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Clinical Application of BHRT

Tracy Marsden BScPharm, DHPh

Types of Hormones
Estrogens Progesterone Testosterone Cortisol & DHEA

Pre-Menopause
OVARY

Testosterone Progesterone Estradiol

aromatase

Estrone

Estriol

Estrogens
3 main types: estradiol, estrone, estriol. Estradiol is the main estrogen produced by

the ovaries.
Estrogen receptors found throughout body:

brain, blood vessels, bone, etc.

Progesterone
Synthetic progestins like Provera are not

the same as progesterone.

All women need progesterone to balance

effects of estrogens (even women who have had the uterus removed!)
Progesterone increases the bodys

sensitivity to the estrogens it has.

Androgens
Testosterone is important to women for: Bone Sex drive Energy, sense of well being DHEA and androstenedione are important

building block hormones: needed to make androgens and estrogens (particularly after menopause).

Cortisol
Is the primary stress hormone. High cortisol levels can interfere with the

actions of all the other hormones.

Prolonged elevation of cortisol can deplete

the adrenal glands.

Post Menopause
ADRENAL GLAND

Cortisol

Dehydroepiandrosterone (DHEA)

Androstenedione
aromatase

Estrone

Testosterone
aromatase

Estriol

Estradiol

Normal Cycles
Progesterone is produced in quantity after

ovulation

Menstrual Cycle 6 month view

Progesterone peaks after ovulation and balances estrogens. Cycles are regular.
Peri-menopause 6 month view

Relative excess of estrogens over progesterone. Cycles are irregular.

Post-menopause 6 month view

Very little progesterone or estrogens released by ovaries. No cycles.

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Hormone Balance
There is an intricate balance

among all the hormones; too much of one can create an imbalance.
Maintaining the right balance

can reduce symptoms and help prevent disease.

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Hormone Therapy Missteps

Giving unopposed estrogen to all women (no

progesterone given to balance estrogens) without testing or proof of need.

When we found out estrogen alone increased

endometrial cancer risk, we added a synthetic progestin instead of natural progesterone.

When we found out synthetic progestins

increased heart attack and stroke risk, we just decreased the dose.

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A better approach
THREE SIMPLE STEPS

Symptom assessment Hormone testing Restore hormone balance with bioidentical hormones

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Symptom Assessment
Symptoms: Please rate your symptoms according to the following scale: 0 - never or rarely experience this symptom (<20% of the time) 1 - experience this symptom some of the time (~20-49% of the time) 2 - experience this symptom most of the time (~50-70% of the time) 3 - experience this symptom all of the time (~80-100% of the time) For example if you experience allergies some of the time, you would indicate this by darkening the 2 next to Allergies: ijvl Allergies. If you do not understand the symptom, please leave circles blank. ijkl Hot flashes ijkl Night sweats ijkl Water retention ijkl Breast tenderness ijkl Decreased sex drive ijkl Memory lapses ijkl Foggy thinking ijkl Heart palpitations ijkl Irritability ijkl Loss of muscle bulk

Step 1: Symptom Assessment

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Hormone Testing Options

Urine Measures what the body throws away

Blood Measures what might eventually get to tissue

Saliva Measures what actually gets to tissue

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What are bio-identical hormones?

Bio-identical means that the hormones are

identical in structure to what is produced naturally in the body.

More accurate to call them Human-Identical

Hormones, but BHRT is a common term.

Studies showing harm from hormones used

synthetic or semi-synthetic hormones (horse estrogens, synthetic progestins)

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Principles of BHRT
Use the identical hormone to that which the

body produces on its own

Give bio-identical hormones in the way that

is closest to the way hormones are released in the body

Use the minimum dose to relieve

symptoms.

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Bio-identical Hormone Replacement

Bio-identical hormone replacement (BHRT)

includes:

Estradiol patches and gels oral micronized progesterone

These bioidentical products are not

controversial

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Transdermal Estrogens
However, BHRT also includes: compounded oral or transdermal combination estrogens (BiEst, TriEst) compounded progesterone creams compounded sustained release oral micronized progesterone

. . . which are more controversial types of bioidentical hormone replacement.

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BiEst and TriEst

BiEst and TriEst contain mostly estriol, the

weakest estrogen.
Theoretically, estriol raises estrogens levels

when they are low, and competes with stronger estrogens for receptor sites when estrogen levels are high.
Some research suggests that estriol may be

protective against breast cancer.

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Bi-Est
BiEst (bi-estrogen) is a combination of estriol

and estradiol in oral or transdermal form

Various combinations available: 80:20, 70:30, 50:50 First number refers to the estriol component

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Tri-Est
Tri-Est not used often as most women do

not require estrone.

TriEst (tri-estrogen) is a combination of

estriol, estrone, and estradiol

Various combinations available: 80:10:10, 90:5:5, 60:20:20

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Estriol (E3)
Effective for hot flashes, insomnia, poor

memory.

Head K. Alt Med Review 1998;Vol. 3(2)

Intravaginal use may be effective for vaginal

dryness, infections, recurrent UTIs and dyspareunia. Head K. Alt Med Review 1998;Vol. 3(2)
Estriol has been safely used in Europe for

decades, although is not approved for use in North America.

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TriEst and BiEst

Unconventional compounded estrogens do

not appear to be worth the extra cost and effort they exact, but they do represent an addition therapeutic option for women who cannot tolerate conventional prescription estrogens.
Taylor M, Clin Obstet Gynecol; 2001 Dec;44(4):864-79

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Bio-identical Progesterone
Progesterone (bio-identical hormone)

compared to Provera (medroxyprogesterone acetate)

Progesterone cream versus oral micronized

progesterone

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Progesterone
Acts with estrogen to relax

MPA
Inhibits relaxation of blood

blood vessels
Does not increase risk of

vessels by estrogens
Increases risk of breast cancer

breast cancer
Does not increase

Increases inflammation

inflammatory markers in blood

Protects against natural brain

causing C-Reactive Protein (CRP)

Does not protect against

natural brain cell death.

cell death.

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Bio-identical progesterone
Oral micronized progesterone (Prometrium) is

bio-identical
Effectively protects the endometrium (lining of

the uterus)
Giving progesterone orally creates metabolites

that have an anti-anxiety and sedative effect.

Pregnanolone Allopregnanolone Hydroxypregnanone

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Progesterone Cream

Progesterone cream is also effective, and

may be less sedating than the oral form.

Progesterone is better absorbed through

skin than either testosterone or estradiol

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Progesterone Cream
Efficacy:

Some evidence that progesterone cream can

protect the endometrium

No bone building effects May help reduce hot flashes

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Compounded Progesterone Cream

Quality depends on
how finely ground the progesterone

powder is
the type of base used the compounding skills of the pharmacist.

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BHRT Study
189 women between the ages of 45 and 60

prescribed BHRT: all received progesterone and BiEst topically. Some also received testosterone, DHEA.
70% complained of brain fog 55% complained of weight gain.

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Study Results
90% completely or partially improved on

symptoms of brain fog.

60% of women who gained weight, lost weight.

Average weight loss was 14.8 pounds.

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Cortisol Effects
High levels of cortisol can compete with

the other hormones, creating a functional deficiency of hormones.

Progesterone or testosterone in normal range, but the body functions as if there is not enough

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Cortisol and DHEAS

Cortisol is catabolic, meaning it breaks down

muscle and bone

DHEA is anabolic, meaning it builds up

muscle and bone

Balance becomes more catabolic with age as

DHEA levels decline and cortisol levels increase

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Adrenal Fatigue
High cortisol levels over time cause damage,

and the body slows cortisol release to prevent further damage.

Decreased cortisol release leads to adrenal

fatigue and inability to regulate other hormones.

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Thyroid
Thyroid issues more common as

perimenopause is reached: higher overall estradiol levels in perimenopause reduced amount of free thyroid hormone.
Too low or too high cortisol can also affect thyroid.

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BHRT Summary
Bio-identical hormone replacement (BHRT) is an

accepted standard of hormone replacement, although there is controversy around custom compounded forms of BHRT
Oral progesterone is accepted, and progesterone

cream is gaining acceptance.

BiEst and TriEst are still unproven therapies, but

preferred by many women.