Let me begin by saying this is a huge topic that is impossible to cover in this short newsletter. In addition, each woman needs to consider whether bioidentical hormones are right for her in the context of her own medical history, symptomatology, and life situation. In other words, you really need to continue this discussion with your health care provider to decide whether bioidentical hormones are right for you. I also want to mention that I use the term "alternative provider" in this discussion to differentiate those who practice conventional medicine from those that may use a more alternative approach. Many of us walk in both worlds, it is not meant to be a divisive term.

Is treating menopausal symptoms with bioidentical hormones better for women? Probably but we need more research to be sure. I try to prescribe them when I am able. There are many FDA-approved bioidentical hormones available by prescription and covered by insurance. Estradiol comes in many different forms including: pills, patches, creams, lotions, and vaginal products. Progesterone is also available by prescription and covered by insurance. There is some research beginning to show that women who take bioidentical progesterone may be at lower risk for breast cancer than women who take other progestins. It's likely that all hormones pose some risk for heart disease, stroke, blood clots, and breast cancer. The truth is, we do not know if bioidentical hormones are really safer than other hormones, we need to do more high quality studies to see if it is true. 

What are compounded hormones? These are prescription hormones that are prepared by a specially trained pharmacist. By compounding the hormones, pharmacists are able to provide a range of dosages and formulations that are not available from pharmaceutical companies (and therefore, are not approved by the FDA). Alternative providers will provide individualized dosing based upon saliva or blood hormone levels and/or symptoms. The compounding pharmacist can put these individualized doses of hormones into many different formulations (creams, drops, lotions, oils, etc.). Most insurance plans do not cover saliva testing or compounded hormones. Here is the statement released by the North American Menopause Society about compounded hormones in response to the Oprah shows.
Note: Most conventional providers do not treat women based on hormone levels because there is little evidence that getting hormones to a certain level actually provides better health outcomes or relieves symptoms. In the conventional setting, women are treated based upon their symptoms.

What route of administration is best? It is probably better to use hormones that are given transdermally (through the skin) like patches, lotions and creams. This is because when you take a pill the medication goes through your liver more times than if it is absorbed through the skin. It is thought that by avoiding this "first pass" through the liver there are less problems with blood lipids (fat), platelets, and storage of hormones in the liver. It looks like the risk of gallbladder disease is lower in women who use transdermal HT and that low dose transdermal HT may not interfere with blood pressure. Again, we need to study this more to be sure this is the case. Transdermal hormones also provide a more consistent dose of the drug over time than oral medications so they may help manage symptoms a little better. Many women like the convenience of transdermal hormones.

Who should take hormones? This is a very difficult question to answer. Certainly if you are perimenopausal and your symptoms are affecting your quality of life than you should consider HT as one of your options. Most conventional providers prefer to prescribe hormones for women who are having moderate to severe hot flashes. That being said, a lot of women suffer from severe sleep disturbances, "brain fog", and other symptoms that greatly impact their quality of life. I think hormone therapy should be considered in those cases as well. Women with a personal or family history of breast cancer, heart disease, blood clots, high blood pressure or stroke should consider non-hormonal treatment options. (See the Newsletter Archive for the January 2009 WHH Newsletter on non-hormonal drug treatments for menopausal symptoms.)

How long should women be on HT? This is the question of the hour. There are many studies in progress that are starting to answer this question. So far it looks like the risks are lower in: younger women, women closer to menopause, and women who take them for less than 5 years. This information is changing though as more research is being done. A recent study shows no increase in breast cancer for first 2 years of HT. The recommendations by most professional organizations (American College of Obstetricians and Gynecologists, FDA, and North American Menopause Society) are to take hormones closest to menopause, the lowest dose possible and for the shortest amount of time possible.

It is really important to remember that hormones are not the only treatment for menopausal symptoms. Many women do not want or are unable to take hormones. Last month I talked about non-hormonal drugs that are used to treat menopausal symptoms such as hot flashes. There are also many herbs and supplements that can be helpful. As always, exercise, nutrition, and mind/body therapies are critical too. Let me know if I can help!