The liver pulls hormones out of the bloodstream, they slide down the bile duct, fiber picks them up, and out they go.

The liver pulls hormones out of the bloodstream, they slide down the bile duct, fiber picks them up, and out they go.

Now, there is plenty of fiber in vegetables, fruits, beans, and whole
grains. So if these foods are a big part of your diet, your “waste disposal”
system works pretty well. The liver pulls hormones out of the bloodstream,
they slide down the bile duct, fiber picks them up, and out they go.

But what happens if your lunch consisted of a chicken breast and a cup
of yogurt? These products don’t come from plants—and that means they
have no fiber at all. Not a speck. So when your liver sends hormones or
other chemicals into the intestinal tract, there is nothing for them to attach
to. They end up being reabsorbed back into your bloodstream, and the
whole process starts over again. This endless cycle—hormones passing
from the bloodstream, through the liver, into the intestinal tract, and,
unfortunately, back into the bloodstream—is called enterohepatic circulation.
It keeps hormones circulating for longer than they should. Fiber stops
this cycle by carrying hormones out once and for all.

Hormone Harmony To Do for breast cancer survivors

Hormone Harmony To Do for breast cancer survivors

Know your estrogens: find out the ratio of your “good” to “bad” estrogens. Take
action to reduce undesirable estrogens:

• Maintain estrogen-progesterone balance
• Manage your weight and your glucose and insulin levels
• Avoid xenoestrogens wherever possible
• Eat lots of cruciferous vegetables, fiber, lignans, pomegranates, and fermented foods to help convert 16α-hydroxyestrone and 4-hydroxyestrone to 2- hydroxyestrone
• Keep levels of exercise up and levels of alcohol down
• Use targeted supplements such as calcium d-glucarate and IC3 as needed
• Support healthy methylation with B vitamins
• Manage aromatase conversion to estrogens with vitamin D

Last Word

I guess my “aha” moment came when I realized that what my doctor had been telling me
for years about cholesterol was also true for estrogen: it could be both good and bad. This
made immediate, intuitive sense to me, as I don’t believe nature would have us carrying
around hormones in our bodies that are there solely to make us sick. That knowledge was
remarkably empowering, because I now have a way to see exactly how my hormones are
contributing to my health picture, and know what changes I need to make if they become
unbalanced.
—Suzi G., breast cancer survivor

EVE HAD IT RIGHT - Managing Your Estrogen Load

EVE HAD IT RIGHT - Managing Your Estrogen Load

Some scholars contend that it was a pomegranate, not an apple, that tempted Eve
in the biblical Garden of Eden. While we’ll never know for sure, we do know that
eating pomegranates or drinking pomegranate juice may help prevent and slow the
growth of ER+ breast cancer. A group of phytochemicals called ellagitannins, found
plentifully in pomegranates, was shown to inhibit the growth of estrogen-responsive
breast cancer in laboratory tests. The researchers (Adams et al. 2010) believe that it’s
the ellagitannins in pomegranates that work as natural aromatase inhibitors; aromatase
is a key enzyme the body uses to make estrogen, particularly after menopause. Further
studies will be needed to confirm this effect; meanwhile, we know that eating
pomegranates and pomegranate products can help keep breast cancer at bay via
several other possible mechanisms.

NUTRIENTS

High-quality, targeted supplements can also go a long way in helping you achieve
the goal of maintaining a health-enhancing balance of estrogens in your body. The
following are some of our favorites, although it is always best to work with a qualified
nutrition professional or other holistic health care practitioner to create just the right
balance for you.

Calcium d-glucarate. Calcium d-glucarate, a natural substance found in apples,
oranges, broccoli, spinach, and Brussels sprouts, helps the liver with its job of
detoxifying estrogens via a process known as glucuronidation. Calcium d-glucarate
also helps inhibit the glucuronidase enzyme mentioned earlier, which in turn
facilitates the elimination of estrogens. A typical dosage is 500 milligrams per day.

Note that the mineral magnesium is the cofactor that helps this whole process run
smoothly. Green, leafy vegetables; legumes; nuts; seeds; and whole grains are good
sources of magnesium. Remember that when flour is refined and processed, the
magnesium-rich germ and bran are removed.

I3C or DIM. Indole-3-carbinol, known by its close friends as I3C, is one of the key
phytonutrients in cruciferous vegetables that gives them their estrogen-modulating
effect. Eating broccoli sprouts, cauliflower, and other crucifers releases I3C, but you
can also take it as a supplement for preventive therapy. Diindolylmethane, or DIM, a
metabolite of I3C created when I3C mixes with juices in the stomach, is also used as a
supplement for prevention. Both compounds are believed to work by promoting the
formation of the healthful estrogen 2-hydroxyestrone.

STRESS IS A PROGESTERONE BUSTER

Maintain a Healthy Estrogen-Progesterone Balance - Hormone Harmony

Maintaining a healthy estrogen-progesterone balance is easier said than done.
Many women have had wonderful results from using bioidentical progesterone creams
or capsules, not to be confused with progestins, which are pharmaceutical progesteronetype
drugs shown to increase breast cancer risk (Bluming and Tavris 2009). While the
labels of many products on the market claim that they are progesterone creams, our
view is that hormone balance is too critical to be left to chance. Therefore, we believe
it’s imperative that you work with an integrative practitioner to measure your
progesterone levels so you can add just the right amount of bioidentical progesterone
to maintain a healthy hormone balance.

Keep in mind that birth control pills only add to your body’s estrogen load,
making this balance even more difficult to attain.

STRESS IS A PROGESTERONE BUSTER

Progesterone is the major precursor of important corticosteroid hormones
(aldosterone and cortisol) made in the adrenal cortex. When progesterone is sidelined
into producing cortisol, the hormone that helps us deal with physical and emotional
stress, there’s less progesterone available for other uses, such as balancing estrogen.
In this way, the fast-paced, demanding lifestyle of the twenty-first century can
deprive the body of its natural progesterone, which already declines dramatically after
menopause under any circumstances. Premenopausally, stress may also affect your
ability to ovulate, restricting or shutting down the production of progesterone entirely.

Assessing Your Status in Hormone Harmony for breast cancer survivors

Assessing Your Status in Hormone Harmony for breast cancer survivors

Dr. Jonathan Wright, medical practitioner since 1973 and author or coauthor of
twelve health books, including Stay Young and Sexy with Bio-Identical Hormone
Replacement (Wright and Lenard 2010), was the first to introduce an integrated,
balanced pattern of bioidentical hormones for women, in the early 1980s. He has been
prescribing, researching, and writing about them ever since. In fact, much of what we
know about the various forms of estrogen and their actions in the body is due to his
exhaustive investigation on the issue. Here’s what he has to say about assessing
estrogen-related cancer risk.

First, Dr. Wright recommends a look at the “EQ” or estrogen quotient, a ratio first
described by Dr. Henry Lemon of the University of Nebraska medical school. The EQ
is the relationship of estriol to estradiol and estrone. The higher your EQ,
mathematically derived as E3/(E1+E2), the better. Dr. Lemon, the originator of the
EQ test, and colleagues (1966) tested estriol along with estrone and estradiol by
having women collect their urine for twenty-four hours and then measuring the
hormone levels in the specimens.

With the authorization of a doctor, nutritionist, or other health professional, the
testing kits can be mailed to you at home, where you collect your specimen and send
it back to the lab. Remember, it’s not the absolute amount of estriol that appears to be
the most important number, but the relative amount of estriol compared with the sum
of estradiol and estrone. According to Dr. Wright (2005), “In today’s environment,
with the amount of estrogen-mimicking carcinogens increasing dramatically, it’s more
important than ever to keep your level of estriol as high as possible. So I don’t see any
reason why we shouldn’t…shoot for an EQ of 1.0 or above.” Interestingly, Dr. Wright
also discovered that iodine raises the EQ for nearly all women.

The second test Dr. Wright recommends is commonly called the "2:16," referring to
the relationship of the estrogen metabolites we discussed earlier (2-hydroxyestrone and
16α-hydroxyestrone). Testing the 2:16 ratio can be done separately or along with the
EQ. You definitely want more “good” (2-hydroxyestrone) estrogen than “bad” (16α-
hydroxyestrone) estrogen—substantially more if possible; any ratio below 1.0 is
unfavorable. Although there’s no consensus concerning the ideal ratio, Dr. Wright
recommends 2.0 or greater, if possible. This lab test will also report on your level of 4-
hydroxyestrone, which also appears to have carcinogenic tendencies, as well as your
level of another metabolite known as 2-methoxyestradiol, an extremely potent, natural
anticarcinogenic form of estrogen made by all women’s bodies.

ESTROGEN AND THYROID in Hormone Harmony

ESTROGEN AND THYROID in Hormone Harmony

The thyroid gland and estrogen share a close and somewhat complicated
relationship. As on a seesaw, when one part is out of balance, it can readily throw the
other one off as well. For instance, while an increase in estrogen does not lower
production of thyroid hormones, it does cause a chain reaction that renders thyroid
hormones less active. Fortunately, millions of women have been helped by research
completed back in 1964, which established that adequate thyroid hormone helps
estradiol metabolize more completely into the “good” estrogen metabolite, 2-
hydroxyestrone (Fishman et al. 1965). Indeed, many, but not all, studies indicate that
having an underactive thyroid slows the process of clearing estrogen from the body,
thus creating a state of estrogen dominance, a known risk factor for breast cancer
(Vasudevan, Ogawa, and Pfaff 2002). Clearly, this is an area that requires significantly
more research and analysis. As always, we believe that balance is key: a thyroid gland
that works properly—that is neither hyperactive nor hypoactive—will help keep the
rest of your metabolism in balance. That is our goal!

ESTROGEN AND MELATONIN

Sleep habits also influence estrogen levels. Melatonin, the “sleep hormone” that
we produce when we sleep in complete darkness, helps reduce excessive estrogen
production. By simply sleeping in a completely dark room (and avoiding working
night shifts, if possible), you take another powerful step in keeping your estrogen levels
under control.

ESTROGEN, OBESITY, AND INSULIN

The current obesity epidemic has taken a toll on our hormonal balance, as
reported in numerous journals over the past decade, including the New England Journal
of Medicine (Yager and Davidson 2006) and the premier medical journal of the United
Kingdom, the Lancet (Bianchini, Kaaks, and Vainio 2002). As we discussed in chapter
6, obese women have a higher risk of developing breast cancer for a variety of reasons.
One key factor underlying this higher risk is an elevated level of circulating estrogens
that is linked to greater amounts of adipose (fat) tissue. Adipose tissue serves as an
additional site for estrogen production.

But there’s another hormone at play here as well. The liver produces a hormone
called sex hormone–binding globulin (SHBG), which carries sex hormones around the
body and regulates their access to tissues. In women, SHBG has a special affinity for
estradiol; that is, the more SHBG we have, the more estradiol is “bound up.” This is,
by and large, a good thing.

Obese women have lower levels of SHBG, making more estrogen available to
breast tissue. Perhaps most ominously, research published in the Journal of Clinical
Investigation showed that a high-fructose diet (containing high-fructose corn syrup, for
example, present in virtually all processed foods and beverages) decreased levels of
SHBG in the liver by a whopping 80 percent, resulting in higher levels of circulating
estrogen (Selva et al. 2007). Fortunately, a foundational Eating for Health plan, plus
the specific suggestions in next eplain, will go a long way toward helping manage
excess weight and insulin, and, in the process, controlling levels of estrogen and
SBGH.

The “Daughter” Metabolites: E2, E4, E16 in Hormone Harmony

The “Daughter” Metabolites: E2, E4, E16 in Hormone Harmony

Over the last three decades, with evolving interest and tools, researchers have been
paying fresh attention to an additional family of estrogen complexes. We might call
them “daughter” metabolites because they are the estrogen by-products that emerge
after estradiol, estrone, and estriol are processed, or detoxified, by the liver. The
technical terms for these by-products are 2-hydroxyestrone (2-OHE), 4-hydroxyestrone
(4-OHE), and 16α-hydroxyestrone (16α-OHE), and together they give us a very clear
picture of whether the amounts and types of estrogen in your body are apt to cause
trouble.

Once the body uses estrogen, like everything else, the estrogen heads to the liver for
detoxification. Properly metabolizing and excreting estrogens, the essence of
detoxification, is a critical but tricky task. If the estrogens are metabolized into 2-
hydroxyestrone, they lose most of their aggressive activity; thus they are known as
“good” estrogen metabolites. Research indicates that when levels of 2-hydroxyestrone
are higher, the body resists cancer, and when these levels are low, cancer risk increases
(Gaikwad et al. 2008). On the other hand, women who metabolize a larger proportion
of their estrogens into 16α-hydroxyestrone and 4-hydroxyestrone show an elevated risk
of breast cancer (ibid.).

Why would the liver use a pathway that could lead to adversity? Recall from
chapter 9 that gut and liver health are intimately tied to estrogen metabolism. A liver
that is compromised by toxicity, alcohol, or estrogen overload from environmental
sources (see chapter 4), for example, will not do as good of a job at clearing out excess
estrogen as a liver that’s at the peak of health. Likewise, a healthy population of gut
bacteria actually helps to detoxify excess estrogen (via the containment of an enzyme
called beta-glucuronidase). In effect, these desirable microbes provide the “bugpower” to
help carry excess estrogen out of the body.

Where’s the proof ? Examining this premise in context, among 10,786
premenopausal women studied in the 1990s, researchers observed that women who
developed breast cancer had notably less 2-hydroxyestrone—a full 40 percent less—
and more 16α-hydroxyestrone metabolites than women who did not develop breast
cancer (Muti et al. 2000). Another study, this one on postmenopausal women, found
that those with the highest ratio of estradiol to 16α-hydroxyestrone had a 30 percent
lower risk of developing breast cancer than women with lower ratios (Meilahn et al.
1998). If we could only find a way to make sure the liver is turning out healthy
estrogen metabolites, as opposed to unhealthy ones, we could lower our breast cancer
risk. It turns out that we can, and we’ll get back to that part of the estrogen story
shortly.

Meet Your Estrogens Hormone Harmony

Meet Your Estrogens Hormone Harmony

While many of us have traditionally thought of estrogen as a single hormone, it is
actually a family of hormones comprising several distinct molecules that the body
secretes naturally, the most well known of which are estrone (E1), estradiol (E2),
and estriol (E3). Along with progesterone, testosterone, 5-dehydroepiandrosterone
(or 5-DHEA, commonly known as DHEA), and corticosteroids, estrogens are in the
steroid group of hormones that are all made from the same basic building block:
cholesterol.

Of the three plentiful forms of estrogen just mentioned, estradiol is the most
potent. Primarily a growth hormone, estradiol shapes tissue growth in the vagina,
breasts, endometrium, fallopian tubes, ovaries, bones, and, of course, the
developing fetus. Before menopause, most of your estradiol is produced by the
ovaries, with lesser amounts produced by the adrenal glands, the liver, and the
breasts. Fat cells also secrete estradiol; hence heavier women tend to carry it in
greater concentrations.

Estrone, a weaker estrogen derived from estradiol in the liver, serves as a
backup form of estrogen. Although we stop manufacturing most estradiol after
menopause, the adrenal glands continue to produce estrone after menopause and for
the rest of our lives.

The third key estrogen compound, estriol, plays its pivotal role during
pregnancy, when levels of this “weak” estrogen start to soar. Although scientists
have considered estriol to be too weak to be relevant except during pregnancy, it
now appears that this “weakness” might actually be its strength.

One study (Siiteri et al. 2002) that suggested this was conducted in Berkeley,
California, where researchers examined frozen blood samples of fifteen thousand
women who had been pregnant forty years earlier. They found that of all the study
subjects, those with the highest levels of estriol relative to other estrogens during
pregnancy had the lowest occurrence of breast cancer. Specifically, women with the
highest level of estriol during pregnancy had a 58 percent lower risk of developing
breast cancer than the women with the lowest estriol levels. It’s noteworthy that
during pregnancy, estriol levels climb enormously, by one thousand times or more.

Even after childbirth, estriol levels usually remain higher than they were before
pregnancy.

To summarize, it’s clear from the data that all estrogens are not the same. And it
gets even more interesting than that.

Hormone Harmony for breast cancer survivors

Hormone Harmony for breast cancer survivors

Goal: Balance your hormones

It seems as if every day, we hear more bad news about estrogen. Both medical
journals and the popular press warn us about its dangers. In fact, after derogatory
news about pharmaceutical hormone replacement emerged from the Women’s
Health Initiative in 2002, both the study and millions of women’s prescriptions were
abruptly halted (NIH 2002). Moving farther into the second decade of the century,
the subject of hormone replacement remains a source of intense controversy.

As we dig deeper, we find a more nuanced story: it is not estrogen itself that is
the problem; it’s the type of estrogen to which we’re exposed, how it is metabolized
by the body, and how it dances with progesterone and other hormones that matters
(Kabat et al. 2006). In this chapter we’ll look closely at the facts, not the hyperbole,
to help you sort through the evolving story surrounding this contentious hormone.

To Do Glucose, Weight, and Insulin Control

Eating for Health is eating from the rainbow. Consuming a wide variety of
colorful vegetables, fruits, and other foods on a regular basis provides the widest
spectrum of health-giving nutrients and may help us all find our way to the “pot of
gold”—our good health. In the process, we will leave behind our blood sugar
irregularities and greatly reduce our risk of insulin resistance, diabetes, and breast
cancer.

Our list of supernutrients in this chapter is by no means exhaustive. In fact, a
varied whole-foods diet, with or without these foods, will provide enormous
benefits toward preventing or reversing dysglycemia and maintaining overall
health. In addition, please keep in mind that whole fruits (not juice) and, especially,
vegetables contain some of the highest levels of vitamins and minerals, as well as
large amounts of fiber, of any foods. They also provide a wide range of
phytonutrients, which helps us with blood sugar control and on so many other
fronts.

To Do Glucose, Weight, and Insulin Control

• Avoid sugar and processed carbohydrates, such as pasta, bread, pastries, and bagels. Be especially wary of anything made with high-fructose corn syrup.

• Use instead in moderation: raw honey, maple syrup (grade B or C), blackstrap or sorghum molasses, date or palm sugar, stevia, or xylitol.

• Create an exercise program that works for you, after consulting your practitioner.

• Eat a breakfast with high-quality proteins, such as eggs, or a smoothie with whey or rice protein powder and yogurt.

• Keep your life simple and your carbohydrates complex!

• Choose fats that are mostly monounsaturated, such as those from olives and avocados; healthy saturated fats, such as coconut oil; and the omega-3 unsaturated fatty acids found in fish, flaxseeds, and walnuts.

• Feed your cells nutritional superstars, such as chile peppers, buckwheat, and cinnamon.

• Consider supplementing with the mineral chromium (or a good multinutrient containing chromium) to manage and prevent hyperglycemia.

Last Word Glucose, Weight, and Insulin Control

I found that keeping sugar and sugar-laden products out of my house was the
key to keeping them out of my life. It was difficult in the beginning; I had to sit
down with my family and explain to them exactly what the stakes were. Once
they were on board, it was so much easier. We all agreed to just say no to
packaged foods, and made the commitment to make one or two changes every
week until I got to where I am today: sugar free, cancer free.

—Sela S., breast cancer survivor

Assessing Your Glucose and Insulin Status

Assessing Your Glucose and Insulin Status

To assess how your body is handling glucose and insulin, your practitioner can
order blood work that examines your fasting glucose and insulin levels, and a
protein called hemoglobin A1c (HA1c). The fasting glucose number will tell you
what your blood glucose level is at a given moment. A range between 70 and 90 is
generally considered optimal.

An HA1c level is taken about once every three months, and reflects an average
blood-sugar level over that period of time. Be aware that it’s possible to have
seemingly normal blood glucose levels and still have high levels of insulin in your
body. This is important to know so that, if necessary, you can adjust your diet to
bring your fasting insulin level into a safe range. This, too, can be assessed through
standard laboratory blood work.

Nurse practitioner and diabetes educator Rebecca Murray is assistant clinical
professor of nursing at Yale University and runs a medical practice in Groton,
Connecticut, where she specializes in diabetes and insulin resistance syndrome.
Based on her thousands of patient case studies, Murray suggests (pers. comm.) that
an optimal range for HA1c is between 4 and 5.6, and for fasting insulin up to 12
microunits per milliliter. These numbers are based on a twelve-hour fast (ibid.).
Keep in mind that if you have a very heavy meal the night before your blood is
drawn, your insulin levels could be higher than normal the next morning. So, be
sure to test more than once (later that week, for example) to be sure you’ve got an
accurate result.

Elevated Blood Glucose, Elevated Fasting Insulin, or Both

Elevated Blood Glucose, Elevated Fasting Insulin, or Both

The amount of sugar and simple carbs you ingest will be fairly obvious to you
in light of the food choices you make. The level of sugar that circulates in your
bloodstream, however, is not nearly as transparent. That’s what makes the cycle
insidious. Eating sugar causes blood sugar to surge and, subsequently, the hormone
insulin to spike. Leaner bodies are better able to move this excess insulin into the
cells, where it’s intended to be received. In overweight bodies, the tendency is for
the excess glucose and insulin to hang around in the bloodstream, causing problems
as the cells become increasingly resistant to the action of insulin.

Like gasoline, sugar is highly combustible, which is why it generates intense but
short-lived energy. Over time, however, the body’s ability to deal with excess sugar
diminishes. Eventually this cycle leads to dysglycemia, or an imbalance of blood
sugar levels and insulin in the body. With dysglycemia, high glucose in the blood
leads to high insulin production, which, in turn, can lead to insulin resistance. This
is most significant for our purposes because recent data suggest that
“hyperinsulinemia [excess insulin] is an independent risk factor for breast cancer
and may have a substantial role in explaining the obesity–breast cancer relationship”
(Gunter et al. 2009). The literature on this topic clearly serves as a wake-up call to
be mindful of blood glucose and insulin control. Fortunately, you have the power to
affect these factors because they are exceedingly responsive to dietary changes.