September 2, 2015 Bioidentical Hormones Sometimes when a patient asks their gynecologist about bioidentical hormone replacement, their gyne says that he or she doesn’t do that. A response like that just demonstrates how little understanding there is sometimes about this term bioidentical. Some doctors think that bioidentical hormones are something that has to be specially prepared in compounding pharmacies, and is not available at Walgreens. But the truth is, bioidentical estradiol and progesterone ARE readily available at pharmacies. And in fact, oral estradiol tablets (even though I don’t recommend the oral route usually) are only $4/month at Walmart! Bioidentical estradiol is available in many forms and under about a dozen names. Here’s just a few of them: • Climara patch • Estraderm • Vivelle Dot • Evamist spray • Estrogel • Gynodiol These also have generics equivalents (which sometimes don’t work as well). Bioidentical simply means that the hormone molecule in the prescription is EXACTLY the same (molecularly identical) to the human form of the estrogen, in spite of the fact that it is “synthesized” in a pharmaceutical lab. Because it’s identical, it is the PREFERRED form of hormone replacement. Compare that to Premarin. The name Premarin is derived from PREgnant MARe urINe. That’s right. It comes from the urine of pregnant horses. So it’s also equine estrogens, and only one of those is the exact form of estrogen that is found in humans – 17-beta estradiol and is present only in a very tiny amount. The other undesirable aspect of Premarin is that it’s usually given as an oral tablet, and oral administration of estrogen is the worst way to give it. That’s because when it’s absorbed through the intestine, it all passes through the liver first (called the “first pass effect”) where most of the hormones are removed from the blood. And when that happens, there is a negative effect on clotting factors which are produced in the liver, which causes an increased risk of blood clots, heart attacks, and stroke, similar to birth control pills. Progesterone is available from the drugstore under the name Prometrium, but it,too, has a generic equivalent. It is okay to give this one orally, but we often just add progesterone to the compounded skin gel. So the best way to give estrogen replacement to women is estradiol through the skin as a patch or a gel, or under the skin using an estradiol pellet implant (about the size of a BB). If I am prescribing a patch, I generally use Vivelle Dot patches. Other times I write for a compounded gel that contains estradiol, progesterone, and oftentimes, testosterone. The progesterone is added mostly to protect the uterine lining from unhealthy build-up, but probably has other benefits as well. The testosterone is added if the woman has low libido, poor orgasms, brain fog, fatigue, moodiness, lacks stamina, or muscles are weak. We measure serum levels of total and free testosterone, and if the free testosterone is not in the upper quartile, I recommend adding it to the regimen, or else use a testosterone pellet implant (about the size of a grain of rice). The cost of the hormone skin gel is usually about $2/day. Some M.D.’s are afraid of using compounding pharmacies for fear that they are not regulated, and therefore, not safe. That is so untrue. They follow strict guidelines and belong to certifying bodies that hold them accountable to high standards. Bioidentical hormone pellet implants are painlessly inserted under the skin of the lateral buttocks through a tiny incision every 3-6 months in our office and the cost is a little higher than compounded gels. More information on pellets can be found at www.PelletTherapy.com. Dr. William Epperly, Fellow American Academy of Family Practice Fellow American Academy of Otolaryngic Allergy Member of Christian Medical and Dental Society.