Susan Kuhns, RNP Photo by Norm Vance

There is considerable controversy and debate over the use of synthetic hormones used to treat menopausal symptoms. Some studies have shown potential health risks, while others report health benefits, creating an environment of confusion as to what to believe. However, an increasing number of women are seeking natural alternatives to make this transitional phase of their lives more comfortable without incurring the possible health risks of synthetics. In January 2005, I spoke with Susan Kuhns, Nurse Practitioner, of Pagosa Women's Health and Wellness, who works extensively with what are called "bio-identical hormones." These hormones are derived from plant sources, and Kuhns feels they are just as effective, if not more effective, than their synthetic counterparts.

Suzanne Matthiessen: First off, please let our readers know what a nurse practitioner is, and what you are able to do.

Susan Kuhns: I am a registered nurse who has gone on to further my education so that I can prescribe and diagnose pretty much the same as a physician can. The only things I don't do are what I don't feel comfortable with in my training, and that's treating emergencies. I'm not a cardiologist, and I don't feel like I am the person to come see if you've had a heart attack, or if you have a major, significant injury, or other significant health problems. But for the general family practice-type illnesses that come up, that's fine. And I do really feel that I kind of have a specialty in women's health, and I can pretty much do the same things as a physician. I definitely know what my limits are, and I will refer at any point I feel necessary.

SM: Does Colorado law require you to work in tandem with a doctor in your practice?

SK: I have to have a collaborative physician, meaning that I have to have a physician that is willing to be there for questions. He doesn't have to be on site, and he has to be willing to back me up if I have concerns, and he has to review my charts every twelve weeks. Dr. Wienpahl, who I've worked with for nine, ten years now, agreed to be my collaborative physician, and he does review my charts, and if do have any medical questions I call him up.

SM: Tell me how you got into the alternatives to regular hormone replacement therapy.

SK: When all the studies started coming out about the Premarin® fears and scares, I just started thinking there has to be another way to help women deal with these issues, because they aren't just a mild hot flash—these are life-altering complaints that women have. They can't sleep, they're moody, they're having marital problems due to it, they can't function at work—these are major issues for a majority of women. There are so many other alternatives out there, and I've tried to educate myself and research the options and kept hitting either the questionable safety with synthetics or, that they don't work.
One patient came to me about natural hormones and said, "This is what I am doing, and it works well." I wasn't sure, because I knew it was a hormone, and my concern was the safety and effectiveness issue. So I started about six, seven years ago working with a compounding pharmacist in Durango by the name of Steve Walker, and I started asking him more and more questions. He gave me a lot of answers and I started trying some of my patients on bio-identicals. With trial and error, I found this stuff really works well. I went to a conference on bio-identical hormones just this past November, and I learned an awful lot about how other providers are prescribing this, and the statistics about the decreased risk of breast cancer with them as well as decreased cardiac disease. I've found of all of the things out there, I think this is the safest and most effective.

SM: What natural hormones are you working with?

SK: Natural progesterone, which is a micronized progesterone, as well as estradiol and estriol, and testosterone too, depending on what the complaints are.

SM: What are the sources of these hormones?

SK: It comes from the Mexican yam, but they are compounded in a laboratory to be identical to the same molecules that your body makes. So we can take a progesterone molecule from a woman's body and actually take a Mexican yam, compound it in a laboratory, and make it to be the exact same formula that your body makes. The same with estrogen and testosterone.

SM: Is what you prescribe a combination of all these hormones, or are they dealt with individually?

SK: Everybody is so unique, and the nice thing about this is you can individualize it so much for each person. I find that most people don't absorb oral medications well, so I've been going more to sublingual or transdermal applications of the hormones and I think it's a safer way of getting it absorbed into your system because then it bypasses the liver, and that can actually reduce your chances of side effects from the estrogen.

SM: I've seen a lot of products that are sold over the counter at both health food and drug stores. I was told that they vary widely in terms of dosage, that there is no standardization.

SK: There's not. The FDA (Food and Drug Administration) does not have control over that since the laws were changed a few years back. There are some good products out there, but once again, we are talking about a very weak amount. Compare that to what Steve the pharmacist compounds, which are at least two-and-one-half to three times stronger than what you're going to get over the counter.

SM: So you definitely know exactly the dosage with what you are prescribing.

SK: Right, just as if I were prescribing Premarin®, lets say. There's the exact milligrams used with these compounds, and we know the majority of which ones women do better on. But again, everyone is unique and you just have to work with how each woman responds to what you try.

SM: How do you make that determination? Do you do saliva testing?

SK: I do on anybody who is questionable. Like, you're still having regular menstrual periods, but all of a sudden you're having estrogen deficiency problems such as hot flashes, or memory problems or vaginal dryness, then I think it is really helpful to get a saliva test to see. For the majority of women, if they are menopausal we know that their estrogen levels are going to be low, and their progesterone levels are going to be low, so a test is not as important. But if they don't get the appropriate response, that's when I can use the saliva testing. I try to save women as much money as possible because the saliva testing can be helpful, but it's a lab, and you use labs to help you do a better job. It's not that you should rely totally on the lab.

SM: Can you explain some of the general symptoms of each hormone deficiency?

SK: Estrogen deficiency typically will give you hot flashes. And that's as the estradiol decreases your body starts going into menopause, we don't know the reason why, but for some reason it affects the regulator of your temperature and you can get these terrible hot flashes. They can be mild, they can be severe, they can be burning, they can be prickly—every woman's are a little bit different. Some are very tolerable, and women don't want to do anything about it, others are so severe that women feel they are unmanageable and possibly can make them feel suicidal. Estrogen definitely is needed to control those types of symptoms.

With progesterone deficiency we see more anxiety, insomnia, fluid retention, migraine headaches—we call it the "estrogen dominance effect." That's when you're producing enough estrogen, but your progesterone levels are bottoming out and you have too much estrogen in comparison to progesterone. I see this a lot in women who are taking hormones prescribed by an ob-gyn or other provider and are not being supplemented with progesterone and they tend to get a lot of abdominal weight gain and fluid retention and aren't sleeping well even though their hot flashes are maintained. Also in perimenopausal women, they're still making a fair amount of estrogen but their progesterone levels start dropping earlier than their estradiol levels.
Testosterone deficiency can be libido issues—that's the biggest one most people think of—but it can also be muscle tone and overall sense of well-being. Testosterone almost has a serotonin effect, and depression can be a real issue. Also, it can even help with hot flashes if estradiol alone is not helping to suppress the hot flashes.

So, like I said, it's a nuance that you just kind of have to work with in each woman and figure out what's going to work best for her. And then after you do come up with some regime for her, it is then tweaking it to make it work for her even better. It's with experience I've gained the knowledge of how to best work with each woman. Steve Walker has helped me immensely, and he's always available for backup when I come up with questions, as "this isn't working, what do you suggest?" and so forth. We talk on the phone an awful lot.

SM: What about the addition of herbs or other things that are supposed to help with this time in a woman's life?

SK: I do recommend other things, especially B-complex in the perimenopausal years. If a woman doesn't want to go to the [synthetic] hormones because of breast cancer scares or whatever, I think that there are some over the counter products that are worthwhile, and it depends on your symptoms. For mild symptoms I think some of them can help, such as Estroven®. I've had some women say it works well enough to make their symptoms tolerable. Evening Primrose, flax seed oil, I also think diet, keeping the complex carbohydrates high and your simple carbohydrates low, and exercise. Exercise, I think, helps most women get through menopause so much easier than not having an exercise regime in their regular daily activities. So all of those things I think are helpful, and I do try to recommend a holistic program, not just hormones. It's the whole body that needs to be treated. Getting enough sunshine is important too; that full spectrum light can be immensely helpful, especially when you are getting the mood swings in the low period with the serotonin effect.

SM: What about soy? First we hear it's good, and then we hear otherwise. It's very confusing.

SK: Soy has a weak estrogen effect. It's one of those things that we know a little bit about, and maybe not enough. Some women feel the soy helps their menopausal symptoms, and if they have mild symptoms I feel that's probably true. As far as danger of it, I think that there's a lot more studies that need to be done.

SM: Are natural hormones absorbed by the body at the same speed as the synthetics?

SK: Once again, everybody is a little different. With the bio-identicals I tell women to give it, especially with the estrogens, a couple of weeks. With the progesterone, give it a cycle, at least a month to see if it's going to help. Sometimes it will start helping within that first week, but within two or three weeks you may notice more of an improvement. It's subtle. It's not as "wham bam" like taking a synthetic hormone pill would be. But I think the sense of well-being and sense of balance and a sense of feeling much better that comes with taking the bio-identicals is amazing when I change women from the synthetics over to the natural hormones. They all tell me, "I feel so much better!" across the board.

SM: Are there any side effects to be concerned with?

SK: Since we are replacing the same things your body used to make, I don't feel there are any toxicity concerns because we're just supplementing with what your body is used to. But there's always the chance of something not being exactly correct. The problem that estrogen has is if it does go through the liver it can actually irritate the gall bladder and cause gall bladder disease and stones, and we see this a lot in women in their forties and fifties, and the thought it is may very well be the estrogen effect. When estrogen goes through your liver, it increases the risk of getting blood clots in the legs, which we call deep vein thrombosis, which can cause pulmonary embolisms and strokes. So if you bypass the mechanism that can potentially cause that increased clotting factor by alternative applications, then it's a huge risk that's decreased.

SM: Is there anything else you'd like women to know?

SK: I've used myself as a guinea pig over the past few years because guess where I'm at in my life? It's just around the corner. I've used myself to see what works for me and it's amazing how much better I feel, and how much easier it is to keep the weight off and all these things I was struggling with before. Stress obviously is still a big factor in many people's lives, and stress affects your hormone levels, and getting that under control is so very helpful. But in general though, I've found that natural hormones can make a huge difference in how you feel. I know a lot of women out there are suffering, because I hear it on almost a daily basis, and I just would like to let them know that there are things we can do. If you're suffering you don't have to.

To learn more about the conclusions made from the findings of the July 2002 Women's Health Initiative Study on synthetic hormone replacement therapy and the February 2006 Calcium/Vitamin D trial, please visit http://www.whi.org.

The Pagosa Women’s Health and Wellness office is located at 103 Pagosa Street, 970-264-2218.

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