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Information: Hormone Replacement Therapy and PD

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Dear Friends, The subject of HRT (hormone replacement therapy) comes

up occasionally, and in light of the various studies, it's a good idea for

women to be well informed. The following article provides information you

can discuss with your neurologist and family doctor. Best, Kathrynne





Hormone Replacement Therapy for Women with Parkinson’s Disease – Yes or No?


Kathrynne Holden, MS, RD

August 2002


(Ms. Holden is a Parkinson nutrition specialist; she moderates the NPF email forum “Ask the Parkinson Dietitian” at: < http://www.parkinson.org/ > and is the author of “Eat well, stay well with Parkinson’s disease” < http://www.nutritionucanlivewith.com/ >


What is hormone replacement therapy?

At menopause, women stop producing the hormone estrogen, and for years have been prescribed an estrogen made from the urine of pregnant horses (Premarin) and progestin, a synthetic form of the hormone progesterone (Provera). The combination is called Prempro. The treatment was originally given to relieve such symptoms as hot flashes, but later in the belief that hormone replacement could reduce bone thinning and heart disease. Estrogen alone relieved symptoms but produced an increased risk for endometrial cancer (cancer of the uterus), so the synthetic progestin was added to lower the risk for uterine cancer. Women who had undergone hysterectomies (removal of the uterus) were given estrogen alone. But did estrogen or an estrogen-progestin combination really work to reduce the risk of disease? Two recent studies have now cast doubt on the safety of both estrogen and estrogen-progestin therapies.


In a large study, conducted by the Women’s Health Initiative (WHI), researchers wanted to find out whether Prempro could decrease the risk for heart disease, stroke, and osteoporosis. Instead, they found a small increased risk for breast cancer, heart disease, and stroke. The risks were small – for example, out of 10,000 women using HRT, eight more would be expected to develop breast cancer than in the control group. However, the risks, although small, were considered significant enough for researchers to halt the study. It should be noted that there was a slightly lower risk for hip fracture and colorectal cancer.


In a separate study by the National Cancer Institute, researchers found a 60% higher risk of ovarian cancer among women using estrogen than those who did not use estrogen, and the risk increased over time. (JAMA 7/17)Thus, women who had the uterus, but not the ovaries, removed were still at risk for cancer. However, the total risk was found to be small – one or two additional cases of ovarian cancer per 10,000 women per year – and did not prove that estrogen itself causes ovarian cancer. Although the women were notifed of the study findings, in this case the study was not halted.


Doctors’ reactions

Many doctors do not believe the results of these studies are a good reason to stop HRT, because the increased risks were very small. Furthermore, the likelihood of colorectal cancer and bone thinning was slightly reduced.

Others, however, were not surprised at the results; some, in fact, noted that menopause is increasingly seen and treated as a “disease” instead of the natural and normal life process that it is. These doctors believe strongly that each woman should be evaluated on an individual basis, and treated accordingly. For example, if hot flashes are so severe as to affect the quality of life, HRT may be appropriate for the few years that the hot flashes occur, and then discontinued.



How do I decide whether or not HRT is right for me?

This is a complex issue, and women, especially those with PD, should educate themselves thoroughly, then discuss the options with their doctors. Women who are using Prempro or other HRT therapy should not stop without first talking with their doctors. Abrupt discontinuation may bring on menopausal symptoms; if you and your decide to stop HRT, the doctor should discuss a gradual weaning from the medication.


Advantages of HRT

Estrogen replacement can relieve hot flashes, which in extreme cases can be debilitating. Further, the WHI study demonstrated a slightly lower risk of colorectal cancer, and some protection against bone thinning and osteoporosis. This is of particular concern to women with PD, whose risk for osteoporosis is increased. Also, although studies are not conclusive, there is some evidence that estrogen may protect against Alzheimer’s disease.

Finally, and of most concern in PD, there is also the possibility that estrogen may slow progression of Parkinson’s disease. Evidence for this is scant but tantalizing.


• Anecdotally, some premenopausal women report that their PD medications become ineffective during ovulation (the middle of the menstrual cycle) and shortly before the start of the monthly menses, or menstrual period, when hormonal changes fluctuate. This appears to indicate that the female hormones have an influence on the symptoms of PD.

• Studies in the laboratory have demonstrated a protective effect of estrogen on neuron cultures.

• And, although not statistically significant, a study of postmenopausal women with and without PD showed that women with PD were more likely to have undergone hysterectomy or early menopause, and were less likely to have used estrogens.


Researchers are continuing to explore the possibility that estrogen may be a significant factor to consider in treatment of PD.



First, consider why you might or might not be a candidate for HRT.

• It will not prevent heart disease; and may slightly increase the risk

• Women who have heart disease, stroke, or breast cancer, or who have a family history of these diseases, should probably not undergo HRT.

• It will help to prevent bone thinning, and this is a consideration for women with a family history of osteoporosis. However, there are natural forms of estrogen, also other medications along with supplements of minerals and vitamins, and weight-bearing exercise, that also help to prevent bone thinning.

• It slightly decreases risk for colorectal cancer, an important consideration for those who have PD, or those with a family history of colorectal cancer; however, dietary means and annual examinations can lower risk for colorectal cancer.

• If you do not have hot flashes, or if they are mild, you don’t require medication; menopause is not a disease, it is a life change, and should not be treated as a disease.

• If you are several years post-menopause, it may not be a good time to begin HRT – this is best initiated early in menopause.

• Nutrition and exercise are a much higher priority than HRT, regardless of menopausal symptoms.

• You may want to discuss the implications of HRT with regard to Alzheimer’s disease and Parkinson’s disease with your doctor.

• If you, like some women, find that your PD symptoms are decreased with HRT, then that could be a good reason to continue, if your doctor agrees.


What if my doctor and I feel that HRT is important for me?

At this time, the best advice is to take the lowest possible amount of hormones that is effective for you. Your doctor can measure hormone levels in your blood or saliva to determine the correct amount for you. You may want to consider using natural hormones, also known as “bio-identical hormones,” such as 17beta estradiol rather than Premarin; and natural micronized progesterone rather than Provera. This is a choice you and your doctor can discuss together. Also discuss use of transdermal estradiol (Alora, Climara, Esclim, Vivelle) – the skin patch – to see if that would be the best choice for you. Prometrium is a bio-identical progesterone, available at drugstores. A source for bio-identical hormones is Women's International Pharmacy, whose pharmacists will work together with your doctor to compound a preparation for you (see Resources).


If I decide against HRT, are there any alternatives?

Yes. Start with a good diet. Whole foods, with as little processing as possible, are a good beginning. Whole-grain breads and cereals provide the natural proportions of minerals, vitamins, fibers, and phytochemicals that our bodies are best designed to recognize and use. Vegetables and fruits, some raw, some cooked, provide a balance of tocopherols, carotenes, and antioxidants that cannot be matched in pill form; and many of them contain small amounts of natural estrogens – wheat germ, apples, nuts and seeds, for instance. Choose some red, yellow, orange, and dark green vegetables and fruits, too – melons, tomatoes, spinach, broccoli, citrus, squash – these offer us a vast and varied array of antioxidants and nutrients. Look for “blue foods” where possible – blueberries, blackberries, raspberries, cherries. These are especially rich in some of the most potent disease-fighting substances known: anthocyanins and phenols. Dried beans contain a wealth of beneficial components – fibers, folate, and magnesium, also proteins and carbohydrates in a balance that works very well with levodopa.

Flaxseed contains natural cancer-fighting lignans as well as estrogenic features. It’s a rich source of fibers, both the kind that lower cholesterol and the kind that help prevent constipation – a good choice for those with Parkinson’s disease. At least two servings of fish a week will provide the omega-3 fatty acids that help combat depression and lower cholesterol. Nuts, such as almonds, walnuts, Brazil nuts, pecans, and filberts, preferably raw, are wonderful food – rich in protective fats and hard-to-find trace minerals.

Exercise is equally important, especially weight-bearing exercise which strengthens the bones of the hip and spine, two of the areas most prone to fracture in osteoporosis. You don’t have to run marathons, walking and even strolling is helpful.

If bone thinning is a concern, your doctor can prescribe raloxifene (Evista). You should also follow a good diet, and may need supplements of calcium, magnesium, and vitamins D and K. You should get regular weight-bearing exercise; and make sure you have an annual DEXAscan to monitor your bone density.

Elevated cholesterol can often be lowered by careful diet and regular exercise. Ask your doctor for a referral to a registered dietitian for help with menu planning. Use of soy, oats, olive oil, and other foods may be helpful in lowering cholesterol. If diet and exercise are not sufficient, there are medications to help lower cholesterol.

To detect breast cancer, perform a regular breast self-examination and have regular mammograms.

For hot flashes, although no alternative therapy is as effective as estrogen at relieving hot flashes, there are other possibilities, and they work reasonably well for many women.


• Add soy foods to your daily diet; these are a rich source of plant estrogens – weak estrogens that may be mildly effective in relieving menopausal symptoms – tofu, edamame, cooked soy beans, roasted “soy nuts”

• Flaxseed is another source of plant estrogens; it must be ground to be effective. Add a tablespoon or two to cooked cereals or casserole; blend into a fruit smoothie

• Black cohosh (Cimicifuga racemosa) is an herb that has been used for centuries to counteract both menstrual and menopausal symptoms. It may interact with some medications, you must discuss this with your doctor. A commonly used preparation is in tablet form, called Remifemin.


What about soy isoflavones?

Soy isoflavones, primarily genistein and daidzein, are weak estrogens that have been removed from the soybean and put into pill form in the hope that they may help with menopausal symptoms. However, animal studies of Parkinsonism using these isoflavones have shown conflicting results. At this time, there is not enough evidence to recommend for or against use of isolated genistein or daidzein by people with PD, although use of the whole soybean, tofu, and other soy products is considered healthful.


In summary, most women do not require HRT to manage menopause. However, estrogen may have other benefits, especially for those with Parkinson’s disease. Use the Resources (see below) to educate yourself about your options, and schedule an appointment with your physician to determine which course is right for you.





Christiane Northrup, M.D.

Obstetrician and Gynecologist, Author

“The Wisdom of Menopause”

“Women's Bodies, Women's Wisdom”

http://www.drnorthrup.com/whatsnew.php? ... 1932772b4b


The National Women’s Health Information Center

Access thousands of publications and organizations with information on hundreds of health topics:

Call: 1-800-994-9662 or 1-888-220-5446 for the hearing impaired. English- and Spanish-speaking specialists will order free health information for you. Phone lines are open Monday through Friday, 9AM to 6PM EST (excluding federal holidays).


Website: Customer feedback form.



Write: 8550 Arlington Blvd., Suite 300, Fairfax, VA 22031. Let us know what type of information you need. Include a return address, phone number, or e-mail address.


Women's International Pharmacy

Natural estrogen and micronized progesterone

12012 N. 111th Avenue

Youngtown, AZ 85363

Phone: 623. 214.7700 // 800.699.8143


Email: info@womensinternational.com


Office on Women's Health

Department of Health and Human Services

200 Independence Avenue, SW Room 730B

Washington, DC 20201

Phone: 202-690-7650

Fax: 202-205-2631

Menopause Resource Guide online:





1. Writing Group for the Women's Health Initiative Investigators. Risks and benefits of estrogen plus progestin in healthy postmenopausal women: principal results from the Women's Health Initiative randomized controlled trial. JAMA. 2002;288:321-333.


2. Lacey JV Jr, Mink PJ, Lubin JH, Sherman ME, Troisi R, Hartge P, Schatzkin A, Schairer C. Menopausal hormone replacement therapy and risk of ovarian cancer. JAMA. 2002;17;288(3):334-41.


3. Cholerton B, Gleason CE, Baker LD, Asthana S. Estrogen and Alzheimer's disease: the story so far. Drugs Aging 2002;19(6):405-27.


4. Rasgon N, Magnuson C, Johansson A, Pedersen N, Gatz M. Estrogen use and risk for cognitive impairment in female Swedish twins: preliminary analyses. Poster presentation, Eighth International Conference on Alzheimer's Disease and Related Disorders, Stockholm, Sweden, July 2002.


5. Callier S, Le Saux M, Lhiaubet AM, Di Paolo T, Rostene W, Pelaprat D. Evaluation of the protective effect of oestradiol against toxicity induced by 6-hydroxydopamine and 1-methyl-4-phenylpyridinium ion (Mpp+) towards dopaminergic mesencephalic neurones in primary culture. J Neurochem 2002;80(2):307-16.


6. Sawada H, Ibi M, Kihara T, Honda K, Nakamizo T, Kanki R, Nakanishi M, Sakka N, Akaike A, Shimohama S. Estradiol protects dopaminergic neurons in a MPP(+)Parkinson's disease model. Neuropharmacology 2002;42(8):1056-64.


7. Benedetti MD, Maraganore DM, Bower JH, McDonnell SK, Peterson BJ, Ahlskog JE, Schaid DJ, Rocca WA. Hysterectomy, menopause, and estrogen use preceding Parkinson's disease: an exploratory case-control study. Mov Disord 2001;16(5):830-7.


8. Lucas EA, Wild RD, Hammond LJ, Khalil DA, Juma S, Daggy BP, Stoecker BJ, Arjmandi BH. Flaxseed improves lipid profile without altering biomarkers of bone metabolism in postmenopausal women. J Clin Endocrinol Metab 2002;87(4):1527-32.




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