The use of bioidentical hormone replacement therapyThe administration of female hormones in cases where they are not sufficiently produced by the body. Abbreviated to HRT. to alleviate the symptoms of the menopauseThe time of a woman’s life when her ovaries stop releasing an egg (ovum) on a monthly cycle. is currently a hot topic. In this article senior Consultant Gynaecologist Professor John Studd answers questions about this treatment.
Bioidentical hormones are manufactured in the laboratory so as to be identical in molecular structure to normal female hormones. There seems to be a widely held view that the use of bioidentical hormones is a clever recent American development that is a vital advance on orthodox hormone replacement therapy (HRT). It is important to realise in light of this that bioidentical hormones in the form of oestradiol, testosteroneThe main male sex hormone. and progesterone have in fact been used in Europe, particularly France, for at least 20 years and I have personally used nothing else during this time.
HRT is used to replace hormones that the body no longer produces following the menopauseThe time when a woman's periods permanently cease., namely, oestrogenA hormone involved in female sexual development, produced by the ovaries. and progesterone, so as to relieve the symptoms associated with the menopause. At the most simplistic level it is certain that oestrogen works well for hot flushes, sweats and vaginal dryness, but in reality the value of HRT far exceeds this.
The debate about Hormone Replacement Therapy (HRT) arose as a result of two clinical studies, The Women’s Health Initiative (WHI) published in 2002 and the Million Women Study (MWS). The initial findings of these studies were interpreted as suggesting that there is a link between HRT and an increased risk of heart disease, strokeAny sudden neurological problem caused by a bleed or a clot in a blood vessel. and cancerAbnormal, uncontrolled cell division resulting in a malignant tumour that may invade surrounding tissues or spread to distant parts of the body..
However, updated information and further interpretation of the WHI study indicates that HRT, particularly oestrogen alone, is both safe and protective in the younger postmenopausal woman below the age of 60.
Such hormone therapy is associated with fewer fractures, less colonThe large intestine. cancer, fewer heart attacks, possibly less breast cancer and certainly fewer deaths. There is a good case for saying that it should be first line therapy in this situation.
Women naturally produce a number of reproductive hormones including oestrogen, progesterone and testosterone. Oestradiol is the natural human oestrogen that is the most active in the body. There is good evidence that oestradiol delivered through the skin is safer and probably more effective than when taken by mouth. If oestradiol is taken as an oral tablet it is changed in the gut and the liver to a less effective oestrogen called Oestrone, whereas the transdermal route of oestradiol whether by gels, patches or implants produces the appropriate level of oestradiol in the bloodA fluid that transports oxygen and other substances through the body, made up of blood cells suspended in a liquid. stream.
There is also clear evidence that by using transdermal oestradiol, stimulation of coagulation factorsA group of substances that can undergo a cascade of reactions in certain conditions, leading to the coagulation of blood. Also known as clotting factors. from the liver is avoided whereas this does occur with the ingestion of oral oestrogens.
Testosterone is a normal female hormone and is present in 5-10 times the amount in the adult female as oestradiol. It is a vital hormone necessary for mood, energy and libidoSexual drive. and it is certainly best given through the skin as gels or implants. There is a license to use testosterone patches in women who have had a hysterectomyThe surgical removal of the uterus (womb).. In my view gels or implants are preferable.
DHEA (Dehydroepiandrosterone) is often considered a bioidentical hormone and is freely available in many countries. It is a precursor of testosterone and has only onefiftieth of the potency. Although useful, it is more sensible and more effective to use transdermal testosterone, which is clearly bioidentical, rather than taking tablets of DHEA.
The problem with bioidentical hormones comes with the progestogen components. The much heralded expensive progesterone cream that comes with exaggerated claims of increase in bone density and improvement of depressionFeelings of sadness, hopelessness and a loss of interest in life, combined with a sense of reduced emotional well-being, hot flushes, sweats, etc is in fact virtually ineffective as it is hardly absorbed. My team have studied this preparation in depth over the last few years and we have concluded that it has no effect whatsoever on bone density, no effect upon mood and no effect upon the symptoms of flushes, sweats and headaches, all of which are the common symptoms of the menopause. It might, however, have a tranquilising and sedating effect if it is absorbed. These results have been published in the journal Menopause International (Benster et al).
It is therefore necessary to give women receiving oestrogens an effective progesterone/progestogen to protect the lining of the wombThe uterus.. Most gynaecologists would use synthetic progesterone such as Norethisterone or Medroyxprogesterone, which certainly protects the uterusThe womb, where embryo implantation occurs and the growing foetus is nourished. and produces regular scanty periods. Unfortunately, it often reproduces PMS symptoms in those women who are progesterone intolerant and therefore there is a move to use more natural progesterone such as Utrogestan. This is in contrast to the orthodox management of 14 days of progestogen a month because of the frequent problems of depression, breast discomfort and loss of energy that occurs with a longer course of progestogen in those women with PMS and progestogen intolerance.
In my view, the best method of taking bioidentical hormones would be Oestrogel 2-3 measures daily with the possible addition of transdermal testosterone gel and then Utrogestan 100 mgs daily for the first 7 days of each calendar month. This would bring about a regular scanty bleed on about the 10th day of each calendar month.