If you prefer an abridged version of this article you can listen to this AI generated audio.
Since I have retired and my patients have been meeting with new providers the 2 most common questions I have received have been about the merits of various hormone therapies and the best method to test hormone levels. Talk about putting me on the spot! I have started and stopped writing this newsletter many times hoping the questions would just go away – but they didn’t. I have been dragging my feet since answering these questions in a newsletter is hard. The answer to these questions is very nuanced and really needs to be individualized. Each provider will have their reasons for the therapy and monitoring that they recommend. So my general answer to these questions has been to ASK YOUR PROVIDER to explain why they have chosen a specific therapy as the best option for you. MANY THINGS FACTOR INTO A PROVIDERS CHOICE and a discussion of those factors oftentimes relieves any anxiety you may have about a proposed treatment.
OK – OK! WITH ALL THAT SAID
MY MISSION IS TO HELP AND EDUCATE WOMEN – SO I WILL ANSWER (IN GENERAL TERMS) THESE 2 COMMON QUESTIONS.
WARNING – be prepared for a long winded explanation of how I developed my preference for certain types of bioidentical hormone replacement therapy (BHRT) and BHRT monitoring methods. There is just no short way to answer these questions! In fact my explanations are so long that I will call this PART 1 OF OUR HORMONE DISCUSSION. I will delve further into my thoughts on hormones in future newsletters since the next most common question has been about hormone risks and benefits.
MY JOURNEY (PERSONAL AND PROFESSIONAL) WITH BHRT THERAPY
For me it has been a long journey – I started prescribing BHRT in my practice in 1993. Since that time, I have never prescribed just one type of BHRT, and I have never recommended BHRT to everyone. In fact, some of my healthiest patients in their 70’s were never on hormone replacement. There are many personal health facts that need to be considered when evaluating the risks and benefits of hormone replacement therapy. I am very opposed to the “hormone shops” that have sprouted up that seem to sell hormones to anyone and usually only offer the hormone formulas that make their clinic the most money. Being a woman who has used hormones myself (thanks to an early menopause and significant symptoms) and my whole career being dedicated to treating women – I take hormone therapy seriously! Since hormones are part of a woman’s overall health picture – at The Midlife Wellness Center I insisted on a big picture view (extensive history and labs) of every woman’s health before any hormone recommendation would be made. I also made it clear that hormone replacement alone was never the perfect solution – diet and lifestyle must also be optimized. Using this approach, over many decades, and seeing tens of thousands of women – it’s safe to say I have had an extensive hormone education! Helping women use hormones in real life (vs what you read about in textbooks or studies) I of course developed some general preferences which I will now outline for you.
MY PREFERENCE FOR BHRT CREAM
In the 1990’s the “GOLD STANDARD” hormone therapy was Premarin (a collection of “estrogen like” hormones obtained from the urine of a pregnant horse) and Provera (a non-bioidentical “progesterone like” hormone called a progestin). I had read the research data done by pharmaceutical companies on these products, but as I have already stated, I have ALWAYS found that the best data is derived from LISTENING to my patients and respecting what they tell me when they are using a new product.
WHAT I DISCOVERED IS THAT MY PATIENTS USING PREMARIN AND PROVERA WERE NOT DOING NEARLY AS WELL AS WHAT WAS DESCRIBED IN THE RESEARCH DATA!
Since I have always gravitated toward more natural solutions it had also bothered me that we were throwing all these foreign hormones into a woman’s body. I felt I owed it to my patients to look for a better solution, so I dug into my knowledge of human physiology to look for some guidance. What I had been taught about the sex steroid hormones is that they are produced in a hormone cascade from the parent molecule cholesterol. The resulting hormones such as estradiol, progesterone and testosterone have characteristic chemical structures/shapes. These hormones work in the TISSUES of the body by fitting onto their corresponding RECEPTOR (like a key fits into a lock). When a hormone FITS onto its receptor it then triggers the expression of many biologic functions that can be beneficial for your health. Obviously, using hormones from horses or non-bioidentical hormones that do not fit the receptor exactly (and do not trigger the same receptor response) could explain the side effects my patients were reporting. The other issue was that the hormones in use at that time were swallowed as oral pills. Oral medications go directly through the GI tract and liver (this is called the first pass effect) where they are metabolized into METABOLITES that have a different shape than the original hormone. Different shapes mean that the metabolites may not fit their hormone receptor exactly, as nature had intended, and not trigger the desired effect, or worse cause unwanted side effects. Oftentimes doses of oral hormones have to be large, since initial metabolism reduces the concentration of the desired hormone. The problem with larger doses is that the liver has to work harder to process and eventually eliminate all those hormones. Believe me, in this modern world, the liver is already working overtime to process toxins. Oral hormones can also stimulate the liver to produce compounds such as hsCRP which when elevated increases a woman’s risk of inflammatory disorders and blood clotting. When the body produces hormones naturally they can exert their effects right away before they are sent to the liver to be metabolized.
BOTTOM LINE – IT SEEMED LOGICAL THAT USING BIOIDENTICAL HORMONES THAT WERE NOT SWALLOWED WOULD BE A BETTER OPTION FOR WOMEN.
The one caveat is that in some instances oral progesterone is preferred since the metabolites of progesterone for some women can be more calming and have a greater effect at the uterus.
Since BHRT transdermal options were not taught in medical school (even to OB/GYN’S) and were not available through traditional pharmacies I turned to compounding pharmacies to obtain bioidentical hormone creams that would be absorbed through the skin. BHRT troches (that dissolve in between the cheek and the gum) were available but after trying them I found them awkward to use, some of the hormone was swallowed while waiting for the troche to dissolve, and testing accurate hormone levels was difficult so I preferred the transdermal hormone creams. Injections and later surgically inserted pellet options were also available. I quickly found them undesirable since they caused fluctuating non-physiologic high and later low hormone levels (which in my experience caused more side effects and had greater risks). In addition, they were also more expensive and not as user friendly since they required more frequent doctor visits.
So how did my patients do on this new transdermal hormone cream? Almost without exception – my patients preferred bioidentical hormone creams due to better relief of their symptoms and fewer side effects.
It was an improvement, but it also involved a learning curve. Since I was doing something new, I paid very close attention to how my patients’ bodies were responding to BHRT creams. Being an OB/GYN was a great advantage since I was able to not only listen to my patients but also to examine them, monitor their labs, mammograms and uterine ultrasounds. I am a longtime believer in the benefits of hormone replacement therapy for many women but with too much estrogen you can get proliferative effects in the breast and uterus that can predispose a woman to cancer.
Like many things in life – there is a goldilocks effect with hormones. You don’t want too little and you don’t want too much, so I was paying close attention to find an optimal dose.
A side note here is that the old “gold standard” Premarin and Provera were given in a mostly one-size-fits-all dose and levels of hormones were never monitored! Obviously another reason why those hormones were not an optimal solution. In fact in 2002 Premarin and Provera were dethroned from their preferred status when the Women’s Health Initiative Study showed unfavorable results. KUDO’S TO MY PATIENTS – you alerted me to the unfavorable side effects of Premarin and Provera almost a decade prior to this study.The unfortunate thing, however, was that as the medical community regrouped to find an alternative to Premarin and Provera – the advice was for all women to stop hormone therapy.
Eventually transdermal forms of hormones such as estrogen creams, gels, patches and mists did become available from the pharmaceutical industry offering safer and more effective alternatives. I do use these options in specific circumstances. An example is using estrogen cream placed into the vagina for better relief of vaginal dryness or using an estrogen patch if hot flashes are intractable (since with the patch the level of the hormone is less variable). An unfortunate trend, however, is that the cost of these pharmaceutical options has gone up and up and many times insurance will not cover them. It is very unfortunate that women’s health is oftentimes treated unfairly.
In this newsletter I am concentrating on the mode of delivery of BHRT. In a future newsletter I will discuss reasons for using Estradiol and/or Estriol since both are options in a compounded hormone cream.
ONCE ON BHRT – HOW SHOULD HORMONE LEVELS BE MONITORED?
The 2nd most common question you have asked – I will now answer. Stay with me – the answer is technical! I will need to explain the difference between blood and saliva hormone testing.
The traditional way of checking hormone levels (before transdermal BHRT became available) was to do a blood draw to determine the amount of hormone floating around in the blood. So early in my use of BHRT creams, I was checking blood levels – which in many cases showed that the blood levels of the hormones being used were LOW. Well, that could have been because this was a new therapy and I was underdosing the hormones. The interesting thing was that on those doses of BHRT cream – the patients were reporting symptoms of HIGH hormone levels (if you ask me the patient is always the best lab – so I believed my patients). I also noticed increased breast density on exams and mammograms and thickened uterine lining on ultrasounds – all pointing to TOO MUCH HORMONE!
VERY CONFUSING SINCE BLOODWORK WAS SHOWING LOW HORMONE LEVELS!!
Luckily for me, I met a breast cancer researcher, Dr Zava , whose interest in reducing breast cancer had led to starting a company that tested hormones in saliva. The premise behind this new type of testing was that the fatty female hormones (which are made from cholesterol) don’t stay long in the watery blood unless a protein carrier is attached to them called sex hormone binding globulin (SHBG). When the body NATURALLY produces the sex hormones, the body ALSO produces this carrier protein to help escort the hormones through the blood. Since hormones work by finding their receptor in tissues – when the body wants to use a hormone the SHBG is detached from it and the free fatty hormone scoots out of the watery blood (oil and water don’t mix!) to find its receptor in the tissues. What was discovered was that when you apply BHRT cream (since the body does not produce these hormones) there is no SHBG attached to the hormones so they quickly enter the tissues to do their job. Looking for the hormones in the blood was not an accurate assessment. Dr Zava at ZRT labs was testing saliva which is A SECRETION FROM A TISSUE. Tissue levels of hormones are desirable (since that is where they WORK). In the tissues we want to know that hormone levels are BALANCED AND SAFE. The problem is it’s not practical to go around taking biopsies of tissues to look at hormone levels so Dr Zava devised the saliva test. The method he had devised made sense to me and once I switched my patients to saliva hormone testing – the results I got from the lab mirrored what my patients and their bodies were telling me. If the saliva test said the dose was too high – that was also what my patients were reporting (remember previously the blood work would often read low). Once the dosage was correctly adjusted, the patients symptoms improved and their mammograms and ultrasounds did not show proliferation.
Saliva testing is a reasonable price and providers can give you codes that you can submit to your insurance for possible reimbursement or HSA/FSA funds can be used to pay for saliva testing.
A LITTLE SIDE NOTE -For those of you with a curious mind – why have we doctors for years used blood levels to test the NATURAL hormones that your body produces. It goes back to what I have explained already. When the body NATURALLY produces a hormone with SHBG attached – it does show up in the blood and blood work which is usually covered through insurance can be used to monitor natural hormone levels. Insurance has been slow to adopt the use of saliva testing except for cortisol saliva testing which has been available through insurance labs for years (as you know there is no rhyme or reason to insurance logic). So bottom line its ok to check NATURAL hormones in bloodwork since that’s easier and cheaper for many patients. Once a patient is on transdermal hormone therapies I feel more accurate results are obtained through saliva (tissue level) testing.
MONITORING HORMONE LEVELS IN URINE
Through specialty labs urine hormone testing is also available. What is measured in the urine is hormone metabolites that the body is ELIMINATING. As I have stated, I am usually more interested in tissue hormone levels. Urine hormone testing is also much more expensive, not paid by insurance and is cumbersome to collect, so I did not use it routinely in all women. Proper hormone metabolism and elimination is affected by diet, supplements and lifestyle so I preferred to teach my patients what they could do to help their bodies use, metabolize and eliminate hormones properly. That’s why in addition to the proper diet and lifestyle that I emphasized to all my patients – many of my patients were placed on supplements from WholeScripts such as – Xymogen’s XenoProtX one in am or MedCaps DPO one in am or Liver Protect one in am. These “hormone helper” type supplements help the body metabolize and eliminate hormones properly. You want the body to have the benefit of hormones but once the hormone has exerted its effect in tissues – it is very important that your body metabolizes and eliminates that hormone. You do not want unhealthy levels of hormones to build up. In some circumstances women would not respond to hormones as expected and in those cases I did find urine hormone testing helpful. Urine hormone testing can always add helpful information but in the interest of not over testing I used it mainly in select cases.
WOW – I KNOW THAT WAS A LOT TO DIGEST! Please remember that what I have outlined is just a general overview of how I approached BHRT therapy. My method is not the only method! Let me reiterate that it is very important to remember that each practitioner will have their own experience using BHRT and their own reasons for what they prefer. They can discuss their preferences with you. Your provider will also factor in the specifics of your unique health history to arrive at your best BHRT option.
