Hormone replacement therapy

Talking about bio-identical hormone replacement therapy with your doctor

by Dixie Mills, MD & Marcy Holmes, NP, Certified Menopause Clinician

Over the past months we’ve been inundated with calls, faxes and e-mails from women desperately seeking information and help in finding a local specialist who prescribes bio-identical hormones. We appreciate that it can be very frustrating finding and getting what you want but we applaud you for trying — we feel this is a certain way to bring about change in the medical system.

This recent surge of interest has been sparked in part by Suzanne Somers’s books, Ageless and The Sexy Years, in which she tells the story of her personal discovery of bio-identical hormone therapy. While bio-identical hormones have been around for a long time — we’ve used them for almost 20 years - most practitioners have little or no experience with the kind of individualized approach that Suzanne Somers writes about in her books.

It has been our experience that women know that something is not right, that their periods are irregular or have stopped, but they do not want a “quick fix.” Women want to “process”- talk about these changes with a healthcare provider. Many of these women turn first to their current doctor, asking “Can you prescribe bio-identical hormones for me?” Here’s our practical advice on how to prepare to talk with your local doctor about the many ways to get bio-identical hormone replacement therapy, and what to do to support your system naturally as well as get the best results on the lowest doses.

Women can be best prepared to discuss their hormonal and life changes with a healthcare provider by understanding three basic things:

• Know where your doctor is coming from.
• Know yourself, your history and your health philosophy.
• Know what you are asking for.

Know where your doctor is coming from

Our goal is for you to have a health provider who will want to partner and work with you to find the best possible means to help you through this challenging period in your life.

Most women have a primary care doctor or gynecologist whom they see for regular Pap tests. Often this is the place to start, or if not with that person, someone else in the group practice may be specializing in menopause. However, if you are new to an area or know you want someone new, we encourage you to call around to find a practitioner who is familiar with bio-identical hormones. Asking friends, calling local offices, checking out local newspapers, and searching the internet or the Yellow Pages for alternative health and holistic health can oftentimes lead you to a surprising resource. You may well find that nurse practitioners have more experience with bio-identical hormone therapy due to their interest in preventative health.

Remember that all health providers, doctors or nurse practitioners, are human. They have spent many years learning to be experts in their field and even more years practicing their expertise and they like to feel that they are good at what they do. They went into medicine to help people, but today, unfortunately, most are overstressed by managed care rules and financial considerations and having to work in factory-like conditions. He or she probably did not get much training in sex hormones (female or male) in medical school or residency programs. (Only in the last five years have women’s health programs in hospitals even been started.)

Moreover, the headlines and drug companies have bombarded your doctor with conflicting arguments that synthetic hormones are just as good as bio-identical hormone replacement therapy, that their trademarked hormones are the most trustworthy because they’ve been so thoroughly tested, and that women have no good alternative for the relief of symptoms of menopause. All these arguments are untrue, but they are the doctrine doctors have heard over and over.

When you are ready to call for your appointment, specifically request an appointment for a "hormone consultation." With all the recent news and released studies on hormones, doctors are certainly expecting these calls. If the office doesn’t know what you are talking about or doesn’t offer one, that should be a signal that you need to try elsewhere. Ask for at least a 15–minute or 30–minute appointment. This should be the sole focus of your visit, and you deserve to have your “hormone consultation” comfortably dressed in your clothes in an office instead of in a “johnnie” on an exam table. If you have not had a check-up or breast and pelvic exam in the last year, be sure to schedule that after the consultation or on another day if necessary. This type of focused consultation appointment assures that you can say what you want to say and not be rushed.

Know yourself and your history

Doctors are taught to first ask for a patient’s “chief complaint,” then to ask more details about it and take a history — when, what, how, where, etc. Unfortunately, with managed care time constraints, a full discussion often fails to take place. We advise women to be prepared with a list of their symptoms, what worries them the most, what they have tried, what seems to have worked in the past, and what they would like to change.

Here is a sample script -

First, provide your chief complaint and symptoms:

Hello, Dr. Jones, I am Mary Smith and I am now 52 years old. I have been having irregular periods for the last year with some heavy bleeding. My last period was 3 months ago. I have a job I love but it is very demanding. My youngest child has just started college. I am having trouble sleeping at night, waking up with hot sweats, and not remembering things as well as in the past.

Then provide your current medical issues and medications:

I am otherwise very healthy and take no prescription medications. I take a multivitamin with calcium when I remember. I try to walk a couple times a week and not eat junk food, but I find I am gaining weight.

Then give your past history and family history:

I get regular mammograms and do not have a family history of breast or ovarian cancer. Both my parents are still alive. Other than having my gallbladder out about 10 years ago, I have never been in the hospital. I have never smoked and have a few drinks a month.

Then sum up with what you are looking for:

I want to continue living with the quality of life I had, but I’m concerned that I may be perimenopausal and need some help in getting what I had back. I have heard about bio-identical hormones and am very interested in them. Can you help me?

You obviously will want to revise this script with your own personal story. You may want to write it out and copy it for your provider or send it prior to your meeting. You can start out writing as much as you need to, but your doctor will appreciate if you keep your summary short and succinct, ideally less than a page. You will want to be assertive and honest — this is your life and this time is a wise investment. It will also be important to be able to talk openly — if a nonexistent libido is a problem you will need to bring up your sex life.

Remember YOU are the expert on your body and its symptoms, needs and feelings, although you may not understand them at this point. If you get the sense that your provider is not listening, or telling you that there are no choices and that you just have to endure or grin and bear it, we would urge you to end the appointment, excuse yourself and find someone else.

Know what you are asking for

There is still a great deal of confusion about bio-identical hormones. Let’s try to clear that up. You can take a look at our article on the fundamentals of bio-identical hormones.

The key points:

• What is the difference between hormones: Bio-identical hormones are made in a laboratory, usually from the components of plants, to match exactly the formula that your body produces and has been used to. In contrast, synthetic hormones are designed by drug companies and are foreign to the human body, unique in ways so they can be patented. The formula has been altered in a small way — if you remember your basic biochemistry class — an H or OH or C has been switched on the basic steroid ring. Scientists did not realize that some of the changes which they originally thought were insignificant would not be — we all remember the DES story.

  We are just now realizing that Provera — a synthetic, non bio-identical progesterone — may be the “bad actor” in increasing the rate of breast cancer. Premarin, the most commonly prescribed estrogen replacement therapy (ERT), is natural to a horse, being derived from pregnant mares’ urine (hence the name “Premarin”). But equine estrogen is not bio-identical to a woman’s. Prempro is the combination of Premarin and Provera: we haven’t recommended it for many years, and since the WHI studies in 2002 most conventional doctors don’t either. (See our 2007 press release for an update on its “safety.”) Other estrogens on the market, like Ogen, are made from plants but not in the same formula as a woman’s.

  Human estrogen is found in three forms, called estrone (E₁), estradiol (E₂), and estriol (E₃), all of which can be custom–compounded as bio-identical ERT. Of these three, only estradiol is available in brand name form — because the pharmaceutical companies have developed and patented various unique delivery methods for it.

• What is usually available: Many doctors have knowledge of other hormone replacement products besides Premarin, but they may not be aware of which brands fall under the category of bio-identical. In regular pharmacies there are brand name, standard-dosage bio-identical products sold in many strengths: estradiol in the form of Estrace, Estraderm, Estrasorb, Climara, Vivelle or Femring; and bio-identical progesterone, sold only under one brand name, Prometrium. A significant percentage of doctors are familiar with these brand name products, and again, they are also natural and bio-identical — the doctors just may not call them that. They come in various forms and doses, including pills, vaginal creams, vaginal rings, and adhesive patches. Many women do very well on them, on daily, weekly, monthly or otherwise cyclical regimes. They only replace estradiol and progesterone, but these are the two main hormones that need replacement.

  No company has yet put bio-identical estradiol and progesterone into one combined product, so if you still have a uterus, two prescriptions are usually needed (e.g., an estradiol patch worn weekly and a Prometrium pill taken nightly or cyclically). If you have had a hysterectomy, you may need prescription estradiol, and low–dose, over-the-counter progesterone cream complements this nicely. (Even post hysterectomy, your body needs both these hormones to achieve hormonal balance.) This is a great simple way to start, and your doctor should be happy to help you with this.

• Custom-compounded bio-identical hormones, as described in Suzanne Somers’s books, are another option. In this approach, a practitioner usually does a hormone test, such as a comprehensive female hormone panel, to measure your existing hormone levels. Based on the results of the panel, your practitioner will then prescribe a hormone supplement for you that includes several hormones matched to your individual needs — either separately or all combined. The hormones usually include estradiol and progesterone, but they may also include a combination of other estrogens, testosterone, and/or DHEA.

  Unfortunately, very few physicians have any experience with the testing or prescribing of compounded formulas, or with the follow-up necessary to tailor things to your individual response. But we are finding that more providers are willing to learn as they are hearing about compounding over and over from their patients.

In a perfect world, every woman would be familiar with her own ideal hormone balance by having had it tested at various times in her life. Maybe our daughters will have baseline hormone testing available to them as a standard of care. But for now we can work with blood tests to monitor our current hormone levels. Our favorite is a hormone panel provided in a kit from Genova Diagnostics. Other labs can also draw hormone levels with a doctor’s prescription. Very few physicians have been trained in interpreting these lab values — we’ve been told they are too variable to be reliable - but again, the science of hormone testing is changing and new standards are being established. And having a baseline is important. How often to continue to test and tweak your prescription is something that you and your provider will have to determine as you proceed, based on your unique response. We have found that some women do well on one dose for several years and others need to change dosages every three months. Changes in lifestyle or life situation can obviously create hormonal changes and necessitate changes in your prescription.

You may be one of the many women frustrated with their medical care. Many women who call us have significant symptoms but were told by their doctors that they are “normal” or that “there is nothing we can do”; these women turn to us because they don’t want the altered HRT or antidepressants they are offered. If you are already convinced you can’t get what you want in your local area, again we invite you call us at the Personal Program or at our medical practice. We cannot offer individual referrals but suggest you contact Women’s International Pharmacy — longtime compounding specialists - and request their referral list for your area (1-800-279-5708). Note that this is simply a list of practitioners, not a rating of their experience or ability. Christine Conrad’s organization, the Natural Woman Institute, also provides a database of physicians and pharmacies by area; however, we do not have personal knowledge of the listings.

You are always welcome to be treated at Women to Women’s medical practice, in person or via phone consultations. We have been using compound bio-identical hormones for nearly 20 years, and offer advanced hormone testing and replacement options. Note that phone consultations and compounded formulations are not usually covered by health insurance. We won’t replace your local practitioner (unless you can get to our clinic in person), but we can help you via phone with everything that affects your hormonal balance. In that way we can complement the regular care you get from your local practitioner.

Feeling your best usually takes more than just the right prescription. In our practice, we recommend trying the most natural, least invasive steps first to create a foundation of health and hormonal balance, gradually adding remedies if and when needed. That foundation usually includes good dietary habits to avoid processed foods and simple carbohydrates, regular exercise, multivitamins and minerals, essential fatty acids, and good day-to-day self-care measures. The earlier you can start this approach, the better!

You can try to create the balance and support on your own, or consider our help. In our Personal Program, we use a universally appropriate foundation of support for health and hormonal balance with pharmaceutical–grade nutritional supplements that include essential fatty acids, a comprehensive dietary guide, and Herbal Equilibrium our exclusive Multibotanical supports estrogen, testosterone and progesterone balance, the key hormones influx during menopause and perimenopause. Our Personal Program also offers optional consultations with our Nurse–Educators for individual support and guidance if needed. If that extra support doesn’t bring you relief from your symptoms, you can consider adding hormones prescribed by your doctor. It is very important that you continue to support your foundation for health and hormonal balance even if you do choose to go on HRT of any kind.

Unless you’re sure your doctor already knows about bio-identical hormones, it may be helpful to take the following reference list to him or her:

• Hargrove, J.T., & Osteen, K.G. 1995. An alternative method of hormone replacement therapy using the natural sex steroids. Infertility & Reproductive Medicine Clinics of North America, 6 (4), 653–674.


• Hargrove, J.T., et al. 1989. Menopausal hormone replacement therapy with continuous oral micronized estradiol and progesterone. Obstetrics & Gynecology, 73 (4), 606–612.


• Some additional books with useful information:
  Natural Woman, Natural Menopause, by Laux and Conrad
  The Sexy Years, by Suzanne Somers
  

For a list of typical questions and answers you might like to review before your hormone consultation, see our FAQ section on bioidentical hormones.

 

Last Modified Date: 05/25/2011
Principal Authors: Dixie Mills, MD & Marcy Holmes, NP