Clinical Application of BHRT

1
Clinical Application of BHRT

• Tracy Marsden BScPharm, DHPh

2
Types of Hormones

• Estrogens
• Progesterone
• Testosterone
• Cortisol DHEA

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Pre-Menopause
 
 
OVARY
Testosterone
Progesterone
aromatase
Estradiol
 
Estrone
Estriol
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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.

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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.

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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).

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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.

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Post Menopause
 
 
ADRENAL GLAND
Dehydroepiandrosterone (DHEA)
Cortisol
Androstenedione
aromatase
Estrone
Testosterone
aromatase
Estradiol
Estriol
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Normal Cycles

• Progesterone is produced in quantity after
  ovulation

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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 bio-identical
  hormones

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Symptom Assessment
Symptoms Please rate your symptoms according to
the following scale 0 - never or rarely
experience this symptom (lt20 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 Memory lapses ijkl
Night sweats ijkl Foggy thinking ijkl
Water retention ijkl Heart
palpitations ijkl Breast tenderness
ijkl Irritability ijkl Decreased sex drive
ijkl Loss of muscle bulk 
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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
  bio-identical 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 8020, 7030,
  5050
• 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 801010, 9055,
  602020

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Estriol (E3)

• Effective for hot flashes, insomnia, poor memory.
  Head K. Alt Med Review 1998Vol. 3(2)
• Intravaginal use may be effective for vaginal
  dryness, infections, recurrent UTIs and
  dyspareunia. Head K. Alt Med Review 1998Vol.
  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
  Dec44(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 MPA

• Acts with estrogen to relax blood vessels
• Does not increase risk of breast cancer
• Does not increase inflammatory markers in blood
• Protects against natural brain cell death.

• Inhibits relaxation of blood vessels by estrogens
• Increases risk of breast cancer
• Increases inflammation causing C-Reactive Protein
  (CRP)
• Does not protect against natural brain 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.