clinical application of bio-identical hormone replacement therapy
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8/13/2019 Clinical Application of Bio-Identical Hormone Replacement Therapy
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Clinical
Application ofBHRT
Tracy Marsden BScPharm, DHPh
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Types of Hormones
Estrogens
Progesterone
Testosterone
Cortisol & DHEA
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Pre-Menopause
OVARY
Testosterone
Estradiol
Estrone
Estriol
Progesteronearomatase
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Estrogens
3 main types: estradiol, estrone, estriol.
Estradiol is the main estrogen produced bythe ovaries.
Estrogen receptors found throughout body:
brain, blood vessels, bone, etc.
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Progesterone
Synthetic progestins like Proveraare not
the same as progesterone.
Allwomen need progesterone to balance
effects of estrogens (even women who have
had the uterus removed!)
Progesterone increases the bodys
sensitivity to the estrogens it has.
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Androgens
Testosterone is important to women for:
Bone
Sex drive Energy, sense of well being
DHEA and androstenedione are important
building block hormones: needed to makeandrogens and estrogens (particularly aftermenopause).
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Cortisol
Is the primary stress hormone.
High cortisol levels can interfere with theactions of all the other hormones.
Prolonged elevation of cortisol can deplete
the adrenal glands.
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Post Menopause
ADRENAL
GLAND
Testosterone
Estradiol
Estrone
Estriol
CortisolDehydroepiandrosterone
(DHEA)
Androstenedione
aromatase
aromatase
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Normal Cycles
Progesterone is produced in quantity after
ovulation
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Relative excess of estrogens
over progesterone. Cyclesare irregular.
Progesterone peaks after
ovulation and balances
estrogens. Cycles are regular.
Very little progesterone orestrogens released by
ovaries. No cycles.
Menstrual Cycle 6 month view
Peri-menopause 6 month view
Post-menopause 6 month view
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Hormone Balance
There is an intricate balanceamong all the hormones; toomuch of one can create
an imbalance.
Maintaining the right balancecan reduce symptoms
and help prevent disease.
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Hormone Therapy Missteps
Giving unopposed estrogen to all women (noprogesterone given to balance estrogens)without testing or proof of need.
When we found out estrogen alone increasedendometrial cancer risk, we added a syntheticprogestin instead of natural progesterone.
When we found out synthetic progestinsincreased heart attack and stroke risk, we justdecreased the dose.
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A better approach
THREE SIMPLE STEPS
Symptom assessment
Hormone testing
Restore hormone balance with bio-
identical hormones
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Step 1: Symptom Assessment
ijklHot flashes ijklMemory lapses
ijklNight sweats ijklFoggy thinkingijklWater retention ijklHeart palpitations
ijklBreast tenderness ijklIrritability
ijklDecreased sex drive ijklLoss of muscle bulk
Symptoms:Please rate your symptoms according to the following scale:
0 - never or rarely experience this symptom (
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Hormone Testing Options
Urine
Measures what the body throws away
Blood
Measures what mighteventually get to
tissue
Saliva
Measures what actually gets to tissue
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What are bio-identical hormones?
Bio-identical means that the hormones are
identical in structure to what is produced
naturally in the body.
More accurate to call them Human-Identical
Hormones, but BHRT is a common term.
Studies showing harm from hormones used
synthetic or semi-synthetic hormones (horse
estrogens, synthetic progestins)
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Principles of BHRT
Use the identical hormone to that which the
body produces on its own
Give bio-identical hormones in the way that
is closest to the way hormones are released
in the body
Use the minimum dose to relieve
symptoms.
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Bio-identical Hormone Replacement
Bio-identical hormone replacement (BHRT)
includes:
Estradiol patches and gels
oral micronized progesterone
These bioidentical products are notcontroversial
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Transdermal Estrogens
However, BHRT also includes:
compounded oral or transdermal combination
estrogens (BiEst, TriEst) compounded progesterone creams
compounded sustained release oral micronizedprogesterone
. . . which are more controversial types of bio-identical hormone replacement.
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BiEst and TriEst
BiEst and TriEst contain mostly estriol, the
weakest estrogen.
Theoretically, estriol raises estrogens levels
when they are low, and competes with
stronger estrogens for receptor sites when
estrogen levels are high.
Some research suggests that estriol may be
protective against breast cancer.
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Bi-Est
BiEst (bi-estrogen) is a combination of estriol
and estradiol in oral or transdermal form
Various combinations available: 80:20, 70:30,
50:50
First number refers to the estriol component
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Tri-Est
Tri-Est not used often as most women do
not require estrone.
TriEst (tri-estrogen) is a combination of
estriol, estrone, and estradiol
Various combinations available: 80:10:10,
90:5:5, 60:20:20
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Estriol (E3)
Effective for hot flashes, insomnia, poormemory. Head K. Alt Med Review 1998;Vol. 3(2)
Intravaginal use may be effective for vaginaldryness, infections, recurrent UTIs anddyspareunia.Head K. Alt Med Review 1998;Vol. 3(2)
Estriol has been safely used in Europe fordecades, although is not approved for use inNorth America.
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TriEst and BiEst
Unconventional compounded estrogens do
not appear to be worth the extra cost and
effort they exact, but they do represent anaddition therapeutic option for women who
cannot tolerate conventional prescription
estrogens.
Taylor M, Clin Obstet Gynecol; 2001 Dec;44(4):864-79
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Bio-identical Progesterone
Progesterone (bio-identical hormone)
compared to Provera (medroxyprogesterone
acetate)
Progesterone cream versus oral micronized
progesterone
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Acts with estrogen to relax
blood vessels
Does not increase risk ofbreast cancer
Does not increase
inflammatory markers in
blood
Protects against natural brain
cell death.
Inhibits relaxation of blood
vessels by estrogens
Increases risk of breast cancer
Increases inflammation
causing C-Reactive Protein
(CRP)
Does not protect against
natural brain cell death.
Progesterone MPA
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Bio-identical progesterone
Oral micronized progesterone (Prometrium) isbio-identical
Effectively protects the endometrium (lining ofthe uterus)
Giving progesterone orally creates metabolitesthat have an anti-anxiety and sedative effect.
Pregnanolone
Allopregnanolone
Hydroxypregnanone
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Progesterone Cream
Progesterone cream is also effective, andmay be less sedating than the oral form.
Progesterone is better absorbed throughskin than either testosterone or estradiol
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Progesterone Cream
Efficacy:
Some evidence that progesterone cream can
protect the endometrium
No bone building effects
May help reduce hot flashes
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Compounded Progesterone Cream
Quality depends on
how finely ground the progesterone
powder is
the type of base used
the compounding skills of the pharmacist.
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BHRT Study
189 women between the ages of 45 and 60
prescribed BHRT: all received progesterone
and BiEst topically. Some also receivedtestosterone, DHEA.
70% complained of brain fog
55% complained of weight gain.
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Study Results
90% completely or partially improved on
symptoms of brain fog.
60% of women who gained weight, lost weight.
Average weight loss was 14.8 pounds.
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Cortisol Effects
High levels of cortisol can compete with
the other hormones, creating a functional
deficiency of hormones. Progesterone or testosterone in normal range,
but the bodyfunctionsas if there is not enough
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Cortisol and DHEAS
Cortisol is catabolic, meaning it breaks down
muscle and bone
DHEA is anabolic, meaning it builds up
muscle and bone
Balance becomes more catabolic with age as
DHEA levels decline and cortisol levels
increase
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Adrenal Fatigue
High cortisol levels over time cause damage,
and the body slows cortisol release to
prevent further damage.
Decreased cortisol release leads to adrenal
fatigue and inability to regulate other
hormones.
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Thyroid
Thyroid issues more common as
perimenopause is reached: higher overall
estradiol levels in perimenopause reducedamount of free thyroid hormone.
Too low or too high cortisol can also affect
thyroid.
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BHRT Summary
Bio-identical hormone replacement (BHRT) is an
accepted standard of hormone replacement,
although there is controversy around custom
compounded forms of BHRT
Oral progesterone is accepted, and progesterone
cream is gaining acceptance.
BiEst and TriEst are still unproven therapies, but
preferred by many women.
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