Individualised Bioidentical Hormone Replacement Therapy for Perimenopause and Menopause
Menopause is officially defined as the cessation of menses for a year as a result of decreasing ovarian function. Menopausal symptoms can occur between the ages of 35 to 55, however some symptoms can occur as early as 30 years in some women. A women undergoing natural menopause really does not know whether any given period is truly her last until a year has passed.
As menopause approaches cycles become quite erratic with the initial hormonal changes associated with perimenopause occurring by the age of 40. Contrary to standard belief, estrogen levels often remain relatively stable during perimenopause until less than a year before the last menstrual period, where levels begin to decline. Testosterone levels also usually do not fall appreciably during perimenopause. Progesterone levels however begin to decline long before changes in estrogen or testosterone. Because estrogen and progesterone are meant to counterbalance each other throughout the menstrual cycle, a decline in progesterone allows estrogen to go unopposed which results in a condition called estrogen dominance. The symptoms of estrogen dominance are decreased sex drive, irregular and/or heavy periods, bloating and fluid retention, breast swelling, mood swings, weight gain and headaches. Unfortunately there is a great deal of overlap in the symptoms of various hormone imbalances and it is not uncommon for women experiencing estrogen dominance to be given a script for more estrogen thus worsening her symptoms.
As the midlife transition continues progesterone levels continue to decline and eventually estrogen levels begin to fluctuate widely. It is at this point where perimenopausal symptoms of estrogen deficiency begin such as: hot flushes, night sweats, loss of sexual desire, vaginal dryness, fuzzy thinking, urinary tract infections and dry skin. These perimenopausal symptoms may last from anywhere between five to ten years. Continuing through the perimenopausal time-line the women finally reaches menopause where menstruation has totally ceased.
After menopause in addition to low estrogen levels, and the associated symptoms, women lose two-thirds of their remaining progesterone and within six months blood levels fall to a barely functional level. A lack of circulating progesterone may cause any of the following symptoms: swollen breasts, headache, low libido, anxiety, depression, insomnia, cramps, emotional swings, weight gain, bloating, fuzzy thinking etc.
There is no need for women to suffer through these mid-life changes as Individualised Bioidentical Hormone Replacement Therapy (IBHRT) is able to effectively treat many menopausal symptoms. The approach taken in IBHRT is to formulate the appropriate replacement hormones according to the individual needs of the patient to ensure their hormone levels are adjusted within the normal physiological range. The bioidentical hormones used include: the estrogens: Estriol, TRIEST or BIEST; progesterone and testosterone.
ESTROGENS
Estrogens are used to relieve the many signs and symptoms of estrogen deficiency. In addition they may also be able to provide a long term prevention of the major health issues related to declining estrogen levels. These health issues include higher risk of suffering cardiovascular disease, specifically angina and heart attack, osteoporosis, increased incidence of urinary tract infections, vaginal shrinkage and possibly Alzheimer’s disease.
There has been a lot of misinformation in the media in regards to estrogen and its roll in breast cancer. The media has made estrogen out to be evil to womens health when in actual fact it is required for over 400 different physiological functions. The truth is that the risk of breast cancer seems to be related to the type of estrogen used, the estrogen (E1,E2 &E3) balance, excessive estrogen levels, estrogen/progesterone imbalance and unfavourable estrogen metabolism. To blame breast cancer on estrogen is far too simplistic! For more information about these risk factors please refer to more detailed information on Estrogen and our news section called Breast Cancer Prevention and Treatments.
The are two estrogen preparations that I recommend for specific situations. The first combination is BIEST which consists of 70% estriol and 30% estradiol. This combination is best suited for most women. As estrone is stored in the body fat most women tend to have sufficient levels so it is usually not necessary to supply any extra. In addition if estrone is required it may be produced directly from the supplemented estradiol in the BIEST mixture. It is considered much safer to maintain lower estrone levels so in most cases it is not supplemented. The second estrogen preparation is to use estriol on its own. This is usually used in cases with a history of breast cancer. TRIEST, which consists of 90% estriol, 7% estradiol and 3% estrone, has been very popular in the past however due to concerns with estrone should be avoided.
PROGESTERONE
Progesterone is used which opposes estrogen induced endometrial hyperplasia and possible endometrial carcinoma. Recent studies also indicate its protective effect against breast carcinoma. Because progesterone is a precursor for so many hormones, the whole body suffers if we are short of it because other hormones cannot be produced in sufficient quantities. This widespread precursor role helps us understand why it has such beneficial effects such as improved sleep and mood, more energy, clearer head, improved thyroid levels, improves migraines, prevents cardiovascular disease, helps with fluid retention, helps dry skin, treats infertility, tremendous sense of well being, end of hot flushes as well as increasing bone density. The ratio of progesterone to estrogen in healthy young women is nicely balanced at approximately 100:1. In IBHRT mother nature’s blueprint is copied by trying to maintain this balance.
TESTOSTERONE
The level of testosterone in menopausal women are often low causing the following symptoms: unexplained fatigue, loss of libido, decreased sensitivity to sexual stimulation in the nipples and clitoris, decreased arousability and capacity for orgasm, diminished vital energy and sense of well being, loss of muscle tone, depression, thinning pubic hair and dry and brittle scalp hair. If you suffer from any of these symptoms and laboratory tests show your testosterone levels are below the normal physiological range then you should consider adding testosterone to your IBHRT regime. The benefits of testosterone replacement as part of IBHRT are increased vital energy and zest for life, improved depression, improved libido and a sense of well being.
In addition to the sex hormones discussed above other hormone imbalances may also effect the symptoms, diagnosis and time of onset of perimenopause and menopause. These hormones are discussed below:
DHEA
Low DHEA levels are known to be a major factor in hormone imbalance and is particularly implicated in perimenopause and menopause. Accumulated adrenal stress reduces DHEA levels which then accelerates naturally diminishing sex hormone levels causing severe hormonal deficiencies. This decline in DHEA is further exacerbated by the natural age related decline. A progressive decline occurs after the age of 30 at a relatively constant rate of 10% per decade. By the age of 70 to 80 the DHEA levels are only 30% of those observed between the ages of 20 to 30. By replenishing low levels of DHEA back to levels of a young healthy women provides many benefits which may include: improved sex drive, enhanced immune function, renewed energy and stamina, better sleep, brighter mood and keener memory. Although these results are impressive the real benefit of DHEA is in its potential for preventing cardiovascular disease, high cholesterol, diabetes, obesity, cancer, Alzheimer’s disease, memory disturbances, osteoporosis, immune system disorders and chronic fatigue. The benefits of combining DHEA into your IBHRT regime cannot be overstated, if laboratory results indicate they are deficient.
THYROID HORMONES
Thyroid malfunction has also been implicated in perimenopause and menopause. Approximately 26% of women in or near perimenopause are diagnosed with hypothyroidism. During periods of estrogen dominance the thyroid gland function may be suppressed reducing the secretion of thyroid hormones. If laboratory results reveal thyroid hormone deficiencies then these hormones will also require supplementation. Sometimes however menopausal women may appear with hypothyroid symptoms even though their thyroid hormone levels are found to be normal. Dr John Lee has found that in these cases estrogen dominance occurs which he hypothesized blocks the action of thyroid hormones, possibly by competing with thyroid hormone receptors, thus rendering the hormones ineffective. Progesterone supplementation is therefore required to counterbalance the estrogen dominance which in effect reactivates the thyroid receptors eliminating hypothyroid symptoms.
From the discussion above, the complexities of hormone balance become evident. A harmonious blend of all sex, adrenal and thyroid hormones is essential for optimal health and any alteration of any hormone level may lead to a cascade effect which ultimately upsets the balance of all other major hormones. It is for this reason that I recommend testing all major hormones in order to obtain an accurate assessment of your overall hormonal health.
Designing a IBHRT Regime
Before starting IBHRT it is important you determine the levels of – estriol, estradiol, estrone, progesterone, testosterone, DHEA-S, and possibly cortisol and the thyroid hormones T 3 and T 4 . This test will rule out any unexpected medical problems such as adrenal exhaustion and hypothyroidism, which are both very closely linked to each other and to hormone imbalances, and will also determine where you stand in the perimenopausal-menopausal time-line. This will identify specific hormone deficiencies ensuring each one is dealt with appropriately. The results can also be used as a comparison for subsequent tests to determine the absorption of each hormone. The test results as well as any symptoms you experience will determine the right combination of hormones for you to try. These hormones may be taken several different ways and it is up to you and your doctor to decide which is the most appropriate for your individual needs. The several routes of administration are discussed below.
Routes of Administration
I recommend using either transdermal creams or slow release capsules depending on the circumstances (discussed below).
Creams
Hormones are effectively absorbed directly into the bloodstream bypassing the stomach and liver. This allows lower doses to be administered thus placeing less stress on the liver and decreasing the chance of side effects. Once absorbed the hormones are stored in body fat under the skin which release the hormones into the blood stream over time thus maintaining steady levels in the blood.
Combination creams may be prepared which can contain any combination of hormones required providing a single convenient dose form. Dosage adjustments are very easy to do with most women being delighted with this dose form as it improves the appearance of the skin, enhances moisture, as well as providing the benefits of IBHRT.
It is best to apply the cream to the skin after bathing ensuring the skin is clean and pores open. It is optimal to apply the cream in the morning to mimic the natural daily hormone surges and to rotate the application sites. It is best absorbed where the skin is relatively thin and well supplied with capillary blood flow such as the neck, upper chest, inner arms, palms of the hand and soles of the feet.
Make sure the cream base being used for your cream does not contain any hidden nasties such as hormone disrupters like the paraben preservatives or propylene glycol. In addition avoid the use of all petrolium based ingredients (paraffins), parabens, sodium lauryl sulphate, propylene glycol, fragrances, artificial colours, waxes and heavy oils. For more information refer to our article Are your Cosmetics Causing you Harm.
Capsules
Hormones taken orally come in contact with the acid in our stomaches which may decompose some and once absorbed are passed into the liver where they are further metabolised before entering circulation. Oral administration thereby requires greater doses to achieve physiological levels.
If any liver problems exist this route of administration is not recommended.
If no contraindications exist oral dosing is an accurate and convenient way to deliver the hormones.
Lozenges/Troches
For more accurate information regarding troches please refer to the article The Truth about Troches.
Lozenges/Troches are held between the cheek and gum and allowed to dissolve. The hormones are claimed to be absorbed directly into the blood vessels that line the buccal area thus avoiding the stomach and liver. However estimates indicate that approximately 50% to 70% of the lozenge is swallowed which inevitably encounters the stomach and liver. Clinical experience shows that doses required for troches are as high as capsules so there is no real benefit using them except in cases where creams are unsuccessful and digestion/absorption problems exsist.
The hormones have a bitter taste which cannot be effectively masked with sweeteners and flavors and they take up to 30 minutes to dissolve in the mouth. It is for these reasons some women find troches unacceptable. The hormones are also rapidly absorbed into the bloodstream and rapidly metabolized by the liver producing large fluctuations in blood levels throughout the day. Lozenges also adversely affect saliva hormone test results if taken within 36 hours of a test.
Treating Perimenopause
During the early stages of perimenopause while still menstruating estrogen dominance is the cause of symptoms. Progesterone supplementation is therefore required to counterbalance the excess estrogens. Metabolic syndrome should also be ruled out as the cause of estrogen dominance.
As perimenopause progresses estrogen levels may begin to decline causing a cessation of menses as well as producing hot flushes, night sweats, dry vagina etc. When these symptoms appear or if menses has ceased for three consecutive months perform a blood/saliva test to determine if estrogen replacement is also required. If so, add a low dose of BIEST taken continuously or from day 7 to 28. It is also a good idea to check testosterone and DHEA levels to see if they too require supplementation. If so, they made be combined with the BIEST.
Treating Menopause
The first hormone to balance is estrogen. This is the trickiest to balance as perimenopausal women have either a high or low estrogen requirement. If estrogen levels increase too high then unwanted side effects occur so it is recommended to start on a low dose and if necessary gradually increase the dose until estrogen deficient symptoms disappear.
It is far easier to derive an optimal progesterone dose as it will be dictated by current estrogen levels. As a general rule progesterone levels should be 100 times that of estradiol in order to achieve a healthy balance. If laboratory tests show testosterone and DHEA are low they too should be supplemented at an appropriate starting dose.
Once you have started on a hormone combination for about 4 to 6 a follow up blood/saliva test should be performed to recheck your hormone levels. The timing of this test is very important in order to get a reliable result. Blood/Saliva samples should be taken about four hours after your morning dose. This test will determine if levels are within a physiological range and will also determine your individual absorption of each hormone. These test results along with any symptoms you may still be experiencing should be used in order to fine tune the doses of each hormone. Hormone doses may then be altered in order to alleviate any symptoms and to bring hormone levels to normal physiological levels. You must be patient at this stage as it might take several dosage adjustments to reach optimal levels but once these levels are obtained you will feel great.
Each women should play a big roll in developing her own HRT regime by monitoring any symptoms that may occur. Certain symptoms will indicate hormone imbalances and should be looked for when fine tuning your individual dose. The main symptoms of hormone imbalances are listed below to help you identify any imbalances:
Estrogen Excess
Sore swollen breasts and tender nipples, fluid retention, vaginal thrush, spotting, weight gain, headache, fatigue and heavy periods. Excess estrogens may also be metabolised into testosterone by 5-alpha reductase in hair follicles and sebaceous glands causing hair loss and oily skin.
Estrogen Deficient
Hot flushes, irritability, insomnia, night sweats, mood swings, skin and vaginal dryness, decreased breast size, memory loss and depression.
Progesterone Excess (rare)
Sleepiness, depression.
Progesterone Deficient
Spotting, fluid retention in hips, chest or head, fuzzy thinking, headache, swollen breasts, headache, mood swings.
Testosterone Excess
Hair loss, acne, oily skin, facial hair.
Testosterone Deficient
Fatigue, loss of libido, depression, lack of muscle tone.
DHEA Excess
Facial hair, acne, headache, hair loss.
DHEA Deficient
Lack of energy, no motivation, no zest for life.
When IBHRT “doesn’t work” – Hormone Hyperexcretion
There appears to be a small number of women who try IBHRT and do not get any results even after a couple of months of treatment on what is usually considered higher doses than usually required for most. In this type of sinario it is very important to check hormone levels via a 24 hour urine analysis which usually indicates very high levels of hormone in the urine. This shows that the patient is uable to retain the hormones as liver enzymes metabolise the hormones and rapidly clear them from the body. If found to be the case try 300 to 600mcg of cobalt chloride daily for three to six months. This compound inhibits the enzymes responsible for clearing the hormones and thus enables the body to retain them for longer and thus allows them to have an effect.
Supervision
During the initial stages of commencing IBHRT where dosage adjustment may be necessary, it is vital you maintain open communication with your pharmacist and your doctor.
If you are unsure do not adjust your doses without consultation as you may only exacerbate any hormone imbalances. Initially you may need to be patient changing the doses until the right dose is found that suits your individual requirements. However once the right doses are found you should feel physically great and mentally secure knowing all the benefits from using bioidentical hormones.
If your doctor is unaware of these hormones and are willing to learn about them they can contact us for a copy of our Comprehensive Prescribers Guide for Bioidentical Hormones. Audio CD’s are also available which are very informative covering many aspects of bioidentical hormones presented by medical experts.
Monitoring Hormone Levels
As mentioned earlier, once you are on IBHRT it is a good idea to have a follow up saliva/blood test after 8 weeks to determine the level of all supplemented hormones. This ensures the dose you are taking is maintaining the hormones within the optimal physiological range. If found to be outside this range appropriate dosage adjustments can be made to ensure the effectiveness of treatment and also to avoid any unnecessary side effects as a result of potentially excessive supplementation. Ongoing monitoring is also recommended every 6 months or so.
We also recommend to have a urinary estrogen metabolite test to determine that the balance of estrogen metabolites is favorable. If found to favor the production of the “bad” metabolite then 50 to 100mg of diindolylmethane (DIM) daily will help rectify it. For more detailed information on estrogen metabolism and DIM click here.
In addition routine endometrial ultrasounds and breast screening are also recommended for early detection of any problems.
If you are having difficulty finding a sympathetic doctor contact us as we may be able to provide you with details of an informed doctor nearby.
