Frequently Asked Questions about Bioidentical Hormones
Q. What are bio-identical hormones and how do they differ from synthetic hormones?
Contrary to what most think is true, bio-identical hormones are not natural. In fact, it would be more accurate to understand them as “Human Identical”. Bio-identical hormones are a product derived from a compound called diogensin, which is taken from the Mexican yam. Diogensin, when put through several synthetic alterations, results in a hormone that is molecularly identical to human hormones. This process is certainly not natural but it does lead to the production of hormones that are identical to the hormones your body produces.
Because pharmaceutical companies cannot patent a naturally-occurring hormone, they modify natural hormones with synthetic additions in the hope that they will retain some of their original native properties and functions. A hormone needs to fit with its hormone receptor in a very specific fashion much like a key fits into its lock.
Synthetic hormones are shaped differently enough to allow for some receptor confusion given their slight structural modification allowing for “crosstalk” with other hormone receptors, which results in either unwanted side effects or the failure to produce the desired physiological effects sought from the hormone therapy in question. In fact, synthetic hormones are more different from their natural counterparts than are totally different natural hormones are from each other.
For instance, Medroxyprogesterone, commercially known as Provera, is more different from natural progesterone than natural progesterone is from natural testosterone! If only a subtle molecular shift marks the difference between natural progesterone and testosterone, then it is not hard to imagine how a more radical molecular departure from natural hormone structures may result in unwanted side effects. The reality is that hormones are not all created equal and that there is no substitute for the real thing.
Q. What was the WHI?
In 1991, Wyeth Pharmaceuticals, in liaison with the National Institute of Health (NIH) and National Heart, Lung, and Blood Institute (NHLBI), launched an unprecedented study of 68,132 women between the ages of 50 and 79 which lasted for 15 years, the largest and most costly health initiative ever undertaken in the United States. The objective of the “Women’s Health Initiative,” or the WHI as it would become more commonly known, was to research the effects of hormone replacement therapy on the prevention of cardiovascular disease, cancer and osteoporosis in post-menopausal women. The WHI employed conventional synthetic hormone replacement therapy (HRT) in two separate legs of the study. The first leg of the WHI concerned women who had not had a hysterectomy. They received either continuous combined Premarin (CEE) and Provera (MPA) or a placebo. The second leg of the study was comprised of women who had already had a hysterectomy and who were prescribed Premarin alone. This became known as the estrogen-only leg of the WHI.
Q. What were the risks associated with the WHI?
In the first combined leg of the study coronary heart disease rose by 29% while the risk of stroke rose by 41%. These figures were alarming, but much less than the risk of thromboembolism (clot formation within a blood vessel) which more than doubled. Taken together, the rise in these risk factors were enough for the oversight safety committee to stop this section of the study. Breast cancer too, in this first leg of the study, rose by 26% and only confirmed the suspension of the WHI. In the second estrogen-only leg of the study the risk of heart disease actually dropped by 9% compared with those on the placebo while the risk of stroke saw only a marginal decline. Compared to the heightened risk of blood clots in the first leg of the study, the second estrogen-only leg saw only a 34% increase, which was still unacceptable.
Eventually, even this leg of the WHI was suspended. Although interpreters of the WHI data went to great lengths in qualifying the differences between those who received conventional Hormone Replacement Therapy (HRT) and those who received only the placebo, as well as differences registered in the two different legs of the study, what was more than curious was their inability to notice the dramatic drop in breast cancer in the estrogen-only leg of the study.
Compare to the placebo, participants registered a 23% drop in instances of breast cancer, but still more markedly, registered a 49% reduction in risk of breast cancer when compared to the first Premarin/Provera combined leg of the study. What this tells us is that even though the WHI used a strong form of estrogen in the estrogen-only leg of the study, it still resulted in a drop in breast cancer.
Q. I heard that estrogen might increase my risk for a heart attack or breast cancer. Is this true? What are the different kinds of estrogen and what estrogen was used in the WHI?
Although there seems to be some special property native to the estrogen-only leg of the WHI that reduces the risk of breast cancer there are some theories that oral estrogen increases the production of sex hormone binding globulin (SHBG). Increased levels of SHBG are associated with a greater incidence of breast cancer. It is important to note at this juncture that not all estrogens are created equally.
Estrone (E1) is a weak form of estrogen, with cancer promoting effects.
Estradiol (E2) is a strong form of estrogen which has all of the good effects of estrogen but which still has some of the cancer promoting effects of Estrone, especially with respect to breast tissue.
Estriol (E3) is the weakest form of estrogen produced in elevated levels during pregnancy and has native cancer protective qualities. This is why women who have more children and have them at an earlier age experience a reduced risk of breast cancer.
Premarin, the synthetic conjugated estrogen tablet used in the estrogen-only leg of the WHI, is comprised of seven different types of estrogen derived from pregnant mares’ (horse) urine from which the name premarin is derived. What most do not know is that the estrogens derived from horse urine were different enough from human estrogens that they needed to be topped up with 50% Estrone, the weak form of cancer-promoting estrogen. In fact, synthetic oral estrogens, such as Premarin, when metabolized in the first pass through the liver, increase Sex Hormone Binding Globulin (SHBG) which absorbs a good part of Estradiol reducing the risk of breast cancer. Again, oral Estrogens like Premarin also increase C-reactive protein (CRP), a blood-clotting protein which is an established factor in heart disease leading ultimately to an elevated risk of coronary atherosclerosis and heart attacks.
Q. How is Bio-Identical Hormone Replacement Therapy different from the HRT used in the WHI?
Unlike either synthetic oral estrogen tablets, bio-identical estrogens are applied in the form of transdermal creams (creams applied across the exterior of the skin) which are absorbed directly into the body’s tissues and bloodstream thereby avoiding the problem of a first-pass metabolizing by the liver. By avoiding the problem of metabolism associated with a first pass through the liver, bio-identical transdermal creams avoid spiking SHBG and C-reactive protein levels thereby avoiding the elevated risks of blood-clotting and cardiac arrest associated with the WHI. It should also be noted here that the WHI prescribed dosages which were four times the body’s natural level whereas at True Balance BHRT transdermal creams are prescribed within normal physiological ranges. More importantly, BHRT does not use Estrone (E1) in any of its treatments but uses instead a preparation cream, known as “Biest”, which is comprised of an 80/20 ratio of Estriol (E3) and Estradiol (E2). Estriol is the weaker form of estrogen and reduces the risk of breast cancer.
It is also important to note here that women involved in the WHI were all postmenopausal with an average age of sixty-three. This is significant inasmuch as most of these women had 15 years of declining hormone levels to develop diseases that estrogen, progesterone, and testosterone supplementation might have prevented. The primary advantage of bio-identical hormone replacement, if diagnosed and begun at the menopause, or when symptoms develop, is that it avoids this long duration of hormone deficiency in which the diseases of inflammation arise.
Q. Why doesn’t my physician prescribe bio-identical hormones?
Considering the fast pace at which most medical practices move, traditional physicians have little time or resource to become proficient in BHRT. Also, prescriptions for bio-identical hormones are dispensed from a compounding pharmacy and it is important that a physician has a thorough knowledge of the compounding pharmacist who is responsible for the preparation creams. At True Balance we have a special relationship with a local compounding pharmacist who prepares transdermal creams of the highest quality.
Q. What is a compounding pharmacy and how does it differ from a regular pharmacy?
Transdermal creams are individualized preparations designed to specifically match the values indicated in your blood work. Unlike conventional pharmacies, which prescribe a “one size fits all” synthetic hormone prescription, compounding pharmacies design hormone replacement therapies detailed to your body’s individualized levels. These pharmacies are similar to the old fashioned concept of a pharmacist with a mortar and pestle. They acquire the pure pharmaceutical-grade hormones and compound it into the form and dosage ordered by your physician as pills, capsules, liquids and creams. They are prepared specifically for you, making your treatment program customized and personalized.
Q. Who should consider bio-identical hormone replacement therapy and is it right for me?
The simple story that needs to be told about the way we age makes every single person a candidate for BHRT. From about age 25 years onward, our hormone levels begin their steady decline until men and women hit andropause and menopause respectively. As our levels of hormone production decrease, the diseases of inflammation increase in direct correlation. Diseases of inflammation are numerous but include cancer, arthritis, osteoporosis, diabetes etc. This would seem enough of a reason to consider hormone replacement therapy but there are other reasons too. For women who are looking for a way to put an end to hot flashes, night sweats, trouble sleeping, memory loss, mood swings, weight gain, and low libido, BHRT is an optimal solution. For andropausal men who are trying to get a handle on their weight, diminished libido and erectile dysfunction, stress and loss of energy and muscle tone, BHRT is an excellent option.
Q. What if I still don’t feel better after my hormone levels are balances. Is it possible I have Adrenal Fatigue? And if so what is the treatment?
There are a number of patients who, even after having their hormone imbalances corrected, will still feel like they lack energy and general health and well being. They could potentially be experiencing adrenal fatigue. A body’s adrenal glands are the frontline defenses against all exteriors threats to our system. Chief among the most common of these threats is stress, but also things like sleep deprivation, acute and chronic infection, poor diet and the list goes on. When we experience stress our adrenal glands, each perched atop our two kidneys, secrete a precise and strategic amount of cortisol which allows one to cope with the effects of stress on the body. Adrenal fatigue occurs when our levels of stress are pronounced and prolonged necessitating the continual production of cortisol by our adrenal glands to the point of burnout. This is when the glands fatigue and can no longer produce sufficient amounts of cortisol, or the many other steroid compounds they are responsible for producing. This results in low energy and sometimes a flu-like sensation.
Unlike most clinics which only treat hormone imbalances, at True Balance we understand that even though hormone levels need to be supplemented and harmonized, a patient still may suffer from adrenal fatigue. The treatment is a combination of nutriceutical all-natural agents which help rebuild the adrenal glandular function:
- Adrenal Rebuilder helps provide naturally bioavailable building blocks which help foster healthy adrenal gland structure and function.
- Adveset is an herbal compound that acts as an adaptogen to optimize adrenal function. It is used for patients with low energy.
- Super Adrenal Stress Formula represents a complete panel of gland-specific nutrients which the adrenals are in need of during times of stress.
- Serenagen is an herbal nutriceutical meant to promote equilibrium between body systems and promote a sense of inner calm.
Q. What does True Balance stand for and what makes True Balance BHRT medical staff experts?
All hormones operate in a lined and co-operative fashion that has been compared to the web of a spider. No change in levels of one hormone goes unnoticed by the entire system. Too often conventional medical treatments have looked at one or two hormones in isolation. This approach often fails to optimize the function of the entire system.
Safety is a basic guiding principle to the True Balance Clinics. Replacement with the least amount of hormones to effect symptom relief minimizes the chance of untoward side effects. Hormone levels are obtained before and upon treatment to accomplish this goal.
Your BHRT consultant has done extensive training in this area. All practitioners are under the direct supervision of a gynecologist when starting. BHRT conference attendance is necessary, as is ongoing education in this rapidly evolving area. Quality and safety of treatment are the primary principles which guide our clinical practices.
Q. What does my first visit look like?
Booking your first visit with one of our True Balance BHRT specialists begins with a phone call or an email. After the first point of contact, our staff will email you a blood requisition form and a diagnostic medical history questionnaire and provide you with the time and date of your appointment. The blood requisition form is to be taken to the lab that will collect your complete blood panel and the diagnostic questionnaire is to be brought completed with you upon your first visit. After initially booking an appointment with us, we will mail you a DVD for your review. This DVD contains all of the teaching surrounding your first visit, and the questions which naturally follow afterward. When you arrive at our clinic you will turn in your completed questionnaire and meet with a BHRT specialist who will consult with you on your background and health and based on your blood and lab values design a customized hormone replacement regime detailed to your body’s needs. We then fax your prescription off to the compounding pharmacy who will then contact you when your prescription is ready. Please note that our clinic requires 48 hours notice for any cancellation or a fee is charged. Because of the demand on our clinic, cancellations also result in the forfeiture of your place in the queue.
Q. Men and Testosterone
As men age, production of the hormone testosterone begins to decline and they experience symptoms of low testosterone. Testosterone is the hormone that is responsible for maintaining mental focus, energy, metabolism, muscle mass, fat levels, and sex drive. By balancing a man’s hormones with bioidentical hormone therapy, men can restore their vitality and reduce the symptoms of andropause.
Q. Will I be prescribed Vitamins and other Supplements?
During your clinical visit, your consulting physician will also prescribe a number of basic nutriceutical supplements needed for basic healthy physiological functioning. Here are the three basic supplements:
Vitamin D: Exposure to sunshine sufficient to produce mild redness produces 10,000 units of vitamin D. Obviously most of us do not have ample opportunity for adequate exposure to sunlight allowing our skin to synthesize sun exposure into vitamin D levels. The presence of adequate levels of Vitamin D in our bloodstream is important because it is associated with a 50% reduction in breast, colon and prostate cancers. Other important benefits of optimal vitamin D levels include its enhancement of our Immune functions, stabilization of our DNA leading to reduced cancer formation and increased ability for calcium absorption from the gut. If optimal levels of vitamin D are reached by age 20 the lifetime risk of multiple sclerosis is reduced by 50%. An optimal dosage is somewhere between 1000-2000 units per day.
Resveratrol: Biological life has only two modes of operation, growth or reproduction. Reproduction requires significant energetic demands on the body and should only proceed when external environmental conditions are favourable. Growth is directed towards prolongation of life until reproductive conditions are likely to allow for success. Interestingly, Plant life has developed a system to delay reproduction until external conditions are once again favourable. This involves the production of compounds called sirtuins which turn off, or “down regulate,” the genes responsible for reproduction thereby promoting plant longevity. These results in a very simple choice for plant life: reproduction or growth, which is yet another way of characterizing the biological tension between death and longevity. In short, biological life is both reproducing, and hence dying, or it is in a maintenance mode which preserves its own longevity.
The name of one sirtuin responsible for the down regulation of gene activity in plants responsible for reproduction is called “Resveratrol.” Its more specific property concerns a “famine-like” maintenance mode which mimics caloric restriction in humans at the genetic level, yet without the actual effects of caloric restriction. In essence, Resveratrol stimulates activity at the genetic level associated with this maintenance mode of life. It has been shown that a 15% caloric restriction results in a 25% increase in longevity. In other words, Resveratrol produces the same pattern of gene expression as caloric restriction without the restriction or calories.
Omega 3: Fish oil has far reaching health effects. It improves cholesterol levels to the same degree as statin drugs yet with no adverse health effects. It also lowers blood pressure to same extent as antihypertensives. Proper supplementation is measurable and results in a 25% reduction in death. Omega 3s are useful in children with ADHD. Prenatal uses of Omega 3s have been linked to an increased IQ and better fine motor co-ordination in the children of mothers who supplemented with fish oil. Aggressive doses have also been known to effect neurologic diseases such as multiple sclerosis for the better. Omegas 3s are also as effective as NSAIDs are for arthritis as has been shown in double blinded clinical studies.
Q. Will my weight change once on BHRT?
Many women develop estrogen dominance in their 40s and 50s. One aspect of estrogen dominance is the tendency to gain weight. Correction of this will often allow excess weight to gradually be lost. If hormonal balance does not lead to your desired weight loss, the True Balance clinic has other options available to achieve your desired weight goals.
As men go through the andropause, a loss of muscle mass is associated with increased body fat composition. Testosterone therapy will assist in the redevelopment of muscle tissue and an improvement in metabolic rate as well as a resultant loss of body fat.
Q. Will you become my new doctor now?
Although our office is happy to liaison and communicate with your local physician you will continue as a patient under their general care. True Balance specializes in BHRT which ultimately treats aging, not diseases. We supplement your physician’s care, not replace. We do, on occasion, consult with your physician when appropriate.
Q: How long does it take for me to see the results?
Many of our patients say that they experience a noticeable improvement in only a matter of days. Most people can expect to notice results from 1 to 3 months after beginning hormone supplementation. Male patients who are on testosterone therapy may notice increased muscle mass and hair growth. Women who were living with insomnia from a hormone imbalance will find themselves sleeping well almost immediately after taking progesterone.
Q. How long will I have to take BHRT?
Restoration of hormone balance and levels improves symptoms and quality of life. At this time we have no way to permanently restore the body’s hormone production to those levels maintained earlier in life. Add to this the observation that these sex hormones bind to cellular DNA and reduce the production of inflammatory mediators directly contributes to one’s longevity. Each individual must make a personal decision about the length of therapy based on a number of factors including the degree of improvement in symptoms, improvement in quality of life, response of inflammatory markers to BHRT and measurement of biologic age to gauge how quickly we are ageing. There is no one answer to each must decide for themselves their individualized course of action with respect to all of these factors.
Q. Where do I get my prescriptions and how will I know when they are ready?
Our clinic will fax your prescription to one of three Dispensaries Pharmacies nearest you and they will contact you when your prescription is ready. Once ready, you have the option for your prescription to be picked up at any of the 7 locations listed below, delivered to your door, or mailed to you. Typically, our specialists will write you a year’s prescription (12 refills) and most patients purchase 3 months at a time. We have a close relationship with this group of compounders and are of the conviction that they take the accuracy and quality of your prescription as seriously as we do. A good compounding pharmacy is critical to the effectiveness of a BHRT program. However, we are happy to work with other compounding pharmacies at the request of the patient.
Q. What are some things I need to know about follow-up blood work?
Our BHRT specialists like to recheck thyroid after 4 weeks. At 8 weeks all thyroid and hormone levels are checked once again requiring another blood panel, which will be reviewed with you by your BHRT specialist during your 12 week recheck. A 4-week delay is required for the appointment after blood work to allow for all hormone levels to be available by the recheck date.
Q. Are there any side effects?
Side effects are usually associated with the hormone dosage but if the symphony of hormones is brought into true balance the side effects should be non-existent.
Q. Are bioidentical hormones approved and regulated by the Health Protection Board of Canada (HPB)?
Yes, federal statutes regulate both the hormones and their manufacture.
Q. Will this treatment interfere with medications that I am already taking?
Generally no. Some medicines may actually be reduced or no longer needed.