Bio-Identical Hormones

The whole idea of using hormones is very confusing for patients as well as doctors.  I have compiled the most accurate up-to-date information possible, and made it as understandable as possible for you.  Many of the ideas on how to dose and manage these medicines are my opinions formulated from much research and years of experience.  Please read the Basic Information below and complete your Personal Questionnaire BEFORE your appointment with me.

PLEASE download and COMPLETE by hand, This Questionnaire and BRING it with you to your appointment. Thank you!

This will help us both clarify what you are best suited for based on your goals.

Thank you.

~  Dr. Terri Vanderlinde

Ovarian BIO-IDENTICAL Hormones:

B-HRT (Bio-identical Hormone Replacement Therapy)

In menopause, ALL ovarian hormones are NORMALLY low. This does NOT require ANY treatment, unless the woman is experiencing symptoms that have not been alleviated in any other fashion, such as changing diet, improving exercise, trying herbal remedies, using a liver cleanse, getting acupuncture or using homeopathy. If her symptoms are still markedly affecting her work, relationships, or sleep, after trying safer and more natural options, then it may be worth considering B-HRT. (See also Hot Flashes and Vaginal Dryness Information Sheets.)

The best overall plan as recommended by the American College of Obstetricians & Gynecologists is to use the “Lowest Dose for the Shortest Time” to achieve your Desired Effect in maintaining the Quality of your Life. This does not apply to topical, local vaginal dryness treatment, only for systemic therapy.

It is imperative to determine what you hope to accomplish, i.e. the GOALS you have for this therapy. Despite what Oprah and Suzanne Summers say, this is NOT a MAGIC fix. It will NOT cure bad relationships at home or at work, it will NOT reduce your stress, and it will NOT cure fatigue (unless it is due to insomnia from night sweats.) It might help somewhat with mild depression, maybe help a little with sexual desires, and it does help prevent osteoporosis to some degree by absorbing calcium better.

HRT very likely DOES help prevent heart disease by lowering cholesterol slightly, but only if started very close to the time of menopause. If started later in life, it can actually worsen the risk of heart disease for 2 – 3 years before it reverts back to a lower rate after 3 years.

Women with certain medical issues, such as breast cancer, heart disease, stroke, or history of blood clots should NOT be on any estrogens. The serious drawbacks to any Hormone Replacement Therapy are: an increased risk of blood clotting, which could lead to a heart attack, stroke, pulmonary embolism or death. Some of these risks can be lessened by choosing a non-oral route for systemic therapy. Theses risks apply to systemic treatments only, not topical, local vaginal dryness treatment, which do not get absorbed very much.

There may be a faster growth with HRT of a breast cancer if it’s already present. This sounds like a ‘bad’ thing, but it is actually ‘good’ news that the cancer is found at an earlier stage, a lower grade, smaller, less likely to have spread and more easily treated. Women who get Breast Cancer on Estrogens, still live longer than women who get Breast Cancer NOT on Estrogens. This is believed to be due to better cardiac health, and assisted earlier detection by rapid, local, less-invasive growth seen on Imaging or felt on Breast Exams. Breast Cancer patients with ER/PR positive Receptors should NOT take Systemic HRT.

Many patients ask to have their hormone levels tested in the laboratory. Only in a rare instance do we find these helpful. The exact number is irrelevant, as long as a woman is noticing the desired effects. Many women will note dramatic improvement at a very low level, while others note very little change at a much higher number. Only when you are at a higher dose and there still seems to be no effect, will we then recommend testing hormone levels to make sure the absorption is good and to make sure that the levels are not too high.

Using these hormones is anything but an exact science. As natural body hormone levels decline, more replacement hormone may be required. And depending on other medications and other hormones, the dosing may need to be adjusted frequently to attain the desired effect. Rarely do we get to too high of a dose, since we start low and adjust slowly, paying careful attention to all side effects. We are constantly trying to hit an ever-moving, ever-changing target. This therapy requires patience and persistence. Are you ready? First let’s define some terms and review the proper use of B-HRT.

‘Bio-identical’ means that the chemical used is exact chemical formula as human female ovarian hormones. It may have originally come from a plant source (soy, yams, peanuts) and been slightly modified in the laboratory to become the identical hormonal compound.

‘Bio-identical’ does NOT mean ‘natural’. It could be completely created from chemicals in the lab and still be accurately called ‘bio-identical’. Most are from modified plant chemical compounds. NONE are totally ‘natural’ (i.e. from a human female).

‘Bio-identical’ does NOT necessarily mean the same as ‘compounded hormones’. Compounding is one option, chosen when commercial products do not meet a person’s needs. Specially trained pharmacists put together in a cream, capsule or other form, specific doses of Estrogen, Progesterone and/or Testosterone by hand. They use much less preservatives and chemicals in their products. Some studies show that sometimes the doses are not as precise as those made by drug companies. And unfortunately, health insurance companies do not cover the cost of this special formulation. Ask us about local and national compounding pharmacy options.

Bio-identical Estrogen (17 B – Estradiol) is available through commercial pharmaceutical companies in a wide range of doses and forms such as a pill, patch, gel, cream or vaginal ring, which health insurances usually DO cover the cost of prescriptions. Some examples are Estrace, Climara, Vivelle, Estragel, Estrasorb, Divigel, Femring Estring, Vagifem, etc.

Other Bio-identical Estrogens include Estrone and Estriol. Estrone is a basically inert type of estrogen made by a menopausal ovary in tiny does. Estriol is naturally made only during pregnancy. They can be compounded additionally with the Estradiol, but with minimal benefit, and presumed – but technically unproven – improved safety profile.

Bio-identical Progesterone (micronized progesterone) is available in only one commercially available oral capsule called ‘Prometrium’.   Bio-identical Progesterone in a different dose, or a different form (cream or capsule), must be compounded at a special pharmacy.

If you have a uterus, you MUST also take a progesterone to protect the lining from estrogen overstimulation, which may lead to abnormal cells, which might lead on to uterine cancer (1%).   Progesterone usually prevents the overgrowth induced by Estrogen.

Some women choose to take their hormones on a cyclic basis so that they can have their period again. Most menopausal ladies choose to do this on a continuous basis, so that they don’t have any bleeding. This is a personal preference.

The menopausal dose level of estrogen and progesterone is NOT high enough to prevent ovulation or to be used as contraception. They are not often used prior to menopause.

Topical Estrogen is applied directly to the vaginal opening. It is an extremely low dose cream, suppository tablet or thin plastic vaginal ring that is used only for vaginal dryness causing sexual discomfort. These do not require progesterone protection of the uterine lining because the doses are so low. They MAY, carefully, intermittently, in low doses be occasionally considered in women who otherwise should NOT take systemic estrogen (women with Breast Cancer or with a history of Blood Clots.)

Systemic Estrogen gives a good enough level of estrogen in many organs throughout the body. This helps well for hot flashes, night sweats, vaginal dryness, insomnia, labile moodiness, skin tone, maintenance of healthy eyes and teeth, heart disease prevention and osteoporosis prevention (- along with good doses of calcium, vitamin D, and weight bearing exercise).

There are Combined Estrogen patches and pills commercially available with bio-identical Estrogen. All the combos are with safe, low dose Synthetic Progesterones (but not ‘Provera’). Examples of combined patches are Combipatch and Climara-Pro. Examples of combined pills are FemHRT, Angelique, and Activella. If you desire both bio-identical estrogen and bio-identical progesterone combined together in one, that formulation requires a compounding pharmacy to make up a special capsule or cream for you.

Methyl-Testosterone is available via only one pharmaceutical brand combined with plant-based conjugated estrogens called Estra-Test. The ‘methyl’ group is helpful in the oral forms so that the Testosterone retains its potency. Topical oils and creams can use straight Testosterone and expect good results. We add in Testosterone only after the Estrogen dose has been optimized. There are potential complications such as increasing cholesterol, worsening heart disease, causing oily skin, acne or hair growth. Cholesterol levels and other side effects must be closely monitored. Testosterone’s has minimal effect on sexual desire since its response is HIGHLY VARIABLE due to the MANY OTHER possible reasons for low libido. (See Sexual Desire Information Sheets for more information.)

Let’s talk more about your personal goals of therapy and see if using hormones is a right choice for you, your needs, and your health and safety concerns. We look forward to meeting with you, answering your questions, and helping you decide your best plan.

Thank you for your time and effort to help us serve you better.  

                                                      ~ Terri Vanderlinde, DO & Laura Hudson FNP-C

PLEASE download and COMPLETE by hand, This Questionnaire and BRING it with you to your appointment. Thank you!