What is the primary concern for a 70-year-old woman taking 0.5mg of Estradiol (estrogen) and 100mg of Progesterone, who previously stopped Levothyroxine (thyroid hormone replacement) and started Thyromin (thyroid supplement containing Parsley leaf powder, Bovine thyroid powder, L-Tyrosine, and other ingredients), and now adds Cortistop (adrenal support supplement containing Pregnenolone, DHEA (dehydroepiandrosterone), and Black cohosh root extract) to her regimen?

From the Guidelines

My biggest concern for this 70-year-old woman adding Cortistop to her current regimen would be potential hormonal interactions and adrenal suppression. The combination of multiple hormone-modulating supplements could disrupt her endocrine balance. Cortistop contains pregnenolone and DHEA, which are hormone precursors that can convert to estrogen, progesterone, and cortisol in the body. Since she's already taking estradiol (0.5mg) and progesterone (100mg), adding these precursors could lead to unpredictable hormone levels. Additionally, ingredients in Cortistop designed to lower cortisol levels could interfere with her body's natural stress response, potentially causing adrenal insufficiency symptoms like fatigue, weakness, and blood pressure changes. This is particularly concerning since she's already using Thyromin instead of conventional thyroid medication. The combination of multiple endocrine-modulating supplements without proper monitoring could lead to complex hormonal imbalances that would be difficult to diagnose and manage. Before adding Cortistop, she should consult with an endocrinologist who can evaluate her current hormone levels and monitor for potential adverse effects if she proceeds with this supplement, as recommended by the USPSTF 1. Some key points to consider include:

• The USPSTF recommends against the use of combined estrogen and progestin for the prevention of chronic conditions in postmenopausal women 1.
• The use of hormone therapy for the primary prevention of chronic medical conditions is not recommended for postmenopausal women who have had a hysterectomy 1.
• The combination of hormone-modulating supplements could increase the risk of cardiovascular events, such as coronary heart disease and stroke 1. It is essential to prioritize her health and well-being by consulting with an endocrinologist before making any changes to her regimen.

From the FDA Drug Label

The Women’s Health Initiative (WHI) study reported increased risks of myocardial infarction, stroke, invasive breast cancer, pulmonary emboli, and deep vein thrombosis in postmenopausal women (50 to 79 years of age) during 5 years of treatment with oral conjugated estrogens (CE 0.625 mg) combined with medroxyprogesterone acetate (MPA 2. 5 mg) relative to placebo. Estrogens with or without progestins should not be used for the prevention of cardiovascular disease. The use of unopposed estrogens in women with intact uteri has been associated with an increased risk of endometrial cancer Adding a progestin to estrogen therapy has been shown to reduce the risk of endometrial hyperplasia, which may be a precursor to endometrial cancer.

The biggest concern is the potential interaction between Estradiol and the ingredients in Cortistop, particularly DHEA, which may exacerbate the risks of estrogen therapy, including:

• Cardiovascular events (myocardial infarction, stroke, pulmonary emboli, and deep vein thrombosis) 2
• Endometrial cancer (due to the potential for increased estrogenic activity) 2
• Breast cancer (due to the potential for increased estrogenic activity) 2

It is essential to closely monitor the patient for any signs of adverse effects, particularly cardiovascular events and abnormal vaginal bleeding, which may indicate an increased risk of endometrial cancer. 2 2

From the Research

Biggest Concerns

• The addition of Cortistop to the woman's regimen may interact with her existing hormone replacement therapy (HRT) consisting of 0.5mg of Estradiol and 100mg of Progesterone, as well as her thyroid supplement Thyromin 3, 4.
• The ingredients in Cortistop, such as DHEA and Black cohosh, may have estrogenic effects, which could potentially exacerbate the interaction between estrogen therapy and thyroid hormone replacement 3.
• The use of Cortistop may also increase the risk of adverse effects associated with corticosteroid therapy, such as avascular necrosis, gastrointestinal bleeding, and psychiatric syndromes, particularly if used in high doses or for prolonged periods 5, 6, 7.
• The woman's history of stopping levothyroxine and starting Thyromin without issues may not be directly relevant to the potential risks associated with adding Cortistop to her regimen, as the interactions between Cortistop and her existing medications may be unique 3, 4.

Potential Interactions

• The estrogenic effects of Cortistop may increase the levels of thyroxine-binding globulin (TBG), leading to changes in thyroid function and potentially requiring adjustments to her thyroid supplement 3, 4.
• The use of Cortistop may also affect the woman's lipid profiles, insulin-like growth factor 1 (IGF-1) levels, and quality of life, particularly if she has a history of hypothyroidism or other underlying medical conditions 4.

Monitoring and Precautions

• Close monitoring of the woman's thyroid function, lipid profiles, and overall health is recommended if she decides to add Cortistop to her regimen 3, 4.
• Her healthcare provider should be aware of the potential interactions between Cortistop and her existing medications, as well as the risks associated with corticosteroid therapy, and provide guidance on safe use and monitoring 5, 6, 7.