Download Compounding Bio-identical Hormonal Replacement Therapy

Pharmacy Technician Education for Association Members
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Compounding
Bio-identical
Hormonal
Replacement
Therapy
M
enopause is a natural process in every woman’s life, generally occurring between the ages of 49-54, where a woman’s menstrual cycle ceases, signifying the end of normal ovarian function.
During this change, there are marked fluctuations in a woman’s
hormone production, as the ovaries transition to stop producing
her primary estrogen (estradiol) and a new, less potent source of
estrogen is produced (estrone) at significantly lower levels. Progesterone levels also decrease substantially during this time.1
The transition into menopause is often accompanied by fluctuations in women’s menstrual cycles, which may last shorter or longer, may be lighter or heavier in volume, and no longer come regularly on a monthly pattern. The hormone fluctuations also produce
a number of uncomfortable symptoms, with the most common
symptoms reported being hot flashes or “flushes”, night sweats, insomnia, mood swings, a “foggy” memory, and both skin and vagi-
By:
Wesley Nuffer, PharmD, BCPS,CDE
Assistant Professor,
Assistant Director of
Experiential Programs
University of Colorado
Skaggs School of Pharmacy &
Pharmaceutical Sciences
Dr. Nuffer is an assistant professor with the University of
Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences. His clinical work is done at the University
of Colorado Hospital in the Endocrinology, Metabolism
and Diabetes Practice clinic. His specialty areas include
diabetes, obesity, women’s health, and experiential
education. Dr. Nuffer previously consulted with menopausal women, compounding and holding BHRT group
classes at an independent pharmacy in Denver for several years. Dr. Nuffer reports no actual or potential conflicts of interest in relation to this continuing pharmacy
education activity and reports off-label use will not be
discussed.
CPE Information:
Universal Activity Number: 107-000-13-039-H01-T
CPE/Hours: 1 contact hours (0.1 CEUs)
Target Audience: Pharmacy Technicians
Activity Type: Knowledge-based
Initial release date: 1/1/2013
Planned expiration date: 12/31/2014
The Collaborative Education Institute is
accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education.
Activity Goal:
To familiarize the pharmacy technician with the field
of bio-identical hormone therapy, focusing on the two
major hormones, and to highlight several key concepts
regarding the compounding of hormones.
Learning Objectives:
Upon successful completion of this knowledge-based
CPE activity, pharmacy technicians should be able to:
1. Distinguish between bio-identical hormone replacement therapies (BHRT) that are available commercially and those that must be prepared by compounding the product
2. Define the basics of which women’s hormones are
compounded and potential benefits of each
3. Recognize a particular compounded formulation
(cream, troche, tablet, etc.) to best meet an individual woman’s needs
4. Recognize how different BHRT products are compounded and estimate the advantages and disadvantages of different formulations
5. Discuss the current evidence surrounding the use
of compounded BHRT products
This activity has been
developed specifically for
pharmacy technicians and is one
of 10 activities in the TEAM series.

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nal dryness. The incidence and severity of these symptoms are
very individual; some women describe them as merely “bothersome” or hardly notice the change, while others experience
very severe symptoms that greatly impact their overall quality
of life.2
In the past, it was thought that with the decline in estradiol, a woman’s risk for heart disease and her risk of bone loss
increased. The standard of care was to prescribe hormone replacement therapy (HRT) to avoid these risks. This approach
changed drastically, however, after the results of the Women’s
Health Initiative trial, which demonstrated that the most prevalent hormone combination of conjugated equine estrogen
(CEE) plus medroxyprogesterone acetate (MPA) may actually carry substantial health risks which outweigh any protective benefits these hormones produced.3 Following this trial,
there was a tremendous paradigm shift in the management
of menopause, with guidelines recommending HRT only for
symptomatic relief, and only for a short period of time. It also
left huge numbers of women looking for alternative solutions
for their menopause symptoms.
WHI Trial
The Women’s Health Initiative was a huge, multi-center research project that, in its entirety, studied more than
160,000 post-menopausal women aged 50-79 over 15
years. While there were actually four different randomized interventions within the project, the trial that received the most attention was a comparison between
conjugated estrogen alone or conjugated estrogen plus progestin compared against placebo in post-menopausal women, evaluating treatment effects on coronary heart disease
and invasive breast cancer. The study design is as follows:
The treatment group showed a higher incidence of heart attacks, strokes, breast cancer and blood clots when compared
to placebo. To put the numbers in perspective, for every
10,000 women who received the treatment of CEE plus MPA,
there would be an additional seven heart attacks, eight cases
of breast cancer, nine cases of stroke and eighteen blood clots
due to treatment. While there were positive results regarding
hip fractures and colon cancer, these benefits were assessed
not to outweigh the risks.
The estrogen-only arm of the trial continued on until 2004,
where it, too, was stopped early, due to an identified increased
risk of stroke in the treatment group. Of note, the substantial
heart disease and breast cancer risks were not seen in this group.4
Practice Points: The entire approach to managing a woman
who has reached menopause changed after the WHI trial, due
to the conventional hormones treatment demonstrating a significant risk with use.
This shows just over 10,500 women receiving CEE treatment or placebo with approximately 16,600 women receiving the combination of CEE and MPA or placebo. Women
who had received a hysterectomy were given estrogen
alone, as they would not be at risk for endometrial cancer,
which MPA is given to prevent. The trial was designed to
follow these patients over approximately 8.5 years. In 2002,
however, the National Institute of Health made the determination to stop the combined CEE + MPA treatment arm
early, after an average of 5.2 years of follow-up, due to the
assessment that the health risks exceeded benefits of treatment.3 The results from this combined arm are depicted here:
Questions regarding the WHI Trial Results
While experts agree that the WHI trial design and sample
size were strong and clearly demonstrate a risk in the women
studied who were using conventional hormone replacement,
there have been some criticisms about the trial’s design. One
observation pointed out the wide diversity in the ages of the
women studied, extending all the way out to the age of 79,
which is well beyond the start of menopause. Many experts feel
that the benefits of hormone therapy are most pronounced at
the start of menopause, in women aged 50-59, and that those
women may respond differently than women over 60. In fact,
further analysis of the WHI trial data examining women taking
estrogen alone indicates that the identified risks from this trial
were not present in the younger cohort of patients who fell
into the 50-59 age group.5 Another criticism is of universally
applying the results to all estrogen and progestin treatments
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since the study focused on only one particular formulation
of each; the conjugated equine estrogen and medroxyprogesterone acetate. Some experts questioned whether other
estrogen and progestin formulations, which have some documented different physiologic effects in the body, may carry the
same risk as these two products.
Change in HRT Approach
Following the publication of this major trial, the entire medical approach towards menopause management shifted. The
American Colleges of Obstetrics and Gynecology (ACOG) and
the North American Menopause Society both released updated guidelines, stating that estrogen replacement or estrogen
and progestin replacement should not be used for treatment
of any chronic condition.6,7 The only remaining indication for
HRT was for symptomatic relief, and guidelines clearly stated
that women should be on the lowest possible dose of hormones for the shortest amount of time. Women currently on
hormones were encouraged to taper their treatment off and
discontinue it, and many women were told by their physicians to “simply stop” their hormones, which in several cases
led to the resurgence of significantly uncomfortable menopausal symptoms. New lower dose formulations of conjugated equine estrogen were developed and produced to better meet these new guidelines. Other medications were also
explored for managing these symptoms, such as antidepressants like fluoxetine and venlafaxine, or the anti-hypertensive
clonidine. While these agents do demonstrate some effectiveness in controlling hot flashes, they do not demonstrate the
same effectiveness shown by supplementing estrogen. Also,
many women did not like the idea of taking an antidepressant
for several years to control menopausal symptoms. Finally, a
different approach to hormone replacement rapidly began to
gain popularity: the use of bio-identical hormones. The success that bio-identical hormone therapy showed led to a revised statement by ACOG in 2012 to endorse its use for shortterm treatment of menopausal symptoms.8
Bio-identical hormone replacement
The term “bio-identical” in regards to hormones is used to
describe molecules that are an exact copy of what a woman
would naturally produce in her body. There are three different
estrogens which naturally occur in a woman’s body: estrone
(E1), estradiol (E2), and estriol (E3). This can be easily remembered by their names: estrONE= E1, estraDIol = E2, and esTRIol
= E3. Of these, estradiol is the most potent, and is the focus of
many of the available prescription estrogen products. While
any of the estradiol prescription products are, by definition,
bio-identical, bio-identical hormone replacement therapy
(BHRT) generally refers to products specially compounded in
compounding pharmacies, utilizing the source hormone powders to formulate hormones in a variety of dosage forms and
vehicles. Bio-identical hormones also include progesterone,
which is available by prescription under the trade name Prometrium, and is also widely compounded into different formulations. Other compounded hormones that are also used for
women include testosterone, dihydroepiandosterone (DHEA),
and pregnenolone, which are beyond the scope of this monograph.
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BHRT therapy has continued to grow in popularity among
women of menopausal age. Many of these women feel that
conventional medicine has not provided them adequate solutions to controlling severe menopause symptoms, and some
are willing to face potential risks of therapy in order to improve
their quality of life, which has been significantly impacted. In
the search for alternative treatments, bio-identical hormone
replacement began to be marketed as a “safer” alternative for
women, based on the idea that the body already recognizes
these molecules and knows how to handle them. Several physicians began to publish books promoting both bio-identical
(natural) progesterone and estrogens, and some key famous
spokespersons (Suzanne Somers, Oprah Winfrey) continued to
publicize successes seen with using these bio-identical products. Compounding pharmacies correctly identified this as a
unique opportunity and began their own marketing to promote an alternative to conventional hormone replacement
by using bio-identical hormones. With the increased use of
the internet, a multitude of internet sites were established
marketing bio-identical hormones. Unfortunately, with this
marketing came a general feeling of “mistrust” of the medical
establishment, propagated by book titles such as What Your
Doctor May Not Tell You about Menopause.9 Providers began
to recognize the need to better understand these products,
so that they could carry on an informed discussion with the
women they are treating, who inevitably come in armed with
questions and information based largely from popular media.
Practice Points: The term “bio-identical” refers to molecules
that are an exact copy of what is naturally produced in the body.
There are bio-identical hormones available by prescription (estradiol, progesterone) and also compounded.
Compounded BHRT products
By far, the most popular of the bio-identical hormones formulated for women are progesterone and estrogen products.
The late Dr. John Lee was a pioneer in what he coined “natural
progesterone” therapy, citing an abundance of his personal
successes in managing women utilizing bio-identical progesterone. While it was quite apparent that he had some tremendous success working with women, it was difficult to determine how much impact the progesterone supplementation
had, as he also implemented some pretty rigorous dietary and
vitamin/nutrient interventions with the women he worked
with.9 After the WHI trial, BHRT advocates began to highlight
that the CEE used for the study actually came from the urine of
pregnant horses, easily pointing out that women would benefit more from a product that is naturally found in their body
than one that comes from a horse. The fact that there is very
little scientific evidence to support BHRT estrogen’s perceived
better safety and tolerability did little to impact the rising momentum this therapy was gaining.
One major advantage that is often highlighted by compounded pharmacies is the ability to “customize” medications
for the individual. As such, there are a variety of different hormone products that can be developed and produced to help
manage a woman’s menopausal symptoms. Delivering a drug
orally (by swallowing a tablet, capsule, or liquid) results in drug
absorption that travels first to the liver before it enters systemic
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circulation. This is significant because the liver can metabolize
the drug partially or completely before the drug ever exerts
its intended systemic effects. This is called the first-pass effect.
Administering a drug by a different route, such as a topical administration across the skin (using a cream or patch) or placing
a drug in the cheek or under the tongue (called buccal administration) avoids this first-pass effect, stopping the liver from metabolizing the drug until after it reaches systemic circulation.
In regards to hormone administration, these different deliveries can have a significant impact on the effects of the
compounded medication. One example is with progesterone,
which is very highly metabolized (>90%) by the liver. Progesterone administered orally will form a number of different
metabolites, some which are active and have effects in the
body, others which are not active. One particular metabolite
of progesterone is extremely sedating, accounting for the major drowsiness side effect seen when taking oral progesterone.
Administering progesterone topically avoids this liver metabolism, allowing the compounding pharmacy to provide a much
lower dose of the drug, which will still reach systemic circulation but will not have nearly the same sedation effects seen
with the oral pill. By understanding these different pharmacokinetic and pharmacodynamics properties of the hormones,
compounding pharmacists can customize the type of product
an individual patient may need. A woman complaining of insomnia, for instance, may benefit from an oral progesterone
capsule, which will cause sedation and may help her sleep. A
different woman may not want marked sedation with her hormone replacement, and may elect to receive a progesterone
cream instead.
When considering which delivery system to utilize for a specific hormone product, it is important to consider the overall
dose that will be delivered. One popular dosage form for estrogens is a “troche” (pronounced tro-key), which is a lozenge
designed to dissolve under the tongue. While this is also possible with progesterone, the larger overall dose needed creates
a troche that is substantially larger in size, which requires the
woman to have the product placed in her mouth for several
minutes while it dissolves. Even with customized flavoring,
many women tire of this prolonged dissolving time, and the
longer the product sits in the mouth, the more likely some of
it gets swallowed, leading to a different absorption path that is
not optimal. Similarly, creams need to be formulated so that a
very small volume (approximately 0.5cc) holds the therapeutic
dose. Cream doses that exceed ~1mL in volume require such
a large surface area of the body to rub the product in that absorption begins to become compromised, or the woman feels
like she is “bathing” in the product. Generally, women are instructed to administer the cream to the inside of the forearm
or thigh(roughly the size of a pea) and to thoroughly rub the
cream into that area for approximately 20 seconds. These areas have good blood perfusion, and the prolonged “rubbing”
facilitates complete absorption and minimizes risks of exposing others (such as the husband or family pet) to hormones by
having cream remain on the skin. Finally, local administration
is also an important consideration. A woman suffering only
from vaginal dryness may benefit from a vaginal estrogen
cream or suppository, which can be administered locally at a
lower dose, resulting in a lower overall blood level of the drug,
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minimizing systemic effects.
With all of these available options for delivering hormones,
there have been significant advances in technology available
to the compounding pharmacist. New cream bases, such as
PLO gels (pluronic lecithin organogel) optimize how the drug
penetrates the skin and absorbs into the bloodstream. There
are different agents, such as methylcellulose, which create a
sustained-release property, allowing the drug to absorb more
slowly and be dosed once a day, improving patient adherence.
Diligent compounding pharmacies also frequently send their
formulated products out to an independent lab for analysis to
verify that the product contains the correct drug at the correct
potency. There have also been a number of improvements to
the dosing devices used to deliver these products; creams are
typically dispensed in syringes with caps that can be utilized
to provide an exact amount of drug, as opposed to “scoops”
or spoons, which are estimates at best and can result in varied
doses delivered. Several patented devices are available for use
in order to facilitate exact dosing.
Practice Points: Different dosage forms allow pharmacists to
change the side effect profile and concentration of the hormone
given by taking advantage of the body’s physiological processes.
Combination products
Due to the fact that compounding pharmacies start with
powder sources of these hormones (usually originating from
yam or soy sources to generate diosgenin, which is then
chemically converted into hormones) it is also possible to
combine several medications into one formulation. Many
compounding pharmacists work closely with a woman’s provider to make recommendations for different combination
products. It is not uncommon for a woman to receive a hormone replacement cream that could contain estrogens, progesterone, and testosterone, all at varying concentrations.
The benefit to this type of approach is improving adherence
by providing multiple drugs in one formulation. One disadvantage is if the dose of one hormone needs to be adjusted,
a woman cannot simply vary the volume of cream applied, as
it would affect the dose of the other active hormones as well.
While there is a certain amount of variability between different
compounding pharmacies, depending on the providers they
work with and the specific pharmacy preferences, there are
some general standardized products used when compounding hormones. As an example, Pharmacy Compounding Centers of America, or PCCA, is one of the leading organizations in
the nation in providing compounding chemicals, recipes, education and support for compounding pharmacies.10 While not
forgetting about individual variability, these are recognized
compounded products:
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Tri-est: Tri-est is a combination of all three bio-identical estrogens: estriol, estradiol, and estrone. These are provided at a
fixed ratio, usually at 80:10:10 (80% estriol, 10% estradiol, and
10% estrone).
Bi-est: Bi-est combines estriol and estradiol, usually in an
80:20 mix (80% estriol, 20% estradiol).
While there is no exact conversion between different hormone products, this chart gives an approximate equivalence
in dose between available estrogen products:
Since estradiol is the most potent of the three estrogens,
the amount of Bi-est or Tri-est is usually based on the equivalent amount of estradiol. For the 0.5mg estradiol example, the
dose of Bi-est would be calculated as follows:
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macies and internet sites began to make claims that were well
beyond what could be substantiated by the existing evidence.
Some data points to benefits that bio-identical hormones
may have compared to the CEE/MPA combination. However,
making claims that go beyond this evidence damages the bioidentical hormone replacement practice and makes it an easy
target for criticism. This section will briefly summarize existing
evidence regarding these hormones.
Estradiol dose = 20% of total Bi-est dose
(or 1/5th of the total Bi-est dose)
0.5mg estradiol= 0.5/0.2 (or 0.5 * 5) = 2.5mg Bi-est
(Conversions provided by consultation with experts at PCCA)
Measuring Hormone Levels
One controversial area regarding hormone replacement
therapy is whether or not levels should be drawn to guide
therapy. Several compounding pharmacies endorse saliva
hormone levels for directing patient treatment. Measuring saliva levels of hormones, a practice done since the 1980s, has
largely been criticized for the high level of variability saliva
samples can yield. Proponents of saliva testing believe that the
saliva is similar to blood ultrafiltrate, and so hormone concentrations in saliva should represent the bioavailable (free/unbound) hormones found in serum.11 Opponents to saliva testing cite evidence that demonstrate saliva levels to have poor
reproducibility, lack data on the stability of the saliva sample
during storage and handling, and demonstrate wide interassay variability (running the same sample two different times
may yield two quite different levels).11 Many of these opponents feel that blood levels are more standardized and are superior to saliva tests. Further confounding this issue is the fact
that national guidelines on hormone replacement do not support basing therapy on hormone levels of any type. Instead,
they cite that hormone replacement should be based on the
woman’s specific symptoms, utilizing the lowest possible dose
that will adequately control these, and re-evaluating therapy
every few years.6
Practice Points: The idea of basing hormone replacement therapy on blood or saliva levels is controversial and not supported by
the leading Women’s Health guidelines at this time.
BHRT - What’s the Evidence?
The major criticism regarding bio-identical hormones is
the lack of scientific evidence to support claims made about
their safety and effectiveness. With aggressive marketing and
promotion of these products, this issue became worse as phar-
One benefit of the virtual “explosion” of bio-identical hormone interest is that the literature is now abound with commentaries, opinions, and articles discussing the use and claims
of BHRT. There were two major review articles published over
the last five years that summarized the available evidence regarding the use of BHRT and are an excellent starting-point
for practitioners.11,12 Dr. Cirigliano published a highly critical
article in 2007, citing a number of different articles and studies
that demonstrated little or no efficacy with using BHRT. He
concludes that “no biologically active estrogen should be considered without risk at this time” and that the majority of the
claims regarding BHRT therapy are driven by the media and
by women’s fears in conventional hormone therapy. He also
expresses concern over using topical progesterone creams
(which may not provide adequate serum levels) in women
who have an intact endometrial lining, as the traditional use
of any progestin is to protect against endometrial cancer. The
article is well-written and well-referenced and provides a compelling argument against the use of BHRT.11
On the other side of this controversy, Dr. Kent Holtorf published an article in 2009 citing a number of smaller randomized
studies, cross-sectional surveys, retrospective analyses, and
animal models that supported the idea that bio-identical hormones, specifically estriol and progesterone, possess unique
qualities that differentiate them from conjugated equine estrogen and medroxyprogesterone acetate. Of particular interest was the documented differences in how the progesterone
performed physiologically compared with medroxyprogesterone; Dr. Holtorf makes a compelling, eloquent argument for
supplementing progesterone for a variety of reasons.12
The truth about BHRT treatment is that further large, welldesigned randomized placebo-controlled trials need to be performed. The existing evidence can neither verify nor disprove
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the safety and efficacy that these hormones have in managing
women’s menopausal symptoms. Unfortunately, there is no
ability to patent a bio-identical hormone, so these trials, which
are so often sponsored by industry in order to produce a new
product, have little financial support. Until a government-led
initiative or other large group takes on this unique challenge,
clinicians will have to base their decisions on clinical experience and on the existing evidence.
Practice Points: The evidence regarding bio-identical hormones is controversial, and further large, well-designed studies
need to be done to determine what role BHRT will hold for women
in the future.
Role for Pharmacy Technicians
Bio-identical hormone replacement therapy continues to
be a topic of extreme interest, particularly to women in or approaching menopausal age. Understanding the basics of this
form of pharmacy practice, and understanding the controversies regarding it are critical for understanding the discussions
with interested patients. While there are still many questions
to be answered regarding the use of BHRT, many women have
benefited from the individualized approach taken by quality
compounding pharmacies. Being able to recognize realistic
expectations of what BHRT can and cannot do will help legitimize the practice and may help curb some of the criticisms this
area has received.
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References:
1. McKinlay SM, Brambilla DJ, Posner JG. The normal menopause transition. Maturitas 1992;14:103-15.
2. Daly E, Gray A, Barlow D, McPherson K, Roche M, Vessey M. Measuring the impact of menopausal symptoms on quality of life. BMJ
1993;307:836-40.
3. Rossouw JE, Anderson GL, Prentice RL, et al. Risks and benefits of
estrogen plus progestin in healthy postmenopausal women: principal
results From the Women’s Health Initiative randomized controlled trial.
JAMA 2002;288:321-33.
4. Anderson GL, Limacher M, Assaf AR, et al. Effects of conjugated equine
estrogen in postmenopausal women with hysterectomy: the Women’s
Health Initiative randomized controlled trial. JAMA 2004;291:1701-12.
5. Update on the Women’s Health Initiative Estrogen-Alone Trial. 2010.
(Accessed 10-5-2012, at http://hp2010.nhlbihin.net/joinhin/news/professional/whi.asp.)
6. ACOG Today. American Congress of Obstetricians and Gynecologists.
2004. (Accessed 10/5/12, at http://www.acog.org/~/media/ACOG%20
Today/acogToday1004.pdf?dmc=1&ts=20121108T1419214207)
7. North American Menopause Society Position Statement 2003. (Accessed 10/5/12, at hhttp://www.menopause.org/docs/default-document-library/psht03.pdf?sfvrsn=2.)
8. The American Congress of Obstetricians and Gynecologists Committee Opinion- Compounded Bioidentical Menopause Hormone Therapy. (Accessed 10-5-12, at http://www.acog.org/Resources_And_Publications/Committee_Opinions/Committee_on_Gynecologic_Practice/
Compounded_Bioidentical_Menopausal_Hormone_Therapy.)
9. Lee RJ. What your doctor may not tell you about premenopause and
what your doctor may not tell you about menopause. 1st Omnibus ed.
New York, NY: Warner Books; 2001.
10. Professional Compounding Centers of America. (Accessed 10/5/12,
at http://www.pccarx.com/.)
11. Cirigliano M. Bioidentical hormone therapy: a review of the evidence. J Womens Health (Larchmt) 2007;16:600-31.
12. Holtorf K. The bioidentical hormone debate: are bioidentical hormones (estradiol, estriol, and progesterone) safer or more efficacious
than commonly used synthetic versions in hormone replacement therapy? Postgrad Med 2009;121:73-85.
6
Assessment Questions
1) Which of the following products would be considered a bioidentical hormone that needs to be compounded?
A) Medroxyprogesterone acetate
B) Tri-est
C) Conjugated equine estrogen
D) Fluoxetine
2) What was one major impact of the WHI trial?
A) It was determined that CEE + MPA does not protect against
heart disease
B) Women should only be on CEE + MPA if they have high risk of
GI bleeding
C) Hormones were found to be superior to placebo in preventing
breast cancer
D) Testosterone should be used in conjunction with CEE + MPA
3) In a woman who is suffering from insomnia, which formulation of progesterone would be the most helpful?
A) Drops, as they absorb the most quickly
B) Topical cream, as topical administration bypasses liver’s clearance
C) Troche, so that she falls asleep trying to dissolve the large lozenge
D) Oral capsule, so that the sedating metabolites generated can
help her sleep
4) What is one of the major advantages to combining several
hormones in one cream?
A) Cost- combining products is cheaper for the patient
B) Portability- it’s easier to carry around in the patient’s purse
C) Adherence- including several hormones in one preparation
makes it easier to adhere to recommended therapy
D) Effectiveness- mixing hormones generates benefits beyond
what they individually offer
5) What is one advantage of using a compounding pharmacy to
create hormone products
A) Compounding pharmacies are generally cheaper than retail stores
B) Only compounding pharmacies have access to bio-identical
hormones
C) Compounding pharmacies have superior purity in their products
D) These pharmacies have the ability to formulate several hormones into one product, such as a cream
6) What are the two most prevalent compounded hormones?
A) Estrogens (bi-est or tri-est) and progesterone
B) Testosterone and estrogen
C) DHEA and pregnenolone
D) CEE and MPA
7) Estradiol is classified as:
A) Progesterone
B) E2
C) E1
D) E3
8) Regarding the evidence, which of the following are true
regarding BHRT?
A) The evidence clearly states NOT to use these products
B) There is some evidence supporting the use of BHRT, but larger,
randomized trials are needed
C) There is clear evidence that BHRT outperforms traditional
hormone treatment
D) No one should consider evidence when considering treatment
options
9) Which statement is correct regarding the use of saliva hormone testing?
A) This practice is analogous to selling “snake oil” and should
never be used
B)This should only be done for women taking multiple hormones
C) While there are some proponents of this practice, it is currently
highly debated as to its accuracy and clinical use
D) Saliva testing is documented clearly superior to blood level
testing
10) What concentration of Tri-est would be equivalent to 1mg
of estradiol?
A) 1mg
B) 2mg
C) 10mg
D) 5mg
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