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What is Bioidentical Hormone Replacement Therapy?


Bioidentical Hormone Replacement Therapy (BHRT) means that the chemical makeup of the replacement hormone is exactly the same as what the human body produces. The ideal natural substances for hormone replacement therapy are readily available. Bioidentical plant-derived estrogen and progesterone products have been safely prescribed by European physicians for over 80 years. These natural hormones are almost entirely without the side effects of the synthetic or semisynthetic HRT drugs which do not allow a person to produce the full range of other hormones which are needed for the body to function at full potential.

Unfortunately, many doctors are unaware of these natural hormones. Since natural hormones can not be patented, manufacturers lack financial incentive to fund research and development costs to commercially market these substances, and physicians receive little information on natural progesterone, estriol, estradiol, and androgens.

Women are no longer willing to accept the risks associated with synthetic hormones, and are searching for safer alternatives. New research is continually emerging. An estimated four million women are now benefiting from natural “plant-derived bioidentical” estrogens and progesterone.
Osteoporosis, heart disease, endometriosis, PMS, premenopausal symptoms, weight gain, low libido, fibrocystic breasts — most women will experience these or other hormone-related problems. Today, millions of women concerned about aging must decide whether or not to undergo synthetic hormone replacement therapy — and suffer its side effects and increased risks of cancer. As we consider the benefit to risk ratio, we must take into account new evidence and ongoing research about alternatives to traditional therapy.

Various dosage forms can be compounded to meet the specific needs of each woman.

Options include:


  • Transdermal or transmucosal dosage forms such as gels or suppositories. Non-oral absorption avoids first pass liver metabolism, providing a more reliable extent of absorption which is independent of liver function;

  • Capsules containing micronized particles for enhanced oral absorption;

  • Custom formulations to meet each woman’s specific needs.


In his book, "Natural Progesterone," John R. Lee, M.D., discusses various benefits of natural progesterone. For example, to reverse osteoporosis, Dr. Lee prescribes natural progesterone cream, a diet rich in vegetables and grains to serve as a source of calcium and magnesium for bone mineralization, mineral and vitamin supplements, and modest exercise. To monitor the success of this regimen, Dr. Lee conducted a study of 100 postmenopausal women ages 38 to 83. Bone mineral density (BMD, a measure of osteoporosis) was monitored. Dr. Lee observed an increase in BMD of 15%, indicating reversal of osteoporosis. Therapy produced relief of bone pain, increased physical activity, height stabilization, and fracture prevention. The benefits of progesterone were independent of age, time from menopause, or estrogen used.

The Benefits of Natural Estrogens

Estrogen is not one hormone, but a group of similar hormones with varying degrees of activity. The three most important hormones of this class are estrone (E1), estradiol (E2), and estriol (E3). Estradiol is the primary estrogen produced by the ovary, and estrone is formed by conversion of estradiol. Estrone is thought to be the estrogen primarily involved in breast cancer.

Estrone metabolizes into 2, 4, and 16 hydroxy estrone. Estrogens probably do not cause cancer, a virus causes breast cancer. But 16 hydroxy estrone can stimulate growth if cancer is present.
Estriol is produced in very large amounts during pregnancy and is thought to be protective against breast cancer. High levels of estriol are found in vegetarians and Asian women, who have a much lower risk of breast cancer. As far back as 1978, in the Journal of the American Medical Association, Dr. Alvin Follingstad advocated the use of the safer form of estrogen, estriol. He reported that 37% of postmenopausal women with metastatic breast cancer who received small doses of estriol had experienced remission or arrest of the metastatic tumors.

Alan R. Gaby, M.D., states that, “estriol has several other advantages over the commonly used forms of estrogen. Because estriol produces very little endometrial proliferation, it rarely causes postmenopausal vaginal bleeding … {and therefore may reduce the need for} diagnostic D&Cs and sometimes even unnecessary hysterectomies.” Estriol may also be more effective at lowering the risk of blood clots in the veins or lungs when compared with other estrogens. New regimens have been developed that use natural estriol and other naturally occurring estrogens in a properly balanced ratio.

Despite all evidence that indicates this is not optimal and appropriate therapy, the most popular form of estrogen replacement in menopausal women remains conjugated estrogens (containing many estrogens that are natural to horses, but few that are natural to humans). In the intestinal tract, these are converted mostly into estrone, the hormone that has been implicated in breast cancer. Synthetic ethinyl estradiol, commonly used in estrogen supplements and contraceptives, also presents a significant risk due to its high oral absorption and slow metabolism and elimination. Quoting Dr. Lee, “Since this factor of slow metabolism and excretion is true of all synthetic estrogens, one would think that, in all cases of estrogen supplementation, the natural hormones would be superior…Estriol is the most active on the vagina, cervix, and vulva. In cases of postmenopausal vaginal dryness and atrophy [tissue breakdown] which predisposes a woman to vaginitis and cystitis [bladder infection], estriol supplementation would theoretically be the most effective and safest estrogen to use.”
Possibly the most compelling reason to use estrogen is the fifty percent reduction in Alzheimer’s disease in women who took estrogen for ten years or more.

Natural Progesterone

A large government sponsored study of cardiovascular risk factors in women taking various estrogen/progestin replacement regimens was published in the Journal of the American Medical Association. Referred to as the PEPI Trial, it confirmed the fact that synthetic progestins partially negate the beneficial effects on cholesterol levels that result from taking estrogen. Another example of the dangers of synthetic progestins comes from the recent “Women’s Health Initiative” studies. The Primpro group showed increased breast cancer risk, no decrease in heart disease or Alzheimer’s. None of these negative effects were found in the Premarin group. Synthetic progestins are the bad girls. Natural progesterone, on the other hand, maintains all the benefits of estrogen on cholesterol without any of the side effects associated with synthetic progestins (such as fluid retention, irritability, and depression).

The role of natural progesterone as a bone growth hormone has also received considerable attention. If low estrogen is the major hormonal factor in osteoporosis in women, then why does significant bone loss occur during the 10 to 15 years before menopause, when estrogen levels are still normal? It is well accepted that estrogen deficiency causes postmenopausal osteoporosis and that the predominant benefit of estrogen replacement is to decrease bone resorption. However, increased resorption, which occurs after menopause, will not cause a net loss of bone if formation is equally increased. Jerilynn Prior, M.D., of the University of British Columbia in Vancouver, measured estrogen and progesterone levels in female marathon runners who had osteoporosis. She found that they developed osteoporosis when their estrogen levels were still high. However, they had stopped ovulating (common in female athletes) and progesterone levels had fallen, triggering the onset of osteoporosis. Dr. Prior has presented evidence that there are progesterone receptors in osteoblasts which mediate new bone formation.

Natural Androgens

In most cases, it is necessary to consider the addition of the androgen testosterone to a woman’s hormone replacement regimen. Typically thought of as a male hormone, testosterone is produced in females by conversion from estrogen and is essential to normal sexual development. Testosterone plays an important role in maintaining sexual desire, as well as the strength and integrity of skin, muscle, and bone.

As a woman enters the transitions of menopause, circulating androgens begin to decrease as a result of age-related reductions in adrenal and ovarian secretion. After menopause, a woman’s total estrogen production decreases by 70% to 80%, and androgen production decreases by as much as 50%. It is possible to supplement a woman’s testosterone deficiency with the same natural testosterone she has produced most of her life. Synthetic hormones with even the slightest alterations can produce side effects not found with the natural hormone.

Testosterone is the major male hormone or androgen. Male andropause, as so eloquently described by Eugene Shippen, M.D., in his book The Testosterone Syndrome (M. Evans and Co. Inc., New York, 1998), is still poorly understood by patients and physicians alike. “I challenge anyone to find a more diversely positive factor in men’s health,” says Dr. Shippen in relation to testosterone.
The male equivalent of female menopause, called andropause, is much more insidious and therefore much less suspected in the symptoms produced. Fat gain, muscle loss, decreased stamina, decreased sexual desire and function, mental fatigue, and irritability are but a few of the symptoms of andropause.

Testosterone is best replaced by using the natural form, either in transdermal cream or shots.
“Each person is a unique chemical entity and requires individual customization of hormone balance and delivery system.”

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DHEA, short for dehydroepiandrosterone, is a naturally occurring steroid hormone produced by the adrenal glands. DHEA is produced in larger amounts than any other adrenal steroid hormone. It is often called the “mother of hormones” by researchers because it is a precursor for the manufacture of many other hormones. These hormones are responsible for maintenance of body functions, such as fat and mineral metabolism, controlling stress, maintaining male and female characteristics, and others.

We have been working with DHEA for over 20 years. The last few years have brought numerous articles on DHEA — its effect as an anti-aging hormone and on its effect to convert fat to muscle. These two factors make it very interesting to our patient population.

DHEA has a great safety profile and, used with medical control, there are no serious side effects. The major aspect of DHEA in people over 50 is that it improves stamina, muscle mass, and generally a sense of well being. Merely being an anti–aging hormone does not mean much if it does not make one feel better. The list of potential benefits is very impressive, particularly for those of us who are mature adults. DHEA helps with memory, recalling numbers, cardiovascular problems, weight control, immune system enhancement, sex hormone improvement, improving brain function, and increasing general sense of well being.

The protocol we have been following is successful as well as safe. Before we start using DHEA supplementation, we draw blood to determine the DHEA level in the body. Based upon that, we give DHEA supplementation by capsules or transdermal cream. Later, we recheck DHEA levels. It is our objective to increase DHEA levels to the mid-range for young adults. Sometimes this is not possible, but we do show that even modest improvements in the DHEA levels over time show continued improvement.

It is our belief that anyone wishing to embark upon DHEA supplementation realize this is not a magic hormone, but a natural occurring hormone of the body and therefore improvement usually takes place over many months. Dr. Ahner will be happy to discuss DHEA and its role in natural hormone replacement.

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All hormones can be bound to various proteins collectively called Sex Hormone Binding Globulin or SHBG. For numerous reasons, SHBG can increase and make increasing amounts of hormones inactive. It is only the FREE hormone that can do the job of stimulating the cells.

We need to have a base line of SHBG as we start hormone therapy to help predict the amount of hormones to be given and as a reference point for future hormone levels. We use blood testing to measure the levels of SHBG.

The most common cause of increased SHBG is oral administration of hormones. The gastrointestinal absorption immediately carries all the hormone to the liver at one time. The liver immediately begins to metabolize the hormones in large quantities. The rapid metabolism often leads to immune activation and the increased production of SHBG.

The transdermal administration allows the hormones to avoid this rapid assimilation through the liver, thus usually lowering the SHBG. The use of Bio-identical Hormones also causes less immune system activation.

SHBG may also be increased in some of the diseases that are associated with immune activation such as chronic fatigue syndrome, rheumatoid arthritis, and potentially any chronic disease.

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