Hormone Replacement Therapy
By Rosanna Sutherby, PharmD
What Is Hormone Replacement Therapy?
Hormone replacement therapy (HRT) is supplementing with hormones that are lost or decreased due to aging or medical conditions. In men, testosterone levels may begin to decline naturally after age 30 to 40. Testosterone levels may also decrease because of a condition called hypogonadism. If you have hypogonadism, your body does not make enough testosterone.
Women’s ovaries stop making estrogen and progesterone at menopause. During any stage of menopause – perimenopause, menopause, or post menopause, the decrease in hormone levels may be accompanied by undesirable symptoms, including hot flashes, night sweats, difficulty sleeping, and mood changes. Some women use HRT to manage these symptoms.
There are several methods of HRT. Conventional HRT commonly uses conjugated equine estrogen (CEE) derived from pregnant horses and progesterone. Compounded HRT typically uses plant-based bioidentical hormones.
What Are Bioidentical Hormones?
Bioidentical hormones are derived from plants and have the same molecular structure as the hormones your body produces. Common bioidentical hormones include estrogens, progestins, and androgens.
What Are Types of Compounded Bioidentical Hormones?
There are three types of estrogens that your pharmacist may use for your compounded HRT:
- Estrone (E1 )
- Estradiol (E2 )
- Estriol (E3 )
Each estrogen varies in potency. Estradiol is the most potent, followed by estrone then estriol. When compounding hormone therapy, your pharmacist must appropriately balance each component for optimal efficacy. To help maintain this balance, two formulations have been developed for use in bioidentical hormone replacement therapy (BHRT) compounding:
- Biest (biestrogen): Biest contains a ratio of 20% estradiol and 80% estriol.
- Triest (triestrogen): Triest contains a ratio of 10% estradiol, 10% estrone, and 80% estriol.
In addition to estrogens, compounded BHRT may include other hormones, such as
micronized progesterone, pregnenolone, testosterone, and dehydroepiandrosterone
(DHEA). Your compounding pharmacist typically combines hormones in ratios and
strengths according to your individual prescription and can prepare them in a variety of
forms, such as:
- creams
- gels
- patches
- pills
- troches
- vaginal suppositories
What Conditions Do Bioidentical Hormones Treat?
Although menopause is a natural stage of a woman’s life, the decrease in hormone levels accompanying menopause may produce some uncomfortable symptoms. Bioidentical hormones can help manage common symptoms associated with menopause, including:
- decreased interest in sex
- difficulty sleeping
- fatigue
- hot flashes
- memory loss
- mood changes
- night sweats
- vaginal dryness
- weight gain
Men’s hormone levels also drop as a natural part of aging. However, if you have hypogonadism, you may have abnormally low testosterone levels at an earlier age. BHRT can help with symptoms of hypogonadism, including the following:
- breast development
- decreased interest in sex
- delayed puberty
- depression
- hot flashes
- infertility
- low energy
- low muscle mass
Are There Side Effects for Bioidentical Hormones?
Bioidentical hormones are plant-based and mimic your body’s natural hormones. However, you may experience some side effects, especially during the beginning of your BHRT. These side effects may improve as your body gets used to the new hormone levels. Common side effects of bioidentical hormones include:
- acne
- blurred vision
- breast tenderness
- cramping
- facial hair growth
- headaches
- mood swings
- redness or irritation at application site
- spotting
If your side effects are severe or do not improve over time, talk to your pharmacist or prescriber. A dose adjustment may help resolve some side effects.
Why Do Women Choose Compounded Bioidentical Hormones?
Although both women and men use compounded bioidentical hormones, there has been a rise in the popularity of compounded BHRT among women seeking relief from menopause symptoms. A 2017 study surveyed women who had used or were currently using compounded BHRT. The following are reasons participants provided for choosing compounded bioidentical hormones:
Fear or Uncertainty About the Safety of Commercially Available HRT
The majority of the women in this study expressed concerns about the safety of conventional HRT. They felt that bioidentical hormones would pose fewer risks and have fewer side effects than conventional HRT.
Aversion to Conventional Conjugated Estrogens
Commercially available conjugated estrogens are sourced from the urine of pregnant horses. Many women find this distasteful or prefer to use animal-free products derived from plant sources.
Skepticism About Biomedicine or the Pharmaceutical Industry
About 95 percent of the study participants felt distrust for the pharmaceutical industry and conventional medicine in general. They felt that conventional medicine was dismissive of their individual needs and overly dependent on medications to address their problems.
Dissatisfaction With Results from Soy or Herbal Supplements
About 80 percent of women in the study tried herbal and soy supplements as alternatives to conventional HRT to relieve their menopause symptoms. Many did not find the supplements to be effective long-term, and they turned to compounded BHRT to manage their symptoms.
Effectiveness of Compounded BHRT
Over 75 percent of women in this study used compounded BHRT because it effectively managed their symptoms. Women reported that the compounded BHRT worked in relieving their hot flashes, insomnia, mood changes, and other symptoms.
Belief That Compounded BHRT Is Safer Than Conventional HRT
About 75 percent of the study participants perceived compounded HRT to be safer than conventional HRT. They believe that bioidentical and plant-based hormones are safer to use than conventional hormones.
Appeal of Individualized Treatment
Over half of the women surveyed chose compounded BHRT because they were seeking individualized treatment. With compounded hormones, they felt they could receive medication tailored to their individual needs and treatment goals. They also liked the option to choose between pill, cream, gel, or patch for their medication form.
Better Clinical Experience
For about 60 percent of the study participants, having pharmacists and other clinicians willing to spend time discussing their condition and treatment options drew them to compounded BHRT. The pharmacists and clinicians took the time to listen to their experience of menopause and counsel them. They also engaged them in making decisions regarding their treatment.
Your Journey Is Unique
You have personal and unique reasons for choosing compounded bioidentical
hormones. Men and women alike can benefit from customized hormone therapy. A
conversation with your compounding pharmacist may help you decide if compounded
BHRT is right for you.
About Author:
Rosanna Sutherby is a freelance medical writer and community pharmacist. She received her PharmD degree from Nova Southeastern University College of Pharmacy in Ft. Lauderdale, FL. Dr. Sutherby’s pharmacy practice has included patient education and medication management for various disease states, including diabetes, cardiovascular disease, mental illness, asthma and pulmonary disease, and pain management. Dr. Sutherby’s published work spans a variety of topics, including cardiovascular health, dermatology, women’s health, sleep disorders, mental health, vaccine education, and medication use and safety.
References:
- Harper-Harrison G, Shanahan MM. Hormone Replacement Therapy. [Updated 2020 Jun 3]. In: StatPearls [Internet]. Treasure Island, FL: StatPearls Publishing; 2021 January. https://www.ncbi.nlm.nih.gov/books/NBK493191/
- Committee on Gynecologic Practice and the American Society for Reproductive Medicine Practice Committee. Compounded bioidentical menopausal hormone therapy. Committee Opinion. 2012;532. https://www.acog.org/clinical/clinical- guidance/committee-opinion/articles/2012/08/compounded-bioidentical- menopausal-hormone-therapy. Reaffirmed 2020. Accessed 31 May 2021.
- Testosterone Therapy: Potential benefits and Risks as You Age. Mayo Clinic. https://www.mayoclinic.org/healthy-lifestyle/sexual-health/in-depth/testosterone- therapy/art-20045728. 4 April 2020. Accessed 5 July 2021.
- Harvey B, Spangler M. Compounded bioidentical hormone therapy. US Pharm. 2020;45(9):27-29. https://www.uspharmacist.com/article/compounded- bioidentical-hormone-therapy
- Bioidentical Hormones. Cleveland Clinic. https://my.clevelandclinic.org/health/articles/15660-bioidentical-hormones. Reviewed 12 December 2014. Accessed 31 May 2021.
- Male Hypogonadism. Mayo Clinic. https://www.mayoclinic.org/diseases- conditions/male-hypogonadism/symptoms-causes/syc-20354881. 5 November 2019. Accessed 5 July 2021.
- Thompson JJ, Ritenbaugh C, Nichter M. Why women choose compounded bioidentical hormone therapy: lessons from a qualitative study of menopausal decision-making. BMC Women’s Health. 2017;17(1):97. Published 2017 Oct 2. doi:10.1186/s12905-017-0449-0