CyberHealth 9

CyberHealth 9

Hormones and the Skin

January 26 1998

CyberHealth Index


  1. Estriol cream combats wrinkles
  2. More on DHEA’s androgenic effects on the skin
  3. Choosing your NHRT doctor; “the Great Switch”
  4. Feeding your face
  5. The Mona Lisa exercise will keep you smiling
  6. Care of the Soul: Doing good and feeling good

Saving your skin: estriol cream combats wrinkles

“Treating women for the past 25 years, I’ve seen that estrogen is restorative to skin, hair, nails. Without estrogen, females cannot maintain the viability of their skin.

The more estrogen, the better skin, hair and nails. This is a dilemma for women and their physicians.”

This from Wilma Bergfeld, M.D., a dermatologist and head of Dermatological Clinical Research at Case Western Reserve University School of Medicine. The dilemma she mentions is that women want great skin and hair, but they want to keep their estrogen dose on the low side.

The effectiveness of systemic estrogen replacement in reversing skin aging has by now been well validated by research. Still, some women simply dread the “E word,” not realizing that hormone replacement can be done correctly and safely. And there is just no convincing them.

Is there any way to obtain the dermal benefits of estrogens locally, without raising serum levels? Yes, but before we go into the details, let us first review what studies have found about the effects of estrogens on the skin. These include:

  • greater epidermal and dermal thickness thanks to increased collagen production
  • filling in of wrinkles
  • better structure and ordering of elastin fibers (aging brings about a “disorderly” laying down of fibers, resulting in uneven texture)
  • greater vascularization (i.e. more blood vessels to bring oxygen and nutrients to the skin)
  • higher levels of hyaluronic acid and mucopolysaccharides, resulting in increased dermal hydration
  • inhibition of excessive sebum (skin oil) production
  • diminished hyperpilosity and virilization of facial hair (translation: there is less facial hair, and that hair is less masculine in type, i.e. less coarse and dark)
  • antioxidant action, protecting the skin against free radical damage

But studies have focused on systemic, generally oral, HRT. What about the effects of estrogens applied topically in the form of a cream? Two studies by Dr. Jolanda Schmidt, a small pilot and a larger follow-up, have finally provided some answers.

Dr. Schmidt compared the effects of two types of cream: .01% estradiol cream (that’s 0.1mg/g) and 0.3% estriol cream (3mg E3/gr) on the skin of 58 women between the ages of 44 and 66. None used HRT.

All subjects were instructed to use the same cleansing and cosmetic regimen, and to apply 1g of cream to the face once a day. Measurements of skin elasticity, moisture content, vascularization, wrinkle depth, and pore size were done at baseline and after 6 months of treatment. There was no “vehicle only” control group, but a previous study using a control group had already confirmed a considerable physiological impact of estriol on the skin.

Results: there was a dramatic improvement on all measures in both the estradiol and the estriol group. The estriol group showed the improvement somewhat sooner. The chief advantage of estriol, however, turned out to be lack of side effects. Only one woman in the estriol group reported a possible side effect, namely itching. In the estradiol group, one subject complained of reddening of the face, and three noticed increased pigmentation. Serum levels of estradiol and estriol were unaffected by the facial treatment. Vaginal smear remained atrophic, confirming the absence of systemic effects.

My problem here is the inability to present to you Dr. Schmidt’s before and after pictures showing the impact of the 0.3% estriol cream on the depth of wrinkles. I know that every woman would say “Wow!” If you have access to a university library, I strongly recommend looking up that article. This is another case where a picture is worth a thousand words. I am surprised that the researchers did not examine THE FADING OF AGE SPOTS, which is frequently reported by HRT users (with both oral and dermal HRT, even progesterone cream alone).

Part of estriol’s effects on the skin may be not just its stimulation of growth factors, but its antioxidant properties. Estriol and its hydroxy metabolites make surprisingly potent antioxidants.

Dr. Schmidt concludes: “Estriol, a biologically weaker estrogen, shows predominantly epidermotropic effects. (. . .) Lack of systemic side effects and promising local effects after external use suggest that estriol will gain importance in topical use in dermatology in the future.” (“Epidermotropic” means promoting the formation of new skin tissue.) Don’t hold your breath. To my knowledge, there is no commercial interest in developing estriol products, either for vaginal restoration (estriol is excellent against vaginal atrophy—try the E3 0.5mg/gr formula) or for facial use.

Fortunately, you CAN obtain estriol cream from compounding pharmacies. Your doctor can phone in or write the prescription in the following manner (I’m using WIP abbreviations):


E3 3mg/g 120gr CR (use as directed) or, in a spoken version: This should last you 120 days, at a cost of a fraction over 3 pennies a day (WIP prices).


Do you know how much a full face lift costs these days? Between $16,000 and $22,000. And after five years, you are supposed to have another one. Or consider the booming business in various anti-wrinkle creams and “youth serums.” While the accelerated aging of the brain is, in my eyes, the most serious of all hormone-deficiency problems, it’s what happens to the skin after menopause that frightens women into paying $75 or more for one ounce of yet another “youth serum.”

Note that peri women can use the estriol cream without worrying about raising their serum estrogen levels. But note also that those women who use the classic extremely weak tri-est formula that contains only .125mg of estradiol have here their answer of why it hasn’t done anything for their vaginal dryness or their memory loss.

What if you already use nhrt, and have a tri-est cream that’s considerably stronger than .3% estriol? In my experience, and that of two friends of mine, one does notice nice benefits when just a tiny dab is applied to the face. When I was an nhrt beginner I overdid it once or twice, and my face ended up looking slightly swollen. I stress “slightly.” It doesn’t seem to happen any more, even when I’m not that careful. With chronic daily use of progesterone, the estrogen receptors are apparently pretty suppressed, so in fact it takes more.

For me, the most dramatic topical effect of using 3-E cream was the filling in of wrinkles on my NECK, together with the fading of keratoses and repair of sun damage. I’m not saying that my neck now looks as good as it did when I was twenty; nevertheless, the improvement has been nothing short of amazing. Before we conclude that estriol is indeed better than any other hormone cream at facial rejuvenation, let us ponder the fact that only one dose of estriol was tried and compared to only one dose of estradiol. Even more important, we need systematic studies on the effects of topical progesterone and pregnenolone on the skin, and of various hormone combinations. We have plenty of anecdotal evidence that progesterone cream improves the quality of the skin. There have been also the first scattered reports that oral pregnenolone results in a “face lift,” and combats acne, in great contrast to DHEA. Does it mean that pregnenolone cascades more along the progesterone pathway? You can see why “more research is needed” is perhaps the most common phrase in scientific literature.


So far there is anecdotal evidence that the use of testosterone cream on the face provides a fabulous facelift. Testosterone is known to promote collagen production even more effectively than estrogens, so it would come as no surprise if a future study should discover that for men a T cream is the best cosmetic. But such a study is yet to be performed. For now it is obvious that the use of T cream or gel in a manner that raises serum T level, in other words testosterone replacement, does have a very quick, positive impact on men’s skin. Within ten days or so, one can see greater freshness and rosiness, and deeper color of the lips. The rejuvenating effects of testosterone replacement on aging male skin are unmistakeable, and begin to happen enviably fast.

(Sources: Dr. Wilma Bergfeld is quoted in Prevention, April 1995, p. 70;

Schmidt JB et al. Treatment of skin aging with topical estrogens. Int J Dermatol 1996; 35: 669-74; research documenting estrogens’ benefits for the skin has been provided by Starla Taliaferro; Jennifer Plaat has scoured various databases for research on progesterone and pregnenolone in relation to skin)

Gail comments:

I read somewhere that estriol cream is available OTC in Sweden. Don’t know about elsewhere. Thought that sounded fantastic!

I don’t see why the major cosmetic firms would NOT jump on the estriol thing and add it to their moisturizing creams if it were possible to do so and keep it OTC.


Estriol cream is also available OTC in Mexico, in 1mg/g potency and a nice cream base. In the U.S. it’s such a hassle and huge expense to get something past the FDA that the commercial interest would have to be very strong.

As far as the FDA is concerned, the fact that estriol has been safely used in Europe for decades just doesn’t seem to matter. But let’s count our blessings instead of wasting time being bitter: any woman who wants to enjoy estriol cream CAN get it if she has an open-minded doctor willing to write a simple prescription. I’ve just been told about yet another wonderful nhrt MD in San Diego, who also has a Ph.D. in physiology and is truly dedicated to the use of natural hormones. Seek and ye shall find. Network and you shall be told.


Tom writes:

Concerning the androgenic effects of DHEA for women, it appears to me that these could be largely eliminated by taking Proscar or saw plametto extract which either prevent DHT formation or its effective binding. This is because most of the androgenic effects of testosterone are not due to the testosterone itself but the DHT (dihydrotestosterone) formed from it, as is pointed out in your essay. Both of these products are well-proven and safe for men with no side effects except a slight reduction of libido in the case of Proscar for some men.

Ivy replies:

As for Proscar, the standard 5 mg dose can also cause breast enlargement in men (gynecomastia) — I know it both from literature and from a report by a Proscar user. On the other hand, the 1mg dose (PROPECIA), just approved as an anti-baldness drug, may indeed be free of side effects. As a matter of fact, the manufacturers hope that Propecia will be widely used not only by men, but also by millions of postmenopausal women who frequently experience hair loss (I suspect they know the results will be better for women than for men, which is typical for anti-baldness treatments). An anti-acne effect may be a side benefit.

But I still doubt that doctors would be willing to prescribe Proscar or Propecia to women who simply want to continue taking DHEA without having to put up with acne and/or increased facial hair. They’d probably tell them to just stop taking DHEA.

But DHEA has some excellent benefits: improved immunity, more energy, lower insulin, protection against many kinds of cancer, possibly even life-extension. It’s just that SOME women seem to be extremely susceptible to DHEA’s androgenic side effects, particularly acne—and simply lowering the dose does not always solve the problem. One blond, Nordic woman I know, who used to have flawless skin before menopause, told me that even 10 mg of DHEA would result in “big red bumps.” This is how Louie (and I happen to know she’s one of those angelic fair-skinned blondes) describes her experience with DHEA: “It seems the DHEA does cause acne, but in my case, it’s like one cyst-like zit that gradually goes away when I cut back on DHEA.” That was typical of my DHEA zits too: just one at a time, but big and cystic. And slow to heal. Most unpleasant.

How come women who’ve enjoyed clear lovely skin in their premenopausal years suddenly develop those nasty bumps and cysts after beginning to supplement with DHEA after menopause? I suspect the answer lies in the dramatically higher androgen-estrogen ratio after menopause. Even women on HRT are typically given such minimalist doses of estrogens that they are a lot more on the androgenic side than before. Hence the lowering of the voice, more facial hair, and, in susceptible women, DHEA-related acne. OK, what about saw palmetto? It’s supposed to inhibit the conversion of T to DHT. I’ve tried both the guaranteed-potency extract (capsules) and the liquid extract, applied topically. The liquid extract produced an orange discoloration, so had to be discontinued; short-term use, however, did not seem to have any impact. I’m also sorry to say that the capsules seemed to have no effect whatsoever, though perhaps I gave up too quickly. IF ANY FEMALE CH READER HAS TRIED SAW PALMETTO, PLEASE LET ME KNOW.

Zinc complexed with arginine is also supposed to inhibit the production of DHT (by inhibiting 5-alpha-reductase). At least a couple of prostate products boast of containing ZINC ARGINATE.

I became excited when I read about topical spironolactone, an anti-androgen, but it’s unstable and difficult to obtain (CH 10 will feature correspondence with a baldness expert and the inventor of topical spironolactone, Dr. Peter Proctor).

Here is what I did find to be extremely effective, allowing me to continue taking DHEA without acne: topical anti-acne agents such as glycolic acid, Differin (a gel related to Retin-A, but non-irritating), and Azalex, a cream containing azaleic acid, an antimicrobial agent. Tea-tree oil, added to jojoba oil, has also proved effective at repressing incipient breakouts. And so has simple aloe vera—not the lotion, but the pure stuff from health food stores.

Obviously androgen excess or oversensitivity to androgens is only part of the mechanism of acne. The proliferation of Propionibacterium acnes plays a crucial part. This vulgar bug lurks in the skin and amuses itself creating papules, pustules, and cysts. But give it a taste of glycolic acid or tea tree oil, and the party is over.

Disciplined daily application of one or more of these agents gives the best results. Don’t overdo—if you inflame the skin, you are defeating the purpose.

Still, it is possible to win the game by working basically on the anti-bacterial front.

Thus, for those women who are susceptible, clear skin is possible even at 50 mg/d of DHEA, but it is a bit of a battle. Hence I’m very interested in pregnenolone as a possible substitute for DHEA. There have been no negative reports about pregnenolone. On the other hand, it is still very poorly researched, and we don’t know about its effects on the immune system or insulin levels. We know very little about its physiological effects, period. But there are anecdotal reports of an anti-acne action, and improvement in skin quality in general.

Born Again makes both DHEA cream and pregnenolone cream. Pregnenolone acetate is also an ingredient in Revlon’s Eterna 27 cream, but unfortunately that cream is as heavy and nasty as creams used to be way back, loaded with mineral oil. It seems fine for the neck, though.

It’s entirely possible that daily application of estriol cream would be the very best solution.

I must stress that studies found that only a small percentage of women develop acne and/or increased facial hair when taking DHEA. Obviously it takes a special susceptibility—for instance, it is likely that the facial skin in susceptible women produces more 5-alpha-reductase, and thus more DHT results even when serum testosterone and DHT levels are not even high, but just in the medium range.

The well-known study by Morales and Yen found that 50mg of oral DHEA nearly tripled DHT levels in women (from .32 ng to .9ng). One possible advantage of higher DHT levels is its anti-estrogen action in breast tissue. For women susceptible to acne, however, the increase in DHT is bad news, since higher DHT is strongly associated with adult female acne—together with higher DHEA and DHEA-S, higher free testosterone, higher cortisol, and, in premenopausal women, lower estradiol.

Note especially “higher cortisol.” This seems to be the common factor in all types of acne, male and female, adult and adolescent. Cortisol helps us cope with stress, but excess can be devastating to skin, bone, brain, heart, arteries. That’s why stress is so visibly aging.

Can we lower cortisol? Yes. One way is through stress management. Those of you interested in stress management might consider getting in touch with Pam Nathan ([email protected]), our CyberHealth stress-reduction expert. I find her idea of “cognitive reframing” (turning negative beliefs into positive statements) a particularly valuable tool. In fact it’s magical! Men generally react very well to DHEA and have no side effects whatsoever. But I’ve had one report of an ELDERLY man who also developed acne after taking DHEA. This makes me wonder about the similarities between the endocrine milieu of elderly men and postmenopausal women. It has been hypothesized that in high-T men DHEA cascades mainly along the estrogenic pathway, while in women and perhaps very T-deficient men it cascades more along the androgenic pathway.

Women who suffer from severe hyperandrogenism (acne, heavy facial and body hair, male-pattern hair loss) might want to consider a drug called flutamide, which blocks androgen receptors. Flutamide has been found to be vastly superior to spironolactone, particularly in restoring hair growth on the scalp.

Hyperandrogenic women are also successfully treated with the new oral contraceptives. These contain third-generation progestins, which are relatively non-androgenic. But note: severely hyperandrogenic women often have elevated insulin, and it’s the insulin disorder that is the root of the problem. “Low carbing” is an essential part of the treatment, sometimes in combination with insulin-lowering drugs such as Metformin. (Sources: Morales AJ. Effects of replacement dose of DHEA in men and women of advancing age. J Clin Endocrinol Metab 1994; 78: 1360-67. In addition, voluminous research confirming the link between elevated DHEA and acne in women has been provided by Jennifer Plaat, a medical librarian and CH research assistant. Anyone interested in seeing over 30 pages of documentation [shrieks, groans], please contact me.)


Kay writes:

I’m between health plans, so I figure this time, instead of finding a practitioner who is on someone’s preferred provider list and shoveling them in, I will start with the best practitioner I can find and then shop for a health plan to cover this person!


Now that’s logical thinking.

What amazes me is that it took menopause to make me think along similar lines—how do I get the best doctor. For the first time in my life, I bothered to take the time to inquire which gynecologist was considered the best, and was willing to wait a long time for an appointment (popular doctors may be booked far in advance). I soon found out why women referred to him as a “sweetheart”: he was willing to listen rather than play the dictator, and to go along with patient preferences. Thus I became his first nhrt patient, and soon referred other women to him.

For me, the “Great Switch” was that all of a sudden I WANTED THE BEST, and was willing to make the effort to get it. Later this attitude began asserting itself in other ways too: I donated away bags and bags of old clothes and bought a few quality pieces; I got a lovely set of dishes and gave away some old plates and cups; now I can’t help but want to upgrade the furniture here and there. Suddenly there is a hunger for quality. Come to think of it, why have I been putting up with my dentist, “Dr.

O’Greedy”? Next project: a holistic dentist.

Does this “Great Switch” have something to do with menopause? A lot of women comment on the phenomenon of blossoming after menopause. In my case, I feel that I can think with greater clarity without being subject to the manic-depressive vagaries of the menstrual cycle (most of my old clothes looked as though bought during PMS).

Steady hormone levels mean a better mood, less anxiety, more confidence, more steady productivity—at least for me. Women who take only half the estrogen dose they need (like 1mg Estrace) keep sighing (to me by email) for the good old days when they felt sharp and energetic. For me optimal nhrt is precisely about being sharp and energetic, and not just for one week of the month. That’s part of the “Great Switch.”

Looking at “makeovers” in women’s magazines makes me want to laugh. No matter how glamorous the experts manage to make the woman look, you know that she’ll go home and wash off all that heavy make-up and never again look as prettified and homogenized she did in those soft-lit pictures. Anyway, who wants to be a “female impersonator,” as Gloria Steinem put it. What mature women yearn for is a life makeover. They sense they are coming into their power years, the no-nonsense years of accomplishment, of quality, of not settling for anything other than the best.


Bess writes:

Do you remember a woman I mentioned who was dismayed by my assertion that she needed to do her own research about hormones, etc.? She wanted her doctor to give it all to her, and my dose of “cold water” didn’t go over well with her.

Well, she decided to plunge in, which included thoroughly reading Vliet’s book, and talking for 20 minutes by phone with a nurse at Madison Pharmacy. She saw her GYN yesterday (one who is just about notorious for dismissing concerns of older women, but she insisted on staying with him), and was so well prepared (and maybe she caught him on a good day) that he was very responsive andeven told her he learned some things! This is the same GYN who, many years ago when I was in Peri and asking him so many questions, finally had his nurse call me and tell me he thought I’d be happier with another doctor who was more interested in menopause……Guess the Baby Boomers have been assaulting him since then, hah…..

Anyway, my friend is so proud of herself now! As well she should be…. She got the hormones she asked for (Estrace instead of Premarin) and natural progesterone instead of Provera. She even brought up testosterone, but he would like her to get “settled ” first on the other two and then come back later to talk about that (he is not against it). This was what she wanted to do, anyway, wait awhile before trying testosterone, so she was doubly happy.

She is having such a severe menopause, including vaginal atrophy. She’s very thin, and her hair has always been very curly. She tells me it’s becoming straight, and her skin has changed. She feels like she’d becoming a different woman. There is a history of breast cancer in her family, but also heart disease and osteo, so she put off making a decision about HRT out of fear about the breast cancer. Until now….. Misery can really bring about decisions….

She is feeling so much more empowered that she told me this morning she’s going to pass along all her information to a co-worker who is having a terrible time with menopause.

She also said she went back and checked some e-mails I had sent her nearly a year ago, when she first started asking me questions about hormones, menopause, etc., and was surprised how much important information was in them—that she had not been ready to hear about at that time. She put so many post-its on my copy of Dr. Vliet’s book, that she’s buying me a new one and keeping the one she borrowed from me! Thank goodness we have so much more information available to women than we used to (and you are such an important part of that)!

Look how the information is going to “domino”….. already her doctor and nurse have new information and have a newly assertive patient, and she is already helping another woman by passing along the information, so you can see this could end up helping dozens of other women, eventually (maybe more). Now look at all the information you have passed along to the women on the Meno List, and in your CyberHealth Digest, and in copies of your books, and in your talks……it boggles my mind to think of how many women you may end up helping and empowering………


Fear and misinformation are the greatest enemy. But the information revolution cannot be stopped, and women are a vital part of it, since they are more likely to feel victimized by conventional medicine, and also more likely to network with other women and pass on information. I try my best, but feel, like Bess, that ultimately it’s the “domino effect”: you just can’t stop the spread of knowledge.

Women who had their menopause before the nineties tell me they had nowhere to turn to: no books, no support groups. Look how much has happened in just the last five years. It’s stunning. It’s fabulous. And it’s only the beginning.

Speaking of conservative mainstream doctors, (definitely not the wonderful doctors on the CH list!!!), someone once said to me, “Doctors treat you like a mushroom: they keep you in the dark and put manure on your head.” (a word stronger than “manure” was used.) Keeping the patient “in the dark” is hardly possible anymore. The dominator model of medicine is crumbling. It’s high time.

We can help speed up the change by networking, sharing information, and seeking out those doctors who respect the patient’s intelligence, are willing to listen, and have a more progressive vision.

Gail comments on readiness to hear information:

I think many of us more or less deny we are in perimenopause, for starters, not liking to believe that we are THAT old (and not having a clue about perimenopause in the first place). But then even when we recognize what is going on, and that menopause is around the corner, there is often still a long learning curve. And there’s just no doubt that little learning takes place until one is ready to learn.


DENIAL is still a huge part of menopause. Women in their forties still wince when they hear the “m” word. That’s part of the reason why I’m trying to get the word out about nhrt and how wonderful it can be to be postmenopausal (I’ve never felt better) once you get your hormones just right and steady-level. My dream is that women will start looking forward to menopause as the gateway to their power years.


Here is a question that I have received hundreds of times, so I’ve decided to quote it, with permission, though the questioner prefers to stay anonymous:

Q: Do you have any printed materials on natural hormones that I can read and provide to my doctor here in Seattle? I’d appreciate any direction on how to learn as much as I can and find a practitioner who will willing to work with me on the natural hormones. Basic questions: are they as effective at heart disease prevention, and are there fewer side effects – especially bloating and weight gain? Thanks.

Ivy replies:

For the sake of the novices, let me try once more to give a collective reply. First of all, there really are HUNDREDS of wonderful doctors out there who do prescribe nhrt, and it is our task to find them and support their pioneering practice.

Just because a doctor calls himself/herself “holistic” is no guarantee that s/he will prescribe natural hormones. The best bet is to choose one of the doctors who steadily orders from one of the major compounding pharmacies (the small compounding pharmacies are notorious for charging ludicrous prices). Doctor referrals can be obtained from the larger compounding pharmacies such as WIP (800-279-5708) or Madison-Bajamar (800-225-8025). Still, it is a good idea to (1) know as much as possible before you see the doctor; (2) call with some inquiries before you make an appointment. You may find that some doctors will prescribe nhrt, but only in some form (oral) to the exclusion of other forms that you may prefer. Some will not prescribe testosterone for women, even though your libido is “in the minus” (that is, even foreplay is unwelcome, even repulsive; without libido sex seems the most ridiculous, pointless activity!).

Others prescribe ONLY progesterone, and are cancer-phobic if you mention anything else. So it really pays to call ahead, or you may be in for a sad (and expensive) surprise.

By the way, based on my experience it IS possible to achieve good serum estradiol levels (100 pg and above) with tri-est cream, but the formula has to be re-written to include a lot more estradiol (say .5mg -1mg/g). But you may opt for estriol cream for its cosmetic benefits, and sublingual estradiol (Estrace or generic). 2 mg gives good serum levels. Or for vaginal estriol cream (usually for temporary use) and a stronger tri-est formula for systemic benefits. There are all kinds of options. The classic tri-est formula is ridiculously weak, but it may be suitable as a beginning formula for women who have been hormone-deficient for a long time, and who may prefer to be gradually eased into a more youthful hormonal state. This minimizes the risk of side effects.

The strongest 3-E formula that WIP has been compounding for some customers is E1E2 1mg/E3 3mg/gr.

The pharmacists at compounding pharmacies are friendly and ready to “hold your hand” through the initial trial-and-error period of nhrt. The pharmacies will also send you and/or your doctor plenty of reading material on natural hormones. My own book, HORMONES WITHOUT FEAR, is listed at the end of CH.

Typically nhrt takes individual tailoring, and it will take some time and experimenting to figure out the optimal doses. One woman’s optimal dose may be another woman’s overdose or underdose. NHRT physicians often err on the side of too much caution, i.e. underdosing. Hence the serum levels of E2 don’t come up to 100 and we can’t be sure of heart benefits or protection against Alzheimer’s disease.

If E2 is over 100, then I don’t see any reason why nhrt should not provide the usual range of benefits. The dermal administration in particular produces better results in terms of higher serotonin, lower insulin, no rise in triglycerides. The use of natural progesterone yields a better lipid profile than the use of progestins (see PEPI).

Higher serotonin means lower appetite, which minimizes weight gain. In the PEPI study, it’s the no-hormone group which gained the most weight. There should be no abdominal bloating as long as estradiol is kept high enough (estradiol speeds up digestion, absorption, and the passage of food through the intestines, so it doesn’t just sit there, fermenting and producing gas). But what also helps, in my experience, is eliminating potatoes and bread (OK, one slice of pumpernickel), and eating plenty of salad and raw or lightly cooked veggies. Raw foods contain their own enzymes, so paradoxically they are easier to digest.

If you must have starches (some women do OK on more starch), try rice. Rice is much easier to digest. If the problem continues, you may also want to try digestive enzymes that are “for real,” i.e. strong enough. Sometimes the problem is insufficient production of stomach acid, which can also be remedied with supplements. But generally speaking, estradiol should take care of normal production of gastric acid and pancreatic enzymes. If by “bloating” you mean “water retention,” that problem is typically caused by progestins. Estrogens hydrate the tissues, but that is as it should be, i.e. within normal range. Natural progesterone is a mild diuretic, according to Dr. Lee. Possibly. In my case, I never experienced any water retention even when using a lot of progesterone, while progestins are notorious for producing water retention, sometimes to a dangerous extent (Megace, used to treat breast cancer).

MEN SEEKING TESTOSTERONE REPLACEMENT (GEL OR CREAM): try talking first with an experienced male pharmacist, such as Ky at Women’s International Pharmacy, 800-279-5708. Finding the right male-nhrt doctor may be even more of a battle than it is for women, but with luck you can find even an HMO doctor who’ll prescribe the miraculously inexpensive, non-irritating cream rather than the patch (Androderm). The sharp, progressive doctors, those who know at least a little about research, are finally coming to the conclusion that “testosterone is great stuff for men.”

Maybe it’s just my experience and those of people who write me, but general practitioners seem more interested in nhrt than endocrinologists. Some women swear by nurse practitioners as being more open-minded. Ultimately what I’ve seen is that anyone who really wants to get natural hormones ends up getting those precious prescriptions one way or another. So if the first doctor you go to doesn’t work out, don’t give up!


Hormones can increase collagen production, but it takes more than abundant hormones in the right balance to have healthy skin. Your nutrition must also be right. If you are either protein or fat deficient, the skin is going to suffer.

For both protein and the right fats, think fish. Think sardines, a marvelous source of nucleic acids and anti-inflammatory EPA. GLA is another anti-inflammatory fatty acid. Some women find that taking evening primrose oil considerably improves their skin. OK, let me explain a little secret to you. If you eat commercial baked goods, you are loading yourself with toxic fatty acids that interfere with your body’s production of GLA. So if you must eat cookies, bake them yourself with fresh traditional ingredients or be prepared to see faster aging of the skin.

(An aside: isn’t it amazing that when food is of more QUALITY, the body is better able to regulate the quantity you consume? The French have always said that one doesn’t get fat from eating fresh, good-tasting food, only from inferior, bad-tasting food.)

This brings me to the necessity of keeping blood sugar reasonably low. High blood sugar accelerates aging through several mechanisms. I know a diabetic woman who can’t seem to wean herself off a high-glycemic diet. Her skin is unbelievably wrinkled for her age. The poor woman is a walking illustration of how high blood sugar is pro-aging. So beware of unopposed starches. Read “The Zone.”

A note here on rice and green tea. I’ve always wondered how the Chinese manage to eat so much high-glycemic white rice and stay slender. Part of the answer seemed to lie in eating the rice together with low-glycemic stir-fried vegetables. Now another piece of the puzzle may be emerging. Green tea inhibits the starch-digesting enzyme amylase, so that if you drink a lot of green tea with a meal, starch is digested slowly and in effect becomes practically low-glycemic, and your blood sugar and insulin stay in the healthy low range.

Also, it is high time to rehabilitate eggs and restore their status as “nature’s most perfect food,” just as grandmother taught us. Eggs provide those rare and extremely valuable sulfur-containing amino acids. And sulfur is crucial for the production of healthy cells. Eggs are known primarily to be great for hair, but anything that’s good for the hair is also good for the skin.

What kind of diet is aging for the skin? The low fat diet. There is no proper hydration without healthy cell membranes, and the formation of healthy cell membranes, as well as the production of moisture-conserving sebum, depends on sufficient amounts of correct fatty acids. Those fatty acids are also crucial for the maintenance of the fatty layer just below the surface. Otherwise the skin loses water. Dehydration is a much-neglected aspect of aging.

Julia Child said, “Cut down on fat and a year later you will be covered with dandruff” (or something along those lines). Maybe not exactly dandruff, but you will be spending a lot of money on moisturizers. You’ll be desperately trying to supply from outside what ought to come from inside. Skin gurus always exhort you to drink enough water, but fail to say that if you are fat-deficient, your skin won’t look moist and fresh no matter how much water you drink.

Not long ago I had an interesting experience at a holistic lecture. The speaker took a look at the skin of my arm (it was summer), and said, “You use a lot of olive oil.”

Sophia Loren says her beauty secret is eating lots of olives. (OK, OK, I know what you are thinking. But let’s give SOME credit to the olives.) Nuts are also a wonderful source of all the right fatty acids. Nuts, seeds, eggs—those have been called “germinative foods,” and it’s not surprising that they provide especially rich nutrition.

Grapeseed oil is another healthy oil that will give you the omega-6 essential fatty acids and antioxidants besides. I think we’ll see more and more grapeseed oil in health food stores.

Udo Erasmus, the foremost holistic authority on fats, writes, “Beautiful skin requires EFAs (essential fatty acids). Skin properly nourished with EFAs is smoother, feels softer, is infected less easily, and looks radiant. It also ages more slowly and remains wrinkle-free longer.” All the antioxidants seem to be important for the skin, including the sometimes forgotten zinc and selenium (yes, zinc can also act as an antioxidant). Niacin is important, and B5. Vitamin C protects against free radicals AND promotes the production of collagen and elastin; it’s the hottest trend in cosmetics.

I have already mentioned sulfur. Besides being necessary for the formation of new cells, it is also an antioxidant.

Grapeseed extract, green tea—anything that fights free radicals tends to help the skin.

Since we’ve gotten into supplements here, GLUCOSAMINE sulfate has also been found to support skin formation and hydration. Glucosamine forms a building block of glycosaminoglycans. Known by the ugly acronym of GAGs, these interesting compounds have a marvelous ability to retain water. SILICON is essential for healthy connective tissue. Estrogens increase the absorption of silicon. Some women swear by horsetail supplements. I stick to eating apples with the peel on.

OK, here comes perhaps the most important statement: this is not about vanity. This is not about mere appearance. As outside, so inside: the health of the skin says a lot about the health of the whole organism. If not enough collagen is being produced in the skin, what do you think is happening to the arteries, or to joints?

(Sources: Research on fatty acids and skin was provided by Dr. Andrea Vangor; Udo Erasmus, “Fats that heal, fats that kill” Alive Books, 1993, p. 348; other sources: mostly popular)


A big problem in facial aging is not only the loss of facial bone mass—that can be prevented easily enough—but the loss of underlying subcutaneous fat and the atrophy of facial muscles.

This problem is particularly bad for slender women. The loss of that fuller-cheeked youthful look can really hurt their appearance. As we age, typically our face gets thinner, so a thin, hollow-cheeked face is a quick giveaway of being in a “senior” category.

I wonder if facial muscle atrophy is perhaps the main reason why so many women who’ve had no end of plastic surgery end up looking not young, but just like someone who’s had a lot of plastic surgery.

OK, how can we save our cheeks? No laughing please. In fact, the first step is to pull both the upper and the lower lip inward, so that no lips show. Now, with no lips showing, lift the upper corners of the mouth into a smile. At least for the first time, you should do it in front of the mirror, so you can see how the cheek muscles work. Smile as hard as you can, then relax. Repeat until the cheek muscles feel tired. If you see that little wrinkles form around the mouth as you perform this exercise, place your fingers in the wrinkle spots to prevent the wrinkling. If wrinkles form both around the mouth and around the eyes, don’t smile quite so hard. A little Mona Lisa smile will do.

Just pulling in the lips as deep inside as they’ll go is a form of exercise. NOTE THE IMPROVED COLOR OF YOUR LIPS. A nice bonus that I’ve noticed with this exercise is the lessening of the nasolabial folds (the “laugh lines”). The finger-sucking exercise for lip enlargement has a similar side benefit.

If you really want to scare yourself, do this exercise in front of the mirror in the “open” version. Pull your lips inward over your teeth, but instead of keeping your mouth closed, keep it open in a kind of distorted “O.” Now try smiling, if you haven’t fainted.

Seriously, the “light” Mona Lisa—just pulling in your lips and mysteriously half-smiling—is just perfect while you drive or wait in line. Easy and effective.

(Source: modified from Reinhold Benz, “Facebuilding,” Sterling Publishing Co 1991)

* * * CARE OF THE SOUL * * *


Bess writes:

Your homeless man in the trolley station reminded me, in a way, of the male clerk behind the donut counter at Safeway this morning (I bought donuts for the office). He smiled at me, and I asked him how he was (you know, being merely polite). He broke into an even bigger smile and responded that he was “super-duper, with an extra scooper”, and then sort of laughed at himself, and I laughed right along with him. It made a difference in that normally very ordinary moment, and I enjoyed it, and was grateful to him for it (ah, these Buddhist teachings!).


Perhaps the most profound thing that Deepak Chopra ever said is that every relationship is ultimately a relationship with God. Even a fleeting social encounter can be graced with kindness and mutual respect. Others might prefer to say that this is about recognizing the essential humanity of the other person, his/her importance and dignity and value for the human family.

Humanity or divinity, it adds up to the same: we can choose to smile, be pleasant, and give the gift of a bit of kindness to everyone we meet. As Emily Dickinson put it, “If I can keep one heart from breaking/ I have not lived in vain.” Anyone has the power to do so much good! St. Teresa of Lisieux, “The Little Flower,” realized that she had no special gifts to be a great mystic like St. Teresa of Avila, or to do great deeds. She therefore chose “the little way” of doing small deeds of kindness, such as smiling at a crochety old woman known for her nasty temper. And the old woman finally started smiling back. As for feeling good when we do good, this was no surprise to our grandmothers and others brought up the strict traditional way, with the motto “We are here to do good, not to feel good.” The seeming paradox here is that there is no contradiction: when we set our priorities right and do good, we end up feeling good. When we make someone else happy, we are often so richly rewarded that it’s almost embarrassing. While it may be “more blessed to give than to receive,” finally giving and receiving are one.

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Editorial assistants: Gail Peterson, Monica Smith (on vacation)

Research assistants: Jennifer Plaat, Starla Taliaferro, Dr. Andrea Vangor

The material contained herein is intended as information only, and not as medical advice.

Books by Ivy Greenwell:

  • HORMONES WITHOUT FEAR (available from Madison-Bajamar, 800-255-8025)
  • HOW TO REVERSE OSTEOARTHRITIS (including an extensive info on hormones and arthritis)