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Additional HRT Resource Articles
An Introduction to BioIdentical HRT
It has been our experience that women know that something is not right, that their periods are irregular or have stopped, but they do not want a “quick fix.” Women want to “process”— talk about these changes with a healthcare provider. Many of these women turn first to their current doctor, asking “Can you prescribe bio-identical hormones for me?” Here’s our practical advice on how to prepare to talk with your local doctor about the many ways to get bio-identical hormone replacement therapy, and what to do to support your system naturally as well as get the best results on the lowest doses.
Women can be best prepared to discuss their hormonal and life changes with a healthcare provider by understanding three basic things:
Know where your doctor is coming from.
Know yourself, your history and your health philosophy.
Know what you are asking for.
Know where your doctor is coming from
Our goal is for you to have a health provider who will want to partner and work with you to find the best possible means to help you through this challenging period in your life.
Most women have a primary care doctor or gynecologist whom they see for regular Pap tests. Often this is the place to start, or if not with that person, someone else in the group practice may be specializing in menopause. However, if you are new to an area or know you want someone new, we encourage you to call around to find a practitioner who is familiar with bio-identical hormones. Asking friends, calling local offices, checking out local newspapers, and searching the internet or the Yellow Pages for alternative health and holistic health can oftentimes lead you to a surprising resource. You may well find that nurse practitioners have more experience with bio-identical hormone therapy due to their interest in preventative health.
Remember that all health providers, doctors or nurse practitioners, are human. They have spent many years learning to be experts in their field and even more years practicing their expertise and they like to feel that they are good at what they do. They went into medicine to help people, but today, unfortunately, most are overstressed by managed care rules and financial considerations and having to work in factory-like conditions. He or she probably did not get much training in sex hormones (female or male) in medical school or residency programs. (Only in the last five years have women’s health programs in hospitals even been started.)
Moreover, the headlines and drug companies have bombarded your doctor with conflicting arguments that synthetic hormones are just as good as bio-identical hormone replacement therapy, that their trademarked hormones are the most trustworthy because they’ve been so thoroughly tested, and that women have no good alternative for the relief of symptoms of menopause. All these arguments are untrue, but they are the doctrine doctors have heard over and over.
When you are ready to call for your appointment, specifically request an appointment for a “hormone consultation.” With all the recent news and released studies on hormones, doctors are certainly expecting these calls. If the office doesn’t know what you are talking about or doesn’t offer one, that should be a signal that you need to try elsewhere. Ask for at least a 15–minute or 30–minute appointment. This should be the sole focus of your visit, and you deserve to have your “hormone consultation” comfortably dressed in your clothes in an office instead of in a “johnnie” on an exam table. If you have not had a check-up or breast and pelvic exam in the last year, be sure to schedule that after the consultation or on another day if necessary. This type of focused consultation appointment assures that you can say what you want to say and not be rushed.
Know yourself and your history
Doctors are taught to first ask for a patient’s “chief complaint,” then to ask more details about it and take a history — when, what, how, where, etc. Unfortunately, with managed care time constraints, a full discussion often fails to take place. We advise women to be prepared with a list of their symptoms, what worries them the most, what they have tried, what seems to have worked in the past, and what they would like to change.
Here is a sample script —
First, provide your chief complaint and symptoms:
Hello, Dr. Jones, I am Mary Smith and I am now 52 years old. I have been having irregular periods for the last year with some heavy bleeding. My last period was 3 months ago. I have a job I love but it is very demanding. My youngest child has just started college. I am having trouble sleeping at night, waking up with hot sweats, and not remembering things as well as in the past.
Then provide your current medical issues and medications:
I am otherwise very healthy and take no prescription medications. I take a multivitamin with calcium when I remember. I try to walk a couple times a week and not eat junk food, but I find I am gaining weight.
Then give your past history and family history:
I get regular mammograms and do not have a family history of breast or ovarian cancer. Both my parents are still alive. Other than having my gallbladder out about 10 years ago, I have never been in the hospital. I have never smoked and have a few drinks a month.
Then sum up with what you are looking for:
I want to continue living with the quality of life I had, but I’m concerned that I may be perimenopausal and need some help in getting what I had back. I have heard about bio-identical hormones and am very interested in them. Can you help me?
You obviously will want to revise this script with your own personal story. You may want to write it out and copy it for your provider or send it prior to your meeting. You can start out writing as much as you need to, but your doctor will appreciate if you keep your summary short and succinct, ideally less than a page. You will want to be assertive and honest — this is your life and this time is a wise investment. It will also be important to be able to talk openly — if a nonexistent libido is a problem you will need to bring up your sex life.
Remember YOU are the expert on your body and its symptoms, needs and feelings, although you may not understand them at this point. If you get the sense that your provider is not listening, or telling you that there are no choices and that you just have to endure or grin and bear it, we would urge you to end the appointment, excuse yourself and find someone else.
Know what you are asking for:
There is still a great deal of confusion about bio-identical hormones. Let’s try to clear that up. You can take a look at our article on the fundamentals of bio-identical hormones here.
The key points:
What is the difference between hormones: Bio-identical hormones are made in a laboratory, usually from the components of plants, to match exactly the formula that your body produces and has been used to. In contrast, synthetic hormones are designed by drug companies and are foreign to the human body, unique in ways so they can be patented. The formula has been altered in a small way — if you remember your basic biochemistry class — an H or OH or C has been switched on the basic steroid ring. Scientists did not realize that some of the changes which they originally thought were insignificant would not be — we all remember the DES story.
We are just now realizing that Provera — a synthetic, non bio-identical progesterone — may be the “bad actor” in increasing the rate of breast cancer. Premarin, the most commonly prescribed estrogen replacement therapy (ERT), is natural to a horse, being derived from pregnant mares’ urine (hence the name “Premarin”). But equine estrogen is not bio-identical to a woman’s. Prempro is the combination of Premarin and Provera: we haven’t recommended it for many years, and since the WHI studies in 2002 most conventional doctors don’t either. Other estrogens on the market, like Ogen, are made from plants but not in the same formula as a woman’s.
Human estrogen is found in three forms, called estrone (E1), estradiol (E2), and estriol (E3), all of which can be custom–compounded as bio-identical ERT. Of these three, only estradiol is available in brand name form — because the pharmaceutical companies have developed and patented various unique delivery methods for it.
What is usually available: Many doctors have knowledge of other hormone replacement products besides Premarin, but they may not be aware of which brands fall under the category of bio-identical. In regular pharmacies there are brand name, standard-dosage bio-identical products sold in many strengths: estradiol in the form of Estrace, Estraderm, Estrasorb, Climara, Vivelle or Femring; and bio-identical progesterone, sold only under one brand name, Prometrium. A significant percentage of doctors are familiar with these brand name products, and again, they are also natural and bio-identical — the doctors just may not call them that. They come in various forms and doses, including pills, vaginal creams, vaginal rings, and adhesive patches. Many women do very well on them, on daily, weekly, monthly or otherwise cyclical regimes. They only replace estradiol and progesterone, but these are the two main hormones that need replacement.
No company has yet put bio-identical estradiol and progesterone into one combined product, so if you still have a uterus, two prescriptions are usually needed (e.g., an estradiol patch worn weekly and a Prometrium pill taken nightly or cyclically). If you have had a hysterectomy, you may need prescription estradiol, and low–dose, over-the-counter progesterone cream complements this nicely. (Even post hysterectomy, your body needs both these hormones to achieve hormonal balance.) This is a great simple way to start, and your doctor should be happy to help you with this.
Custom-compounded bio-identical hormones, as described in Suzanne Somers’s books, are another option. In this approach, a practitioner usually does a hormone test, such as a comprehensive female hormone panel, to measure your existing hormone levels. Based on the results of the panel, your practitioner will then prescribe a hormone supplement for you that includes several hormones matched to your individual needs — either separately or all combined. The hormones usually include estradiol and progesterone, but they may also include a combination of other estrogens, testosterone, and/or DHEA.
Unfortunately, very few physicians have any experience with the testing or prescribing of compounded formulas, or with the follow-up necessary to tailor things to your individual response. But we are finding that more providers are willing to learn as they are hearing about compounding over and over from their patients.
In a perfect world, every woman would be familiar with her own ideal hormone balance by having had it tested at various times in her life. Maybe our daughters will have baseline hormone testing available to them as a standard of care. But for now we can work with blood tests to monitor our current hormone levels. Our favorite is a hormone panel provided in a kit from Genova Diagnostics. Other labs can also draw hormone levels with a doctor’s prescription. Very few physicians have been trained in interpreting these lab values — we’ve been told they are too variable to be reliable — but again, the science of hormone testing is changing and new standards are being established. And having a baseline is important. How often to continue to test and tweak your prescription is something that you and your provider will have to determine as you proceed, based on your unique response. We have found that some women do well on one dose for several years and others need to change dosages every three months. Changes in lifestyle or life situation can obviously create hormonal changes and necessitate changes in your prescription.
Who is a candidate for HRT?
Suzanne Somers has brought bioidentical hormones onto center stage. In her books, Ageless and The Sexy Years, and in media appearances to promote them, she describes how bioidentical hormones relieved her menopause symptoms. She also makes it clear that she intends to stay on them for the rest of her life.
As a result, The Institute for Optimal Health is now deluged with calls about bioidentical hormones. The basic question women ask is, “Are they for me?” Let’s explore what we’ve learned about bioidentical hormone replacement therapy (BHRT) in over 15 years of use in our clinical practice, and help you answer that basic question for yourself.
Just what are “bioidentical hormones”?
Bioidentical hormones are manufactured to have the same molecular structure as the hormones made by your own body. By contrast, synthetic hormones are intentionally different. Drug companies can’t patent a bioidentical structure, so they invent synthetic hormones that are patentable (Premarin, Prempro and Provera being the most widely used examples).
Though bioidentical hormones have been around for years, most practitioners are unfamiliar with them. There are several branded versions now available for use in the kind of hormone replacement therapy (“HRT”) typical of synthetic hormones. This is generally a one-size-fits-all dosage regime.
In our practice, we have had the greatest success with an individualized approach. We begin with laboratory tests of hormone levels (a so-called “hormone panel”). We then prescribe a precise dosage of bioidentical estrogen, testosterone or DHEA that is made up at a compounding pharmacy. Each patient is then monitored carefully through regular follow-up hormone panels to ensure we get symptom relief at the lowest possible dosage. In the initial stages, we will do a hormone panel every three months. Once balance is restored, we’ll do one panel a year at the time of the annual exam.
Are bioidentical hormones better than synthetic hormones?
We long ago concluded that the answer to this question is yes. But that doesn’t mean bioidentical hormones are perfect.
The great appeal of bioidentical hormones is that they are natural, and our bodies can metabolize them as it was designed to do, minimizing side effects. Synthetic hormones are quite strong and often produce intolerable side effects. Moreover, the compounded bioidentical hormones can be matched individually to each woman’s needs — something that’s just impossible with mass-produced products.
Are bioidentical hormones safer than synthetics?
European medical studies suggest that yes, bioidentical hormones are safer than synthetic versions. This makes perfect sense. But we must be cautious here, because they have not been well-studied, especially for long-term use. And in any case, we never recommend that a woman think of a drug as completely safe.
Let us note here that the WHI studies on the effectiveness and health risks of HRT were based on synthetic/equine-based hormones. Read our article on the risks of HRT for our perspective on these studies.)
(Let us note here that the WHI studies on the effectiveness and health risks of HRT were based on synthetic/equine-based hormones. Read our article on the risks of HRT for our perspective on these studies.)
What does The Instititute for Optimal Health recommend?
The great majority of women can rebalance their hormones without the use of drugs. We have found that about 85% can find relief through an approach that combines medical-grade nutritional supplements, gentle endocrine support, and dietary and lifestyle changes. We recommend that every woman start with this combination approach as a foundation of health.
(A personal program is designed for you as part of your initial evaluation. Our dietary guidelines are based on Dr. Diana Schwarzbein’s work — the same endocrinologist who introduced Suzanne Somers to bioidentical hormones.)
Even with this foundation, a minority of women will need to add prescription-strength hormone supplements to get complete relief, at least through a transition period. We recommend they use bioidentical hormones, preferably in a compounded form personalized to their needs by an experienced practitioner. It’s important that the hormones be used in addition to the combination approach outlined above.
(Note that Suzanne Somers is among this minority — she began with a healthy diet and lifestyle that supported her endocrine system, but still experienced intractable symptoms.)
We don’t recommend that any hormones be used long-term unless essential for symptom relief, and then only with a complete risk assessment. We also don’t support the idea that bioidentical hormone therapy should be used indefinitely as some kind of fountain of youth.
What about bioidentical hormones for breast cancer patients?
The pendulum has swung so far that today, very few doctors will prescribe any type of HRT — synthetic or bioidentical — for women who have had breast cancer or even a family history of breast cancer. In fact, many such women are given anti-estrogen drugs.
Dr Seema Patel at The Institute for Optimal Health, feels that we just do not have enough data to rule out HRT in every case, and prefers to look at each woman’s particular situation, history, pathology and blood work.
Janet was a 54-year-old woman who came to us with severe menopausal symptoms. We changed her diet to increase her protein and vegetables and reduce carbohydrates, added a pharmaceutical-grade nutritional supplement, and did a complete blood hormone panel.
At her first follow-up visit six weeks later, Janet definitely felt better, but she still suffered too many hot flashes and sleepless nights. Our next step would have been to increase her soy intake, but Janet wanted immediate relief and chose to try bioidentical hormone replacement therapy.
After reviewing her hormone panel we placed Janet on a combination of bioidentical estradiol (one of the three forms of estrogen), testosterone, DHEA and progesterone, all in cream form. Six weeks later Janet came back for another follow-up. “I feel fabulous,” she said, explaining she hadn’t felt this good since her early 30’s.
A year later Janet still feels great. She’s carefully compliant with her diet and exercise regime, and takes her bioidentical hormones faithfully. Her latest hormone panel shows she’s still in balance and there is no need to adjust her dosages.
Not every patient is as easy to help as Janet. Sometimes we have to adjust the formulas three to five times to get it right. But it’s a very effective solution.
So — are bioidentical hormones for you?
At The Institute, our goal is to help inform women about their options so that they can make the choice that’s best for them. We’ll support you in any way we can. The good news is that women can feel incredibly well right through menopause.
Our Personal Program is an at-home version of the approach we use at our clinic. Its medical-grade supplements, gentle endocrine support, and dietary changes are often all you need to restore hormonal balance.
Assess Your Risk: Hormonal Health Profile
Most women are surprised to learn that the symptoms they've been dealing with for months or years are really signs of hormonal imbalance — and that there's a lot they can do to heal themselves. The following questions are designed to assess your own hormonal health, and to help you on your journey towards personal wellness.
The assessment takes most women no more than a few minutes to complete.
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