Bio-identical Hormones 

Goals of therapy:

- patient specific, individualised treatment

- hormone associated presenting symptom reduction (e.g. fatigue, hot flashes, irritability, depression, low libido)

- education and management of risks associated with bio-identical hormone replacement

- improved quality of life with better mood, energy, and sleep

 

Risk / benefit discussion:

The Women’s Health Initiative was a ground-breaking study that dispelled myths that drug based hormone replacement reduced cardiovascular risk. In fact, use of synthetic estrogens such as conjugated equine estrogens and progestins such as medroxyprogesterone acetate increased risk of cardiovascular disease and certain types of cancer. 

There is a conception amongst the public that if we use bio-identical hormones, instead of horse urine estrogens or synthetic progestins, the risk is less. While this may be the case, we do not know if it is. Therefore, we would prefer the patient to be educated on what the actual risk with synthetic hormone replacement is, and then assume that bio-identical hormone replacement gives the same risk.  Route of administration may be an important factor, especially with estrogens.  Oral estrogens may be associated with increased risk of clotting related risks.  Thus in our practice, estrogens are most commonly applied transdermally.

 

It’s all about the balance:

Our program then goes one step further. If a patient is willing to accept the above risk, we then try to reduce risk by testing comprehensively their current hormone picture, and then replacing indicated hormones, as per symptom picture, history, family history, physical exam findings and lab test results, with the goal of restoring better balance .  Nutritional means are often recommended with the goal of promoting a more healthy metabolism of these hormones.

Our preferred test that most comprehensively captures the current hormone picture is a 24 hour urine test for both sex and adrenal hormones, along with blood tests for thyroid hormones.

Sex hormones, estrogen, progesterone, and testosterone, fluctuate during the day. A 24 hour urine test allows us to capture all of those hormones in full day, allowing us to see what underlying imbalances are present.

For example:  Some women may have lower than optimal progesterone, as per symptom picture and labs.  Adding additional progesterone may improve quality of life.

The 24 hour urine hormone test also allows us to capture all three types of estrogen that are normally present in the body, estriol, estradiol, and estrone. Estrogen metabolites may be included, which may be preferable as to assess patterns in how a woman may be metabolising her estrogens.  Dietary and lifestyle changes, nutrients and botanicals may be recommended as per estrogen metabolism results.  Running the 24 hour urine profile that includes estrogen metabolites is a bit more expensive, although individual variations in estrogen metabolism patterns may be better elucidated, helping better personalise her treatment.

While some physicians prefer using the urine test for thyroid hormone as well, we prefer the blood thyroid hormone tests in combination with symptom assessment. This allows for better dosing and monitoring of thyroid hormone replacement.

 

Replacing hormones naturally:

Once we have our comprehensive assessment of a patient’s hormonal status, we can decide on a treatment plan that replaces those hormones to restore balance.  Potential risks and benefits will be discussed.

We prefer to use the hormones that the body naturally produces, identical (or similar) in structure and function. We have compounding pharmacies make up a cream or pill that is specific for the patient’s test results. This might be a combination cream of different estrogens, or it might be simply bio-identical progesterone, or may be the thyroid hormones in pill form. 

We typically follow up in 1-3 months to assess changes in symptom picture and decide with the patient whether dosage modifications may be recommended. At 3-6-12 months a repeat of the urine and/or blood test may be recommended to assess dosage, route of administration, and metabolism depending on the hormone.  For thyroid hormone blood testing is preferred, typically after 1-3 months, depending on type of thyroid hormone being tested, and individual case variables.  Reassessment of symptom picture is important for hormones, symptom pictures often change slightly between cycles, especially around the time of menopause, and also periods of acute and/or prolonged chronic stress.