What French Women Know About
Estrogen…and American Women Don’t!By Elizabeth Lee Vliet, M.D.
Founder of HER Place: Health Enhancement and Renewal for Women, Inc.
The Savvy Woman’s Guide to Hormone Headlines: What America Got Wrong About Estrogen
Many of you saw the national news reports in late ing bioidentical estradiol, was approved by the French
February 2007 announcing the findings of the ES- equivalent of the FDA about 30 years ago!
THER study, sponsored by health agencies of the troGel is the most widely used form of estradiol in
French government. ESTHER, which stands for Estro- Europe. Even though EstroGel has been used so suc-
gen and Thromboembolism Risk, showed that wom- cessfully in European countries for so many years,
en taking oral estrogens were four times more likely
American women did not get this product until the
to have a blood clot than women using estrogen in a FDA approved it in February 2004! So it seems the
transdermal gel or patch delivery. In fact, the women French have handled women’s hormone therapy a lot
using estradiol gel or patches had no more blood clots better than the Americans have for a long, long
than women using no hormones at all (placebo)! 56%
Keep in mind, all of the various products using
of ESTHER women on transdermal therapy were us- 17-beta estradiol deliver the identical molecular copy
I wrote about lower risk of blood clots with non-oral
estrogen in the first
edition of Screaming to Be Heard,
published in 1995. Studies since the 1970s have shown
this important difference between oral and transder-
mal estrogen. Research data has become even stronger
to support this longstanding observation that differ-
ences in the way hormones are delivered play a major
Climara, Vivelle DOT, and generic versions;
Health Enhancement & Renewal for Women, Inc.
In the United States, this research comes as a sur-
Estrace, generic estradiol, Angelique,* Activel a,*
prise to women and most doctors. But French women
and their doctors have known about these differences
for over thirty years…what gives? The answer may lie
in the different types of hormone products doctors
Transdermal estradiol products deliver the human
American women have traditional y been given oral 17-beta estradiol in a way that is the most “natural”
pil s of Premarin (a mixture of horse estrogens) or of all. The estradiol is absorbed through the skin, di-
Prempro (horse estrogens plus a potent synthetic pro- rectly into the bloodstream, similar to the release of
gestin). Both products contain hormones that are for-
hormones from the ovaries. Direct delivery to the
to the human body, and not identical to anything bloodstream bypasses the “first pass” metabolism in
women make natural y. Yet, these two products alone the liver that breaks down and changes estradiol into
have accounted for 80 to 85% of al hormone prescrip-
other forms that may not be as effective for its normal
tions in the United States
for the last fifty years!
European women, on the other hand, have tradi-
The primary difference between pill form and
tionally used products with bioidentical estradiol
and transdermal gel/patch is that oral estrogens all have to
, hormones that are identical to what the be metabolized (changed) first in the liver, called the
“first pass” effect. Everything we eat swallow by mouth
But even more critical is the difference in route goes through the liver first so it can be changed into
of delivery here in the U.S.A. compared to Europe: compounds that can be carried in the bloodstream.
of women in France and Italy, for example, use This first pass through the liver stimulates production
transdermal forms of estradiol such as gels, lotions or of some clotting factors and proteins that lead to both
patches that have been approved by their regulatory pluses, and minuses, or oral medications.
bodies (like our FDA). Contrast that 70%
with the U.S.
One “plus” of oral estrogen is that it stimulates the
statistics: only 3%
of American women use a transder- liver to make more of the “good” cholesterol, or HDL.
mal form of estradiol, even though British researchers That means if you are a woman who has a very low
first published studies in the 1970s showing reduced level of HDL, you may need this boost in production
risk of blood clots with non-oral estrogen.
provided by oral estrogen for the heart-protective ef-
One of the most successful options overseas, fects of HDL. EstroGel, Estrasorb
lotion or the patches
, a pleasant, easy-to-use clear gel contain- (Climara
and Vivelle DOT
) still give you the natural
2007 Elizabeth Lee Vliet, M.D.
physiological benefits of estradiol to maintain the normal level
Healthy? Only in America would we call women with these
of HDL cholesterol. They just don’t give you that “first-pass” characteristics “healthy!” No country in Europe has such a high
liver stimulation to ramp up production of HDL.
percentage of hypertension or obesity, both of which are risk
The “minuses” of oral estrogen can lead to a higher risk of factors for stroke, heart disease and breast cancer. Consider
blood clots: the liver “first-pass” effect can stimulate more these statistics from the WHI study data:
production of clotting factors that in some women can cause • 35% of the women were already being treated for high blood
deep vein thrombosis (DVT), or blood clots to the lungs, called
pulmonary emboli (PE). Obesity, smoking, and inactivity, and • 35% were significantly overweight
genetic mutations like Factor V Leiden (a blood coagulation • another 34% were obese
by the medical definition, making
disorder) further increase the risk of clots.
a total of 69% of the entire study group having an abnormal
Other “minuses” of oral estrogens, particularly mixed equine
body mass index, which affects all kinds of health risks from
estrogens like Premarin, include stimulation of liver produc-
tion of triglycerides (a blood fat associated with increased risk • 12.5% had high enough cholesterol to require medication
of heart disease if too high), renin (a substance that can cause •
high blood pressure), and greater likelihood of gallstones if you
16% had a family history of breast cancer
rong About Estrogen
have a predisposition to those problems.
American women often say that “pills are easier” and they
40% were former smokers, and 10% continued to smoke
don’t want to be bothered with putting on the gel, or they don’t
like the look of the “ring” with the patches as the adhesive
These women were “typical” Americans maybe, but certainly
around the edge picks up lint from clothes. But it if makes an
important difference for your health, aren’t these pretty minor
The only thing meant by healthy
in the published research
studies was that the women in the study just didn’t have symp-
Apparently French women think so—and the widespread toms of menopause!
I’ll bet you didn’t even know that the WHI
use of EstroGel thoughout Europe attests to its ease of use and even excluded
women experiencing hot flashes! Seems strange,
pleasant, non-greasy feeling on the skin. So maybe it’s time for doesn’t it?
you to get savvy and take advantage of the estrogen benefits
Older women in the WHI already had evidence of heart dis-
and lower risks that European women have known for so long! ease, high cholesterol and high blood pressure. So these base-
Advantages of transdermal delivery include:
line problems affect the response to hormones, especially when
(1) It maintains steadier blood levels of estradiol, similar to the high dose, “unnatural” products are used in women so long af-
hormone production by the ovary (helpful for women with ter menopause.
blood pressure or “hormonal” headache problems);
Recent worldwide research on hormone use has shown there
(2) It leads to better improvement in glucose control and insu- is a “window of opportunity” early in the menopause transition
lin sensitivity than with oral estrogens;
for hormone therapy to prevent damage to various tissues and
(3) It causes less rise in blood level of estrone, the estrogen of organs. Once this window of time is past, however, hormone
body fat, than seen with oral estrogens, again because trans- therapy doesn’t reverse damages that have occurred. This was
uide to H
dermal estradiol bypasses the liver “first pass;”
demonstrated clearly in the Women’s Health Initiative using
(4) The estradiol is less likely to be adversely affected by other Premarin and Prempro in elderly postmenopausal women.
medications, since it is not metabolized first in the liver;
The International Menopause Society position paper in Sep-
(5) Transdermal delivery of estradiol does not elevate triglycer- tember, 2002, said: “The WHI results, and particularly the data
ides as occurs in some women taking oral estrogens;
on cardiovascular disease risk, should only be related to the
(6) Non-oral estradiol is less likely to cause gallstones;
continuous combined treatment of 0.625 mg CEE (conjugated
(7) Transdermal estradiol helps maintain a premenopausal equine estrogens, Premarin) together with 2.5 mg MPA (me-
healthy balance of good HDL to bad LDL cholesterol even droxy-progesterone acetate), prescribed to elderly, obese women
though it doesn’t raise HDL as rapidly or quite as high as
with characteristics similar to those depicted in the WHI study”
The bottom line is that many of the health risks you have heard (parenthetical explanations of terms mine).
about from “estrogen” in the headlines over the last five years
In fact, the above comments and WHI findings validate con-
have been based on the Women’s Health Initiative studies using cerns I have been raising about Premarin and Prempro in my
estrogens and synthetic progestins.
previous books and medical articles since the early 1990s.
My clinical experience over twenty years, and the interna-
And now, French researchers have given us even more fuel
tional research, show that those risks don’t apply in the same for the fire that there are other, safer ways to use estrogen—
way to all other types of estrogens and other ways of giving the ways that help you feel better, feel more vital and energetic, and
not have all the risks you have read about in the press.
The WHI—which studied older postmenopausal women
Now it’s time for American women to appreciate, and ben-
using either Premarin alone if they had a hysterectomy, or efit from, the differences in type of estrogen and how it can be
Prempro (horse estrogens plus medroxyprogesterone acetate, given to better meet individual needs. If you are using, or con-
a potent synthetic progestin) if they did not—is the major U.S. sidering, estrogen to relieve menopausal symptoms, ask your
study that has caused so much turmoil and confusion about doctor if you can try EstroGel or one of the patch brands that
hormones since 2002. The WHI was presented in the press as a are FDA-approved bioidentical options for estradiol.
study of “healthy” menopausal women.
As the French say, Vive la difference!
2007 Elizabeth Lee Vliet, M.D.
Circular n.º 27/2007 13 de Fevereiro de 2007 Assunto: Promoção on-line de actos de registo comercial e a solicitação da certidão Foi publicada em Diário da República, n.º 242, I Série A, de 19 de Dezembro, a Portaria n.º 1416-A/2006, que regula o regime da promoção electrónica de actos de registo comercial e cria a certidão permanente, alterando a tabela de honorários e encargo
Q& A on anticoagulants and warfarin What are the anticoagulants? When are they required in Children? Anticoagulants interfere with the process of clot formation by inhibiting vitamin K. Sometimes, children have more than normal capacity to form clots inside the heart or circulatory system and may suffer due to that. Any such condition would require the anticoagulant to maintain normal bl