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Tap It Back…Add It Back: Hormonal Add-Back Therapy

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All you indoor cycle enthusiasts probably got the reference pretty quickly… Tap Backs are not only good for your core and your gluts but for your quads and your arms (and they are sort of fun at the same time). Dancing on a bike is liberating, to say the least, and lets you think, at least for 45 minutes, that you too could be Beyoncé’s next back-up dancer!

Tap backs are not just good for the body; they are good for the soul (no pun intended!). In the same way, add-back hormonal therapy is good for many different organs. With oral progesterone + estrogen, you are hitting many of those key areas and shaping your future.

Let’s take a seat in the saddle and review why you would need add-back therapy and how it does its job. Many GYN pathologies think fibroids, endometriosis, and adenomyosis run on hormones. No hormones usually = no pain/no symptoms. Therefore, our treatment choices for such problems frequently center on taking the hormones away. Our first line of attack usually includes oral contraceptive pills (OCPs). The synthetic estrogen and progesterone in OCPs feeds back on your brain and shuts off your natural production of estrogen and progesterone.  It’s a complicated pathway of events, but this one daily pill is usually very good at putting the brakes on the body’s own hormone production and keeping those pesky symptoms (pain, bleeding) at bay.

However, in certain cases, the OCPs are no match for the pathology pervading your pelvis—in these instances, we need to look into our bag of tricks and pull out something more powerful. Cue GnRH agonists (a.k.a. Lupron). These injectable (and in some forms nasal) medications shut off the brain’s production of the hormones that stimulate ovarian estrogen production. They don’t waste their time with feedback but rather go right to the source and turn off that switch. And while they are good at keeping things dark when this switch has been flipped to OFF by Lupron, it’s like a major blackout occurred in your body.

Everything hormonal goes dark. And while this darkness is good for stopping endometriosis, fibroids, and the like, it is not so good for those organs that desperately depend on estrogen (think bones). Therefore, in order to satisfy both parties (those that like the dark and those that need some light), we give what is called hormonal add-back therapy alongside the Lupron.

Think of the add-back therapy as a flashlight. It shines light on the areas that are really afraid of the dark (a.k.a. the bones). And like all good nightlights, it does its job well—it can keep the bones happy without reducing the efficacy of the Lupron. It also quells those crazy hot flashes that women can get while taking a GnRH agonist (Lupron). You may be making a funny face, thinking this doesn’t really make sense? If endo is fed by estrogen and then the doctor gives estrogen, won’t that make matters worse? You are sort of right and also sort of wrong. Here’s why.

The doses at which you are taking oral add-back therapy are right at the hormone sweet spot. They are just enough to protect your bones and stop the hot flashes but not enough to fuel your disease (endo, fibroids, etc.). As a result, add-back therapy has become all the rage for women taking GnRH agonists (Lupron). By supplying it, we can give Lupron without much stress over the possible negative side effects. Examples of add-back therapy include norethindrone acetate alone or norethindrone acetate + estrogen. Either combo has been shown to work; however, what works for you must be figured out with your doctor. Most of the time, we start add-back right when the agonist is started. While we used to wait a few months before initiating add-back, we now don’t really think there is any benefit to delaying its start.

Whether you are a SoulCycle or a Flywheel girl, an Equinox fan or a Crunch crazy, you know that, while on the bike, you will burn a serious number of calories. Add-back therapy is the lubricant that allows those wheels to keep turning. Without a little juice, over time, the bike will break down, and you will come to a screeching halt. We want to prevent that in your body by giving add-back hormonal therapy alongside a GnRH agonist. It will allow you to keep “cycling” without much pain. Not bad… Now, let’s see you Tap It Back!

SPF: Don’t Let Your Bones Get Burned

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Whether you opt for 15, 30, or 50, it’s rare to find someone amongst us that doesn’t lather up before laying out (or even being out on a summer day!). The sun and its rays are no joke. They can leave their mark in the form of burns, peels, sunspots, and even wrinkles—ugh! And if that wasn’t enough to scare you into some good water-resistant SPF, think skin disease and skin cancer. But while sunscreen fills the shelves at nearly every drugstore, reminding you to lather up or pay the price, what lies under your skin is much quieter. Your bones don’t tell you when they are about to burn (a.k.a. break), and the reminders to protect them are much subtler. However, if they are ignored, the burn can be just as severe as the strongest rays.

In the same way that you would protect your skin during the summer, you should protect what lies under your skin #yourbones all year round. Adequate calcium and vitamin D intake, coupled with a healthy diet, weight-bearing exercises, and estrogen during the reproductive years are the SPF that your bones need. In fact, this is the formula that makes up the SPF 70 sunscreen for your bones!

But while most of us know that milk (a.k.a. calcium and vitamin D) is “what does a body good,” you might be surprised to know that estrogen is equally as important. News flash: estrogen is not just a hormone made by your ovaries to keep your eggs developing. It is also necessary for bone buildup and bone strength. In fact, how much you take in during your adolescent and young adult years can dictate what happens in your later years. No estrogen in your younger years can cause some major breakage in your later years (think osteoporosis and osteopenia).

Bones reach their peak mass by about age 30. However, to reach the “summit,” they need estrogen during your teens and twenties. Therefore, women who are not on hormonal contraception and don’t get regular periods (a lack of periods because of continuous pill usage does not count!), is sort of standing out in the sun without sunscreen. When your bones don’t reach peak bone mass, there is nowhere for them to go but down later.

And as most of us know, the estrogen story does not end at age 30. Your bones continue to rely on their fountain of youth for years and years to come. Estrogen production is essential deep into our 40s and even 50s. Therefore, for women whose periods bid them adieu early it’s important to make sure that you speak to your GYN about hormonal replacement therapy.

While postmenopausal hormone therapy has gotten more bad press than both Democrats and Republicans making a decision combined, it’s actually not bad for most women. In fact, estrogen supplementation, started at the right time in the right woman, can be the key to reducing your chances for heart disease, bone disease, memory loss, and serious vaginal dryness. So, don’t listen to everything you hear on TV; this is one decision for which you should hear what your doctor has to say.

It’s really no different than sun damage. Burns sustained in your younger years make your skin way more susceptible in the later years. And while freckles and sun spots may be cute at age 15, they’re not so much at age 55. Additionally, they pose a risk for skin cancer at age 50. The same goes for how you treat your bones then and now. So, don’t forget to lather them in milk, vitamin D, calcium, and exercise: this SPF will save you big-time breakage in the future.

Is Testosterone the End All-Be All for Sexual Dysfunction?

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Whether it be for our skin, our hair, or our vaginas, we are always in search of the Fountain of Youth. You know, that product or device that will keep everything looking and feeling young. In the land of sexual dysfunction, testosterone was thought to be just that. The magic medication that would keep us like our 20-year-old self—need we say more? And while it certainly can do the trick for some women, it has probably gotten much more press than it deserved. Let us explain…

As women age, androgen levels decrease. As androgen levels decrease, so does sexual desire. This connection led scientists to study the impact of androgen replacement treatment on sexual dysfunction, specifically hypoactive sexual desire disorder (Sexual Dysfunction). And like all good competitions, the results were split. Some studies showed improvements in sexual functioning, and others showed no change. And because there was no good tiebreaker for the long-term use of testosterone to treat sexual dysfunction (a.k.a. a prospective randomized controlled study), doctors were hesitant to prescribe it.

Furthermore, due to the limited data, the FDA was not willing to put their stamp of approval on testosterone treatment. For this reason, transdermal testosterone is only used to treat hypoactive sexual disorder in the short term, that is, no greater than six months. Long-term use is not recommended, no matter how hypoactive your sexual desire is.

We tread lightly when using testosterone because it is teeming with negative side effects. Think acne, facial hair growth, deepening of your voice, and cardiovascular complications. Not fun. Additionally, some researchers have noted an association between testosterone use and breast cancer. While the link is loose, it is another reason to opt for the short-term rather than long-term use of testosterone.

When it comes to hormones, testosterone is not the only game in town. While testosterone has gotten a lot of attention, it seems to work best on hypoactive sexual disorder (a.k.a. I am just not that interested).

When the desire is there but vaginal dryness is holding you back, cue estrogen. Low estrogen (think menopause and breastfeeding) leads to a loss of vaginal lubrication. Vaginal dryness equals vaginal discomfort, and collectively, these symptoms are a common culprit in sexual dysfunction. Vaginal estrogen (tablets, gels, creams, and rings) can be particularly helpful in alleviating vaginal dryness (picture a hose in a desert).

Oral estrogen can also add some water to the well but is generally not as effective as vaginal estrogen for the treatment of vaginal dryness. Going straight to the source is way more effective! Last, adding vaginal lubricants or moisturizers (Astroglide, Replens, etc.) will help to turn up the power on that hose and further reduce the dryness.

Hormones are certainly helpful in hampering sexual dysfunction. However, they are only the half of it. Treatment will generally take on many other forms, such as the addition or subtraction of other medications, counseling, and physical therapy. So, while our Fountain of Youth remains dry (no pun intended), the combination of treatments may just do the trick. It may not fill up that well, but it’s worth a shot!

The Low Down on the Low-Dose Oral Contraceptive Pills

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Loestrin, Mircette, Yasmin, Yaz, Ortho-Tricyclin, Ortho-Novum, and Alesse—the list goes on and on. Many of us have sampled more pills than flavors at our local ice cream shop (even when the sign says one per customer). And no, it is not all in your head; different pills make you feel differently! Who is the culprit, or the Oz, making your body and maybe even mind feel different on Ortho-Tricyclen vs. Yasmin? Drum roll, please: it’s the progesterone!

While almost all oral contraceptive pills share the same type of synthetic estrogen component (ethinyl estradiol, a.k.a. EE) the progesterone content can vary significantly. Some may make you feel good, even great, while others can make you feel down right crummy. In order to understand the difference in progestins, we want you to picture your family tree. Hone in on four consecutive branches, or generations: from great grandma right down to you. And as with most families, generational changes are huge—think landline to the iPhone, black and white TVs to flat-screen monstrosities, a quarter to ride the subway to a whopping $2.50 per ride.

Similar changes can be seen in the generational changes of synthetic progesterone. The first-generation crew was not so specific in whom they “mated and connected with.” Therefore, they would bind to both progesterone and androgen receptors alike. Their affinity for the androgen receptors resulted in some unwanted side effects: think hair, acne, and bloating. Oh, what a joy! Such side effects made them somewhat unattractive and unpopular.

However, over the next several years, scientists found ways to alter the synthetic progesterone component and reduce the androgenic properties; this translated into way less negative side effects and even some positive ones! Such alterations made pills way more appealing and widespread in their use. Bottom line, if one type of pill (a.k.a. progesterone) doesn’t agree with you, try another. There are many “branches” to climb!

Now, while the progestin component varies, the synthetic estrogen component is pretty much always the same—think of the menu at Applebee’s. It’s just not going to change! However, while the estrogen content is always the same, the dose will differ. And what makes the modern-day pills low dose or, even better, low, low dose is the very low dose of estrogen that each pill contains.

Today, most pills have between 20–35 mcg of EE. This is in contrast to traditional pills (circa 1960), which contained about 50 micrograms of estrogen in each pill. The past 50 years have shown us how low we can go on the estrogen—minimizing clots, strokes, and a slew of negative side effects—while maintaining the efficacy. So although lower dose EE = lower negative side effects, lower dose ≠an increased chance of pregnancy. Currently, we are, taking it back to the limbo reference, as low as you can go without giving up on efficacy.

While intuitively, it seems that the lowest would be the best, this is not the case for everyone. Sometimes the low-low versions cause lots-lots of breakthrough bleeding; this can often be fixed by raising the estrogen dose. So just because low-low seems to be the “in thing” to do, it may not be right for your uterus. A slight bump up in the estrogen dose won’t take you back to the doses seen in the 1960s, but it will give your body just enough estrogen to maintain the lining and maintain your sanity.

You might be wondering what is up with the Tri and even Bi part in the name of some pills (e.g., OrthoTri-Cyclen vs. Ortho-Cyclen). For all of you number fans who can’t wait to travel back in time to middle school math class, tri means three, bi means two, and mono means one. The number part of the name describes the number of phases or changes in hormones that will occur throughout the cycle (a.k.a. the pill pack). Monophasic pills (Loestrin, Ortho-Cyclen, Yaz, Yasmin, Seasonale) contain the same amount of estrogen and progestin in all of the active pills. Biphasic pills (two-phase pills; e.g., Mircette, Ortho-Novum) alter the level of estrogen and progestin twice during the active pack. Last, triphasic pills (three-phase pills; e.g., Ortho Tri-Cyclen, Enpresse) have three different doses of estrogen and progestin in the active pills; the dose changes every seven days during the first three weeks of the pack. These triphasics were the original pills. Scientists were doing their best to mimic the natural cycle. However, research soon showed us that we didn’t need to vary the dose each week. Slow and steady could also win the race! In fact, monophasic pills are equally as effective and in many ways more tolerable. The consistency of the dose translates into less side effects and less breakthrough bleeding.

We have covered doses, phases, and progestins. Last but certainly not least is the number of active pills contained within the pill pack. Traditionally, pill packs contained 21 active pills and seven inactive (a.k.a. placebo or sugar pills). This, like the triphasic pills, was designed to mimic the natural cycle. However, newer formulations have increased the number of active pills to 24 and reduced the number of inactive pills to four. By altering the balance and pushing the pendulum a bit further to the right, there are fewer days off the active pills. Fewer days off the active pills means fewer days of bleeding. In fact, some women skip the placebo pills all together every month and only take the active pills. This does no harm to them or their fertility. It merely removes the need to buy tampons or pads.

Believe it or not, the pill has benefits beyond contraception. It can reduce the risk of ovarian and endometrial cancer, improve acne and unwanted hair growth, regulate the menstrual cycle, decrease heavy menses, reduce the size of fibroids and painful periods, treat PMS symptoms and menstrual migraines, and offer symptomatic relief to women with endometriosis. The list is long, and the benefits variable. Simply stated, the pill can do a lot more than prevent pregnancy!

However, with every peak there is always a valley, and with every pro, there is also a con. Even with the best medications, you must read the fine print. Although the pill has a lot of benefits, there are some of us for whom the glass slipper just doesn’t fit. Certain medical problems preclude women from even trying to shove their foot in! Such conditions include women with a history of blood clots (or a family member who harbors an inherited clotting disorder), impaired liver function, smokers older than 35 years, elevated blood pressure, migraines with visual aura (think flashing lights), and markedly elevated cholesterol/triglycerides. Before starting you on the pill your doctor will likely take a thorough medical and family history to make sure you are a good candidate.

You will likely not marry the first person you date or say yes to the first dress you try on. Don’t quit after one bad month on OCPs; just because one didn’t agree with you it doesn’t mean the dozen others will too. OCPs are a great form of birth control and come with a lot of other benefits. As long as you can remember to take it daily (put it by your toothbrush or face wash!), it’s worth giving it a go. You’ll find something that fits!