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Bioidentical Hormone Replacement Therapy – Good or Bad?

I met with a new patient recently. She was strongly “encouraged” to come visit me by her daughter after a recent collapse of her health– a sinus infection that turned to bronchitis and required two rounds of antibiotics,  followed by a skin infection and then shingles!!  She insisted that she was usually very healthy and that she was not a “sick” person. And I believe her — yet, the truth is there comes a point where the bottom falls out.

Like so many women, we show up for everyone around us and meanwhile our own health could be slowly, steadily declining.  We often do not have any indication that our foundation is crumbling until numerous health events intersect and cause us to take notice.  When I quizzed this 60-something-year-old patient, she responded that she had never been on hormones  and did not want to ever take them -a likely reaction to the WHI- Women’s Health Initiative study released in 2002. The the WHI studied over 160, 000 women and their experience with synthetic hormone use post menopausal, diet modification, calcium and vitamin D supplements on heart disease, fractures, breast and colorectal cancer. The trial stands out in the minds of practitioners and patients because the trial was stopped mid-way through the study when the investigators found that the risks of using synthetic estrogen and progestins outweighed the benefits of its use. (Heiss, Gerardo et al., Health risks and Benefits 3 years After Stopping Randomized Treatment with Estrogen and Progestin, JAMA March 5, 2008, Vol 299, No. 9 ). It was determined that there was an increased risk of heart attack, stroke, blood clots, breast cancer, and colorectal cancer.  The news and media spread these findings like wildfire without looking closely at the study’s pitfalls and limitations.
Since this study was stopped and subsequently published there have been numerous critiques of the study design.The first of which is the inclusion of many patients who were not healthy and well to begin with: 35% of the women participating in this study had hypertension, 1/3 of the women were obese (BMI >30)and 2/3 of the women were overweight (BMI 25-29.9), 50% of the population were smokers – which has been found to increase your risk of heart disease, stroke, blood clots, and cancer even without using hormones. So to use a smoker in this study confounds the findings. 20% of study participants had hormone replacement before the study began.

The study’s findings still scared just about every woman and may have confused her about the safety of using bioidentical hormone replacement therapy (bHRT). So, many women have just not used any replacement hormones since becoming post-menopausal. Having very, very low hormones is considered dangerous to a woman’s health just as the over-use of synthetic hormones have been found to be.  Low hormone levels can cause an increase in fracture risk, cardiovascular risk, depression, anxiety,  and can cause a woman to feel that she is falling apart, literally, and that her quality of life has all of a sudden changed.

Quality of life issues:

With very low hormone levels, we can experience a wide range of symptoms that we may not even attribute to hormone deficiency:

  • weight gain
  • headaches
  • depression
  • lack of interest in almost anything
  • insomnia
  • dry thin skin
  • heart palpitations
  • anxiety
  • muscle weakness
  • chronic immune dysfunction
  • skin rashes
  • vertigo
  • urinary tract infections

The symptoms that we are more aware of being related to hormone deficiency include:

  • hot flashes
  • vaginal dryness
  • hair loss
  • bone density changes
  • short term memory loss
  • migraines
  • loss of sleep quality

According to a study conducted by Kent Holtorf in 2009, “physiologic data and clinical outcomes demonstrate that bioidentical hormones are associated with lower risks, including the risk of breast cancer and cardiovascular disease, and are more efficacious than their synthetic and animal-derived counterparts. Until evidence is found to the contrary, bioidentical hormones remain the preferred method of HRT.” (Holtorf, K. The Bioidentical Hormone Debate: Are Bioidentical Hormones (Estradiol, Estriol, and Progesterone) Safer or More Efficacious than Commonly Used Synthetic Versions in Hormone Replacement Therapy? Postgraduate Medicine, Volume 121, Issue 1, January 2009)

A comprehensive review of the safety and efficacy of bHRT for the management of menopause was published in 2006. This review compared and contrasted the effects of synthetic hormones with bioidentical hormones.  The studies reviewed suggest that ” bioidentical progesterone does not have a negative effect on blood lipids or veins as do many synthetic progestins and may carry less risk with respect to breast cancer risk.” Studies of both bioidentical estrogens and progesterone suggest a reduced risk of blood clots compared to non-bioidentical preparations”(Alt Med Review 2006 Sep;11 (3): 208-223).

The first goal with using hormone replacement is to use the correct dose for the patient, which means just enough to manage the symptoms of menopause. The dose needs to be tailored to each patient given her particular symptoms, history, and general health. Secondly, the goal is to measure hormone levels frequently and to use urine and saliva testing to monitor these levels. Using blood tests alone for hormone level evaluation not only does not provide accurate assessment of where the hormones are after beginning hormone therapy but also, does not help with the assessment of how the each hormone (i.e. estrogen, progesterone, testosterone) is being metabolized.  Monitoring how the hormones metabolize allows us to determine risk for unhealthy cell growth. Finally, hormone replacement therapy requires patience, as it can take a few months to find the dose that works best for your body. However, it IS possible to get you to a stable point again and feeling better than ever!