Hormone therapy is still considered the most effective treatment for relieving menopausal symptoms of hot flashes, night sweats, and vaginal dryness. Many women dislike the traditional hormonal therapy due to side effects of such as breast tenderness or bleeding. Others worry about estrogen’s link with breast cancer and man objected to the use of pregnant mares’ urine — the source of estrogen in oral conjugated equine estrogens (Premarin).
Natural versus Synthetic
Any product whose principal ingredient has an animal, plant, or mineral source is technically natural. It doesn’t matter whether the substance is ground, put into capsules, and sold over the counter — or extracted in a laboratory, manufactured by a pharmaceutical company, and made available only by prescription. For example, the soy plant is the source of supplements that some women take to ease menopausal symptoms; it’s also used, along with yams, to make the estrogen in the FDA-approved hormone drug Estrace.
The interest in a more natural approach to hormone therapy has focused attention on bioidentical hormones — hormones that are identical in molecular structure to the hormones women make in their bodies. They’re not found in this form in nature but are made, or synthesized, from a plant chemical extracted from yams and soy. Bioidentical estrogens are 17 beta-estradiol, estrone, Bioidentical progesterone is simply progesterone. It’s micronized (finely ground) in the laboratory for better absorption in the body.
Technically, the body can’t distinguish bioidentical hormones from the ones your ovaries produce. On a blood test, your total estradiol reflects the bioidentical estradiol you’ve taken as well as the estradiol your body makes. One advantage of bioidentical estrogen over Premarin is that estrogen levels can be monitored more precisely and treatment individualized accordingly. However some practitioners evaluate effectiveness based on symptom relief, using the least amount for the shortest period of time.
Bioidentical estrogens and micronized progesterone are made into a range of products, many of which are FDA-approved and available with a prescription at your local drugstore (see chart, “FDA-approved hormones for menopausal symptoms”). Commercially available bioidentical estradiol comes in several forms, including pill, patch, cream, and various vaginal preparations. Micronized progesterone comes in a capsule or as a vaginal gel.
|FDA-approved hormones for menopausal symptoms|
|Conjugated equine estrogens (CEE)/
pregnant mares’ urine
|Synthetic conjugated estrogens/plants||Cenestin, Enjuvia||Pill||No|
|Alora, Climara, Esclim, Estraderm, Vivelle, others||Patch||Yes|
|Estropipate (modified estrone)/plants||Ortho-Est, Ogen, others||Pill||No|
|Estradiol acetate||Femring||Vaginal ring||Yes|
|Estradiol hemihydrate||Vagifem||Vaginal tablet+||Yes|
|Progestins, micronized progesterone|
|Medroxyprogesterone acetate (MPA)||Amen, Cycrin, Provera||Pill||No|
|Micronized* progesterone USP||Prometrium||Pill||Yes|
|Prochieve 4%||Vaginal gel||Yes|
|Norethindrone||Micronor, Nor-QD, others||Pill||No|
|Norethindrone acetate||Aygestin, others||Pill||No|
|CEE and MPA||Premphase, Prempro||Pill||No|
|Ethinyl estradiol and norethindrone acetate||Femhrt||Pill||No|
|17 beta-estradiol and norethindrone acetate||Activella||Pill||No|
|17 beta-estradiol and norgestimate||Prefest||Pill||No++|
|17 beta-estradiol and levonorgestrel||Climara Pro||Patch||No++|
|*Particles are made smaller for better absorption.
**Bioidentical estradiol until ingested and converted in the liver to estrone.
+For vaginal symptoms only.
++The estradiol is bioidentical but not the progestin.
Bioidentical estradiol in pill form is converted in the liver to estrone, . But given in a patch, it enters the bloodstream as bioidentical estradiol. Creams, gels, and lotions applied to the legs or arms can also deliver bioidentical estradiol directly to the bloodstream.
Studies have shown bioidenticals can help relieve hot flashes and vaginal dryness, but as yet, few large studies have investigated the differences among the various hormones and methods of administration. More research is needed to further understand these differences and compare the risks and benefits.
Women taking bioidentical estrogen who have a uterus must still take an FDA-approved progestin or micronized progesterone to prevent endometrial cancer. So-called natural, plant-derived progesterone creams sold over the counter contain too little of the hormone to be effective. And yam extract creams don’t help because your body cannot convert them into progesterone.
Much of the confusion about bioidentical hormones comes from the mistaken notion that bioidentical hormones must be custom-mixed at a compounding pharmacy. Custom compounding is necessary when a clinician prescribes hormones in combinations, doses, or preparations (such as lozenges or suppositories) not routinely available — or to order additional hormones such as testosterone and DHEA. Compounding pharmacies that belong to PCCA (Professional Compounding Centers of America) or IACP (International Academy of Compounding Pharmacist) pharmacies following particular standards and only use the same FDA-approved ingredients in compounding formulation.
One size doesn’t fit all in women’s health. Compounded hormones can certainly help to individualize treatment, but if you’re considering them, consider the following:
- Your provider should inform you of any potential side effects.
- Women with an intact uterus should not take an estrogen alone
- There is controversy on saliva testing and such testing is not covered by insurance. Many providers use blood tests for monitoring hormonal levels.
- Heath insurers don’t always cover compounded drugs.
- Compounded hormones require a prescription and as such you should see an experienced and reputable practitioner who has specialized in such treatments.
As with any hormone, women need to work closely with their provider, discuss symptoms, quality of life and utilize the least amount for the shortest period of time. To learn more about bioidentical hormones visit a practitioner who specializes in prescribing bioidentical hormone replacement therapy.
Women’s health advanced practice nurses and certified nurse midwives are trained in holistically approaching healthcare symptoms and take the time to talk and listen to your needs. To find one in your area check Nurse Practitioners in Women’s Health or The American College of Nurse-Midwives