Patient Questions – HRT and Weight Gain

hormone replacement therapy weight gain

Question 

I’m an active baby boomer who tries to stay in good shape. I walk a lot, go to aerobics twice a week, inline skate in summer, and curl twice a week in the winter. I try to eat healthy food but I’m finding it nearly impossible to lose that excess fat around my waist. My question is, does taking hormonal drugs, such as Premarin and Prometrium, have any effect on trying to lose weight? I’ve tried several times to get completely off the drugs and although I’m only taking half my original dosage, I can’t bear the hot flashes and night sweats without the drugs. I personally believe that I’d be better off without the drugs but I don’t know if it would then be any easier to lose the abdominal fat.

Thank you,
Cathy 

Answer 

Dear Cathy,

Your letter has raised a number of very pertinent questions that every woman that’s approaching menopause should be aware of. 

First of all, we know that the negative conclusions reached by the Women’s Health Initiative study¹ led to 50 percent of women being removed from or voluntarily stopping their hormone replacement therapy. The negative findings were suggestive of an increased risk of heart disease, strokes, breast cancer, and dementia.

However, in later reviews and critiques of the study, many researchers have reversed some of their earlier conclusions. Please see my blog post on this subject, entitled Risks of Hormone Replacement Therapy in Women. The researchers suggest that women become informed regarding the many helpful benefits of hormone replacement therapy, not just about the symptomatic treatment of hot flushes and night sweats. In the journal Fertility and Sterility in December 2005, the authors critiqued the study design and proposed two major reasons why the original authors of the study reached the conclusions that they did². The authors criticized the use of continuous combined estrogen/progestin or estrogen alone as a standard regime to an aging female population with little previous hormonal treatment, who because of their age were naturally predisposed to cardiovascular and cerebrovascular disease. The authors also criticized the use of continuous synthetic progestin or Provera, which is known to have significant side effects and has been linked to increasing rates of breast cancer. There are now over a hundred published studies indicating that estrogen can be safely prescribed to women with a history of breast cancer. The hormone estrogen when prescribed alone, rather than in combination with the synthetic progestin Provera, hasn’t been found to be harmful in any study to date. The hormone combination Prempro was to blame and more specifically, the synthetic progestin, Provera. 

Due to the premature termination of hormone replacement therapy, many women are being exposed to increased risks of osteoporosis and hip fractures, colon cancer, and increased risks of heart disease, strokes, and breast cancer. In the field of anti-aging medicine, we’ve been warning patients of the detrimental effects of synthetic hormones and have strongly suggested that women use bioidentical hormones instead. Restoring one’s hormones to youthful levels seems highly appropriate and is supported by scientific literature. It’s strongly encouraged that you begin to use hormones as soon as possible after menopause. You should also check with your doctor that you have no personal or family history risk factors for hormone replacement therapy before beginning your regime.   

Cathy, bearing this in mind I’d strongly suggest that you continue your hormone replacement therapy, but switch to bioidentical hormones and be sure to reach therapeutic levels. If your doctor prescribes hormones to merely relieve hot flushes and night sweats, and doesn’t reach therapeutic levels with your hormones, you’ll not be protected against the deterioration of your bones, brain, and cardiovascular system. In addition, your risk of colon cancer will increase. 

With regards to the weight issue, it’s well established that Provera, which is synthetic progesterone, can lead to significant weight gain. Sometimes physicians use synthetic progestin in cancer patients suffering from severe wasting to increase their appetite and reverse a condition known as cachexia³. I suggest that you switch to bioidentical progesterone and see if this makes any difference. Prometrium is a reasonable choice but I prefer sublingual slow-release progesterone, which is available from compounding pharmacies. 

I suggest that you also check your levels of estradiol. If the level’s too high, this may lead to weight gain. The suggested level is between 186-367 pmol/l. I also suggest that you have your blood level taken approximately twenty-four hours after your last estrogen dose, if you’re taking oral estradiol. This will reflect the ‘steady state’ level in your bloodstream. If you’re taking transdermal estrogen cream, you’ll need to do a saliva hormone test to measure estradiol, estriol, and estrone levels to more accurately reflect your levels at the surface of your cell’s receptors. Blood levels of estrogen do not reflect levels of estrogen when given in a transdermal form, a mistake made by many practitioners new to the prescribing bioidentical hormones. You’ll also need to test your urinary metabolites of estradiol to ascertain if you’re making the less harmful metabolites of estradiol, which is known as 2-hydroxyestradiol, as opposed to the potentially more harmful metabolites of estradiol known as 4-hydroxy and 16-hydroxyestradiol.

In a study published by the Oregon Health and Science University, scientists observed a group of forty-six pre- and post-menopausal women. The scientists reached the conclusion that the drop in estrogen levels commonly associated with menopause is linked to an increase in the stress hormone cortisol. This hormone is strongly linked to an increase in abdominal obesity. It was determined that if the women received therapeutic levels of estrogen, cortisol levels decreased and there was a reduction in visceral fat.

In addition, as we age, we lose muscle mass and there’s a corresponding decline in the metabolic rate. As a result, many perimenopausal and menopausal women who continue to eat the same amount of food that they did when they were younger find that with decreasing energy expenditure, they gain weight that’s difficult to lose. Find out if the gym or health clinic closest to you has a bioimpedance machine that can measure your percentage of muscle mass and ask them to track it over time. We routinely measure such biometrics at every visit when patients complain of weight gain or loss. 

Most weight gain during perimenopause and menopause is usually secondary to an increase in appetite. It’s well known that all hormones can significantly increase a person’s appetite. If there’s been rapid weight gain, this is usually due to fluid retention and brief use of a diuretic may be helpful. If your weight gain is gradual, it’s most likely due to an increase in appetite. 

It’s established that hormones have no caloric value. In fact, in a study in 1999⁴, the authors concluded that not only does hormone replacement therapy prevent weight gain, it also favours weight loss by significantly increasing the breakdown of fat after three months of treatment. It also positively influences the insulin/blood sugar response, plasma cholesterol, and energy expenditure.  

In another study published in 2004⁵, the authors determined that hormone replacement therapy in postmenopausal women, along with testosterone replacement therapy in older men, appeared to reduce the degree of central obesity. 

So Cathy, in conclusion I suggest the following:

  • Continue your hormone replacement therapy, but find a doctor who knows how to prescribe bioidentical hormones in therapeutic doses. 
  • Eat a low glycemic paleo autoimmune type diet with a decrease in the total daily dose of calories consumed.
  • Increase the amount of hot, spicy, bitter foods that you consume, as it has been shown in studies of Ayurvedic medicine that these tastes increase one’s metabolism. 
  • Concurrently, decrease your consumption of sweet, sour, and salty foods as these tastes have been shown to increase weight gain. 
  • Exercise five days a week with an exercise regime that includes significant muscle strengthening with large muscle groups, such as those in the legs, to increase your metabolic rate. 
  • Be sure to get a good night’s sleep as this naturally increases your levels of growth hormone, which has also been linked to weight reduction. 

If you’re interested in learning more about how hormone replacement therapy can affect or is affecting your health, then please don’t hesitate to read the other posts on the Hoffman Centre blog or contact my office to set up an appointment.

Resources:

¹JAMA. 2002;288(3) 321-333

²Fert Steril. 2005 Dec; 84 (6): 1589 -601

³Sem Oncol 1991: 18:35-42

⁴Maturitas 1999 Aug 16; 32(3);147 -53

⁵Obesity Review 2004 Nov; 5 (4);197 -216

Risks of Hormone Replacement Therapy in Women

Risks of Hormone Replacement Therapy in Women

Does Estrogen and Progesterone HRT Increase Breast Cancer?

Hormone replacement therapy, or HRT, for peri or postmenopausal women is one of the most satisfying treatments that we, as ‘anti-aging’ doctors, are able to prescribe. We all have high numbers of very satisfied women who let us know that since the prescribing of HRT, they ‘got their lives back.’ I can attest to this as I have post-graduate training in HRT, being board-certified and having a Fellowship in HRT therapies with the American Academy of Anti-Aging Medicine (A4M).

However, getting to this place of being able to help women through the hormonal transitions of life using natural and bioidentical options has been a long time coming. Many were turned away from a large early study from the Women’s Health Initiative that warned of the dangers of synthetic hormones, and unfortunately this fear continues to permeate much of the conversation around using HRT. 

In this article, I’m going to walk you through the history of HRT, along with the studies that came after that first Women’s Health Initiative trial that clarified many of our questions regarding HRT, so that it can be used safely and effectively to improve the quality of life for so many women. 

Keep reading to learn more about HRT – Is it our enemy or our friend? 

This article will cover: 

  • Hormone replacement therapy for women,
  • Health risks of hormone replacement therapy,
  • Estrogen HRT breast cancer risk,
  • The history of HRT,
  • Findings of observational studies and randomized controlled trials,
  • Benefits of estrogen and progesterone HRT,
  • Conclusions about hormone replacement therapy and breast cancer, 
  • And where medicine is moving in terms of HRT.

Hormone replacement therapy for women

When discussing HRT for women in their perimenopausal or post-menopausal years, we are mostly talking about estrogen and progesterone hormone replacement therapy, the two main sex hormones involved in a woman’s sense of well-being.

As estrogen and progesterone levels fluctuate and eventually decline through the perimenopausal years and then reach the very low levels during menopause, many women experience uncomfortable symptoms and a loss of the wellness and protection that these hormones provide. Replacing these hormones often does wonders for how a woman feels, looks and enjoys her life. 

Estrogen is known to protect against depression, mood disorders, insomnia, loss of memory and cognition, dementia, colon cancer, reduction in bone fractures, dry vaginal tissue, wrinkles, and loss of teeth. Estrogen also contributes to the prevention of urogenital atrophy, the improvement of lipid metabolism and increasing libido. Overall, estrogen improves wellbeing and general symptoms of malaise. 

The benefits of progesterone include improved sleep, reduced anxiety, and protection against breast cancer, coronary artery disease, and osteoporosis.  

Risks of hormone replacement therapy – The WHI study

Does HRT increase the risk of breast cancer? Does HRT cause cancer? What about increase strokes, heart disease, and blood clots? What are the risks of hormone replacement therapy? 

These are the most common questions I get from women when discussing HRT. 

The reason for their concern is still firmly etched in everyone’s mind from when the conclusions of the Women’s Health Initiative (WHI) study were published in 2002. This showed that women on HRT had increased rates of breast cancer of 34 percent, strokes of 37 percent, blood clots and pulmonary emboli of 24 percent, and heart disease of 27 percent. When these figures were published, there was a huge media frenzy highlighting HRT risks, patients were immediately taken off HRT, and all research into this type of therapy was seriously curtailed. 

Since that time, there’s been considerable research, some carried out by the same WHI group, that actually refutes aspects of these findings and also examines some of the pitfalls and perils of the original WHI publication. However, none of the same fanfare and publicity has been given to these new findings. Many patients and doctors are still influenced by the 2002 guidelines initiated after this trial was first published.  

Keep in mind that when we prescribe HRT for women in the postmenopausal years, the hormones that we use include, but are not limited to, estrogen, progesterone, testosterone, DHEA, pregnenolone, thyroid, oxytocin, hydrocortisone, and melatonin. However, the WHI study was concerned with oral Premarin, a synthetic, non-bioidentical estrogen made from horse urine, along with oral Progestin, which is also a synthetic progestin rather than bioidentical progesterone HRT. The elucidation of these distinctions is vital to understanding these results, as we’ll explore later. 

HRT and breast cancer

With breast cancer incidences, it’s well established in oncology that anti-estrogen approaches to breast cancer, such as oophorectomy (removal of one or both ovaries), tamoxifen (a medication that blocks estrogen), or aromatase inhibitors (medication that blocks the conversion of testosterone to estrogen), are all beneficial for breast cancer response, survival, and even prevention. 

So, if these anti-estrogenic approaches are beneficial, by inference estrogen must be carcinogenic. However, as mentioned above, with recent updated publications on breast cancer and hormone replacement therapy, the results reflect that this may not be the case. 

In fact, recent data suggests the exact opposite: Estrogen-based hormone replacement therapy appears to reduce breast cancer and all-cause mortality rates

How can this be? Let’s explore this conundrum and the history of breast cancer and HRT. 

Here are the results from some historical studies outlining forty years of research on this very question, with some surprisingly new observations that will require our serious attention. 

The history of HRT

The relationship between hormones and breast cancer dates back to the late nineteenth century. At that time a George Beatson, a British surgeon, was the first to postulate an association between the hormonal action of the ovaries and the proliferation of breast cells, first discovering the relationship in lactating sheep. He wondered if removing the ovaries, that produce estrogen and progesterone, could be a treatment for breast cancer. He tested his theory in June of 1895.

A thirty-three-year-old woman had noticed a small lump on her left breast while she was breast-feeding her first child. This lump became larger after the birth of her second baby. A large tumor was successfully removed from her breast, but the cancer was already far advanced. She was referred to Dr. Beatson who removed both her ovaries. He reported the case to the Edinburgh Medico-Chirurgical Society and published details in the Lancet in July 1896. The woman survived for nearly four years before dying of recurrent disease. Thus, the removal of the ovaries as therapy for breast cancer was born and continues in present day. What’s so interesting is this discovery was made thirty years before estrogens were identified. 

But, Dr. Beatson didn’t know what the full function of the ovaries was. In the 1920s, researchers Edgar Allen and Edward A. Doisy from St. Louis University identified, extracted, and characterized the molecule of estrogen from a pig’s ovarian follicle. This was a major scientific breakthrough and explained the success of oophorectomy. Once estrogen was isolated from the ovaries and an oophorectomy induced a positive breast cancer response, it implied that estrogen is most likely breast carcinogenic. 

Indeed, when anti-estrogens such as tamoxifen and aromatase inhibitors were subsequently developed in the 1970s and 1980s, with tamoxifen as the best example of a dedicated, specialized antiestrogen, a positive response rate of between 20 and 50 percent was seen in stage IV breast cancer. In the 1980s, when aromatase inhibitors were used, a 25 to 30 percent reduction of breast cancer mortality was noted and a reduction in new breast cancer incidence was determined to be between 30 and 40 percent.  

Estrogen HRT has been used since the 1940s, became popular in the 1960s then gained a very high level of popularity in the 1990s. It was primarily used to reduce hot flashes, the classic sign of menopause. Yet, in the very beginning their use was also tied to the issues of femininity and sexuality, very well described by Masters and Johnson in the early 1970s. After the seventies, more science emerged within HRT research, confirming that the therapy improved energy, reduced the incidence of bone loss and bone fractures, reduced cholesterol, and had many potential benefits for the cardiovascular system and the risk for heart attacks.

Observational studies

There are approximately fifty-nine observational studies summarized by the Oxford Group on the question of HRT and breast cancer mortality over the past forty years. These studies show an increase in breast cancer mortality with HRT, ranging from 30 to 80 percent, meaning that HRT increases the risk by a considerable amount. Let’s dive more into what this means and the limitations of this type of study. 

In observational studies, participants aren’t randomly assigned to a treatment or a control group. Instead, they’re simply observed over time to see whether a particular treatment or intervention helped, harmed, or did nothing. The results are then compared to a similar group that received a placebo or no treatment at all. In the HRT studies, women selected themselves to receive treatment. After twenty years, the researchers would eventually follow up and study these self-selected HRT users against the general population of non-HRT users in a non-randomized fashion.

The benefit of observational studies is that they’re less expensive, can be done more quickly, and can include a broader range of patients. They’re often used when a randomized trial would be impossible or unethical.

The Collaborative Group on Hormonal Factors in Breast Cancer, in Oxford in the UK, the leading authorities recognized in this particular field of epidemiological studies, summarized the observational studies of the previous thirty years of research and published their findings in the Lancet Journal in September 2019, using the comparative analysis of users against non-users. They showed that taking Premarin or progestins had double or a 208 percent increase in the risk of breast cancer. 

With estrogen alone, for women after hysterectomy, the risk is lower but incidence is still increased by almost a third or 33 percent. Progestin is used along with estrogen in women who still have a uterus to prevent the risk of endometrial cancer, since estrogen alone stimulates the growth of the endometrial lining. 

When looking at mortality rates or death cases with estrogen alone HRT versus non-users, there was a 35 percent increase in mortality. For estrogen plus progestin, there was an almost 64 percent increase in breast cancer mortality. This is the present understanding of the HRT outcomes, when you examine observational non-randomized studies, as reported by the Oxford overview group. 

Indeed, from these studies it appears that the incidence and mortality of breast cancer associated with HRT was definitely increased and thus by deduction, estrogen is undoubtedly breast carcinogenic. This information, understandably, would raise caution in a woman looking for symptom relief and anti-aging benefits in menopause. Luckily, there is more to the story. 

Limitations of observational studies

Other researchers have looked into the issue of potential flaws in these studies, particularly when new studies have shown that estrogen use alone has shown a reduced incidence of breast cancer, with many added benefits of estrogen HRT. Dr. Ragaz’s group has raised the issue that in non-randomized studies like the Oxford overview, with self-selection of HRT users, a potential bias could be created in that women with high-risk of breast cancer were selected. One bias was that more affluent women take HRT. Therefore, the question arises regarding the link between affluence and breast cancer risk.

Affluence and higher socio-economic status have been associated in many studies with an increased risk of breast cancer. 

Affluent women have:

  • More carbohydrate-rich diets 
  • Higher body mass index
  • Less physical activity
  • Reproductive factors that are substantially different from non-affluent women, such as lower parity, less breastfeeding, and later age pregnancy
  • More frequent breast examinations and mammograms 

There’s plenty of data indicating that all these particular factors are very much linked with higher breast cancer rates.

What’s most important is that randomization is essential when attempting to analyze breast cancer risk in HRT users. Researchers must use a sampling of women from all socioeconomic groups in order to equivalize as many variables as possible.

Randomized studies

Randomized controlled trials (RCTs) are considered the gold standard and an ideal method when it comes to medical research.  In an RCT, women are randomly assigned to receive hormones, or any other treatment being studied, or a placebo. If the study is double-blinded, neither the patient nor the investigators know which patient is taking what. 

The start of large randomized HRT trials began with the WHI studies. The Women’s Health Initiative (WHI) was established in the 1990s under the leadership of Bernadine Healy, the first female director of the National Institute of Health. In 1992, the WHI project conducted a series of four randomized trials examining issues of women’s health, two of which were aimed at the HRT issue. 

The Women’s Health Initiative is the most active epidemiological group in USA. Unfortunately, soon after the beginning of these WHI studies, Bernadine Healy died of brain tumors resulting from glioblastoma. She sadly never saw the result of her initiative. 

The biggest randomized study to date was initiated by the WHI and called Trial 1. In routine randomized studies the numbers usually amount to a few hundred, but in this study group there were 16,000, a huge amount by routine standards.  

In the WHI Trial 1, 16,608 women with an intact uterus were randomised to Arm 1 using estrogen (Premarin) plus a progestin (Provera). Arm 2 received a placebo only. This was the first study looking at both estrogen and progestin and showed a 44 percent increase in breast cancer mortality.  

The WHI Trial 1 was terminated prematurely and the results published in JAMA 2002. As mentioned earlier, there was a substantial media frenzy. The media and television networks were full of the data and publicity was aggressive and prolific. This study showed an almost 27 percent increase in heart attacks, 34 percent increase in breast cancer, 37 percent increase in strokes, and a 24 percent increase in pulmonary emboli or blood clots in the lungs. There were some benefits, as quality of life markedly improved and bone fractures were reduced quite significantly. The interpretation by the lead investigators of the WHI Trail 1 dramatically changed guidelines for HRT. 

  • HRT was to be used for the shortest time only 
  • HRT should only to be administered for the treatment of postmenopausal symptoms 
  • The risks of HRT far outweighed the benefits
  • The risks of coronary heart disease and breast cancer far exceeded the benefits of osteoporosis prevention and a decrease in colon cancer

With HRT discredited as a therapy, sales dropped by 50 percent in one month and all the major clinical organizations, such as the American Association of Clinical Endocrinologists (AACE), the American College of Obstetricians and Gynecologists (ACOG), and the North American Menopause Society (NAMS) recommended only using HRT for a very short time and solely for the control of menopausal symptoms. 

With regards to the cardiovascular risk factors, some of the initial criticisms of the study declared that most of the women studied were much older and already had significant baseline coronary artery disease. In addition, they were given oral estrogen which is known, particularly in the first year of taking it, to increase clotting factors in the liver. 

Soon after the WHI Trial 1 findings were made public, Dr. Lobo published the findings from four large randomized trials in Family Practice News in 2003. These showed that that the risk of cardiovascular diseases is extremely low in healthy women in early menopause and that the results of the WHI didn’t apply to younger women between fifty and sixty years of age who initiate HRT around menopause. 

There was overwhelming evidence that the anti-atherosclerotic effect of HRT depends on the time of initiation and that early initiation is protective. The Nurses’ Health Study (NHS), which has produced the most data for observational studies for risk factors for major chronic disease causation in women, didn’t find any association between coronary artery disease (CAD) and HRT. It was hypothesised that once CAD is established, HRT has no protective or beneficial effect, but estrogen given to menopausal women significantly retards progression of CAD by its positive effects on lipids and endothelial functioning, which is related to the inner lining of blood vessels. However, oral estrogen given to women over sixty with CAD may make the condition worse. 

WHI Trial 2 – Positive results for HRT

A second study by WHI, called Trial 2, using estrogen hormone replacement therapy alone, showed astounding results, but in the other direction. 

In the WHI Trial 2, 10,739 women, after hysterectomy, were randomized to estrogen against placebo. Arm 1 used estrogen-based HRT alone, while Arm 2 was a placebo only.

In 2004, the first publication of the WHI Trial 2was released regarding the estrogen-alone arm, which has continued onwards until the present. These results were from women under the age of sixty. 

The WHI Trial 2 mostly indicated benefits, including a 40 percent reduction in breast cancer mortality! Remember, in WHI 1 there was an increase in breast cancer, but here we have a 40 percent reduction in breast cancer mortality with the use of estrogen HRT alone. It’s very important to note in this case that progestin wasn’t used. 

Furthermore, there was a 25 percent reduction of diabetes, a 26 percent reduction of Alzheimer’s dementia mortality, a 55 percent reduction in myocardial infarction among patients between fifty and fifty-nine years old, a 21 percent reduction in all-cause mortality, and a 32 percent reduction in bone fractures with an 80 percent improvement in quality-of-life benefits. This is remarkable and the findings are very different from the WHI Trial 1 results. 

However, unlike the WHI Trial 1, which according to these publications had revealed mostly remarkable benefits, there was no publicity. There wasn’t a single article or television report. Not a thing. From 2004 to 2020, the WHI has updated this study, with the same benefits being shown, but they’ve entirely suppressed their own publicity. Consequently, nobody knows much about these outcomes. 

Does HRT cause cancer? – What I tell my patients about the risks

So, when patients inevitably ask me if HRT therapy is safe or inform me that their doctor has told them to stop using HRT because it isn’t safe, I immediately know that they aren’t aware of the WHI Trial 2 studies, which have refuted the majority of the WHI Trial 1 findings. 

These findings are completely opposite to the WHI Trial 1 studies, which incorporated estrogen and progestin. A further WHI Trail 2 study published by Stefanick et al in 2006 showed a reduction in the estrogen-alone HRT group, the breast cancer incidence reduced by between 20 and 43 percent. However, nobody has heard about these outcomes. There was no publicity at all. As a result, the consensual opinion of patients and the majority of health practitioners continue to be based on the WHI Trail 1 findings.   

With continuation of the WHI Trial 2, published by Andersen et al in Lancet Oncology 2012, showed the persistence of benefit with estrogen alone. There was a 23 percent reduction in breast cancer incidence with a 63 percent reduction in breast cancer mortality and a 38 percent reduction in all-cause mortality with estrogen alone. This is unbelievable. 

Almost twenty years later, the WHI Trial 2 continues to publish data. An updated study, published by Manson J. et al in JAMA 2017 showed a 45 percent mortality reduction with estrogen alone and the 2020 Chlebowski R. et al JAMA 2020 publication showed mortality for breast cancer reduced by 40 percent. 

Please note that the conclusions from the WHI Trial 2 findings from all studies from 2004 to date show a very statistically significant 40 percent breast cancer mortality reduction with estrogen.  

Benefits of Estrogen

So here we have to ask how is it possible that estrogen, which for decades has been linked to breast cancer, provides benefits? 

There’s some evidence for the biological impact of estrogen on breast cancer cells. Research by Dr. Joseph Ragaz’s group has shown the following:

  • Estrogen reduces apoptosis 
  • An increase or improved stem cell differentiation with lower invasiveness of breast cancer cells means that the breast cancer becomes less aggressive
  • Estrogen also influences insulin growth factors in a positive way  

As far back as 2010, Dr. Ragaz’s group presented the potentially very important concept of estrogen duality, which shows that exogenous estrogen in HRT is protective, whereas endogenous estrogen made by the body proliferates the breast cancer cells. We know that exogenous estrogen in HRT is protective as the WHI Trial 2 data above attests. 

We also know that because of the endogenous estrogen, we can remove the ovaries and administer anti-estrogens such as tamoxifen, with these being aimed against endogenous estrogen. These studies show that suppression of endogenous estrogen is breast cancer beneficial. Therefore, endogenous estrogen stimulates and remains carcinogenic. 

The message is that now there’s clear evidence of exogenous estrogen emerging as a potent, powerful anti-estrogen to the endogenous estrogen. This is basically the information that needs to be published, publicised, and the message spread amongst the lay and medical communities. 

What about progesterone?

The other question is why there’s so much difference between the two trials. The evidence very clearly appears to be centered on the issue of the synthetic progestins used. It’s been known for some time and there’s adequate evidence to show that the progestin/Provera used is actually carcinogenic and inflammatory and can erase the benefit of estrogen. 

In Trial 1 with estrogen and Provera, the incidence of breast cancer mortality was increased by 44 percent. In the WHI Trial 2, with no progesterone but estrogen alone, there was a 45 percent reduction in breast cancer mortality. However, the new generation of bioidentical progesterone, including Prometrium and compounded bioidentical progesterone rather than progestin, don’t appear to be as harmful to breast cancer. That’s a very important concept as most patients and many doctors equate the two, meaning progestins such as Provera and bioidentical progesterone, as being the same. 

Progesterone was isolated and produced in the 1930s and so named because it’s the hormone that supports pregnancy and is pro-gestation. Today, the word progesterone is often misleadingly applied to many different forms of this hormone, rather than the natural progesterone that the body produces. Prometrium is the most common bioidentical micronized form of progesterone used in North America. 

In contrast, progestins are synthetic compounds, not bioidentical to what your body produces. The most frequently prescribed synthetic progestin in North America is called methoxy progesterone acetate (MPA), which has the trade name Provera. Prempro is a combination of synthetic estrogen and synthetic progestin and was the one used in the WHI Trial 1. 

Progestins are known to adversely affect mood, fatigue, edema, anxiety, bloating, depression, breast swelling, and reduce HDL levels. Progesterone is devoid of these side effects, unless given in amounts above what’s normal for the body. 

All this to say that the form of HRT really matters and bioidentical is the most beneficial with the least risk. 

Estrogen and all-cause mortality 

Estrogen has an impact on all-cause mortality, referring to the health of women and the cause of death for all other conditions other than breast cancer, and is decreased considerably in those who take estrogen-only HRT. 

Dr. Ragaz and his group obtained data from the WHI and transformed the numbers into crude, absolute numbers of deaths that could be avoided each year by women taking estrogen-only HRT. Their final aim was to influence the HRT prescribing guidelines, because the current HRT guidelines haven’t yet taken into consideration the updated data or results since 2004, which have been explained above.

In the 2017 overview from Mason’s WHI Trial 2 publication, breast cancer mortality reduction was 45 percent, Alzheimer dementia mortality reduction was 26 percent, and all-cause mortality reduction was 21 percent. This includes every other cause of death, other than dementia and breast cancer. They took the annualized mortality rates for these three conditions, applied the reduction in deaths from them as published in the WHI Trial 2 and came up with the following figures. The results were stunning! 

Every year in the United States, with the use of estrogen-only HRT, there would be 9,292 fewer breast cancer deaths, 18,966 fewer Alzheimer’s dementia deaths, and 21,750 fewer deaths from other causes, such as diabetes, bone fractures, or from cardiac factors. In total, the lower mortality rates amounted to 50,008 fewer deaths from all causes every year by using estrogen-only HRT. 

The evidence is clear that we see an unexpected numerical HRT benefit with avoidance or breast cancer cases, Alzheimer’s dementia, and all-cause mortality. 

Moving forward with anti-aging medicine

Dr. Ragaz’s recommendation is to adopt and implement HRT, without synthetic progestins, to the current medical guidelines in order to pass on the benefit to millions of women. This means that hundreds or even thousands of deaths could be avoided worldwide. In the USA alone, 50,000 deaths could be prevented and many more women could be saved if these recommendations are adopted worldwide.  

In summary, the absence of randomization in the previous observational studies highlights the fact that these studies were methodologically flawed and the conclusions they reached have to be viewed from this perspective. Secondly, because of the carcinogenicity of progestin/Provera included in the randomized WHI Trial No 1, this trial’s conclusion can’t be applied to modern prescribing of HRT, which excludes progestin/Provera in favour of bioidentical progesterone. 

As a result, the estrogen-alone based HRT evaluated in the WHI Trial 2constitutes the new gold standard. This is a basic constituent for present HRT regimens to be recommended in new guidelines, with the new generation of progesterone, which aren’t carcinogenic, to be applied for most women approaching menopause.

There’s hope that breast cancer prevention is possible and that estrogen will likely play a larger role.  If you’d like to explore if HRT is a good fit for you, please contact my office to schedule a consultation.

Blue Light Blocking Glasses: Do You Need Them?

Blue light blocking glasses

In a world where we spend hours each day looking at various digital screens, most people know how important it is that we protect our vision. However, many don’t understand the risk excessive blue light exposure poses to more than just our vision. Blue light can affect the circadian rhythms of our wake-sleep patterns and reduce the quantity and quality of our sleeping hours.

This is why glasses that block blue light can be a useful tool for people who spend a great deal of time working in front of computer screens, watching television, or using their cell phone.

In this article, you will learn:

  • What blue light is
  • The benefits of natural blue light
  • What do blue light glasses do
  • The downsides of artificial blue light and excessive nighttime blue light
  • If you need to wear glasses that block blue light
  • What to look for when purchasing blue light glasses
  • Why you need both daytime and nighttime blue light glasses
  • Some of my personal recommendations for glasses that block blue light
  • How to limit your blue light exposure and the harm this exposure causes

What is blue light?

The sun’s rays, which we perceive as white, are actually made of several different colored wavelengths, including red, yellow, orange, green, purple, and blue. The red, yellow, orange wavelengths on the warm end of the spectrum tend to be longer with less energy, while the cooler-toned wavelengths, such as blue and purple, are shorter with higher energy.

Blue light is one such light wavelength. In the past, the sun was our only source of blue light, only available to us during the daytime. In fact, the highly refractive blue light from the sun is the reason why the sky appears blue. Most evenings and nights prior to the advent of electricity were spent in relative darkness. However, in the modern era blue light is everywhere, at all hours of the day and night. 

The most common blue light sources in our everyday lives (1) are electronic screens such aslaptop and desktop computers, televisions, cell phones, handheld gaming consoles, and tablets.

Light fixtures, including fluorescent light bulbs, compact fluorescent light (CFL) bulbs, and light emitting diode (LED) bulbs are also sources of blue light.

While there’s no denying the importance of these technological advances in both digital devices and indoor and outdoor lighting, they’ve drastically increased our exposure to blue light during the daytime and at night. (2)

Unfortunately, there’s a strong and growing body of evidence to support the idea that these unnatural levels of blue light exposure can be harmful to health.

Blue light benefits

Natural blue light does offer some benefits, as exposure to it is associated with natural sunlight.

Daytime blue light exposure can regulate your body’s circadian rhythm, ensuring that you’re alert and awake during the daytime and ready for sleep at night. (2) Blue light as experienced in the daytime within visible light synchronizes the human biological master clock in an area of the brain known as the suprachiasmatic nucleus of the hypothalamus to the 24-hour cycle. These short wavelengths, perceived as a blue color, are the strongest synchronizing agent for the entire circadian system that keeps most biological and psychological rhythms internally synchronized.

Average teen circadian cycle

Natural blue light exposure may also help to promote normal vision, especially in children. Some evidence shows that people who aren’t exposed to adequate levels of blue light may be more likely to have vision problems such as nearsightedness. (3, 4)

Blue light downsides

Unfortunately, the downsides of excessive blue light exposure, particularly nighttime exposure, far outweigh the potential benefits, especially since we’re constantly bombarded with blue light from our devices and light fixtures.

Digital eye strain is a uniquely modern condition brought on by excessive or prolonged time in front of screens, whether for work or leisure. (5) Spending hours in front of a screen with few breaks can make your eyes tired and cause symptoms such as blurred vision, headache, dry eye, or other eye discomfort. (6) Up to ninety percent of all digital device users may be affected by digital eye strain. This can be a particularly difficult issue to deal with if you work at a computer and can’t simply decrease your screen time. (5)

In addition to digital eye strain, excessive blue light exposure may potentially lead to more serious and chronic vision problems. The main issues presented by excessive exposure are cataracts and macular degeneration. (7) Cataracts are cloudy areas in the lens of your eye. They develop slowly and are common in the elderly, but are also one of the leading causes of blindness around the world. Blue light exposure may increase your risk of developing cataracts because of the damage it can cause to your lens, initiating the buildup of proteins that accumulate to form these cloudy spots. In fact, it’s possible that the formation of cataracts is a protective adaptation to prevent further eye damage. This is because cataracts are able to absorb higher amounts of blue light without allowing it to affect other parts of the eye. (7)

Additionally, blue light may hasten the onset of age-related macular degeneration or vision loss. Blue light exposure is widely considered a risk factor for this kind of degeneration. Test tube studies show that aged eye cells may produce higher levels of vascular endothelial growth factor (VEGF), which increases their sensitivity to blue light. This type of light may also trigger mitochondrial dysfunction that leads to the death of healthy eye cells, speeding up the process of vision loss. (8, 9, 10)

What is circadian rhythm? 

Your circadian rhythm, or your body’s internal clock, is primarily dictated by your hormone levels, which can shift significantly over the course of the day and into the night. Unfortunately, excessive blue light exposure can alter your body’s melatonin levels, which is a key player in circadian rhythm and sleep patterns. (11, 12)

Natural blue light exposure during the daytime suppresses melatonin levels, keeping you more awake and alert. However, nighttime blue light exposure has the same effect, which can lead to poor sleep and insomnia. (11) A small randomized controlled trial of fourteen people suffering from insomnia found that wearing lenses that block blue light in the two hours preceding bedtime for just 7seven days significantly increased sleep time, along with the quality and soundness of sleep, compared to placebo lenses. (13)

Circadian rhythm graphic

What are blue light glasses? Benefits of blue light glasses

The many downsides of overexposure to blue light make the case for wearing appropriate blue light filter glasses or lenses. Although you may not need them all the time, they’re certainly benefits of blue light glasses for people who work indoors at computers or other screens. Blue light filter glasses may also be helpful for night shift workers who want to suppress their daytime exposure to blue light so that they can sleep better at night. I also highly recommended using blue light glasses if you’re using any kind of digital screen after dark.

Buyer’s guide

This brief buyer’s guide will help you select the glasses that will best meet your needs in blocking blue light.

These types of glasses are designed to filter out all or part of the blue light you’re exposed to, depending on whether they’re made for day or night use. If you work at a computer, I strongly recommend you at least purchase daytime blue light glasses. These glasses will reduce the amount of blue light you’re exposed to, to normal levels so that you can still get the beneficial, energizing effects of blue light while decreasing your risk of excessive blue light exposure.

If you also spend a great deal of time after dark working on your computer, watching TV, or on your phone, you should consider purchasing nighttime blockers as well. These block all blue light wavelengths, in order to more naturally replicate true nighttime conditions and prevent the suppression of melatonin after dark that can interfere with your circadian rhythm and sleep patterns.

If you work nights, you may want to consider purchasing nighttime blockers to use during the day to help foster better sleep during the period you’re off work.

What to look for

According to Block Blue Light, a brand that I personally trust and recommend, for daytime use you should look for clear-tinted lenses that block between forty and fifty percent of blue light. These provide protection against 450-455 nanometer blue wavelengths that appear to be the most harmful. For nighttime use,orange-tinted lenses block a hundred percent of blue light, while also filtering green light which may also suppress melatonin, up to 550 nm.

Recommended picks

Daytime: Block Blue Light ScreenTime Computer Glasses

These glasses filter out fifty percent of blue light, including the 455 nm wavelength, which is the most harmful and intense type of blue light.

Nighttime:Block Blue Light Nightfall Wayfarer Blue Light Blocking Glasses

These nighttime blue blockers block a hundred percent of blue and green light, making them ideal for nighttime use to minimize sleep and avoid circadian rhythm disorder.

How to limit blue light exposure and harm

In addition to glasses that block blue light, there are also several other ways you can limit your exposure, particularly at nighttime. Many of these strategies are also easy and inexpensive, or even totally free, to implement. These are some of the other options to reduce your blue light exposure and help mitigate the damage caused by excessive nighttime blue light exposure.

  • Avoid all digital screens in the two or three hours before bedtime.
  • Install an app such as f.lux or https://iristech.co/ or activate ‘night mode’ on all your electronic devices to reduce blue light levels, especially after dark.
  • Use red bulbs for your night lights to reduce eye strain. Soft red lights are much easier on the eyes than white bulbs, which contain high levels of blue light, especially at night.
  • During the daytime, spend time outdoors in the sun or in well-lit areas to help normalize your body’s circadian rhythms. 
  • Opt for soft white or yellow light bulbs in your home rather than bright white.
  • When working in front of a screen, take frequent breaks to relieve your eyes and prevent digital eye strain.
  • Blink frequently when using a screen, as this can help keep your eyes moist and prevent digital eye strain.
  • If you’re concerned about your vision, try supplementing with lutein and zeaxanthin or eating a diet rich in green, red, and orange vegetables. These antioxidants may help decrease your risk of macular degeneration and protect your eyes from light damage. (14)

Blue light exposure may seem like a minor issue, especially compared to other environmental factors that are linked to devastating chronic health conditions. However, I implore you to recognize how sleep affects your overall health and how seriously blue light can interfere with your sleep. 

In my opinion, glasses designed to block blue light are an easy and non-intrusive way to minimize your health risks and help maximize the quality of your sleep. If you’re interested in learning more about how your environment can affect or is affecting your health, then please don’t hesitate to read the other posts on the Hoffman Centre blog or contact my office to set up an appointment.

References

  1. Renard G, Leid J. Les dangers de la lumière bleue : la vérité ! [The dangers of blue light: True story!]. J Fr Ophtalmol. 2016 May;39(5):483-8. French. doi: 10.1016/j.jfo.2016.02.003. Epub 2016 Mar 31.
  2. Holzman DC. What’s in a color? The unique human health effect of blue light. Environ Health Perspect. 2010;118(1):A22-A27. doi:10.1289/ehp.118-a22
  3. Rucker F, Britton S, Spatcher M, Hanowsky S. Blue Light Protects Against Temporal Frequency Sensitive Refractive Changes. Invest Ophthalmol Vis Sci. 2015 Sep;56(10):6121-31. doi: 10.1167/iovs.15-17238. 
  4. Torii H, Kurihara T, Seko Y, Negishi K, Ohnuma K, Inaba T, Kawashima M, Jiang X, Kondo S, Miyauchi M, Miwa Y, Katada Y, Mori K, Kato K, Tsubota K, Goto H, Oda M, Hatori M, Tsubota K. Violet Light Exposure Can Be a Preventive Strategy Against Myopia Progression. EBioMedicine. 2017 Feb;15:210-219. doi: 10.1016/j.ebiom.2016.12.007. Epub 2016 Dec 16. 
  5. Coles-Brennan C, Sulley A, Young G. Management of digital eye strain. Clin Exp Optom. 2019 Jan;102(1):18-29. doi: 10.1111/cxo.12798. Epub 2018 May 23. PMID: 29797453.
  6. Sheppard AL, Wolffsohn JS. Digital eye strain: prevalence, measurement and amelioration. BMJ Open Ophthalmol. 2018 Apr 16;3(1):e000146. doi: 10.1136/bmjophth-2018-000146. 
  7. Zhao ZC, Zhou Y, Tan G, Li J. Research progress about the effect and prevention of blue light on eyes. Int J Ophthalmol. 2018 Dec 18;11(12):1999-2003. doi: 10.18240/ijo.2018.12.20. 
  8. Modenese A, Gobba F. Macular degeneration and occupational risk factors: a systematic review. Int Arch Occup Environ Health. 2019 Jan;92(1):1-11. doi: 10.1007/s00420-018-1355-y. Epub 2018 Sep 6. 
  9. Alaimo A, Liñares GG, Bujjamer JM, et al. Toxicity of blue led light and A2E is associated to mitochondrial dynamics impairment in ARPE-19 cells: implications for age-related macular degeneration. Arch Toxicol. 2019;93(5):1401-1415. doi:10.1007/s00204-019-02409-6
  10. Marie M, Gondouin P, Pagan D, et al. Blue-violet light decreases VEGFa production in an in vitro model of AMD. PLoS One. 2019;14(10):e0223839. Published 2019 Oct 23. doi:10.1371/journal.pone.0223839
  11. West KE, Jablonski MR, Warfield B, et al. Blue light from light-emitting diodes elicits a dose-dependent suppression of melatonin in humans. J Appl Physiol (1985). 2011;110(3):619-626. doi:10.1152/japplphysiol.01413.2009
  12. Bonmati-Carrion MA, Arguelles-Prieto R, Martinez-Madrid MJ, Reiter R, Hardeland R, Rol MA, Madrid JA. Protecting the melatonin rhythm through circadian healthy light exposure. Int J Mol Sci. 2014 Dec 17;15(12):23448-500. doi: 10.3390/ijms151223448. PMID: 25526564; PMCID: PMC4284776.
  13. Shechter A, Kim EW, St-Onge MP, Westwood AJ. Blocking nocturnal blue light for insomnia: A randomized controlled trial. J Psychiatr Res. 2018;96:196-202. doi:10.1016/j.jpsychires.2017.10.015
  14. Jia YP, Sun L, Yu HS, et al. The Pharmacological Effects of Lutein and Zeaxanthin on Visual Disorders and Cognition Diseases. Molecules. 2017;22(4):610. Published 2017 Apr 20. doi:10.3390/molecules22040610
  15. National Institute of General Medical Sciences. Circadian Rhythms Fact Sheet. https://www.nigms.nih.gov/education/fact-sheets/Documents/fact-sheet-circadian-rhythms.pdf 
  16. Sleep Disorder Resource. Circadian Rhythm Sleep Disorder. http://www.sleepdisordersresource.com/circadian-rhythm-sleep/cricadian-rhythm-sleep/circadian-rhythm-sleep-disorder/