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Dear Paula,
I just had to comment on your statements about estrogen use and young-looking skin. You might want to read Dr. Susan Love's The Hormone Book. Dr. Love is a leading breast surgeon who is very against using long-term estrogen therapy, and in her book she talks about the false data about estrogen supplements and their benefit to skin. According to Dr. Love, the measurable difference between estrogen-supplemented skin and nonsupplemented skin is very minuscule. You make it sound like women will get all wrinkly without estrogen use despite staying out of the sun and not smoking as you advocate in your book.

Judy, via email search

Dear Judy,
I have the deepest respect for Dr. Love's work. Her research and books have provided invaluable insights and support when my sister and other friends struggled with and, thankfully, survived breast cancer. Her information and contribution to the issues involving women's health is significant. There are, however, those who disagree with her (and not just the companies that sell hormone replacement therapy, HRT). The research on how the lack of estrogen affects skin is not random or unsubstantiated (Sources: Plastic and Reconstructive Surgery, February 2003, pages 935-938; American Journal of Clinical Dermatology, 2001, volume 4, number 3, pages 143-150, and 2003, volume 4, number 6, pages 371-378; Clinical Geriatric Medicine, November 2001, pages 661-672; and Gynecological Endocrinology, December 2002, pages 431-441).

Many factors contribute to the wrinkling and aging of skin. Sun is a major factor, but so are free-radical damage, cigarette smoking, muscle movement, skin-cell senescence (that occurs when skin-cell renewal is slowed or stops), and loss of estrogen. Whether or not Dr. Love agrees with this, I merely reported the research that exists on what is available. There are lots of controversies involved with HRT regarding breast cancer risk, and possible heart disease issues. Other than Dr. Love's comments about hormones and skin, though, I haven't seen any information suggesting that loss of estrogen has anything but a negative effect on skin.

I am in no way advocating or discouraging the use of HRT. My intent is only to help women understand what is taking place in their skin as they age so they are better able to see why a wrinkle cream can't possibly be the answer to the wrinkling and sagging they see showing up in the mirror.

For those of you interested in Dr. Love's approach to hormone replacement therapy, consider her new book Dr. Susan Love's Menopause Book: Making Informed Choices, by Susan Love, MD, (January 2003, Three Rivers Press, $15.95).

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Category: Menopause/HRT

Dear Paula,
I am peri-menopausal and, at age 51, I use the Vivelle dot patch for natural estrogen, and the Prometrium (natural progesterone), with no problems. I agree with your answer that there is no substitute for estrogen for the skin. We can see what happens when older women's hormone levels are too low. I just thought I should mention the alternative to Prempro that does not have the same side effects. My doctor has told me not to quit HRT. There is very good information in a book titled Listening to Your Hormones by Gillian Ford that explains the hormone type difference. It's a big mistake to lump synthetic and natural together as being one and the same. Maybe someday something new will come along for the skin that does what estrogen does.

Linda, via email search

Dear Linda,
Thank you for your information. I am glad you found a combination (both are prescription only) that is working for you. Just to be clear though, the Prometrium you are taking "is synthetically derived ... from plant sources and is structurally identical to endogenous (naturally occurring) progesterone found in a woman's body" (Source: Solvay Pharmaceuticals, www.solvaypharmaceuticals-us.com—this is the company that manufactures Prometrium). Technically, it is no more natural than the estrogen derived from horse urine. Vivelle is estradiol 17B (also synthetically derived) and is the most potent steroid hormone in women, and, as a result, there are potential problems to be aware of when using it. "Adverse reactions associated with Vivelle include (but are not limited to) the following: headache, nausea, breast tenderness or enlargement, back pain, vaginal spotting or bleeding, [and] [t]here is evidence from several studies that estrogens, unopposed by progestins, increase the risk of carcinoma of the endometrium in humans. The incidence of endometrial hyperplasia is reported to be lowered with sequential coadministration of a progestin" (Source: www.pharma.ca.novartis.com—this is the company that manufactures Vivelle), which is why your doctor has you taking Prometrium at the same time.

As I've stated many times, something natural is no more a magic answer than something synthetic. At least with the versions you've chosen we have research to point us in the right direction in regard to risks.

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Category: Menopause/HRT

Dear Paula,
What skin-care advice do you have for the thousands of women who most likely will be discontinuing their hormone replacement therapy (HRT), now that the extensive study of PremPro by the Women's Health Initiative has been ended several years early due to the proven increased risk of heart disease, stroke, blood clots, etc.? While I realize that there are many less-cosmetic reasons for discontinuing HRT, I admit that I am concerned about how the decrease in estrogen and progesterone in my body will affect my skin and hair. I'm 52, post-menopausal, and have been taking PremPro for five years. For various reasons, I've elected to stop my therapy. Right now, my skin and hair are in very nice shape, I'd like to keep them that way for as long as possible!

Cindy, via e-mail

Dear Cindy,
The study you mentioned is indeed significant. The Women's Health Initiative assessed the major health benefits and risks of the most commonly used combined hormone preparation in the United States (Source: Journal of the American Medical Association, July 2002, pages 321-333). In this study, 16,608 postmenopausal women aged 50-79 received a combination of estrogen and progesterone (8,506 women) or placebo (8,102 women) from 1993 to 1998. According to the study, "On May 31, 2002, after a mean of 5.2 years of follow-up, the data and safety monitoring board recommended stopping the trial of estrogen plus progestin versus placebo because the test statistic for invasive breast cancer exceeded the stopping boundary for this adverse effect and the global index statistic supported risks exceeding benefits. Absolute excess risks per 10,000 attributable to estrogen plus progestin were 7 more [coronary heart disease] events, 8 more strokes, 8 more [pulmonary embolism], and 8 more invasive breast cancers, while absolute risk reductions per 10,000 were 6 fewer colorectal cancers and 5 fewer hip fractures."

I understand the concerns regarding the use of HRT (hormone replacement therapy) I am considered at high risk for breast cancer because my sister and my maternal aunt have had breast cancer. In my situation, I have decided that the risks of taking estrogen/progesterone of any kind outweigh the positives (though I should mention that I also do not have any major peri-menopausal symptoms which may alter my decision down the road).

Unfortunately, I have not seen any research showing that skin-care products can provide the kind of benefits estrogen does for skin, and believe me, for both my readers and myself, I have been looking diligently. Of course, there are lots of cosmetic companies claiming that the use of soy or some other phytoestrogen extract in their skin care products can influence skin the same way systemic use of estrogen can, but that is just not supported by scientific research.

Yes, moisturizers with antioxidants, exfoliants such as AHAs and BHA, retinoids such as Renova, and sunscreens can all impart significant benefits for skin. Not smoking (that's a huge one), exercising, and diet considerations are all equally crucial to the health and youthful appearance of skin. But in regard to what taking estrogen bestows on skin, there just isn't a comparison. The actual texture of skin (think of it in terms of the way a man's skin feels versus a woman's) and the fat content of skin (which directly affects skin's suppleness) are greatly influenced by estrogen, and there just isn't a substitute for that.

Dietary or supplement considerations can be of major benefit. Please refer to www.drweil.com for the latest information regarding alternative supplements and dietary options for estrogen and progesterone benefits.

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Category: Menopause/HRT

Dear Paula,
I just read your correspondence concerning the Prempro study and the effects hormone replacement therapy might have on the condition of your skin and hair. The original media reports failed to mention that all the women in the study already had heart disease; the goal was to see if Prempro could prevent deaths from strokes or heart disease in these women.

Yet as a result of incomplete reporting, most women who read about the study thought the results showed that Prempro itself causes heart disease. My local newspaper, the San Diego Union-Tribune, was apparently not aware of the fact that the study was done on women who already had heart disease and did not report that. A columnist, Jane Brody, got the complete facts and reported these in a separate column on why taking results of studies as facts without taking into account all the various factors involved is problematic.

Leotalyn, via email

Dear Leotalyn,
Your comments are well taken, though not exactly accurate. The WHI study used a combination of estrogen and progestin, like Prempro, but there were other brands used also with the same exact dosage. In fact, the standardization of dosing has been cited as one of the study's drawbacks. "In the WHI study, as in previous observational studies, the dose of 0.625 mg/d of Premarin or its equivalent has been chosen--a 'one size fits all' approach irrespective of the patient's age or weight" (Source: Journal of the American Medical Association, Letters, December 11, 2002).

Further, the women in the study did not have heart disease (at least not reported); the only qualifications for the 16,608 women in the study were their age (50 to 79) and that they were postmenopausal. The average age of the women in the study was 65 and the vast majority had never used HRT before. The age consideration and the late start in taking HRT is believed by some to be extremely significant in regard to the study's outcome. "To test the hypothesis that HRT reduces the risk of atherosclerosis [coronary heart disease-CHD], an optimal primary prevention trial would randomize younger, newly menopausal [or perimenopausal] women to HRT or to placebo.... In contrast, almost half the women in the WHI study were 65 years or older and the vast majority had never used HRT. Thus, the opportunity for HRT to prevent the development of [CHD] was well past in these older women. The prevalence of [heart disease] may have been high in these 'healthy' older women. Moreover, given the substantial literature that details the lower rates of diagnostic testing in women than in men with cardiovascular symptoms, the low rates of self-reported CHD in these women do not exclude the presence of significant underdiagnosed CHD. We suspect that the majority of cardiovascular events occurred in women with subclinical and undiagnosed CHD who were treated with HRT. While these findings would reinforce recent recommendations that older women with cardiovascular disease who have not taken HRT should not begin it to prevent clinical coronary events, they do not support the conclusion that HRT has no role in the primary prevention of coronary atherosclerosis in newly menopausal women who have low rates of subclinical and clinical CHD" (Source: Journal of the American Medical Association, Letters, December 11, 2002).

Unfortunately, many women stopped taking HRT out of fear and without complete information. Women still may have opted not to take HRT if they had all the facts because lots of women are at risk of heart disease because they smoke, are overweight, consume a high-fat diet, or have other contributing health problems such as diabetes, ethnic background, or family history. It is of significance to all of us that heart disease, not breast cancer, is the number one cause of death for women over 40.

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Category: Menopause/HRT

Dear Paula,
The Web site www.womenshealth.com/hrtsafety.html may be helpful for those concerned with hormone replacement therapy. This is completely different from synthetic hormones, but has received little or no press attention. I have been using these hormones for a number of years with wonderful results. I was unable to use synthetic hormones because of side effects. I hope the information on this doctor's Web site is helpful to you and others.

Kristin, via email

Dear Kristin,
So-called "natural" or plant-based hormones have received a lot of attention in the press (particularly on the Internet) although they are not popular in the medical world. That isn't surprising given that there aren't any real documented studies to go to for data and facts. Most of the information, even the Web site you mentioned, is loaded with data meant to sell products and does not offer a balanced approach. Instead, the conclusion is simply that synthetic hormones are bad, natural ones are good. The notion that there is no downside and no problems associated with "natural" hormone treatment is only theoretically true, because there is no research proving that to be the case. Plant- or herb-based hormones are not automatically without risk, as recent studies regarding herbal supplements such as kava kava and ephedrine have shown (Source: www.fda.gov). There is risk with synthetically derived HRT, but the only reason we know that is because there is published research of studies on these substances.

Please understand that although I personally follow a plant-based hormone diet and take supplements (at least 8 ounces of soy milk a day along with tofu and edamame), that doesn't mean I ignore the information showing the benefits many women receive from taking various forms of HRT.

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Category: Menopause/HRT

Dear Paula,
I have a comment on the estrogen issue mentioned in your newsletter. However, I am not sure that the option is available in the United States, namely estrogen creams. Here in Europe, estrogen creams are available with prescription only. They contain estriol, a natural estrogen having a weak affinity to estrogen receptor sites and that is not considered effective when taken orally. However, it does work topically and is usually prescribed for women who have vaginal dryness due to estrogen deficiency. This vaginal cream contains 1 mg of estriol per gram of cream. It seems to be a sort of "open secret" in gynecological and maternity facilities, with many nurses, midwives, and female doctors using it on the face. I am a doctor myself, so I can get it without a prescription, and I have been using it for many years now. I apply only a tiny amount around the eyes once a day. There is so little estrogen in it that it does not disturb my cycle (I have a few years until menopause yet), but I have no lines around the eyes at all at 42. Of course, I also use a sunscreen and don't smoke.

So local estrogen treatment may be a viable option for women who are primarily concerned about their skin, it is just a matter of getting a prescription. One would assume that what is safe for the vagina is safe for the face.

Let me just add that your advice has changed my whole skin-care routine and has saved me a lot of money over the years.

Friederike, Berlin, Germany

Dear Friederike,
Vaginally applied hormone creams (which contain either synthetic or natural estrogen) are available in the United States and they are applied vaginally for problems with dryness and thinning. They are also applied in "secret" as a skin-care cream. Whether or not that accounts for your lack of wrinkles is possible but unknown. I would suspect the estrogen would account far more for texture improvement, skin thickness, overall pliability, and softness than a lack of actual wrinkles. For that, I think the sunscreen is a bigger contributor than not smoking. But then again, it can be a combination.

In regard to risk, it is a bit shocking to realize that there are almost no studies evaluating the safety of topical estrogens. To date, we have only insufficient, limited, and even contradictory reports concerning the risks of uterine cancer and topical estrogen use. Some studies have found the risks to be dose-dependent, increasing with larger doses. Others have found the type of estrogen to be significant (estradiol versus combination estrogens). Also in question are the methods used to measure success. Some studies use devices that measure the uterine lining before and after estrogen use, which is fine for depicting the health and normal functioning of the vaginal walls (thickness and lubrication), but this is not helpful for other pathologies taking place in the uterus or endometrial lining (Sources: Obstetrics and Gynecology, 1995, volume 85, pages 304-313; Annals of Epidemiology, 1993, volume 3, pages 308-318; and Acta Obstetricia and Gynecologica Scandinavica, 2000, volume 79, pages 293-297). There are definitely no long-term studies for any of this and none for the use of estrogen cream to fight wrinkles on the face.

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Category: Menopause/HRT

Dear Paula,
As a longtime subscriber and user of your products, I was concerned about the letter a few months ago describing symptoms from using possibly too much of natural progesterone cream. I am surprised to hear that and would like to know what the "symptoms" or "side-effects" were. Dr. Lee, who is the self-proclaimed authority on natural progesterone, states that the only possible side effect of too much is "a calming effect or subduing of the mood." He says it can't possibly hurt you.

As a user of progesterone cream from age 50 to the present (58), I would find it helpful if this person let us know what was happening so others might avoid the problem or even know if they were having it. Did she say, or do you have any more info? Thanks and keep up the great work and good advice.

Carole, via e-mail

Dear Carole,
I wish I could be of more help, but trying to find independent, objective information about "natural" progesterone cream, specifically progesterone USP, is a task best described as impossible. (Progesterone USP isn't really natural, by the way-it is synthetically manufactured to be identical in form to human progesterone.) Additionally, some wild yams, thought to contain a plant form of progesterone, are considered unusable topically. Even Dr. Lee states that there are no enzymes in the human body that will convert diosgenin, the active component of wild yams, into progesterone.

Most of the information available about topical progesterone USP cream is of the type offered by Dr. Lee, whose research methodology is questionable. Some comes from companies selling progesterone products who speak of it as just short of a miracle; or from medical sources that have a definite leaning toward prescription medications. If there are risks for topical progesterone (and many medical practitioners would say there are, though they don't elaborate on what those may be), the bottom line is that there are no studies quantifying it. The same holds true for the other side of the coin, because those who say there are no risks can show no quantifying research either.

According to an article on the Healthcare Reality Check (HCRC, www.hcrc.org), the most commonly cited reference for the claims made about natural progesterone is a volume written by Dr. John R. Lee, Natural Progesterone: The Multiple Roles of a Remarkable Hormone. While claiming that natural progesterone is the optimal steroid for hormone replacement, the bibliography of the book actually includes few studies using natural progesterone. The vast majority of the references mentioned are studies using oxyprogesterone acetate or C-19 nortestosterone derivatives, the progestins found in oral contraceptives. Further, HCRC states that "Dr. Lee has published the results of studies of a series of 100 patients who used progesterone cream as a treatment for osteoporosis. During the 3-year study period, he cites an average increase in bone mineral density in the lumbar spine of 14% in 63 women who were studied serially, with the greatest improvements seen in those with the worst bone density at the outset." No controls were included, and in his concluding remarks, Dr. Lee says: 'It does not require [a] double-blind, placebo-controlled experiment to conclude that progesterone, used in this fashion, is of great benefit in treating (and preventing) osteoporosis.' That isn't exactly great science.

Aside from researched findings, there's a great deal of subjective information on progesterone creams from both sides of the medical world (both alternative and traditional medicine), with each finding that progesterone cream is an option for many perimenopausal and menopausal health issues. The alternative medicine approach is to paint progesterone as a panacea with no downsides; the traditional medical world sees progesterone as helpful with caveats about unknown health risks because the research hasn't been done.

On a personal note, as I have written before, I have chosen to use progesterone cream, and have experienced significant benefit (primarily normalized periods), and I too wonder about untold risks. Each of us must make a decision as best we can based on our needs versus risk. In this arena, although it is unclear exactly what the risks are, the benefits anecdotally seem to be significant.

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Category: Menopause/HRT

Dear Paula,
I have loved and used your products and advice since the days when you caused havoc at the cosmetics counters at the Bon Marché in Bellevue, Washington, where I used to work. I noticed in the recent newsletter that you are using progesterone cream, and I wanted to alert you to a problem that has occurred with myself and a few other gals I know who used it. The cream is used for all the right reasons, and really does help with hormonal changes, but unfortunately it quickly builds up in fatty tissue (and I mean quickly) and then can be drawn from by your body at the wrong times. This can cause a whole new set of problems. This was made very apparent to me when I took a month-long hormonal test. The solution was to use progesterone for half of the month. The dosage was set up by my naturopath.

Penny, via e-mail

Dear Penny, Thank you for your information. However, I was not able to confirm your information about progesterone cream building up in fat cells. In fact, there is limited research on the use of topical nonprescription progesterone creams in general so it is hard to find any information at all. The body makes progesterone for most of a woman's life while she is menstruating. When progesterone production drops during perimenopause and menopause it can help to maintain normal levels by using supplemental progesterone. However, setting up a program where you are using the cream appropriately (and this goes for any hormone replacement therapy [HRT] or estrogen replacement therapy [ERT] for that matter) is critical. Self-prescribing can easily mean you could be applying too much of the progesterone cream or using it too often, which can cause problems. The goal is to give your body the same levels of progesterone (or estrogen) at the same times of the month it would normally be producing it. If you're a perimenopausal woman using a progesterone cream for two weeks out of your cycle, it's typical to begin it 12 days after the start of a cycle, but this should absolutely be checked out with a health professional who is familiar with this kind of treatment.

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About the Experts

Paula Begoun is the best-selling author of 20 books on skin care and makeup. She is known worldwide as the Cosmetics Cop and creator of Paula's Choice. Paula's expertise has led to hundreds of appearances on national and international television including:

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The Paula's Choice Research Team is dedicated to helping you find the absolute best products for your skin, using research-based criteria to review beauty products from an honest, balanced perspective. Each member of the team was personally trained by Paula herself.

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