Book Review

Perfect Balance

Robert A. Green, MD and Leah Feldon
Clarkson Potter/Publishers, 2005

This book is neither “perfect” nor “balanced.” It is difficult to read, poorly formatted, and, according to this reviewer, filled with incorrect statements and ideas.

Although this 336-page book seeks to attract women desiring bioidentical hormone balance and is, in fact, endorsed by Suzanne Somers, it recommends hormone therapy only as a last resort and indeed recommends synthetic oral contraceptive pills as treatment in some patients. Dr. Greene advocates changes in diet, exercise, and lifestyle; mind-centering techniques; vitamin supplements; herbal preparations; and, if necessary as a last resort, synthetic oral contraceptives or bioidentical hormones.

Dr. Greene created his own terminology under the rubric of his self-devised Perfect Balance Hormone Biosystem. His system categorizes viable hormone therapies into five groups: BioIdentical hormones, those that are so close to what the body produces that even the brain can’t tell the difference; BioSimiliar hormones, formulations that are similar but not identical to the body’s hormones and offer some distinct advantages (eg, birth control pills containing estrogen/ progestin combinations); BioLimited hormones, designed to replicate some functions of the body’s own hormones while deliberately limiting the function of others (eg, clomiphene, tamoxifen); BioUnknowns, which includes phytoestrogens such as soy, flax, and some herbs that are under investigation and act in ways that are still unknown; and BioAntagonists, which effectively turn off natural hormones and are used to control or prevent diseases such as breast cancer (eg, letrozole, nafarelin). He also refers to BioMutagens, which are toxic chemicals in the environment that disrupt hormones, cause imbalances, and should be avoided. This terminology is confusing and does not enhance communication between healthcare providers.

Dr. Greene speaks highly of estrogen and prescribes it frequently in his practice. He prescribes transdermal ethinyl estradiol/ norelgestromin (Ortho Evra), ethinyl estradiol/ etonogestrel vaginal ring (NovaRing), ethinyl estradiol/norgestimate tablets (Ortho Tri-cyclen), estradiol/norethindrone acetate, ethinyl estradiol/levonorgestrel (Seasonale), and esterified estrogen/methyltestosterone (EstraTest) to treat some patients. He classifies these combinations as “BioSimiliar” and views them no differently than bioidentical hormones. He does not use Bi-est or Tri-est because he believes estrone is a “bad” estrogen; he states that estriol is found only in pregnancy and is merely a waste product. When he does use compounded estrogen, he prescribes only a formulation of estradiol. Moreover, he does not discuss the proportion of progesterone to estrogen or estrogen excess and does not believe that estrogens cause breast cancer.

Dr. Greene rarely prescribes progesterone and when he does, he uses micronized progesterone (Prometrium or Crinone) gel, as he has not found progesterone creams to be effective. He feels that progesterone is highly sedating and causes thickening of vaginal secretions, which leads to difficulty in sexual intercourse. He believes that premenstrual dysphoric disorder (PMDD) is caused by the increase of progesterone in the luteal phase of the menstrual cycle. Dr. Greene reports using Prometrium with success in a few cases of postpartum depression and anxiety, but he has not prescribed progesterone to treat PMDD. A layperson reading this book may be misled into thinking that progesterone causes mainly fatigue, depression, and premenstrual syndrome, and that estradiol reduces skin wrinkles, improves memory, prevents colon cancer, and has no negative consequences. Dr. Greene does not, moreover, explore the implications of estrogen/progesterone imbalance.

One case report cited is indicative of Dr. Greene’s treatment protocols. It involves Dayle, a 21-year-old woman in the military with documented PMDD, who decided to train as a fighter pilot. Her commanding officer told her that she could enter the program only if she had a total hysterectomy. Dr. Greene treated her with a “BioAgonist” (such as nafarelin), “to temporarily induce menopause and eliminate her PMDD.” This caused her to experience severe menopausal symptoms, which were eventually controlled with an estradiol patch and testosterone gel. In spite of feeling better, Dayle chose to proceed with the hysterectomy and removal of both ovaries, which Dr. Greene performed. She went on to complete her pilot training, which was important to her, but the tradeoff was immense.

Without any documentation or references, Dr. Greene discounts the validity of saliva testing and discourages its use.

The author recommends that women take more responsibility for their own health care. He suggests that patients obtain a copy of their medical record, review it, and schedule a visit with their physician. He advises patients to set an agenda for the visit to “direct and control the flow of your meeting. By taking control you’ll not only earn the doctor’s respect, but also demonstrate your knowledge of the situation.” In my experience, however, this technique may only antagonize the healthcare practitioner and interfere with the therapeutic relationship. He also encourages patients to take his book to their doctor for reference on hormone balance. Some of his concepts, however, are not recognized in traditional allopathic medicine, and the format of his book does not promote easy reading and reference during a patient visit; therefore, I do not recommend that it be used in that manner.

On the upside, in his diet chapter, he includes some helpful cooking instructions for unusual grains such as amaranth, quinoa, triticale, bulgur, millet, buckwheat, and couscous. He discusses foods that are high in calcium, magnesium, and antioxidants. He encourages readers to drink water, noting that the sensation of hunger may actually be caused by thirst. The cardiovascular benefit of chocolate is discussed. Dr. Greene encourages exercise and touches on aromatherapy, conscious breathing, meditation, and the importance of social contact.

In sum, I believe that Dr. Greene is trying to make the public and medical practitioners more aware of bioidentical hormone balancing, but this book will only cause more confusion in the realm of hormonal health. Suzanne Somers has withdrawn her endorsement of this book.—The Editor