Bio-identical Hormone Replacement Therapy Is Simple — Just Follow Mother Nature’s Recipe
If you’ve wondered about the value of Bio-identical Hormone Replacement Therapy, you need to know about the estrodial/progesterone balance, the best way to take it, and how to test for hormone levels.
IT’S TIME to pay some attention to the ladies; after all, it’s Mother’s Day!
I’ve blathered about testosterone in numerous articles, but have been silent about the sex hormones most predominant in women. Today, we’re taking a deep dive into estrodial and progosterone as they relate to BHRT, the acronym for “Bio-identical Hormone Replacement Therapy”.
If you’re a man, send this to your woman.
If you’re a woman, there are only two likelihoods:
- You’re of the age when you want to know about this right now; or
- You will be.
My intention is to equip you with some information that you can take to a qualified doctor and find out if BHRT can improve your life. Because I’m not expert in these matters, we’re going to rely on one person who has built an expertise based on study and experimentation, and another whose expertise comes from medical school and decades of clinical experience.
I’m referring to Susan Somers, the former TV star, and Dr. Jonathan V. Wright, who with Lane Lenard, PhD., wrote Stay Young and Sexy with Bio-Identical Hormones. What follows has been adapted and edited from Chapter 9 of that book.
Let’s begin with Susan Somers. You remember her from the popular late 70’s/early 80’s Three’s Company. What you might not know is that she’s become the poster girl for BHRT, and has written several books on or related to the topic.
Here’s how she looks now and 40 years ago:
You may think she’s looking good, or not, but according to her doctors and herself, she’s feeling great and is healthy.
Some say she’s gonna pay the Piper; that someday all this hormone therapy is going to run her body into a brick wall at 100 miles per hour. Some of the people who say that are medical doctors, and that surely should get our attention. And yet there are also prominent medical types that have spent their careers investigating what works in the bio-identical hormonal world, and they applaud her efforts.
The pro BHRT camp say its really simple: Just Follow Mother Nature’s Hormone Recipe. And we will…
Estradiol Needs To Be Balanced
You’re not using genuine BHRT simply by swallowing pills containing bio-identical estradiol and progesterone. Yes, estradiol is the primary estrogen produced by the premenopausal ovary, but normal metabolic processes eventually result in three primary circulating estrogens:
estriol, estradiol, and estrone.
Estradiol is less than 10% of the total circulating estrogen, but is the most potent and carcinogenic. When women “replace” deficient ovarian hormones with 100% estradiol, they can distort the natural balance of circulating estrogens, and there’s no guarantee that their natural metabolic processes will produce sufficient estriol to counteract the inherent carcinogenicity of estradiol and the estrone, which the body forms from estradiol.
According to Drs. Wright and Lenard (and, again, all of this article represents their studied opinion and clinical experience), the correct BHRT – with its potentially carcinogenic estradiol – is balanced by relatively high doses of the more benign, anti-carcinogenic estriol, which inhibits estradiol’s carcinogenic propensities.
Well just remember this:
In order to best approximate the natural premenopausal hormonal environment, it’s best to take estradiol and estriol, and occasionally estrone.
Conventional Hormone Replacement Therapy Is At Odds With Nature
BHRT is contrary to most conventional doctors’ erroneous belief, the authors’ maintain, because it requires a philosophical approach to medicine that’s alien to what they have been taught throughout their entire careers.
The conventional medical approach, the authors assert, is to see a symptom then suppress it with a patented drug is at odds with Nature and completely inappropriate for BHRT. In the conventional view, the causes of symptoms are of secondary concern; if the treatment works and is not too toxic, it’s considered acceptable.
The key misconception in this case is that many doctors believe the aim of conventional hormonal treatment is not to restore the physiological serum levels occurring in ovulatory cycles of fertile women, but to prevent or improve complaints and symptoms caused by estrogen deficiency.
For the Federal Drug Administration, the treatment protocol need not be better or safer than a natural or bio-identical alternative, but only more efficacious at muting complaints and symptoms without being toxic.
Rather than merely suppressing premenopause symptoms, such as hot flushes, the primary goal of BHRT is to restore a hormonal environment as close to the natural, premenopausal state as possible.
BHRT requires that we follow the hormonal recipe Mother Nature has worked out over millions of years of evolution in the human female. Since menopausal complaints and symptoms are largely a result of a “hormone deficiency,” once that deficiency is resolved by replacing the deficient hormones with bio-identical copies, the complaints and symptoms generally go away of their own accord. There is no need to suppress them artificially. This may seem like a subtle distinction, but when it comes to the overall health of women using hormone replacement, it makes all the difference in the world.
To optimize the value of BHRT, doctors must have a real appreciation of the way these hormones are metabolized, and how much the body actually needs and safely handle. Using too little may yield unsatisfactory results, and the risks of using too much are unacceptably high.
If BHRT has any disadvantages, it’s that it requires more oversight. What’s needed is:
- The correct mix of human bio-identical hormones
- The optimal amount of each hormone
- Taking hormones by the safest, most natural route
- Approximating the natural timing of hormone secretion
- Close monitoring levels of hormones and metabolites for safety
What’s the Best Way to Take Bio-Identical Hormones?
You can take bio-identical hormones via one of several methods:
- Oral capsules. Just as with any pill, swallow compounded bio-identical hormone capsules and the body does the rest, although as we shall see, not always for the best. Oral administration of steroid hormones has distinct disadvantages, as discussed below.
- Creams or gels. Rub hormone-containing creams or gels into your skin (transdermal), or preferably on the vaginal mucosa or labia (transmucosal or transvaginal). Based on more than 25 years of Dr. Wright’s experience, the topical methods (especially transmucosal) is the preferred ways of using bio-identical hormones, especially if they are personally formulated by a compounding pharmacist.
- Suppositories. The hormone is formed into a suppository by a compounding pharmacist, and is inserted either in the vagina or the rectum for rapid transmucosal absorption.
- Lozenges (troches). The hormone-containing lozenge is dissolved, not swallowed, in the mouth, thereby enabling it to get absorbed directly into your blood stream through the mucous membranes that line your mouth. This method, which is technically considered to be a transmucosal method of administration, is designed to avoid having the hormones pass through the gastrointestinal (GI) tract.
- Sublingual (under-the-tongue) drops. This works like the lozenges, but when it comes to sex steroids replacement, Wright and Lenard contend that oral administration can seriously detract from their optimal use for reasons that, frankly, was not clear to me, as I did not understand why the lozenges would be so much more effective than sublingual use, particularly given what they present in the next section.
Go for the method that your doctor can convince you is the best AND that you’re willing to consistently do.
Running the GI-Liver Gauntlet
The ovaries are not in the mouth or GI tract, and thus, the authors’ emphasize, a women should not take hormone replacements by mouth. Given that the ovaries are located in the pelvic region of the lower abdomen, outside the GI tract, and connected to the uterus and vagina via the fallopian tubes, they have direct access to the circulatory system via a pelvic plexus of veins, which delivers their hormone secretions to estrogen-, progesterone-, and testosterone-sensitive cells all over the body.
Viewed from this perspective, taking hormones by mouth is an unnecessary and unnatural way for sex steroids to enter the body. Instead, hormones can be carefully measured and formulated in a cream or gel, and then rubbed once or twice a day into the skin, or preferably, on mucous (epithelial) membranes, especially those that line the labia or vagina. Applied this way, the hormones diffuse through the skin or epithelial tissue and pass easily and directly into the bloodstream.
With no destructive detours through the GI tract and liver, bio-identical estrogens and progesterone applied topically enter the blood stream metabolically unchanged. When you apply estrogen, progesterone, and testosterone topically it is estrogen, progesterone, and testosterone that go into your blood stream. Admittedly, this may take a little more effort than popping a pill in the morning, but the advantages are substantial, say Wright and Lenard.
Intravaginal Dosing Avoids “Dermal Absorption Fatigue”
In Drs. Wright and Lenard’s experience, intravaginal application offers more than merely theoretical advantages. At the Tahoma Clinic in Washington State, Dr. Wright’s team monitors the 24-hour urinary hormone levels of women using BHRT at regular intervals to make certain their levels are within their individual physiologic “target range.” Over several years, this monitoring has shown us them that, in many women using transdermal estrogen preparations, urinary estrogen levels begin to decline progressively, suggesting that they are absorbing less and less estrogen through their skin over time.
However, when they switch the route of administration from transdermal to transvaginal – without altering the dose – their urinary levels rise right back up to their target range, and any symptoms of low estrogen they might have been experiencing quickly disappear. This loss of effect of transdermal administration is attributable to a factor they call dermal absorption fatigue, which refers how the skin mysteriously seems to lose some of its ability to transport the hormones into the blood stream after repeated transdermal applications over the course of many months. That said, switching to intravaginal dosing avoids the absorption issue.
Progesterone: Never Take Estrogen without It
Quantities of topical progesterone, can vary from 25 to 30 milligrams (after menopause) and up to 50 to 100 milligrams (during the menopausal transition), depending on each woman’s age and response. Progesterone is typically started on days 10 to 15 of the cycle and continued through day 25, as noted below.
DHEA Helps Restore Testosterone Levels
DHEA (dehydroepiandrosterone) is an androgen secreted by the adrenal glands. Like testosterone, DHEA levels decline with age; so most women of menopausal age (or even younger) might consider supplementing with this hormone, too. Drs. Wright and Lenard think DHEA replacement is essential for maintaining optimum immune function, and for helping to reduce the risk of cancer, but my reading about DHEA suggests that it’s a bit of a wild card; meaning, that you can’t be which steroid hormone DHEA will increase, so – like with all hormones – you’ll need to regularly monitor the effects, typically with saliva or blood tests.
A daily schedule is recommended when replacing DHEA, because the adrenals secrete DHEA daily (not cyclically, like estrogen and progesterone). Since women’s bodies typically metabolize DHEA into testosterone, testosterone replacement should be delayed until tests show whether DHEA is restoring testosterone levels to normal.
The starting dose of DHEA for most women is a conservative 15 milligrams per day, although for a few women, follow-up testing may indicate that the daily dose needs to be raised to 30 milligrams.
Like progesterone, over-the-counter versions of DHEA are also available; however, these are typically oral capsules, and as above-mentioned, the transdermal or transmucosal route is best for all steroid hormones, even DHEA. Your doctor can write a prescription for topical DHEA formulated through compounding pharmacists, as topical DHEA products may be hard to find.
Testosterone: Women Need It Too, But At Much Lower Doses
If testing shows that a woman’s DHEA is not getting metabolized to produce sufficient testosterone, she can also take testosterone (at an average dose of 5‑10 milligrams daily). It’s very important to remember that women require a fraction of the testosterone that men do. Accordingly, bio-identical testosterone patches or gels designed for men are completely inappropriate – and dangerous – for women. Women need to get their testosterone formulated by a compounding pharmacist.
A good starting topical dose for women is 2.5 milligrams per day. A woman’s body will metabolize much of this testosterone into estrogens, so follow-up testing is mandatory to be sure that levels of both hormones are optimized – neither too high nor too low.
Timing Hormone Replacement According to Nature’s Clock
Women who use conventional HRT are given all sorts of misinformation about the “hormones” they are taking, including when to take them. Here are a few examples that reported in Stay Young and Sexy with Bio-Identical Hormones:
- “My doctor told me to take Premarin® and Provera® on weekdays and not on weekends.”
- “I just take Premarin® every day, no pauses.”
- “I’ve used the ‘estrogen patch’ every few days for the last year or more.”
- “My doctor says my uterus is gone [surgically removed], so cycling hormones isn’t important anymore.”
Nature does work in cycles, but not with five days on (weekdays) and two days off (weekends). Ovaries don’t secrete estrogens, progesterone, and testosterone on such a schedule; nor do they secrete hormones continuously for months or years without ever pausing.
When a woman starts BHRT, she should mimic the timing of the full menstrual cycles she experienced during her 30s, or whenever her periods were regular and the number of days known and consistent. That number of days is used as a starting point to modify the schedule.
Since she is no longer menstruating, the date chosen to start her BHRT cycle is arbitrary. She needs to keep track of the days she starts and stops each hormone and may do this by crossing off days on a calendar. The pharmacist should specify the exact pattern on the prescription.
While estrogen cycling is pretty straightforward, the pattern for progesterone can be a bit more complicated. This is because progesterone’s functions (despite what conventional medicine preaches) go beyond merely “opposing” estrogen activities. In addition to its role in the menstrual cycle, the body uses some progesterone as the basis for making a whole other class of steroids that include cortisone, aldosterone, and many others. So when progesterone production drops, so does the production of these other important hormones.
Given progesterone’s multifaceted role, some women find they feel much better with continuous progesterone, rather than adding it midway through the “cycle”. If that’s the case, they can modify their regimen by adding a small amount of progesterone (e.g., 10-20 milligrams per day), depending on whether they’re having a “bleeding cycle” or not.
The highest daily dose of progesterone – about 25 to 50 milligrams – should be used during the “luteal phase” (Days 12-25). If she needs to use it the rest of the month, a “step-down” dose of about 10 milligrams per day should be adequate.
Are Monthly Menstrual Periods Really Necessary or Desirable?
An important principle of natural medicine is to prescribe the least amount of a substance necessary to do the job. Following this principle, many practitioners of natural medicine recommend sufficient hormones to eliminate menopausal symptoms, and to provide protection against osteoporosis, heart and blood vessel disease, senile dementia and Alzheimer’s disease, but not enough to induce a monthly menstrual period.
Some proponents of BHRT advocate taking high doses of estradiol in order to induce a monthly “menstrual period” (with no ovulation, of course). They claim that this assures that the body is getting enough estrogen to provide its other benefits, that it is advantageous to “flush” the uterus on a regular basis, and that it may also help women feel more “youthful.”
When Stay Young and Sexy with Bio-Identical Hormones was published five years ago in 2010, the only research on this topic so far failed to support any health value of inducing a monthly period in postmenopausal women. A five-year study (during which routine endometrial biopsies were done to look for cancer cells) of women using estrogen and progesterone on a cyclic basis found no cancer cells in either the women who had monthly bleeding or those who did not.
Monitoring Hormone Levels for Safety — Saliva, Blood, or Urine Testing?
There are at least three different kinds of tests to determine hormone levels, such as saliva, urine and blood.
Which should you do?
Saliva Testing: Inexpensive, Convenient, and Highly Unreliable
Saliva tests are available by mail order, through some compounding pharmacies, or some physicians, and they tend to be less expensive than blood tests. Basically, you fill a small bottle with saliva, seal it and send it off to a laboratory for testing, and the results are sent to your doctor. Other than being cheaper, the primary advantage of saliva tests for hormone levels is that they’re noninvasive and convenient, because they can be done from home without having to go to a doctor’s office or lab.
That said, you get what you pay for. Saliva testing may provide some useful information about sex steroid levels for younger women who are not using BHRT, but of the three major test modalities (saliva, urine and blood), it’s the least reliable, according to Drs. Wright and Lenard. But like a lot of pronouncements when it comes to health, doctors debate the relative efficacy of these tests, some arguing that saliva is the way to go.
Dr. Wright does agree that saliva testing is not useful for women on BHRT , because it’s likely to indicate “sky high” hormone levels that bear no relation to their actual physiologic levels, and may falsely suggest a hormone overdose.
Blood Testing Is Useful but Can Be Difficult to Interpret
Blood tests can measure levels of total estradiol, estrone, progesterone, testosterone, and DHEA in serum (the liquid portion of blood). They’re relatively accurate for women whether or not they are on BHRT. Nonetheless, interpretation of hormone levels based on blood tests must be done carefully, because levels may vary depending on the timing of the test.
After menopause, women usually take their replacement hormones once or twice a day. Either way, the hormones do not circulate throughout the body at steady levels (unless you’re using a “patch”). Thus, the results of a blood test will depend on when the replacement hormones were taken relative to the time the blood was drawn.
Blood tests also can’t even find the important anti-carcinogenic estriol, which is always present in urine in pre-menopausal women, and most frequently in amounts greater than estradiol or estrone. One researcher found that estriol gets “cleared” from the blood very rapidly, within a few minutes to slightly over an hour.
24-Hour Urine Testing Is The “Gold Standard”
Because sex steroids are excreted in the urine, urine collection is without doubt the oldest and most reliable method of collecting steroid hormones. Although conventional doctors know about the advantages of urine tests, they rarely use urine assays for measuring steroid hormones. The reason could be that compliance to the required capture method is spotty.
Unlike the small urine sample most of us are used to giving for a typical urinalysis, urine collected to measure hormone levels is collected over 24 consecutive hours in a large bottle. For that whole day, if you’ve gotta pee, it goes into the bottle. Frustrating perhaps, but doing this flattens the peaks and valleys that complicate analysis of blood test results, and facilitates the measurement of “unbound” (ie, “free”) levels of estradiol, estrone, estriol, progesterone, testosterone, and DHEA.
Urine tests don’t measure protein-bound hormones, which are the largest portion of “total” hormone production yet functionally irrelevant, but – unlike saliva testing – they are accurate for all women, whether or not they’re on BHRT.
There are two other things to know about why 24-Hour urine collections are preferable to saliva and blood tests, say Wright and Lenard:
First, they provide much more information, including whether the hormones taken as BHRT are getting metabolized to mostly “safe” metabolites including estriol (anti-carcinogenic), 2-methoxyestradiol (very, very anti-carcinogenic), and 4-hydroxyestrone (pro-carcinogenic).
Second, the expense for capturing a 24-hour urine “picture” of 25 to 30 metabolites of the hormones administered as BHRT is very much lower than checking for all these metabolites in blood. In fact, as noted above, many of these metabolites can’t even be measured with standard blood tests.
In women just starting BHRT, Wright and Lenard usually recommend a 24-hour urine test every three to six months, until acceptable, stable levels of all hormones are achieved.
OK, that’s it… if I write any more about this my estrogen is going to overwhelm my testosterone and I’m going to get the dreaded manboobs!
My last words will be to underscore the importance of not jumping onto the BHRT bandwagon alone! Messing with hormones is tough even for trained medical doctors with many years of clinical training, so don’t think you’re going to optimized your hormones all by your lonesome.
If you have any words of wisdom or questions I’ll undoubtedly have to Google to answer, please type them in the Comments section below.
Ciao for now.