Question 1

What are bioidentical hormones? What are the "experts" saying?

Accepted Answer

Ever since Oprah Winfrey aired two shows on bioidentical hormones there have been questions and concerns about comments voiced by the “experts” that appeared on the program. Unfortunately, the interviews created some confusion, even amongst our enlightened clients. The following is an attempt to clarify some of the issues raised. It remains amazing to me that these “experts” do not understand and/or are unaware of the medical literature supporting bioidentical hormones, as well as hormones in general.

Question 2

Are hormones harmful? Should they be taken less often to control perimenopausal symptoms?

Accepted Answer

If the hormones are synthetic, like Premarin® and Provera®, then they can be harmful. The combination Premarin® and Provera® have demonstrated an increased risk of breast cancer, strokes and heart attacks. This was published in the WHI trial. However, do not extrapolate the harm of synthetic hormones to bioidentical HRT.
Natural progesterone has never been demonstrated, in any study, to increase these risks, whereas Provera® has definitely been shown to increase these risks. Natural progesterone has been shown to decrease the risk of breast cancer, whereas Provera® increases breast cancer in every study to date. Natural estradiol has been proven to not have the clotting or inflammatory properties as does Premarin®.

Question 3

Are all hormones the same, whether bioidentical or synthetic? Do they all share the same risks?

Accepted Answer

Dr. Wolfe Utian from the North American Menopausal Society (NAMS) stated that, "hormones are all the same, whether bioidentical or synthetic. Therefore, they all share the same risks and harm." This is absolutely false! Nothing could be further from the truth.

The chemical structures are different and that makes a difference in how the cells in the body respond to the hormone. A synthetic hormone (non-human, chemically-altered) does not fit perfectly into the hormone receptor site and thereby can cause harm and side effects. The human-identical hormones have demonstrated much less side effect and harm in comparison with the non-human, chemically-altered hormones. In my book, “How To Achieve Healthy Aging,” over 200 references are cited to medical articles that support the healthy benefits of bioidentical hormones without the harm of synthetic hormones. Evidently these "experts" aren't reading the same research that I am.

Question 4

Should all women use a transdermal application (skin cream or patch) of estrogen?

Accepted Answer

No. Although the current trend is to prescribe transdermal creams in place of oral estrogen, the medical studies give us some compelling data. Oral estrogen is far better at cardiovascular protection (fewer heart attacks, strokes and plaque formation in blood vessels) than transdermal cream. Transdermal estrogen has minimal effect on improving serum lipids (good or bad cholesterol), whereas oral estrogen certainly does. Studies have demonstrated that oral estrogens marked beneficial effect on cholesterol, LDL and HDL, provides the most protection, whereas transdermal provides much less cholesterol effect and therefore much less cardiovascular protection in the long run. In a few women with a particular health history, oral estrogen is contraindicated and transdermal is therefore recommended. However this is not the case for most women. Oral estrogen has many more health protective benefits than does transdermal estrogen and thus is the preferred form of estrogen unless there is the rare contraindication.

Question 5

Can oral estrogen cause blood clots in legs and lungs?

Accepted Answer

Yes and no. It is primarily Premarin® and Provera® that cause this, particularly Provera®. However, the Journal of the American Medical Association (JAMA) published an article demonstrating increased blood clots with Premarin® but not with other oral estrogens. Another study proved that oral estradiol did not increase blood clots. If you have experienced a blood clot in the legs or lungs, or have a genetic clotting disorder, transdermal estrogen is safe and preferred. If you do not have a high risk for a blood clot, oral estrogen is more effective and protective.

Question 6

Should all women on oral estrogen take aspirin?

Accepted Answer

Yes, but only if you have had a heart attack or stroke. If you have not had a heart attack or stroke, then absolutely not. Recent studies demonstrate that aspirin benefits women only if you have had a prior incident. But aspirin is of no benefit in prevention if you have never had a heart attack or stroke. In fact, several studies show that aspirin might actually be harmful. In fact, more than 20,000 people die every year from bleeding or hemorrhaging while taking aspirin.

If you have had a prior heart attack or stroke, then you should be taking aspirin. If you have not, you should not take aspirin and you should be on oral estrogen for maximal cardiovascular protection.

Question 7

Should progesterone be prescribed only as a cream?

Accepted Answer

Absolutely not. In our experience, creams are inconsistently absorbed and often should be applied 2-3 times per day in order to maintain adequate levels. Most women can’t be compliant with this regimen. Optimal levels of progesterone are particularly important because of the breast and uterine protection. Two recent studies demonstrated that progesterone cream was not strong enough to protect against uterine cancer. Optimal levels are best obtained with sublingual or oral progesterone which then protects against breast cancer and uterine cancer. Studies demonstrate that the higher the level, the better the protection. Where would you like your levels to be?

Question 8

Are saliva tests better at assessing hormone levels?

Accepted Answer

We're constantly studying the information about saliva testing. There's no scientific evidence or basis for using saliva levels over blood levels. There is some correlation between saliva levels and blood levels for evaluating baseline levels of hormones while not taking any hormones. This is not true when monitoring hormone levels while a person is taking hormones. Saliva levels can be high when blood levels are low. This can give a false confidence that your hormone doses are giving you levels that are protective when they usually are not. Therefore, we should abide by the medical studies that give us the guidelines for hormone levels that are the most protective. These studies utilize blood levels and not saliva levels. We want to achieve these protective blood levels that are well documented in all our medical studies for maximum breast and uterine protection. If you don't achieve and maintain these protective levels, your hormone program will not provide optimal protection and may put you at risk.

Question 9

Should I use estriol as my estrogen replacement (not estradiol)? Does estriol prevent breast cancer?

Accepted Answer

There is no scientific evidence that estriol prevents breast cancer, nor protects against heart disease, bone loss or Alzheimer’s disease. In fact, estriol is an end-stage metabolite of estradiol and provides only very weak symptom improvement and no protective benefits. Therefore, estriol has minimal beneficial effect in comparison to estradiol which is the primary estrogen. Estriol’s primary beneficial effect is on the skin. Estradiol has been shown to provide the most protection and therefore is the estrogen of choice. (Multiple studies have demonstrated a decrease in breast cancer incidence when progesterone—not progestin—is added, but not estriol).

Question 10

Are compounded, bioidentical better than conventional, pre-manufactured products?

Accepted Answer

The experts from the menopausal and gynecological academies claim that there are no studies to support the use or benefit of compounded, bioidentical hormones as opposed to conventional, pre-manufactured products.

The FDA approval process for synthetic drugs is meant to prove that a drug is effective for the purpose intended, is absorbed properly, and maintains adequate serum levels to guarantee efficacy. These conventional, manufactured drugs are standardized and guaranteed to have a certain consistency and effectiveness. So how do we know that the prescriptions compounded by hand in compounding pharmacies are consistent and effective?

We test levels in our patients and assure that the hormones prescribed consistently provide protective levels. The medical studies demonstrate exactly where the hormone levels should be for maximum protection. Every doctor prescribing compounded bioidentical hormones should abide by these scientific standards in order to assure the optimal protection for the patient. If we are seeing a pattern of poor levels, we question the pharmacy on the source of their pure ingredients and their compounding process. Compounding pharmacies can dispense different grades of hormones from different suppliers, but we must assure through serum testing that what is being dispensed provides exact amounts of hormones and efficacy.

DJL | Dr. Jonathan Lee, M.D.

FAQs: Hormones

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