BHRT

Bioidentical Hormone Replacement Therapy (BHRT)

Hormone  levels decline as we age. Bioidentical hormone therapy replenishes the  hormones that your body needs to function optimally. The molecule of the  bioidentical hormone is identical in structure to the hormones  naturally found in the body, including estrogen, progesterone,  testosterone, DHEA, and thyroid. We at Chadds Ford Wellness use  bioidentical hormones instead of synthetic hormones. We will assess your  individual needs and help you bring your hormone levels into an  optimal, more youthful range.

  • Where do bioidentical hormones come from?
    These  biologically identical hormones are extracted from plants and made in a  lab. The end result is a hormone molecule identical to the molecule  that is made in the human body. Some experts refer to these hormones as  "natural.” However, we at Chadds Ford Wellness believe the term  "natural" can be misleading. The only thing natural about these hormones  is the fact that they are made in a compounding pharmacy lab to be  identical to our own natural human hormones.
  • Who needs Bioidentical Hormone Replacement Therapy (BHRT)?
    Women  suffering from early menopause symptoms looking to put an end to hot  flashes, night sweats, memory loss, mood swings, weight gain, and low  libido will experience improved symptoms when we replace declining  hormones with bioidentical hormones. We design individualized programs  specifically for each woman suffering from early menopause symptoms,  menopause, perimenopause, and severe PMS.
  • Men experiencing male  menopause or andropause who want to improve lost libido, fatigue,  stress, low energy, loss of muscle mass, and increased body fat will  also experience success with BHRT. For men, andropause happens gradually  and when diagnosed, the symptoms are successfully treated using  bioidentical hormones.
  • What kind of pharmacy can fill a prescription for Bioidentical Hormones?
    Prescriptions  are filled at a special type of pharmacy called a compounding pharmacy.  These pharmacies can provide you with any drug from pharmaceutical  companies. However, compounding pharmacies are able to do more.  Compounding pharmacists use pure pharmaceutical grade hormones and  prepare it in the dose and form that we prescribe for your individual  needs. Your program is customized and personalized based on your  symptoms and lab levels. In order to assure an adequate dose and  response to treatment, your hormone levels are monitored and adjusted to  maintain optimal levels.
  • In summary, bioidentical hormones are  identical in structure to the hormones that your body makes. Synthetic  hormones are similar to but not exactly the same as the hormones  produced in your body. Synthetic hormones act differently, produce  different effects and have different side effects than the safer, more  effective bioidentical hormones. 

Estrogen and Progesterone Replacement

Estrogen  and progesterone are sex hormones essential for health and well-being.  Not only are the absolute amounts of each hormone important, but also  the ratio of progesterone to estrogen is equally important. The  following is a discussion of these two important hormones.

Estrogen
The  primary female sex hormones are the Estrogens, which are derived from  steroid compounds. While present in the highest level in women during  their reproductive years, estrogens are present in both men and women.  Estrogens promote the development of female secondary sex  characteristics, such as breasts, and are also involved in the  thickening of the endometrium of the uterus and other aspects of  regulating the menstrual cycle. Follicle stimulating hormone (FSH) and  luteinizing hormone (LH) regulate the production of estrogen in  ovulating women.

The three major naturally occurring estrogens in  women are estrone (E1), estradiol (E2), and estriol (E3). In the body  these are all produced from androgens through enzyme action. Estradiol  is produced from testosterone, and estrone is made from androstenedione.  Estrone is weaker than estradiol, and in post-menopausal women more  estrone is present than estradiol. Estrone may be cancer-inducing.  Estradiol is the most potent estrogen and may be cancer preventing.  Estriol has most of it’s effect on the mucosa and maintaining moisture  and lubrication.

Estrogen Production
Estrogen  is produced primarily by developing follicles in the ovaries, the  corpus luteum and the placenta. Some estrogens are also produced in  smaller amounts by other tissues such as liver, adrenal glands and the  breasts. These secondary sources of estrogen are especially important in  post-menopausal women.

Estrogens are also common in our  environment. Animals raised for commercial food purposes often are fed  hormones containing estrogen to speed their development and time to  market, and to enhance taste and marketable characteristics. Pesticides  often contain hormones and work by disrupting the insects’ normal  hormone cycle. Foods sprayed with pesticides may absorb some of the  estrogen-like compounds. A class of estrogen-like substances called  phthalates are part of the formulation of many plastics. Heating foods  in plastic containers may allow some of these phthalates to leach out  into your food. These estrogens and estrogen-like compounds are known as  xenoestrogens (ZEE-no-estrogens). “Xeno-“ means “foreign.” These  estrogens are not human estrogens, and are therefore foreign to our  bodies. Yet when absorbed in our bodies they can exert estrogen-like  effects.

Estrogen Benefits

  • Protection from Heart Disease
  • Reducing the risk of Stroke and Vascular Disease
  • Treating and Preventing Osteoporosis
  • Decreasing the risk of Alzheimer’s Disease
  • Preventing Atrophy of the Urogenital Organs, ie, Urethra, Vagina, etc.
  • Reducing the risk of Macular Degeneration of the Eye
  • Improving Menopause symptoms such as hot flashes, depression, and mood swings
  • Preventing Memory Loss
  • Preventing Tooth Loss
  • Colon Cancer risk reduction

Estrogen Deficiency

  • Vaginal Atrophy and Vaginal dryness causing painful intercourse
  • Skin Drynes
  • Thinning Bones, Fractures
  • Bladder Incontinence
  • Temperature Dysregulation (feeling hot, cold, or temperature swings)
  • Breast changes, i.e., drooping breasts
  • Fatigue or being tired
  • Loss of Libido or sexual desire
  • Loss of anti-aging effects, i.e., feeling full of life and vigor
  • Vasomotor symptoms– such as flushing, or feeling hot
  • Increased risk of cardiovascular symptoms such as palpitations, shortness of breath or chest pain
  • Increased risk of osteoporosis symptoms such as bone pain in the back or extremities
  • Increased vaginal dryness
  • In men, estrogen blocks testosterone receptor sites, causing symptoms that reflect low testosterone levels
  • Loss of Cognitive Function and Memory

In  addition, as noted above, some researchers maintain that most women in  the U.S. are estrogen dominant, due to high environmental estrogen  exposure (the xenoestrogens). However, lab tests for estrogens typically  do not reflect this increased estrogen exposure. Perimenopause or Poly  Cystic Ovararian Syndrome can also cause a relative estrogen dominance  state.

Symptoms and diseases due to Estrogen Dominance can include:

  • Endometriosis causing severe, hard to treat pelvic pain
  • Fibrocystic breast disease causing painful lumpy breasts
  • Irritability due to Estrogen Dominance
  • Weight gain, especially at the hips and thighs (estrogen is preferentially stored fat cells)
  • PMS, Depression and mood swings
  • Sugar craving
  • Acne
  • Fluid Retention
  • Uterine Fibroids- benign but painful tumors of the uterus

These signs may indicate your estrogen status, including:

  • If your breasts are tender to the touch or swollen your estrogen level may be too high.
  • Drooping breasts or loss of breast fullness may mean your estrogen levels are too low.
  • If your rings are too tight due to Fluid Rention, your estrogen level may be too high.
  • If you suffer from night sweats that affecting your sleep, your estrogen level may be too low.

Estrogen Replacement Therapy
The  most common hormone replacement therapy in use today is actually just  Estrogen replacement. (It really should be called “ERT” not “HRT.”)  Actually, estrogen replacement therapy is the most well-documented  anti-aging therapy in the medical literature. The problem is the drugs  used as estrogen replacement. None of the commercial products contain  natural or a better term, bioidentical estrogen.

By far the most  common estrogen replacement medication is Premarin®. The name “Premarin”  actually comes from a “pregnant mare’s urine.” This means it’s  “natural.” But it is not “bio-identical” to human estrogen. Premarin  contains over 40 different xenoestrogens, plus E1 & E2. It also  contains Equillin, a horse estrogen and a known breast carcinogen! No  wonder there has been a growing concern over the adverse effects of its  use! Prempro® is a mixture of the same conjugated estrogens found in  Premarin and medroxyprogesterone.

The problem with Estrogens that  are not bioidentical are the side effects they posses. In a land mark  trial called the World Health Initiative Trial (WHI) trial, researchers  studied the effects of Premarin and Provera on 160,000 thousand nurses  with an age range of 50-79 over a 15 year period. The study focused on  the prevention of heart disease, cancer and osteoporosis. When used  alone in women less than 10 years from the start of menopause, Estrogen  decreased the risk of heart disease, which is a good thing. However when  combined with Medroxyprogesterone Acetate or Provera (a  non-bioidentical type of progestin), the risk of heart disease went up.  The risk of heart disease also increased in women who started HRT more  than 10 years after starting menopause (even without the dangerous  progestin, Provera). We now know when prescribing HRT to our female  patients, we must use bioidentical estradiol and progesterone. Newer  studies have shown a reduced risk of coronary artery disease when using  Estrogen orally, (especially when started before the 10th year after  menopause and low cardiac risk factors, non-smokers) combined with an  adequate dose of Progesterone.

Our preferred method of  administering ERT is by way of an oral estradiol pill  (E2). This is due  to it’s added cardio-protective effects after being metabolized in the  liver. Oral estrogen is preferred over topically delivered estrogen if  the woman being treated is less than 10 years from beginning menopause  and her risk of developing heart disease is low.  Using a custom  compounded Estradiol cream is also very good, but not as good as the  pill due to the reason’s above. Creams get absorbed directly into the  blood stream through the skin, avoiding breakdown in the stomach and  liver.

Controversy
When you ask your primary  care physician or OB/GYN physician about the difference between Hormone  Replacement Therapy (HRT) and Bio-identical Hormone Replacement Therapy  (BHRT), they may say there is no difference! Estrogen and Progesterone  are all the same! They will also quote organizations such as ACOG (the  American College of Obstetrics and Gynecology) as stating the same  thing. They will say that long-term use of Estrogen and Progesterone can  cause heart attacks, strokes, and breast cancer. In fact when treating  symptoms of menopause, your doctor is trained to only use HRT at the  lowest dose, for the shortest period of time necessary to control your  symptoms and then discontinue the medication for fear that it will harm  you. In contrast we are certified by the World Link Medical Organization  and we have been trained by masters of the Age Management Medical  Literature that have looked at all of the available evidence on the  safety and efficacy of HRT versus BHRT. The evidence clearly shows that  HRT is not equal to BHRT. The side effects and health effects of the  progestins and unopposed estrogen is dangerous to our patients. On the  other hand, when prescribed by well trained practioners, who follow up  regularly with their patients and follow their lab levels, BHRT can be  done safely and effectively to help our patients feel better, look  better, prevent diseases of aging and avoid long term complications and  diseases of aging, such as heart disease, diabetes, stroke, breast  cancer, Alzheimer’s disease and osteoporosis among many others.

Progesterone
Progesterone  is a steroid hormone involved in the female menstrual cycle, pregnancy,  and human fetal development. Progesterone belongs to a class of  hormones called progestagens, and progesterone is the major naturally  occurring human progestagen. Progesterone should not be confused with  progestins, which are synthetically produced progestagens, such as in  Provera.

Progesterone, like all other steroid hormones, is  synthesized from pregnenolone, a derivative of cholesterol (yes,  cholesterol is a steroid hormone!). Progesterone is a precursor of other  hormones such as cortisol and androstenedione. Androstenedione can  subsequently be converted to testosterone and the estrogens estrone and  estradiol.

Sources
Progesterone is produced  in the adrenal glands, the ovaries, the brain, and—during pregnancy—in  the placenta. In humans, increasing amounts of progesterone are produced  during pregnancy, initially in the ovary, but after the 8th week of  pregnancy production of progesterone shifts to the placenta. The  placenta utilizes maternal cholesterol as the initial substrate, and  most of the produced progesterone enters the maternal circulation, but  some is picked up by the fetal circulation and is used as substrate for  fetal hormones. At pregnancy term, the placenta produces about 250-400  mg progesterone/day. One of the reasons pregnant women often feel so  much better is the high circulating levels of progesterone!

Progesterone levels are low in children, men, and peri or postmenopausal women.

Progesterone Deficiency

  • Anxiety, panic attacks
  • Premenstrual Pain in back or breasts or abdomen and pelvis, cramping pain
  • Cysts in ovaries and breasts
  • Uterine Fibroid tumors
  • Night Sweats
  • Early Aging of skin
  • Breast tenderness
  • Hot Flashes
  • Loss of Period or erratic menstrual flow
  • Depression during pre-menstrual period, peri-menopause or menopause
  • Sleep disturbances and insomnia
  • Loss of hair from head in women
  • Brittle nails
  • Mood swings
  • Water retention
  • Chronic fatigue
  • Loss of libido
  • Weight gain especially at puberty, childbirth and menopause
  • Dry skin and Psoriasis
  • Varicose Veins
  • Headaches and migraines
  • Incontinence

Progesterone Effects
Progesterone  has a number of physiological effects, usually to counteract the  effects caused by estrogen. The effects and benefits of progesterone  include:

  • Increases breakdown of Fat
  • Helps prevent Endometrial Cancer
  • It is a natural Diuretic
  • It has a natural Anti-Depressant effect
  • It has an Anti-Anxiety effect
  • Increases Libido (sex drive)
  • Helps prevent and treat Osteoporosis (when combined with estrogen, testosterone, vitamin D3, etc.)
  • Decreases Pre-Menstrual Symptoms
  • Decreases carbohydrate cravings
  • Helps normalize the sleep cycle

Progesterone  plays an important role in brain function and is often called the "feel  good hormone" because of its mood enhancing and antidepressant effects.  Optimum levels of progesterone can promote feelings of calm and well  being, while low levels of progesterone can induce feelings of anxiety,  irritability and even anger.

Let’s look at some of these in more detail.

Effects on bone metabolism
Progesterone  influences or regulates certain proteins in bone-forming cells. This  assists in bone formation. In addition, Progesterone binds to certain  hormone receptors, thereby helping prevent bone loss caused by  naturally-occurring steroid hormones.

Effects on breast CA
Progesterone  reduces breast cancer risk by inducing cell death in T47-D cancer  cells. In addition, Progesterone increases production of the protective  P53 enzyme that may protect against developing breast cancer.

Effects on the Brain
Progesterone  is synthesized by Schwann cells, the cells that form the protective  myelin coating around many nerve fibers. This enhances myelin formation  in peripheral nerves and repair of the myelin sheath around the nerves  in the brain. Furthermore, Progesterone affects expression of several  brain proteins. These factors have implications for maintenance of nerve  function in menopause and aging, and protection against  neurodegenerative diseases, such as Alzheimer’s. The use of progesterone  is also being heavily investigated for use in Multiple Sclerosis,  because of its benefits on myelin formation and nerve protection.

Effects on the Cardiovascular System
Progesterone  protects against atherosclerosis (hardening of the arteries) by  preventing multiplication and migration of smooth muscle cells, which  are involved in arterial plaque formation. Progesterone also reduces  platelet aggregation (a key component of blood clots and the cause of  heart attacks and stroke) through the effects of nitric oxide, a  naturally-occurring chemical that causes relaxation of the smooth muscle  lining of the blood vessels.

Synthetic Progesterone
While  all progesterones are considered progestins, not all progestins are  progesterones. There is only one real progesterone; it is produced by  the human body or in a laboratory from plant hormones such as the Yam.  Synthetic progestins are not human progesterone, and they will not cause  many of the favorable actions of endogenous or bio-identical  progesterone. As a matter of fact the different chemical side chain  molecules on the chemically different progestins are believed to cause  many harmful diseases and side effects not seen with bioidentical  progesterone. For example, synthetic progestins (Provera®,  norethindrone) bind to the natural Progesterone receptor sites and  inhibit the action of natural Progesterone. In addition, unlike natural  Progesterone, synthetic progestins prevent the production of the  protective P53 gene, thereby losing the protective effect against cancer  cell formation. Furthermore, proliferation of breast epithelial cells  (increasing the risk of cancer) is greater when synthetic progestins are  combined with estrogen, when compared either to estrogen alone or no  hormone replacement at all. But, unopposed estrogen also increases the  risk of breast and uterine cancer and estrogen should never be  prescribed without progesterone.

Progesterone Supplementation
Following  the discussion, the preferred method is to use bio-identical  progesterone replacement. But progesterone is poorly absorbed by oral  ingestion unless micronized. “Micronized” means that it is milled to a  very small particle size to allow the progesterone to pass into cells  and distribute throughout the body. Progesterone, and other  bio-identical hormones, also can be custom formulated into creams, gels,  lotions, tablets, liquids, suppositories, sublingual (under the tongue)  tablets, and troches (medication on a stick that dissolves in the  mouth). Many clinicians prescribe progesterone as a cream to be applied  to the skin of the forearm. Unfortunately adsorption through the skin is  only 1/4th of that of through the mucous membrane or the gut so the  preferred method is by sublingual through a troche or by mouth in a pill  form. If our patients suffer from insomnia, progesterone by mouth can  kill two birds with one stone! A very important point for those women  who are prescribed topical progesterone and estrogen is to realize since  progesterone is adsorbed so poorly through the skin you are not  attaining adequate healthy blood levels that will counteract the harmful  effects of unopposed estrogen and you can end up with an increased risk  of breast and uterine cancer as well as symptoms of estrogen dominance!  If your doctor is prescribing topical hormones for you and checking  saliva tests to confirm good adsorption there’s a problem with that  practice. Saliva testing gives a decent picture of hormone levels before  medications are applied topically, but once they’re applied to the skin  the hormones saturate the skin as an organ including the saliva glands  and do not correlate with blood levels. To prove this fact, ask your  doctor to check blood levels at the same time as saliva levels and see  if this is true for you as well. You can get an adequate blood level  with topical progesterone, but it would take 4X the amount most doctors  prescribe, which is too costly and messy.

Many "natural  progesterone" products are heavily marketed to consumers, often said to  contain extract of yams, with extensive claims and without need of  prescription. Many contain fillers and unknown products. If they  actually do contain any real progesterone, they are not likely to have  U.S.P. quality, and the strength is always of considerably lower value  than that which is available from products available from compounding  pharmacies. In other words, don’t waste your money! Insurance companies  are not covering compounded medications like they used to. There is one  way that progesterone is usually covered and that is with a generic  progesterone pill called Prometrium. Again, this is a great solution for  a woman who suffers from insomnia. In order to get adequate blood  levels we need to usually give two times the dose as we would need to  give for someone on a sublingual form of progesterone, which is the best  way to absorb the hormone.

For menstruating women, progesterone  is typically administered in cycles, most commonly on days 14-21 or  14-25 of the menstrual cycle. Post-menopausal women, or women who have  had total hysterectomies may receive continuous daily progesterone,  since there is not need for withdrawal bleeding.

Normal doses for  natural progesterone range from 100mg to 200mg total a day, either once  or twice daily. Dosing is adjusted based on changes in symptoms and by  following lab values (blood levels).

Peri-Menopause and Menopause
Progesterone  levels are usually the first to decline as a woman ages and enters  peri-menopause. Menopausal symptoms generally are related to Estrogen  and Progesterone deficiency. Indirect effects include hot flashes,  insomnia, and irritability. Primary Estrogen deficiency symptoms include  vaginal dryness, painful urination, painful intercourse, and loss of  menstruation. Secondary symptoms of Estrogen deficiency include dry  skin, sagging breasts, osteoporosis, cardiovascular disease, and  increased risk of Alzheimer’s Disease.

Bio-Identical Hormones and Compounding Pharmacies
Most  commonly, bio-identical hormones are obtained by physician prescription  from a “compounding pharmacy”. These are special pharmacies that can  create unique or special-order medications, using U.S.P. certified and  standardized medical grade ingredients. (“USP” stands for U.S.  Pharmacopeia, and is your assurance of quality and standardization.)  Typical chain-store pharmacies, such as CVS, Walgreen’s, Brooks,  WalMart, etc., are dispensing pharmacies. They simply dispense  commercial medications. They do not have the capability to compound or  custom-formulate medications.

One of the benefits of custom  compounding is the ability to combine multiple hormones in one cream or  product, making application much more convenient. However, some  physicians choose to use individual products initially until a final  optimum dose of each supplement is determined. Then a combined product  may be used.

A word on surgically applied hormone pellets. They  are an acceptable form of hormone supplementation. However, we do not  use them for a couple reasons. It's a surgical procedure that leaves a  small scar when they are inserted 2-3 times a year. If the dose of any  of the hormones in the pellet are off you either deal with the symptoms  and side effects until the next pellet insertion, surgically remove it  and try again with a new pellet or add a pill or cream to supplement  until the next pellet is due. I believe it makes more sense to use  creams, pills and sublingual hormones until the hormone levels are  titrated to your optimal clinical effect and your blood levels are in  the optimal safe zone and then a pellet might make sense.

Controversy
Please  see the Controversy section above under Estrogen. Your doctor will have  the same reaction with progesterone replacement as estrogen. Also, many  practioners that are practicing BHRT will advise you to use topical  progesterone at too low a dose and follow your labs with saliva testing.  This will leave you with too low of blood levels of progesterone and  will in effect be giving you an unbalanced prescription of estrogen to  progesterone. This is the same thing and gives you the risk of unopposed  estrogen, namely estrogen dominance effects and increases the risk of  female cancers. One other controversy should you cycle your hormones or  do them continuously. If you are in menopause there is a faction of  doctors and women who think it is natural and healthy to cycle the  hormones so you go back to having your monthly period. That is fine  under the old adage ‘to each there own’. but I want to say there is no  medical reason to do this form of replacement. As a matter of fact, if  the hormones are helping us age better, feel better, look better and  reduce the risk of age related diseases, why would you want to eliminate  the very hormones that are responsible for these optimal effects for  25% of the month that you are off of them when you are having your  menses? Again, this is a personal decision. I am fine with it as long as  my patients have all the information to make an informed decision on  the chosen treatment strategy.

For more information on compounding, go to:
International Academy of Compounding Pharmacists
Project AWARE
Professional Compounding Centers of America
Portions of the information above used with permission form Dr. Paul Tortland’s website jocdoctors.com