Since the publication of Suzanne Summers’ “The Sexy Years” several months ago, and my book (“The Midlife Bible–A Woman’s Survival Guide”) earlier this year, interest has peaked in alternatives for therapy of pre-menopause, peri-menopause and menopausal symptoms to improve quality of life in middle and later years. Much of this interest has centered around the use of bioidentical hormones.
No longer are women satisfied (nor should they be) with a comment from a clinician to the effect of “That stuff doesn’t work” or “I don’t know much about bioidenticals”. No longer are women or their partners satisfied (nor should they be) with quick ten-minute office assessments and a prescription for “estrogen pills” to treat this complex set of circumstances. Women and their partners rightfully desire and demand information about sexual health and androgen therapy, information about and therapy for stress-induced adrenal fatigue and adrenal burnout, and they would like to do it in a way most naturally accepted by their bodies. Thus the interest in bioidentical products.
Often erroneously referred to as “natural hormones”, a bioidentical hormone is a compound synthesized in the lab from a “natural” source (usually soybeans in the case of estrogens and testosterone; wild Mexican yam in the case of progesterone and sometimes testosterone) to exactly mimic the chemical structure of the naturally occurring compound it is supplementing or replacing.
In contradistinction, a “natural” substance is a compound directly produced from a plant or animal source. By that definition then, Premarin (made from pregnant mare’s urine) is a “natural compound”. Although it may make sense to eat “naturally” and organically, “natural” does not always mean “safe” or “good”. “Natural” has become more of a sales gimmick than anything.
Better to use the words “botanical” to describe plant-sourced and herbal remedies, and “bioidentical” to describe hormonal therapies utilizing products resembling as close as possible those that the human body (used to) produce.
If disturbing pre/peri- or menopausal symptoms (hot flashes, crawly skin, mood and memory alterations, poor sleep quality, sexual disinterest, joint aches, depression, fatigue, palpitations, etc.) are mild, and you have some time to experiment, herbs and botanicals work approximately 50% of the time. Most likely to help are a combination of increased isoflavones (consuming increased amount of soy and other beans, flax seed, flax seed oil, isoflavones from soy or red clover sources) and black cohosh, chasteberry, evening primrose oil and sometimes dong quai in combination with other Chinese herbs (dong quai alone rarely works).
If symptoms are severe and disrupting home or work function, or if diminished vaginal lubrication and other sexual issues are disturbing, botanicals usually do not provide adequate relief and it is only after re-stabilization with hormones (estrogen, frequently testosterone only, also with or without progesterone) that relief is obtained. While relief is frequently just as profound with synthetics as with bioidentical hormones, for a variety of reasons, the “nod” goes to the bioidentical products.
While synthetic hormones are usually only available in oral form, bioidentical hormones are available in a variety of delivery systems (oral, transdermal patch, cream, lotion or sublingual drops, as well as a vaginal ring). Bypassing the GI tract and liver on the “first pass” can be advantageous for the body, plus transdermal delivery usually leads to better and more consistent hormonal tissue levels. Additionally, it makes intellectual sense to give a compound (e.g., estradiol, testosterone, progesterone) that the body is used to metabolizing, rather than a synthetic, which may be metabolized and react differently than expected in a given individual.
Significant (peri-) menopausal symptoms, especially sexual dysfunction, is usually the result of sudden fluctuations or lowering of both estrogen and testosterone levels. Most times, testosterone as well as estrogen needs to be supplemented. Sadly, this is rarely done. It is only by proper testing and frequently compounding bioidentical products that the balancing is successful, as unfortunately the only commercially available product that has both estrogen and testosterone in it is an oral form of synthetic estrogens and testosterone (“Estratest”), which works for many women but is frequently suboptimal.
Most of the time estradiol alone (estradiol is the hormone made in greatest quantity by the normally functioning ovary) is satisfactory–and it is available commercially in patches (Vivelle Dot, Climara, Alora, etc.), lotion or gel (Estrasorb, Estragel) vaginal ring (Femring) and oral (Estrace) forms. Occasionally, however, a true balancing is necessary, and bioidentical estriol (“E3”) and/or estrone (“E1”) are carefully compounded with estradiol (“E2”) by a knowledgeable healthcare practitioner as necessary. Bioidentical testosterone certainly helps with sexual desire, energy and quality of life issues. Frequently bioidentical progesterone is helpful to diminish anxiety, help with sleep and aid in adrenal support. Synthetic progesterone (e.g. Provera) is absolutely worthless in this area although it (as well as bioidentical progesterone and other synthetics) can help protect the uterus against endometrial cancer.
I would be remiss, in a discussion of bioidenticals, not to discuss adrenal support, although space limits all but a mention. Much more often than is realized in midlife women, the stress of the menopausal passage added on to the stresses of life accelerated at midlife (partnership issues, financial issues, care of aging parents, teenagers, stress in the workplace, etc.) impacts negatively on the adrenal glands, the “energy supporters” and energy regulators of the body. Cortisol from the adrenals may be dysregulated; DHEA and/or pregnenolone not produced in adequate amounts and energy disruption and fatigue result.
A good clinician utilizes judicious judgment and laboratory testing as necessary to separate ovarian from adrenal causes and work out both the proper ovarian and adrenal hormonal balancing and oversee lifestyle modifications to ensure successful relief of symptoms and greatly improved quality of life. Bioidentical DHEA, pregnenolone, progesterone and/or cortisol may all be compounded and supplemented to aid in this regulation, although obviously relief of stress through counseling, awareness, exercise, meditation and other lifestyle changes is important for long-term success.
Although there are many reasons to recommend the use of bioidentical compounds for pre/peri- and menopausal relief, safety may not be one of them. Don’t get me wrong, I unequivocally believe that these therapies (especially and including estrogen) can be given VERY safely to aid in the midlife passage; however, I find nothing in the literature or in common-sense biochemistry to suggest that the bioidentical products are any safer (e.g. less breast cancer, blood clots, etc.) than synthetics; however, if used in proper doses, in the proper way, and for relatively limited periods of time, there is no research, physiologic or common-sense reason to doubt their safety.