Wednesday, June 4, 2008

Verbal fluency and hormone therapy

Verbal fluency is defined as the ability to find the right word at the right time and use it with ease when appropriate. I wrote a post on it earlier this year on Doc of Ages, my other blog.

I got an interesting comment and question on the subject today. Verbal fluency (VF) is very much an estrogen-supported brain function. Out of estrogen and you may be out of luck with respect to having your say in an okay way. This lady writes:

In the last few years I have noticed what seems to me more VF problems than my friends. I am not as bothered by it when writing which I do a great deal.

I'm 73 and have taken Premarin, .625 mg daily, since I had a complete hysterectomy at age 54 (done for multiple non-malignant reasons). Some doctors lately say I should discontinue the Premarin because it increases my likelihood of getting cancer - uterine and breast - and major clots. (I had bilateral mastectomies in my 30s for major non-malignant breast changes and a high family cancer history). I am healthy otherwise (minor heart change, excellent bone density, some arthritis).

Two questions: Why the VF problem? Discontinue the Premarin? The answers I get are vague and don't satisfy me.

I answered:

While VF is sensitive to estrogen or the lack thereof, it also falls off with age. That said, you're not that old, and I never know what to make of this citation of age as a reason for anything; it seems that there must always be an underlying problem that perhaps worsens with age but not explained by age alone. As VF is a frontal lobe function, and the frontal lobe is more susceptible to stroke damage than other parts of the brain, I wonder if you should have an MRI to look for the tiny white spots that correlate with small vessel disease in the brain.

Premarin or no, here's my take on that. While estrogen is known to support frontal lobe function, oral estrogen supplements, and in particular Premarin taken orally, are known to cause some problems even as they may benefit brain function.

Once orally-ingested hormones are absorbed into the bloodstream, they head straight for the liver via the portal circulation. The liver gears up to break these foreign molecules down and, in doing so, produces some unwanted proteins such as angiotensinogen (which can raise blood pressure), C-reactive protein (which causes inflammation), clotting factors (which raise risk of clots and blood vessel inflammation) and triglycerides (which raise risk of heart disease and stroke).

If you haven't had a major clot from Premarin, you are unlikely to get one now unless you have to undergo major surgery such as a knee replacement. You don't have breasts or uterus to worry about cancer risk. But you do have to worry about stroke.

I would consider going off Premarin. But...estrogen supports frontal lobe function. You might consider replacing the Premarin with a transdermal estradiol patch such as Vivelle Dot. That way, the estrogen you take is not foreign (like the horse estrogens of Premarin) and it does not go through your liver (causing all the above troubles). It is known that transdermal estrogen does not raise clotting factors, C-reactive protein, or angiotensinogen. It has not been studied whether or not transdermal estrogen increases risk of stroke the way oral estrogen does, but logically it should not.

The only vague part of my information is whether or not you should change hormone delivery systems or go off it altogether. That is a weighted decision best made by yourself and your doctor.

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