Controversies in Bioidentical hormone treatment
Michelle Indianer, D.O.
Some basic points that most people agree with are:
to use an
effective dose,
use a reputable
compounding pharmacy for compounded hormones,
find a physician well versed in these treatments
to prescribe them for you (including but not just a blood
test, a saliva test or a
pharmacists recommendation)
and use them for specific symptoms.
E
ven though Bio-Identical Hormones are manufactured, therefore
not "natural" in an absolute sense, the reason these
hormones are called "bioidentical" is that their chemical structure is
the same as those naturally occurring in humans. This is not a small
point. Premarin (the Prem part of PremPro) is produced
(inhumanely in my opinion) from
pregnant mares. The main problem with this is that our bodies don't
have the correct enzymes to metabolize (break down) horse hormones,
many of which
remain in our bodies way too long. Many of these metabolites are toxic
and can lead to cancer.
The Provera part of PremPro is NOT progesterone. It is a progestin,
which is quite different in it's effects on the body. Most of the
adverse side effects in the Women's Health Initiative (WHI) study were
due to
the use of Provera portion of the PremPro. I have rarely seen women
tolerate Provera even in small doses. Again this is not a naturally
occurring hormone in humans and the metabolism of it also isn't the
same. It is not progesterone replacement
and should not be advertised as such.
By using hormones that are
identical to the ones our bodies naturally produce we can metabolize
them and then they can be removed from our body without causing
excessive harm. Should we still be cautious with their use? Of course.
However to invalidate the differences is naive and dangerous. The
commercial brands can be good to use and insurance will pay. The
commercial
brand of progesterone can be given orally. Many physicians who
prescribe bioidentical hormones use the commercial estradiol patches
and Prometrium(tm) with great success. This is bioidentical hormone
replacement essentially, although the dose can not be customized to the
lowest effective level often.
It is often said that there are no long term studies about the
effectiveness of bioidentical hormone replacement besides the WHI. This
is not the case. There are numerous studies that do differentiate
between various forms of replacement therapy. These do indicate that
Provera is a dangerous drug. It increases the risk for cancer and
stroke. The WHI was stopped early mainly because of the negative
outcomes for the women on PremPro. The women on Premarin only had a decreased incidence of
deaths from all caused mortality. What all these studies show is that
the longer patients are on real hormone replacement therapy the more
positive benefits they obtain. These hormones help protect women's
brains, bones, heart and skin. The overall statistics show that
Estradiol (the most active form of Estrogen) has no effect on breast
cancer incidence and Progesterone actually deceases the incidence of
breast cancer. There is no therapy with as positive effect on
preserving, and replacing bone as Estrogen. The second most effective
treatment is Vitamin D (actually a hormone, not a vitamin). When people
are placed on Fosamax and other bisphosphonates they continue to lose
bones. Yet the average doctor is more likely to prescribe these for
bone loss rather than the combination of bioidentical hormone
replacement and Vitamin D. This is an important issue, as more women
will die from issues related to Osteoporosis that will die from the
combination of Breast, Uterus and Ovarian Cancer.
As far as the types of estrogen, there is some
controversy in the field, but most people agree that as we age we
produce too much estrone, whose 2,4,and 16 Hydroxy Metabolites can
become excessive or imbalanced. These metabolites are believed to be
formed less when using a supplement of combined estradiol with
estriol. Importantly, many practitioners use DIM (a
supplement derived from cruciferous vegetables such as broccoli) and
other supplements to help the body metabolize the hormone replacements
more rapidly and with a better balance. Some women also have problems
with absorbing though their gastrointestinal tract or liver and get
better results with transdermal forms of the medications, which can be
individualized to much lower doses that are available commercially,
especially in the case of progesterone and testosterone.
Some recent research has indicated the mechanism for
some of the Cardiovascular advantages of oral Estradiol. When this form
of estrogen passes through the liver there is excreted an enzyme that
dissolves plaque formation in the blood vessels. Unfortunately, if they
are started after the plaque had had many years to form and has a
necrotic (dead) core, the dissolving of plaque will release particles
that can break off and cause strokes. So, the oral is best started
early in menopause, and again continued for as long as possible. The
one caveat would be that it shouldn't be used in a woman with a
clotting disorder. One mechanism for the problems in the WHI is that
the average age of the women in the study was over 65 who had more than
10 years passage since the onset of menopause, thus they also probably
had a lot of unstable plaque ready to get dissolved and dislodged by
the oral form of estrogen given to them.
There
is no therapy with as positive effect on preserving, and replacing bone
as Estrogen. The second most effective treatment is Vitamin D (actually
a hormone, not a vitamin). When people are placed on Fosamax and other
bisphosphonates they continue to lose bone minerals. Yet the average
doctor is
more likely to prescribe these for bone loss rather than the
combination of bioidentical hormone replacement and Vitamin D. This is
an important issue, as more women will die from issues related to
Osteoporosis that will die from the combination of Breast, Uterus and
Ovarian Cancer.
Estrogen combined with progesterone can be
essential in the proper uptake of calcium and correct rebuilding of
bone. Do not forget the importance of adequate magnesium, boron and
Vitamin D for bone health. (By the way, Fosamax , Actonel and similar
drugs put calcium in
the bone, but in a haphazard way that doesn't make for strong
bones--and you should check out the truly horrible side effect of
severely painful bone loss in the jaws of many women taking these
drugs.)
Some people question the need for hormone
testing prior to starting replacement therapy. Saliva versus blood
testing has some controversial aspects, but saliva testing with a
reputable lab is generally very accurate for baseline levels, and is
reimbursed by
Medicare and most other insurance companies. However, recent studies
indicate that the Saliva tests stop being a reliable measure after the
person starts taking hormone replacement therapy, especially
transdermal. There is a belief that the hormones "hide" on the red
blood cells thus making blood levels unreliable, but recent research
has disproved this theory. The bulk of the research on effective levels
of this hormone replacements is on serum (blood).
Many
physicians
give women "hormones" without testing them first, at the
"standard" dose, many times without even knowing that they aren't
replacing the hormones with human hormones if they are using Oral
Contraceptives or PremPro as the hormones they are giving. Just because
this is common and less expensive does not mean it is good medicine. I
addition to using saliva or blood levels prior to doing
replacement,
obviously a history need to be taken, and symptoms need to be targeted.
Most skilled physicians in the field still would never want to guess
what needs to be replaced.
By getting hormone levels first, you can replace hormones only
if they are low.
An extremely important reality is that many
women in Perimenopause do
not need estrogen
at all even if
they are plagued with severe
hot flashes, but may need progesterone
only. Progesterone increases the body's
sensitivity to its remaining estrogen. Most women have adequate levels
of estrogen until their late 40s or early 50s, whereas they may have
inadequate progesterone as early as their mid 30s due to changes in
ovulation. This is just one of the many reasons to make sure you get
tested for the actual free hormone levels first.
Many people in the Functional
Medicine or Anti-Aging Medicine fields (who are the ones
generally concerned with these issues)
are looking at many other factors with blood and/or saliva testing,
including looking for adrenal fatigue or thyroid disease and
"rebuilding" the adrenals and thyroid prior to starting sex hormone
replacement therapy. Sometimes by getting the adrenal glands
functioning well, they can produce enough of the sex hormones that
further replacement isn't needed. This is especially true in the
perimenopausal period. After menopause there are numerous reasons to
take hormones replacement--again to preserve our brains, bones, hearts,
blood vessels and skin.
One particularly bad mistake conventional
doctors make is to give only
estrogen if a woman has had a
hysterectomy, as if he only purpose of progesterone is to protect the
uterus instead of impacting many organ systems. Everywhere in our
bodies that there is estrogen receptors, there is also progesterone
receptors. As stated above, the research indicates that
progesterone is protective against breast cancer. Estrogen
dominance (and the relative, or absolute,lack of progesterone) causes
many problems including breast tenderness and bloating, fibroids in the
uterus and severe perimenopausal PMS. Ironically, proper balancing with
progesterone (not estrogens or oral contraceptives) might save many a
woman her uterus! Using any of these hormones in an improper balance is
just asking for
trouble along the way.
Also
giving testosterone in women for sex
drive without seeing if it is even lacking may cause problems in
many
women. On the other hand, oral estrogen causes an increase in sex
hormone binding globulin, which will bind the free (active form of)
testosterone, so these women usually need testosterone replacement
therapy. Sexual function is many factorial, but the average Ob-Gyn
physician is just too busy to take the time to find out what is really
going on.
Yes, going once a year is cheap as is giving a
common medicine without knowing if it is the right one, but that has
little to do
with quality of care. As I have been taught, the hormones are a
symphony that needs the right balance for the individual patient. Just
from the few things I have mentioned here you can see that this is a
complicated field and good care may take several visits.
I am a Psychiatrist. I began
learning about this field and offering hormone replacement therapy
about a decade ago when I began seeing patients whose psychiatric
symptoms being impacted by hormone imbalances and I had no colleagues
to send them to. My conventional psychiatric medications and therapy
were often inadequate and I was seeking ways to relieve suffering.
Since a
primary philosophical goal in medicine is to "First do no harm" and
because there was no way as I was approaching menopause that I would
ever consider taking Premarin or Provera, (which I have always
considered to be essentially poisons), I began to study this field and
treat my patients myself. Make no mistake, many women fly through
menopause with hardly any symptoms, and if their bone densities are
good and they aren't losing calcium through their urine they probably
will get by without hormone replacement therapy. The people who come to
see me are usually suffering from myriad symptoms, and are very
gratified when I can do an individualized treatment that is integrative
of many forms of treatment including these hormones.