Bioidentical Hormones - Marketing Hype or Medical Breakthrough?

HRT is all over the headlines; "bioidentical" is the latest buzzword used by public figures-many of whom have no medical training. Get the facts from a gynecologist who wrote the book on understanding hormones.

The best way to understand Bioidentical Hormones is to simply take away the term "bioidentical." Don't get me wrong, I love the term...it is descriptive, positive, and sounds very--"healthy." The problem is that while it is meant to describe a hormone that is molecularly identical to human hormones, it (the word bioidentical), is a distraction from the clarity of facts that women (and men) must have to understand hormonal aging and what options, benefits and risks are out there for those who need help.

The first rule of understanding HRT is: Menopause is not a disease.

Unlike a low acting thyroid, or a failing adrenal gland, as human women our ovaries are programmed to retire. The most likely reason that this retirement is remote from our life expectancy is that (unlike most other mammals) our young have an incredibly long latency period...it takes longer to raise our offspring to maturity than any other known species. In order for us not to simply reproduce and slither off to die (like some cold blooded creatures presumed to be less evolved), our reproductive capacity must be "turned off," some 13-20 years before we are likely to die. We are the only species who are not pleased that our reproductive vitality becomes "off duty." It's no wonder we are less than thrilled with ovarian decline when we look at some of the changes our sex hormones bring to us as teens and tweens:

Positive Changes our Bodies undergo with Puberty that Peak in the Mid Twenties, (greatly enhanced by estrogen and testosterone):

* Height maximizes
* Breasts develop
* The waistline is carved out
* Hair is stimulated to be thicker, longer, and more full
* Skin becomes more elastic, especially in the genital area
* Collagen and bone density peak
* Muscle mass increases
* Metabolism becomes more efficient
* Libido evolves and peaks
* Verbal memory is enhanced
* Sleep is hormonally supported

Now think of these changes in reverse (as with menopause):

* Loss of height
* Breasts deflate (or worse, get enormous)
* Waist disappears
* Hair thins, grays, or falls out
* Skin thins
* Collagen declines, bones begin to thin
* Muscle mass declines
* Metabolism slows
* Libido falls
* Verbal memory declines
* Sleep quality lessens

The bottom line is: The signals that we are fertile become less distinct, and what our human eyes see as attractive and feminine is clearly tied to what is fertile.
But what about those parts of the cycle that no menopausal woman misses?

Most of us are relieved to no longer have a period, or PMS. The second half (the days after ovulation) of the hormonal cycle-- the progesterone dominant days are usually not missed by most, in fact, menopausal zest described by many women can be a welcomed relief from the part of the cycle intended to nurture a pregnancy, or the hormonal resetting time of the period itself. In fact there are many women happy to resign from the hormone associated duties that maintain an active sex life facilitated by their brain's vitality and that of the adrenal glands (which also secrete a decent amount of sex hormones).

But just as many women have banked on the effects of their reproductive hormones, assuming the positive effects were their own, not to abruptly dwindle or retire. Their relationships, their jobs, their hobbies, even their personal identity is often tied to the seemingly fleeting feminine aesthetic. What are their choices and what does "bioidentical" mean to them?

The bottom line is that reproductive vitality has benefits and risks. Since a woman's own estrogen, progesterone, and testosterone have risks, so does any hormone that works with the same receptors...in fact, the more bioidentical, the more it will work as a "human" hormone.

What are the risks? There are several, but the major problems are:

* Estrogen increases the ability of blood to clot (an adaptation that was meant to be helpful to our species), and in the absence of progesterone, thickens the lining of the uterus.
* Progesterone increases insulin resistance (the hormone's goal is to elevate blood sugar for the fetus; the result is an increase in heart disease, diabetes, and possibly some cancers).
* Testosterone can be converted to estrogen

For the positive effects of these hormones, see the above (long) list associated with puberty until the mid twenties.

After the famous Women's Health Initiative revealed some of the lesser understood risks with HRT, many women abruptly stopped their hormonal therapy. However, renewed hot flashes, insomnia, osteopenia, changes in libido and other symptoms have caused many to look at options again and "bioidentical" makes HRT sound new and different...and seemingly safer. Negotiation with nature is not always a bad thing, but every negotiator needs to know the terms, and needs to keep up with the terms if they change. There is ongoing research that may change the pendulum swing every day.

Let's use my favorite analogy; hormones are like fertilizer in a garden. If your garden has weeds, especially if they are out of control (poor health, smoking, hormone related cancer, high risk of heart disease, and others) it is not wise to fertilize. While the fertilizer itself can be toxic if it is not balanced, if too much is used, if it is poor quality, etc., most gardeners do use it. It can help cultivate the more desirable plants, it can help strengthen hybrid plants and improve their health.

If you feel that you may benefit from hormone replacement therapy your doctor will be happy to discuss it with you and there are several "bioidentical" options for her, or him to prescribe, if you opt to accept the risks with the benefits. In the meantime do your best to cultivate the garden that is your body and fertilizer or not; it will flourish.

Comments

[pinkgoldfish]

You gotta love Dr. Booth - menopause is NOT a disease. So nice to hear from a doc who is smart enough to know how to deliver information in an understandable way. Knowledge is power and I so appreciate her ability to present the facts to us this way so we can make informed decisions. It helps immensely just to understand the why's of the changes our bodies experience. Although I do miss the positives of puberty I am also enjoying some menopausal zest! After discussing it with my doctor, HRT's are not a good medical option for me. I would encourage anyone who does not choose HRT's to check out Dr. Booth's suggestions in the Venus Maximus section of her website. Not only do they work, but they're actually easy to incorporate into your life - especially when your hormones are making you feel that adding something else to your "to do" list is deflating.

[thecompounder]

As a pharmacist traditionally educated in conventional hormone replacement therapy, it was very eye opening when I finally looked at the scientific evidence supporting bioidentical hormone replacement . In almost category, bioidentical proves to be superior in safety and effectiveness to conventional hormone replacement, which makes sense considering the increadible conplexity of the human endocrine system. Giving hormones that do not perfectly match the receptor sites or metabolic enzymes in the human body has a huge potential to have unexpected adverse effects (as we now know for certain).

I agree with much of what is written, although I have never seen any evidence to suggest that progesterone elevates blood sugar, increasse heart disease, diabetes, or cancers. Quite the contrary - most studies have shown beneficial effects of progesterone in all of these categories.

I have worked with patients recieving bioidentical hormone replacement for several years now, and am so convinced that it is a valid therapy option for women experiencing menopausal symptoms that I've begun publishing a blog helping explain this therapy in an easy to understand and, hopefully, useful format. My blog can be found at http://thecompounder.wordpress.com. My goal is to educate patients and doctors alike to bring some sanity to this topic so we can take seriously the notion that women in menopause deserve to aspire to a high quality of life.

Peter Koshland, Pharm.D

[wisewoman7]

Finally, a balanced an honest presentation of "bioidentical" hormones!

There is so much hype about this subject. It is the latest trend and there are some doctors dishing out bioidentical hormones without assessing the risks and benefits honestly.

I am so grateful that Dr. Booth has posted. I can't wait to read her book, and I hope she posts a lot. It is nice to see such a knowledgeable women's health advocate.

[futuregirl]

What Dr. Booth says makes total sense and I've always noticed that week after my period when I have fewer cravings and seem to have a few "skinny" days. Those days seem numbered, however, as I age and the impact on skin, hair and mood is increasingly noticeable. There seem to be a lot of experts chiming in but what everyone seems to agree on is that the great sex hormones Mother Nature gives us during our fertile time can be greatly missed. I certainly am going to weigh my options (and hope not to have my waistline disappear!). I checked out her website and it is great - esp. the chart on the hormones which help explain the changes we feel virtually every week (and what we'll miss when they wane!).
http://venusweek.com/aboutvenus/about_venus_week3.asp

[VirHop]

You may be confused about the effects of progestins (synthetic progesterone) vs. bioidentical progesterone. Bioidentical is an important term for the very reason that it distinguishes between the two.

A 2008 review in the prestigious European journal Maturitas, shows that progesterone lowers blood pressure, helps control insulin and glucose levels, improves cholesterol profiles, reduces heart disease risk factors associated with inflammation, helps prevent blood vessel spasm, does not increase the risk of stroke, protects the brain and the nervous system, and does not increase the risk of breast cancer:

“HRT started at the menopausal transition and optimized through expert personalization (for example combining low doses of E2 [estradiol] given transdermally and micronized progesterone), will be cardioprotective and avoid an increased incidence of thromboembolic events as well as of breast cancer; it could eventually prevent to some extent the development of diabetes mellitus and possibly protect cognition.” (L’Hermite et al, “Could transdermal estradiol+progesterone be a safer postmenopausal HRT? A review,” Maturitas, Volume 60, Issue 3, Pages 185-201.)

Women with PMS usually have low or no progesterone to balance the effects of estrogen. Estrogen is a stimulating hormone, but also responsible for the bloating, headaches and irritability of PMS when it is not in the proper ratio to progesterone, a calming hormone.

For details and references, visit www.virginiahopkinstestkits.com. I recommend reading What Your Doctor May Not Tell You about Menopause, which I co-authored with John R. Lee, M.D.

Virginia Hopkins

[avicenna]

Thanks for clarifying this misunderstanding within the medical community. Many are actually unaware that synthetic progestins actually aren't even molecularly similar or derived from the actual hormone progesterone - but are chemicals that exhibit "progesterone-like action" on tissues bearing progesterone receptors. One of the most clear example of the differential effects of ovarian hormones is the condition polycystic ovary syndrome - where women have excess testosterone and estrogen, but very low or absent progesterone levels due to anovulation - and clearly, the "fertile waist line" is lacking and insulin resistance is prevalent.

[DrRebeccaBooth]

I agree that progesterone may be preferable to progestins for menopausal women with a uterus, but the key is the combination with estrogen. Even synthetic progestins can be metabolically protective when combined with estrogens (see: S Salpeter et al," Meta-analysis: effect of hormone-replacement therapy on components of the metabolic syndrome in postmenopausal women."Diabetes Obes Metab. 2006 Sep;8(5):538-54).

Most menstruating women feel and look their best during the days in the menstrual cycle when progesterone is virtually absent and estrogen and testosterone are dominant: the week after the period ends. When mid-cycle ovulation occurs, many women feel their metabolism change on a dime as progesterone rises causing the breast fullness, increased appetite and water retention so familiar to early pregnancy. PMS is at its worst when all of the sex hormones are at the lowest levels, not just when progesterone is low.

The best evidence that high progesterone may increase insulin resistance is the risk of gestational diabetes in the late stages of pregnancy when (natural) progesterone is most dominant. Progesterone has a clear purpose of protecting the fetus, even the anti-inflammatory properties could be argued to protect the fetus from the immune system of the "host."

When women have PCOS, the cause is not the absence of progesterone, but the presence of too much insulin wreaking hormonal balance as ovulation is interrupted. Progesterone alone will not cure PCOS—or the waist to hip ratio.

[CardioE2]

Dr Booth: I appreciate your medical expertise on this topic. Menopause is a natural transition that for most women does not require medical management. Medical training/expertise, like yours helps women make informed health decisions.
Women can expect to live one third of their lives in the postmenopausal years.
A health concern for many postmenopausal women is maintaining vaginal moisture and suppleness during these years. Just as we see the affects of diminished estrogen externally, (skin dryness and loss of support) diminished estrogen effects vaginal and bladder tissue.
I would like women to feel more comfortable understanding postmenopausal vaginal dryness and options for relief. For a meaningful overview regarding vaginal dryness visit
http://www.vascular-events.com/dryness.aspx
Estrogen Matters is a non profit women’s health sanctuary regarding menstrual and menopause physiology.

[avicenna]

I think it is important to point out that it is actually estrogen, and not progesterone, that is related to insulin resistance http://jcem.endojournals.org/cgi/content/abstract/88/4/16466). Coming from the field of endocrinology and metabolism, I am rather surprised how many physicians from the field of gyn & obs seem to impart the "negatives" of ovarian hormones to progesterone action - and imply that the saving graces are do to estrogen - which actually leads to accumulation of fat mass.

[BonnieJW]

I have been on bioidenticals for five years and feel wonderful. I don't take much; just enough to relieve menopausal symptoms. I do struggle with vanishing waist and try my best by eating a vegetarian whole food diet. But I thought that menopause itself would cause the weight problems whether or not HRT was used.