alternatives and the Ethical Dilemma
by Jessica Stanton
At any given time, there are approximately 30 million menopausal women in North America and there are currently about 20 million female baby boomers on the brink of menopause (Lee 3). The pharmaceutical companies have not failed to notice this large number of aging women and hormonal supplements are being pushed across the nation. In fact, Premarin - a synthetic estrogen - was the most prescribed medication in the United States in 1999 and the projected sales of hormone replacements in general were an estimated one billion dollars in the year 2000 (Laucella 30). With statistics like these, it is no wonder that pharmaceutical companies continue to encourage the use of such products. One must question, however, whether or not these hormone replacements are actually beneficial to the women who use them. This paper will examine the workings of the female body, specifically during menopause, and will then suggest that the synthetic supplements as prescribed by physicians and promoted by pharmaceutical companies are not actually the most beneficial option and will then conclude that natural supplementation is a more safe and effective method which in turn deserves further research by the medical and scientific community.
In order for one to better grasp the concept and consequences of hormone replacement therapy, one must first examine the intricate processes of the female body, including that of menopause. First, however, it is important to understand that menopause itself lasts only for a few days and one is never absolutely certain that it has occurred until approximately one year after the cessation of menstrual periods.
Therefore, all symptoms after this cessation are "postmenopausal." However, to avoid confusion within this paper, terms like "menopause" and "menopausal symptoms" will be used in reference to the time after one's last menstrual period, much like popular custom would have it known (Love 9).
At birth, the female ovaries contain the maximum amount of eggs that they will house and there these eggs remain inactive until the onset of puberty. At this time, hormone levels begin fluctuating wildly, specifically a follicle-stimulating hormone (FSH) and a luteinizing hormone (LH) - both of which are produced by the pituitary gland - and also estrogen and progesterone, which come from the ovaries.
After puberty, the following can roughly be expected until a woman reaches menopause, excluding the instance of pregnancy. Estrogen, being the dominant hormone for the first week or so after menstruation, stimulates the buildup of tissue and blood in the uterus as the ovarian follicles simultaneously begin their development of the eggs, which are individually encased in small sacs, known as follicles (Lee 6). These follicles are stimulated by FSH to produce estrogen. When estrogen levels reach a specified amount within the body, the pituitary gland turns off FSH production and instead releases a surge of LH. When LH is at its peak, ovulation occurs - more specifically, the body releases an egg from the follicle (Love 12). After this release, the follicle becomes the corpus luteum and begins to produce progesterone in addition to estrogen, which is the dominant hormone during the second half of the menstrual cycle (Lee 9). Thus, the important balanced relationship between estrogen and progesterone begins to take shape and become more evident.
The average woman's ovaries gradually begin to produce lower levels of hormones during her thirties and this decline will most likely continue during her forties as well. Most women are not aware of this change until their menstrual periods become irregular or stop altogether. While the ovaries may still be producing hormones at this time, it is not a sufficient quantity in order to maintain the reproductive qualities of the uterus and eventually the menstrual periods will stop (Laucella 16).
So what exactly are women doing about this sudden decrease in hormone production, which brings hot flashes, night sweats, and a lack of energy among other things? First conceived in the late 1950s, many women are turning to hormone replacement therapy, or HRT (Lee 21). "HRT is a physician-prescribed program of treatment for women who are experiencing hormonal imbalances, usually during and after menopause." It may consist of estrogen alone or a combination of estrogen, progestin, natural progesterone, or testosterone (Laucella 29).
One must now ask, however, what are the differences between all of these hormones? First, it is important to understand that there is no hormone called estrogen. There are estrogens for instance named estrone, estradiol, and estriol - each of which has a different function - and while it is common for a writer to refer to estrogen as a hormone that does one thing or another, it is incorrect. For the purposes of this paper, however, and in order to cause less confusion, the generic term "estrogen" may be used at points throughout the paper in reference to a specific type of estrogen.
As previously noted, the differences between the types of hormones used in HRT are vast and important to consider before making a decision regarding possible treatment. These differences, in fact, bring about an ethical debate of much importance which in fact concerns the very lives of the women who choose to use such products. Why exactly, are the lives of millions of women at stake? The answer lies within the incorrect diagnoses of doctors and the pharmaceutical companies which sell the drugs that are used.
Within medicine there is a common misconception that menopause is an estrogen deficiency disease. However, recent research has shown that estrogen levels drop only 40 to 60 percent at menopause, while progesterone levels - on the other hand - can drop to nearly zero, leaving the estrogen unopposed (Lee 124). Regardless of whether or not HRT is being used, unopposed estrogen carries a long list of health risks in itself. Not only does it increase the risk of endometrial cancer but studies show that it probably promotes breast cancer as well. It alters cell membrane function such that sodium and water influxes into body cells, while potassium and magnesium are lost from cells. This results in intracellular edema or bloating and water retention. Estrogen also promotes abnormal cellular retention of copper and loss of zinc. These important changes in intracellular electrolytes and cellular edema go a long way to explain mood swings, loss of concentration, and the aches and pains that menopausal women suffer from, even with estrogen replacement. Furthermore, unopposed estrogen also reduces the amount of oxygen present in the cells, promotes histamine release (which causes allergy-type symptoms), promotes blood clotting thus increasing the risk of stroke, thickens bile and promotes gallbladder disease. It may also decrease sex drive and increase the likelihood of fibrocystic breasts, uterine fibroids, uterine (endometrial) cancer, and breast cancer. Progesterone, on the other hand, works to protect the cell membrane from these estrogen-induced problems; therefore, these undesirable effects are countered by progesterone (Lee 71, 124).
With evidence of these symptoms available to doctors and the public, one would assume that doctors are taking the correct steps in order to balance the hormone levels within menopausal woman. However, in many instances, this is not the case. Incorrectly diagnosing women as being "estrogen deficient," doctors are prescribing estrogen replacement therapy - as opposed to progesterone replacement therapy - which only makes matters worse. Furthermore, yet another problem comes into play in regards to the pharmaceutical companies that promote these drugs.
First isolated in laboratory studies during the 1920s, synthetic estrogen has become the drug of choice for many doctors and when doctors do choose to prescribe progesterone replacement - as opposed to estrogen - they too prescribe synthetic progesterone, otherwise known as progestin (Laucella 30). While this may not appear to be a problem, the side effects of years of synthetic estrogen and progestin use are now becoming increasingly evident.
While estrogens in general tend to promote cell division, particularly in hormone-sensitive tissue such as the breast and uterine lining, synthetic estrogen, commonly used in estrogen supplements and contraceptives, is even more of a breast cancer risk because it is efficiently absorbed by mouth and slow to be metabolized and excreted. Therefore, the longer a synthetic estrogen stays in the body, the more opportunity it has to do damage. Since this is the case with all synthetic estrogens, one would think that in cases of estrogen supplementation the natural hormones would be superior to the synthetic (Lee 38). The case for natural hormone replacement is further made by examining the effects of synthetic progesterone use, previously mentioned as progestin.
While natural progesterone has no known side effects, the list of problems associated with synthetic progestin is extensive (Lee 65). One of the more recent lists of side effects associated with the most commonly prescribed progestin, Provera, is as follows:
" Increased risk of birth defects such as heart and limb defects if taken during the first four months of pregnancy.
" May cause sudden or partial loss of vision.
" This drug passes into the breast milk, consequences unknown.
" May cause fluid retention, epilepsy, migraine, asthma, cardiac or renal dysfunction.
" May cause or contribute to depression.
" The effect of prolonged use of this drug on pituitary, ovarian, adrenal, hepatic, or uterine function is unknown.
" May decrease glucose tolerance; diabetic patients must be carefully monitored.
Adverse reactions include:
" breast tenderness
" acne and alopecia
" edema and weight changes
" cervical erosions
" mental depression, pyrexia, nausea, and insomnia
Furthermore, when taken with estrogens, the following have been observed:
" Rise in blood pressure, headache, dizziness, nervousness, and fatigue.
" Changes in sex drive, loss of scalp hair, decrease in T3 uptake values.
" Urinary tract infections (Lee 86-87)
With evidence as clear as that previously mentioned and nearly all signs pointing in the direction of natural hormone replacement therapy, why do doctors continue to prescribe synthetic medicines which may hurt a patient more than they are able to help? Simply put, most doctors are more familiar with progestin not only because they learn about them in medical school, but also because the large drug companies promote the use of the products that contain progestin (Laucella 40). In the late 1800s laws were passed in the United States that allowed medicines to be patented only if they were not natural substances. If a drug company discovered a naturally occurring medicine, anyone else was free to capitalize on the discovery, causing drug companies to quickly become disinterested in naturally occurring medicines (Lee 82). Therefore, because it can not be patented by drug companies and no prescription is required for its purchase, extensive drug testing has not been done using natural estrogen or progesterone for the purpose of FDA approval, and furthermore, there is no benefit for drug companies to under-write studies to promote a product they cannot patent and which can be easily produced (Laucella 41). The end result leaves women with few choices and life-altering consequences.
Upon the consideration of the previously mentioned statements, women are now faced with more questions. What exactly is one supposed to do upon reaching
menopause? Are there safe alternatives to synthetic estrogen and progestin? Is it okay to take matters into one's own hands? One possible option involves the medicinal use of herbs. Because herbs come from a living and natural source, they have many of the nutrients of concentrated foods and it is believed that they can nourish and balance the body, thus enabling it to heal and regulate itself (Laucella 83). One such herb believed to be beneficial to menopausal women is known as black cohosh.
Botanically known as Cimicifuga racemosa, black cohosh is native to the eastern woodlands of North America, but can be found in areas ranging from southern Canada to southern Georgia. While the plant was first used in old European countries as an insect repellant, it soon became widely known for its medicinal purposes. Native Americans, for instance, have used these medicinal plants for centuries by boiling the root and drinking the resulting brew in order to treat a large variety of ailments including kidney problems, sore throat, malaria, rheumatism, and specifically "women's problems" such as menstrual irregularity (Landis 194). Although the first alcohol-based extract of black cohosh was developed in 1835, it had not yet been formally researched; however, by the mid 1950s, this popular plant was widely prescribed by gynecologists in Germany.
In 1959, however, some of the first evidence concerning black cohosh and its estrogenic effects on women was produced. A group of 82 pre- and perimenopausal women were subjected to the study. While half of which were given the alcoholic extract of black cohosh, the remaining half unknowingly received a placebo. Of the half receiving the preparation, thirty-one women experienced a reduction in the severity and frequency of hot flashes, headaches, and nervousness (Foster 3). Continuing to grow in popularity, by the early 1960's, fourteen clinical studies involving over 1500 patients had been published in Germany on the use of black cohosh extract as a form of medicinal treatment for symptoms related to menopause (3).
So why does black cohosh have such an astonishing effect on menopausal symptoms, such as hot flashes? Because there is still little research in regards to this plant, it is hard to say; however, this paper will offer two possible answers. The first answer lies within the presence of phytoestrogens. Phytoestrogens refer to plant compounds with estrogen-like activity. They are usually considerably weaker than one's own estrogens and furthermore, they compete for the same estrogen receptors throughout the body. Thus they have been successfully used to decrease symptoms of estrogen excess (Lee 35).
Black cohosh contains these very phytoestrogens which aide in understanding why it has such combative effects upon menopausal symptoms. (Meletis 143). One can also further recognize the importance of this medicinal herb by examining a recent theory concerning black cohosh and its estrogenic effects.
This theory suggests that black cohosh lowers the luteinizing hormone known as LH (Landis 215). The occurrence and increase in hot flashes surrounding the time of menopause have been linked to this luteinizing hormone which - as previously mentioned - is released by the pituitary gland. Coincidentally, a constituent of black cohosh which has been referred to as Fraction VIII, is speculated to have the ability to inhibit LH secretion. It is hypothesized that Fraction VIII may contain estrogenically active compounds which are then rapidly metabolized, suppressing the effect of LH on the body, thus providing a medical explanation for the success of black cohosh in fighting menopausal symptoms (Foster 5). Strangely enough, this medicinal plant appears comparable to the drugs used in hormone replacement therapy without the side effects that often accompany such treatments (Meletis 29).
As these recent findings are becoming more publicized, one can not help but observe the increasing popularity of black cohosh as a treatment for menopausal symptoms. One must ask, however, from where is this plant being harvested? While this plant is native to the woods of eastern North America, European growers - who already receive shipments of cohosh from the United States - have begun to cultivate black cohosh in an effort to meet the growing demand for this popular remedy (Montgomery 2). It is no surprise that the United States will soon be following suit. Because nearly one hundred percent of the United States' supply of black cohosh is harvested from the wild, many conservationists have expressed growing concerns with the decreasing population of the plant and its sustainability while medicinal suppliers, on the other hand, fear that they will soon be unable to meet the demands of the consumer and herbal industry. (Lata 912). This problem is heightened due to the fact that black cohosh does not reach a suitable maturity for harvestation until approximately 3-5 years after its implantation into the soil.
This, in turn, proposes many questions and a greater need for research. Under what conditions should black cohosh be grown? Can it be cultivated on a large scale? When should it be harvested? Are there alternatives? Because botanists have only recently begun research from this end of the spectrum, there is obviously little information available concerning these questions. However, many universities and large scale research facilities are attempting to find answers. The University of Missouri at Columbia, for instance, recently initiated a series of two experiments in 2001. The first of these experiments examined the horticultural requirements of black cohosh in Missouri in hopes of developing a list of recommendations for farmers wishing to cultivate this plant. Secondly, the university studied the effects on the black cohosh plant when grown at various spacing and in various degrees of shade in order to determine the appropriate conditions for growing a healthy plant with a maximum extract and medicinal potential (internet source).
One must now ask, however, if this is the only answer to the possible shortage of black cohosh. The answer is "no." A process known as plant tissue culture could possible provide the solution to this problem of the future. Tissue culture basically consists of growing plant cells on a medium of some sort. More specifically, during this process, small pieces of living tissue - whether it be buds, root tips, nodal segments, germinating seeds, shoot tips, or callus - are isolated from an organism and grown on a suitable culture media. If shoot tips were used, for instance, the shoot tips would develop into single seedling like shoots. These can then be further subdivided into smaller clumps or separate shoots, which will in turn form similar clusters when subcultured on a fresh medium. This form of micropropogation is very useful in obtaining a large-scale multiplication of crop plants that are uniform in quality and are disease free plants.
Upon examining the previous statements as presented in this paper, one must obviously question what exactly should now be done in order to better the current situation involving hormone replacement therapy and possible herbal alternatives. The answer first lies in educating not only the public, but doctors as well on the current research associated with hormone replacement therapy, including its related risks and furthermore, the possible benefits of herbal alternatives such as black cohosh. The next step involves further research, not only into the field of herbal medicine, but also into the possible ways in which black cohosh can be grown and cultivated, more specifically, an attempt should be made on a large scale to micropropagate black cohosh in a lab setting. Through these efforts, one can only hope that millions of women world-wide will be given a more safe and effective treatment for hormonal imbalances.
Works Cited
Foster, Steven. "Black Cohosh" American Botanical Council, 1996. (Available at http://www.herbalgram.org)
Landis, Robyn. Herbal Defense: Positioning Yourself to Triumph over Illness and Aging. Warner Books. New York, NY: 1997.
Lata, H. "In vitro plant regeneration from leaf-derived callus of Cimicifuga racemosa." Plant Medicine 68 (2002): 912-915.
Laucella, Linda. Hormone Replacement Therapy: Conventional Medicine and Natural Alternatives. Lowell House. Los Angeles, CA: 1994.
Lee, John R. M.D and Virginia Hopkins. What Your Doctor May Not Tell You About Menopause. Warner Books. New York, NY: 1996.
Love, Susan M. MD. Dr. Susan Love's Menopause and Hormone Book. Three River Press. New York, NY: 2003.
Meletis, Chris. Complete Guide to Safe Herbs: What Everyone Should Know About Herbal Interactions and Side Effects. DK Publishing. New York, NY: 2002.
Montgomery, John. "A Tale of Two Cohoshes - Black and Blue" 2000. (Available at (http://www.hellbender.com)
Thomas, Andrew; Lubhan, Dennis; Fold, William; Rottinghaus, George; Miller, Jim; Woodbury, Scott; Applequist, Wendy; Havermann, Larry; Salick, Jan. "Black Cohosh Cultivation in Missouri, and Quantification of its Medicinal Compounds in Response to Various Cultivation Regiments." Southwest Center 2001 Field Day Report. (Available http://aes.missouri.edu)
unknown author. "Seeds - Tissue Culture" (Available http://www.indiaagronet.com)
