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
Clinical
Application of
BHRT
Tracy Marsden BScPharm, DHPh
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Types of Hormones
 Estrogens
 Progesterone
 Testosterone
 Cortisol & DHEA
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Pre-Menopause
OVARY
Testosterone
Progesterone
aromatase
Estradiol
Estrone
Estriol
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Estrogens
 3 main types: estradiol, estrone, estriol.
 Estradiol is the main estrogen produced by
the ovaries.
 Estrogen receptors found throughout body:
brain, blood vessels, bone, etc.
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Progesterone
 Synthetic progestins like Provera® are not
the same as progesterone.
 All women need progesterone to balance
effects of estrogens (even women who have
had the uterus removed!)
 Progesterone increases the body’s
sensitivity to the estrogens it has.
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Androgens
 Testosterone is important to women for:
 Bone
 Sex drive
 Energy, sense of well being
 DHEA and androstenedione are important
building block hormones: needed to make
androgens and estrogens (particularly after
menopause).
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Cortisol
 Is the primary ‘stress’ hormone.
 High cortisol levels can interfere with the
actions of all the other hormones.
 Prolonged elevation of cortisol can deplete
the adrenal glands.
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Post Menopause
ADRENAL
GLAND
Dehydroepiandrosterone
(DHEA)
Cortisol
Androstenedione
aromatase
Estrone
Testosterone
aromatase
Estriol
Estradiol
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Normal Cycles
 Progesterone is produced in quantity after
ovulation
Menstrual Cycle – 6 month view
Progesterone peaks after
ovulation and balances
estrogens. Cycles are regular.
Peri-menopause – 6 month view
Relative excess of estrogens
over progesterone. Cycles
are irregular.
Post-menopause – 6 month view
Very little progesterone or
estrogens released by
ovaries. No cycles.
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Hormone Balance
 There is an intricate balance
among all the hormones; too
much of one can create
an imbalance.
 Maintaining the right balance
can reduce symptoms
and help prevent disease.
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Hormone Therapy Missteps
 Giving unopposed estrogen to all women (no
progesterone given to balance estrogens)
without testing or proof of need.
 When we found out estrogen alone increased
endometrial cancer risk, we added a synthetic
progestin instead of natural progesterone.
 When we found out synthetic progestins
increased heart attack and stroke risk, we just
decreased the dose.
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A better approach
THREE SIMPLE STEPS

Symptom assessment

Hormone testing

Restore hormone balance with bioidentical hormones
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Symptom Assessment
Symptoms: Please rate your symptoms according to the following scale:
0 - never or rarely experience this symptom (<20% of the time)
1 - experience this symptom some of the time (~20-49% of the time)
2 - experience this symptom most of the time (~50-70% of the time)
3 - experience this symptom all of the time
(~80-100% of the time)
For example if you experience allergies some of the time, you would
indicate this by darkening the 2 next to ‘Allergies’: ijvl Allergies. If
you do not understand the symptom, please leave circles blank.
ijkl Hot flashes
ijkl Night sweats
ijkl Water retention
ijkl Breast tenderness
ijkl Decreased sex drive
Step 1: Symptom Assessment
ijkl Memory lapses
ijkl Foggy thinking
ijkl Heart palpitations
ijkl Irritability
ijkl Loss of muscle bulk
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Hormone Testing Options
Urine
 Measures what the body throws away
Blood
 Measures what might eventually get to
tissue
Saliva
 Measures what actually gets to tissue
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What are bio-identical hormones?
 Bio-identical means that the hormones are
identical in structure to what is produced
naturally in the body.
 More accurate to call them Human-Identical
Hormones, but BHRT is a common term.
 Studies showing harm from hormones used
synthetic or semi-synthetic hormones (horse
estrogens, synthetic progestins)
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Principles of BHRT
 Use the identical hormone to that which the
body produces on its own
 Give bio-identical hormones in the way that
is closest to the way hormones are released
in the body
 Use the minimum dose to relieve
symptoms.
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Bio-identical Hormone Replacement
 Bio-identical hormone replacement (BHRT)
includes:


Estradiol patches and gels
oral micronized progesterone
 These bioidentical products are not
controversial
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Transdermal Estrogens
 However, BHRT also includes:
 compounded oral or transdermal combination
estrogens (BiEst, TriEst)
 compounded progesterone creams
 compounded sustained release oral micronized
progesterone
. . . which are more controversial types of bioidentical hormone replacement.
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BiEst and TriEst
 BiEst and TriEst contain mostly estriol, the
weakest estrogen.
 Theoretically, estriol raises estrogens levels
when they are low, and competes with
stronger estrogens for receptor sites when
estrogen levels are high.
 Some research suggests that estriol may be
protective against breast cancer.
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Bi-Est
 BiEst (bi-estrogen) is a combination of estriol
and estradiol in oral or transdermal form


Various combinations available: 80:20, 70:30,
50:50
First number refers to the estriol component
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Tri-Est
 Tri-Est not used often as most women do
not require estrone.
 TriEst (tri-estrogen) is a combination of
estriol, estrone, and estradiol

Various combinations available: 80:10:10,
90:5:5, 60:20:20
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Estriol (E3)
 Effective for hot flashes, insomnia, poor
memory.
Head K. Alt Med Review 1998;Vol. 3(2)
 Intravaginal use may be effective for vaginal
dryness, infections, recurrent UTI’s and
dyspareunia. Head K. Alt Med Review 1998;Vol. 3(2)
 Estriol has been safely used in Europe for
decades, although is not approved for use in
North America.
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TriEst and BiEst
 “Unconventional compounded estrogens do
not appear to be worth the extra cost and
effort they exact, but they do represent an
addition therapeutic option for women who
cannot tolerate conventional prescription
estrogens.”
Taylor M, Clin Obstet Gynecol; 2001 Dec;44(4):864-79
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Bio-identical Progesterone
 Progesterone (bio-identical hormone)
compared to Provera (medroxyprogesterone
acetate)
 Progesterone cream versus oral micronized
progesterone
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Progesterone
 Acts with estrogen to relax
blood vessels
 Does not increase risk of
breast cancer
 Does not increase
inflammatory markers in
blood
 Protects against natural brain
cell death.
MPA
 Inhibits relaxation of blood
vessels by estrogens
 Increases risk of breast cancer
 Increases inflammation
causing C-Reactive Protein
(CRP)
 Does not protect against
natural brain cell death.
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Bio-identical progesterone
 Oral micronized progesterone (Prometrium™) is
bio-identical
 Effectively protects the endometrium (lining of
the uterus)
 Giving progesterone orally creates metabolites
that have an anti-anxiety and sedative effect.



Pregnanolone
Allopregnanolone
Hydroxypregnanone
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Progesterone Cream
 Progesterone cream is also effective, and
may be less sedating than the oral form.
 Progesterone is better absorbed through
skin than either testosterone or estradiol
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Progesterone Cream
Efficacy:
 Some evidence that progesterone cream can
protect the endometrium
 No bone building effects
 May help reduce hot flashes
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Compounded Progesterone Cream
Quality depends on
 how finely ground the progesterone
powder is
 the type of base used
 the compounding skills of the pharmacist.
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BHRT Study
 189 women between the ages of 45 and 60
prescribed BHRT: all received progesterone
and BiEst topically. Some also received
testosterone, DHEA.
 70% complained of ‘brain fog’
 55% complained of weight gain.
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Study Results
 90% completely or partially improved on
symptoms of brain fog.
 60% of women who gained weight, lost weight.
Average weight loss was 14.8 pounds.
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Cortisol Effects
 High levels of cortisol can compete with
the other hormones, creating a ‘functional
deficiency’ of hormones.

Progesterone or testosterone in normal range,
but the body functions as if there is not enough
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Cortisol and DHEAS
 Cortisol is catabolic, meaning it breaks down
muscle and bone
 DHEA is anabolic, meaning it builds up
muscle and bone
 Balance becomes more catabolic with age as
DHEA levels decline and cortisol levels
increase
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Adrenal Fatigue
 High cortisol levels over time cause damage,
and the body slows cortisol release to
prevent further damage.
 Decreased cortisol release leads to adrenal
fatigue and inability to regulate other
hormones.
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Thyroid
 Thyroid issues more common as
perimenopause is reached: higher overall
estradiol levels in perimenopause reduced
amount of free thyroid hormone.
 Too low or too high cortisol can also affect
thyroid.
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BHRT Summary
 Bio-identical hormone replacement (BHRT) is an
accepted standard of hormone replacement,
although there is controversy around custom
compounded forms of BHRT
 Oral progesterone is accepted, and progesterone
cream is gaining acceptance.
 BiEst and TriEst are still unproven therapies, but
preferred by many women.