Moving Forward with Bioidentical HRT
Given the wealth of data demonstrating the superiority of bioidentical HRT, a noted researcher in hormone replacement therapy proclaimed, “Physiological data and clinical outcomes demonstrate that bioidentical hormones are associated with lower risks, including the risk of breast cancer and cardiovascular disease, and are more efficacious than their… animal-derived [non-bioidentical] counterparts. Until evidence is found to the contrary, bioidentical hormones remain the preferred method of HRT” (Holtorf 2009).
Compounded prescription bioidentical estrogen formulas include Bi-Est and Tri-Est. Bi-Est consists of 20% estradiol (E2) and 80% estriol (E3). Tri-Est contains 10% E2, 10% estrone (E1), and 80% E3 (Taylor 2001). In some situations these ratios do not meet individual needs. In one study, the amounts observed naturally in reproductive age women were 90% E3, 7% E2, and 3% E1 (Wright 1999). In this case, a prescription (based upon the results of hormone tests and assessment of symptoms) is tailored to the needs of the patient by an experienced physician. A comprehensive hormone restoration program should also include progesterone, DHEA, pregnenolone, and perhaps testosterone.
There are two different philosophies regarding the dosing of hormones. The first encourages using the lowest possible dose that will ameliorate the symptoms. This more conservative approach is unlikely to cause a menstrual cycle in menopausal woman. However, it is also unlikely to bring hormones back to what Life Extension considers optimal levels.
The second approach involves significantly higher hormone dosages. The idea here is to “trick” a woman’s brain into thinking she is still of reproductive age. The goal is to achieve levels that mimic the hormonal fluctuations of a menstruating woman, thereby restoring the menstrual cycle.
Utilizing the results of hormone testing and clinical evaluation(s), physicians with experience in bioidentical hormone replacement can help women find an optimal dosing strategy. Most women find they respond desirably to bioidentical HRT when based upon this combined approach. To obtain contact information for physicians in your area who are knowledgeable about bioidentical hormone replacement therapy, or to request information about Life Extension’s Female Comprehensive Hormone Profile blood test, call 1-800-226-2370 or visit our blood testing section.
Women taking any kind of estrogen replacement therapy (including bioidentical) should refer to the Breast Cancer Prevention protocol in order to understand the importance of making healthy lifestyle choices that could reduce the risk of breast cancer.
How Bioidentical Estrogen-Progesterone is Prescribed
The commercial availability of individually tailored bioidentical hormone products is limited. As a result, many physicians utilize compounding pharmacies to prepare and dispense bioidentical hormone prescriptions to their patients. To obtain the phone number of a compounding pharmacist in your area, call 1-800-226-2370.
In order to gauge the initial dose of bioidentical estrogen, the estradiol (E2) and/or total estrogen blood levels should be considered in conjunction with other hormones levels (e.g., progesterone).
A menopausal woman typically has an E2 blood level of 0-19 pg/mL. With the use of bioidentical estrogen cream (e.g., compounded E3 and E2), the blood E2 level may increase to 100 pg/mL or higher, which would indicate to the prescribing doctor that the formula is being absorbed and has increased the patient’s E2 to a more youthful level.
If the patient reports that her menopausal symptoms have been resolved, most practitioners will continue the current dosage and conduct periodic follow-ups.
If, however, the patient is still having symptoms, the dose of bioidentical estrogen cream can be increased. In addition, a urinary hormone profile might be ordered to assess other estrogens and their associated metabolites. Based on the results of these tests, a more precise dose of E3, E2, progesterone, and occasionally, testosterone can be prescribed. A typical starting dose for bioidentical estrogen cream might read as follows:
Please note this is a general suggestion for an initial prescription. A physician experienced in bioidentical hormone replacement will tailor the prescription to the individual woman’s needs.
The dose can be increased when severe symptoms of estrogen deficiency are present.
Women on an estrogen replacement regimen should also be prescribed natural progesterone (in contrast to synthetic progestin drugs like Provera®) in a dose that achieves a youthful balance. Natural progesterone produces many benefits when properly balanced with estrogen. The typical dose for topical progesterone cream may vary between 50-200mg, depending upon a woman’s individual biochemical needs.
Typically, progesterone cream should be applied twice daily to different parts of the body. Specific dosing instructions are as follows:
- Premenstrual and perimenopausal women: 1/4 tsp. of a 2.5% progesterone topical cream (approximately 30 mg natural progesterone) twice daily, starting on day 12 of the menstrual cycle and continuing up to day 28.
- Menopausal women: 1/4 tsp. twice daily for 21 days, followed by 7 days off.
The dose can be adjusted up or down depending on a woman’s symptoms and her response to treatment. If using natural progesterone cream from a pharmacy, a prescription for a postmenopausal woman might be written as follows:
A prescription for a premenopausal woman might read:
Some physicians prescribe topical progesterone similarly to estrogen, i.e., in milligrams per fraction of a cubic centimeter (cc). These are applied via a syringe onto the skin, and have the dual advantage of more precise dosage adjustment and smaller volume of cream (which is less likely to make a mess on clothing).
The blood level targets in aging women might be:
- Estradiol: 90-211 pg/mL
- Progesterone: 2.0-6.0 ng/mL
- Free testosterone: 1.0-2.2 pg/mL
Before a prescription for bioidentical hormones can be written, it is important to have a baseline blood test to determine the doses of bioidenticals that might be needed. To order a comprehensive Female Panel that includes estradiol, progesterone, and free testosterone, call 1-800-226-2370.
In order to achieve optimal hormonal balance, it is important to also address testosterone levels. Although testosterone is thought of as a male hormone, it plays an important role in women’s health. Testosterone levels decrease in women as they age. Low testosterone in postmenopausal women can have a negative impact upon sex drive, mood, psychological well-being, bone and muscle mass, and cardiovascular health (Ling 2009; Stuckey 2008; Maia 2009; Martin-Du Pan 2007). A physician experienced in bioidentical hormone therapy will measure testosterone levels in women and prescribe bioidentical testosterone if needed. Correcting low testosterone in women usually requires a 150-300 mcg patch or an individually prescribed testosterone cream (Davis 2008).
Since DHEA (dehydroepiandrosterone) can convert to testosterone in a woman’s body (i.e., naturally), a woman with low testosterone might be able to increase her level by taking 15 to 25 mg daily of DHEA, which is available as a low cost dietary supplement (Weiss 2009).
The Pros and Cons of the Different Hormone Testing Methods
There is continuing debate regarding the best testing methods for hormones. Hormones can be analyzed in the blood, urine or saliva. There are benefits and drawbacks to each of these methods. Life Extension Foundation® currently offers blood and 24-hour urinary testing.
Pros- This easy, at home collection process is a measurement of bioavailable hormone levels.
Cons- Accuracy and testing variability are issues to consider. Hormone levels in saliva are significantly less than in blood, which can affect the accuracy of the test. In addition, saliva flow rate as well as gum disease (even if subclinical) will alter the results of the test. There are limited laboratories available for this type of testing.
Note: Although Life Extension does not utilize saliva testing at this time, some experienced physicians use this type of testing, in conjunction with clinical symptoms, to successfully evaluate and treat hormone deficiencies.
Pros- This method provides a 24-hour picture of hormone levels rather than a snapshot in time. It allows for testing of not only the three main estrogens— estrone, estadiol and estriol—but also metabolites like 2- and 16- hydroxyestrone.
Cons- Inconvenient and more costly for a full hormone profile.
Pros- This method has been used consistently for decades. There is typically good correlation with symptoms. The testing is inexpensive, routine, and readily available through blood draw centers.
Cons- Blood draw involves a needle stick. Estrone and estradiol can be evaluated. This test, however, is not sensitive enough to assess estriol levels in menopausal women because the estriol test used by traditional laboratories is for the purposes of evaluating fetal growth in pregnancy, during which time levels of this hormone are much higher. Finally, there is no blood estrogen metabolite testing available.