Hormone Replacement Therapy
by Dr. Michael Colgan

Optimal HRT concerns six hormones. Usually only two are replaced, using equine estrogen and synthetic progestin's. That's where all the trouble lies. Melatonin, estradiol, estriol, estrone, progesterone and testosterone. If you are going to replace one hormone, you have to replace all six, and you have to use hormones that are biologically identical to those of human females. We will examine each in turn.

The first hormone to decline in perimenopause is the pineal hormone melatonin. Melatonin is an essential synchronizer of the whole hormone cascade. If you replace anything, then melatonin is first on the HRT list, because, without it all other hormones lose their natural synchronicity.1 Imposing extra estrogen, or anything else, on a de-synchronized system is playing endocrine Russian roulette.

From thousands of cases, we have found that 1-3 mg of melatonin, taken sublingually (under the tongue) at night, immediately upon going to bed, raises night peak melatonin levels to within the range of a 35-year-old. It also assists sleep in perimenopause and menopause in about 60% of cases.

For many of the others, for whom melatonin does not work well, 50 mg of 5-hydroxy-tryptophan (5-HTP), a precursor of melatonin, restores sleep patterns. We advise against any use of HRT that does not include melatonin or 5-HTP.

While I was teaching at Auckland University Medical School in the 1970's, we reviewed the research on hormone replacement for women, and concluded that it was beyond doubt that horse estrogens and synthetic progestins, primarily medroxy-progesterone, caused a number of illnesses, including reproductive cancers. We also concluded that these man-made drugs, which have never been a natural part of the human body, failed to protect the human brain against degeneration, and did only a poor job of protecting the heart and bones.

We taught these findings to the medical students of the time, and I updated them in my 1994 book Hormonal health.1 Numerous other researchers also brought the same facts to public attention. Nevertheless, such is the power of pharmaceutical advertising to suppress evidence and to hire tame scientists to fabricate opposing data, that it took until 2002 for the American Medical Association bureaucrats,1 not the brightest buns in the bag, to finally catch on.

I want to state unequivocally, that no physician worth their credentials who was familiar with the evidence of their damaging effects that first surfaced in the 1980's, and every physician should be, would ever prescribe these drugs. That they continued to be widely prescribed until 2002, AND still continue to be prescribed by physicians who don't even read their own journal JAMA, is a humbling indication that human intelligence has not increased much since we discovered how to make fire.

The Need For HRT
Do women need HRT? Isn't it unnatural? Shouldn't we leave the body alone to age naturally? These are some of the confused questions we get frequently. Again I want to state unequivocally, for better or worse, humans have decided to extend their lives as far as possible, and in doing so, to remain as healthy as possible. To object to HRT is to object to contact lenses, tooth fillings, antibiotics, life-saving surgery, and all the other artificial medical procedures that extend human life and health.

Without HRT, once a woman passes the prime reproductive years and enters perimenopause between ages 35 and 45, Nature has little further use for her body, and the hormone cascade declines. And at least a thousand systems in the body decline also, most notably intelligence and memory, emotional tone, heart function, bone density, liver and kidney function, muscle strength, mobility, flexibility, and sexual function.

So what happened before HRT? All of the above plus a host of horrible symptoms. For many women, life after menopause was "nasty, brutal and short". Fortunately women then didn't live so long. Now with the prospect of an average female lifespan of near 90 years, HRT is essential to preserve a women's health for half her life.

To update my 1994 book, in which I advised the use of Tri-Est, circa 2003 the most advanced natural estrogen formula, exactly duplicates the average proportions of the three estrogens in the healthy human female system before menopause. Called Esnatri in Europe, this formula is 7% estradiol, 3% estrone and 90% estriol.

The proportion of estriol is especially important, because it is anti-carcinogenic and probably acts to keep the other two estrogens under control.

Formulas, loosely called BiEst, that do not contain estrone purport to reduce carcinogenic potential, exhibit only the crudest understanding of hormonal function, and may increase hormonal mayhem in the female system. And formulas that are straight estradiol, or that contain only a small proportion of estriol, will likely prove to be as carcinogenic as horse estrogens, though it may take the same period of 25 years before the public is informed.

The amount of Esnatri (or Tri-Est) to use depends on the woman. Some are naturally low estrogen and others are high estrogen. HRT is always an experiment with any individual and may require a number of adjustments to find the optimal dose. Sensible physicians use the least amount possible, as they know they are playing with the most powerful hormones known to science. HRT should use the least triple estrogen formula that will protect a woman's brain, organs, and bones, will eliminate menopausal symptoms and will not increase the risk of cancer.

In monitoring thousands of women on natural HRT over the last 20 years, we have found that an effective dose yields a serum estradiol level on the low end of the normal range. For many menopausal and postmenopausal women, this is achieved with an amount of only 1.5 -2.5 mg per day, applied as a penetrating cream or gel.

As far as possible, the use of triple estrogen formulas should also mimic the natural cycle of estrogen. In healthy, cycling women, estrogen is low during menstruation and peaks between Days 12-15 (Day 1 is the first day of your period), then drops sharply at ovulation, and continues at a moderate level until days 27-28.

Externally applied estrogen in the correct small dose, builds up only slowly, taking 4-5 days to raise estrogen appreciably. Consequently, a reasonable cycle of estrogen replacement application is Days 1 through 25 of each month with no application for Days 26-28 (28 day cycle). For individuals with shorter or longer natural cycles, their physician should adapt this application program.

Progesterone declines even earlier during perimenopause than estrogen. As a natural hormonal component of the system, and a vital controller of estrogen, progesterone should always be used n conjunction with estrogen replacement. For many women, we have found that a cream or gel containing 25 mg of natural progesterone per dose is effective at controlling menopausal symptoms.

In healthy, cycling women progesterone is low until ovulation (Days 12-15) then raises to peak at about Days 22-24. To mimic this cycle, we have found that progesterone application is effective if started on Days 12-14 and finished on Day 26 (28 day cycle). Different individuals respond better in terms of menopausal symptoms by using different lengths of application cycle within this range.

Testosterone is the sixth vital component of hormone replacement. The first hormone to decline in perimenopause is dehydroepiandrosterone (DHEA). Women readily make testosterone from DHEA in peripheral tissues of the lungs, organs and skin. For many women, a pill of 10-25 mg of DHEA is sufficient to maintain testosterone levels. In cycling women DHEA is made daily and remains relatively stable, so should be replaced daily.

As menopause progresses, however, a small amount of testosterone, applied as a cream or gel, may be necessary to eliminate symptoms and maintain well being. We have found that 2-5 mg per day is an effective dose range, applied on the same days as estrogen.

HRT Timing
Research to date yields the following pattern for using these hormones and precursors.

Perimenopause and Menopause:
This is based on a 28 day cycle.
Day 1 is the first day of your period.
Esnatri (or Tri-Est): Day 1 through Day 25.
Progesterone: Day 12 through Day 25.
Three days of non-use, then repeat the cycle.
DHEA: 10-25 mg per day.
Melatonin: 1-3 mg per day or 50 mg 5-HTP taken at bedtime.

Choose one day of the calendar month as Day 1. (The first day of the month is the easiest).
Esnatri (or Tri-Est): Day 1 through Day 30 or 31, use each day.
Progesterone: Day 8 through Day 30 or 31, use progesterone each day.
DHEA: 10-25 mg per day or Testosterone cream 2-5 mg per day.
Melatonin: 1-3 mg per day or 50 mg 5-HTP taken at bedtime.

1. Colgan, M. Hormonal Health. Vancouver: Apple Publishing, 1996.