The In’s and Out’s of Hormone Replacement Therapy

What is bioidential hormone replacement therapy (BHRT)?

Bioidentical hormone therapy refers to hormone replacement with hormonal substances that are, on a molecular level, identical to what our own bodies make.  This, as opposed to replacement with synthetic hormones, allows for several advantages.  First, because the bioidentical hormones you receive are identical to your own, they have a complete action in the body.  That is, they act exactly like your own hormones would.  Synthetic hormones are molecularly similar, and will exert similar effects to your own hormones, but will not have complete action.  This incomplete action often does not elicit a balanced hormone response in the body.  In addition, because synthetics have a unique molecular structure, they have the potential to have effects on the body that your own hormones would not exert.

Because of this “complete action” effect, using bioidentical hormones allows doctors to use smaller doses than with synthetics.  Bioidentical sources of hormones include both plants and animals, but most bioidentical hormones are sourced from plants.

Further, when we replace deficient hormones with a bioidentical version, the replacement compounds are specifically tailored to the individual.  Taking into consideration the symptoms as well as the objective levels found on testing, hormones are compounded in tailored doses and combinations for each patient.

Hormones include more than the well-known estrogen and testosterone.  For example, insulin is a hormone that helps regulate growth and is responsible for shuttling glucose from food into cells for energy; your thyroid produces different hormones to help regulate metabolism; and your adrenal glands produce cortisol, known as “the stress hormone,” which, among other things, helps the body store energy from food.

What symptoms might I experience if I have a hormonal imbalance?

Hormones affect all systems of the body, so hormone imbalance can have a wide array of effects.  Everything from fatigue to weight gain to hair loss can be affected by hormones, in addition to better known effects of hormone shifts like hot flashes, night sweats, insomnia, and mood swings.  Menopause in particular can cause any of the following symptoms, in addition to many others:  depression, irritability, insomnia, mood swings, hot flashes, reduced sexual interest, painful intercourse, bloating, panic attacks, hair loss, urinary symptoms and even infections, headaches, “brain fog” or memory loss.

Who suffers from hormone imbalance?

There is a generalization that hormones are only for women going through menopause.  Menopause, also known as “ovarian failure,” is when the ovaries stop producing eggs, and levels of estrogen and progesterone fall.  While menopause certainly brings significant changes to overall hormonal balance, women in this phase of life are not the only ones who may suffer from symptoms of imbalanced hormones.  Men go through a parallel process to menopause, called andropause.  Essentially this refers to age-related hormone changes in men, specifically, the decrease in testosterone.  This, like menopause, is a natural part of aging and may cause unpleasant symptoms such as fatigue, reduced muscle mass, and depression.  Unlike menopause, however, this decline is typically more gradual than the decline of estrogen and progesterone in women during menopause.  A typical rate of decline in testosterone is about 1% per year after age 30.

Adrenal insufficiency, often resulting from a prolonged period of stress be it emotional, mental, or physical, can cause a subsequent decline in sex hormones in both men and women.  DHEA is an androgen-like hormone that helps produce cortisol, the stress hormone released by the adrenals.  DHEA also helps support testosterone production.  When the adrenals require more DHEA, there is less to be utilized in testosterone production, and often men can experience faster rates of decline in their testosterone levels than what would be expected from aging alone.  Many men are treated for testosterone deficiency with testosterone alone, but read on as this often does not completely address the problem.  Adrenal support and prevention of testosterone conversion into estrogen is a crucial part of treating testosterone deficiency in men.

How are hormones monitored?

Your doctor may choose to monitor your hormones through saliva or blood testing.  Some hormones, such as pregnenolone, are best monitored by blood levels, while it is preferable to monitor cortisol and estrogen through saliva testing.  The frequency of hormone testing will be determined by your doctor, but often hormones are tested three months after any changes are made to your hormone regimen.

What do the hormones do?

Each hormone has many functions and operates in harmony with the other hormones in your body.  Here is a brief summary of some functions of each:

  • Estrogen: increases metabolism, increases insulin sensitivity, improves sleep, regulates body temperature, maintains bone density, relaxes blood vessels, encourages blood vessel growth particularly in the uterine lining, supports production of neurotransmitters such as serotonin
  • Progesterone: Modulates the effects of estrogen, helps promote sleep and reduces hot flashes
  • Testosterone: supports mood, energy, and self esteem; aids in muscle recovery, increases sex drive
  • DHEA:  supports testosterone and cortisol manufacturing, thereby increasing muscle mass and improving energy and focus
  • Cortisol: your energy hormone!  It helps you wake up in the morning and gets the inflammatory cascade going with neurotransmitters like epinephrine in stressful situations (Think: running from a bear!).

Why treat hormone imbalance?

There are many reasons to address hormone imbalance, not least of all to relieve symptoms of imbalance.  Certain hormone deficiencies, for example estrogen and progesterone, can increase risk of osteoporosis and heart disease.  Additionally, certain imbalances such as estrogen dominance, can increase your risk of certain cancers when left untreated.

What does treatment look like?

Hormone imbalance, depending on the severity of the imbalance and the severity of symptoms, can be addressed in different ways.  There are natural ways to enhance your own hormone production in some cases if you have mild symptoms or imbalance.  For example, increasing your muscle mass through weight lifting can boost your testosterone levels, and adhering to a diet low in simple carbohydrates can help regulate cortisol levels.  You can also treat deficiencies by directly replacing the deficient hormones with prescription bioidentical hormones.  Certain hormones like progesterone, pregnenolone, and DHEA, can also be found in small doses over the counter.  If you feel you may have a hormone imbalance, it is critical that you undergo baseline testing and discuss the options with your doctor.  Just like hormone deficiencies can be problematic, so can hormone excess.  It is important to have your levels monitored throughout therapy for this reason.

If you are prescribed bioidentical hormones, the hormones are made into a formulation at a compounding pharmacy.  Most often they are made into a topical formulation.  Compounding allows the therapy to be customized to each patient by dose, formulation, and combination of hormones.  Your doctor will choose a formula, dosage, and combination for you based on your symptoms, risk factors, lifestyle, and measured levels of hormone.  Hormones are most often mixed into a fragrance- and dye-free cream that absorbs readily into the skin and is usually applied daily, although your practitioner may choose a different frequency of application for you based on your levels and symptoms.

What about cancer risk?

The concern with hormones and risk of cancer centers largely around estrogen supplementation, or hormones that can convert into estrogen by various pathways.  First, it is important to know there are many types of estrogen.  Estradiol, the form most often tested, is prevalent before menopause.  Estradiol is much less potent than estrone, the form of estrogen that becomes dominant after menopause.  Estrogens promote blood vessel growth, and when a malignancy has started to grow and recruit blood vessels, an increase in estrogen can be like adding fuel to the fire.  For this reason, it is important to talk to your doctor about your individual risk factors, and to work with an experienced practitioner if you decide that hormone replacement is right for you.  Bioidentical hormone replacement is the safest way to do this for several reasons.  First, estrone is a form of estrogen that is not prescribed in bioidentical hormone replacement therapy, but notably, it is found in the popular prescription drug Premarin.  Additionally, estrogen is seldom prescribed without progesterone, which balances the actions of estrogen.  Often people will be far more depleted in progesterone than estrogen, and when hormones are tested the progesterone: estrogen ratio is taken into consideration when deciding which hormones to replete and in what doses.  Third, your doctor will monitor your hormone levels periodically to ensure that balance is being maintained.  Even if you only replace one hormone, you should have all hormone levels tested at regular intervals, since each of the hormones affect one another.

How else can hormone imbalance be addressed?

Along with supporting your body’s intrinsic hormones directly with an extrinsic supply like with hormone replacement therapy, your own physiology can, and should, be supported during this process.  For example, when we are treating adrenal fatigue, it is important to address the cause of the adrenal fatigue.  We discuss things like stress management, proper nutritional support for your adrenal glands, adaptogenic herbs, stabilizing blood glucose, neurophysiologic repatterning to retrain your own response to stress triggers, and reducing overall oxidative load on the body.  This might include modalities such as nutritional counseling, since a higher glycemic load will stress the adrenal glands – they fire every time your blood glucose level crashes in order to protect you.  When the adrenal glands release cortisol, glucose is supplied to your bloodstream from the liver.  When someone eats higher glycemic meals, blood glucose levels will rise quickly, and as your body uses or stores this extra fuel, the glucose levels will come crashing down a few hours later, leading to a cortisol release, which again raises glucose levels.  When your body goes through this pattern day in and day out, the adrenals can become taxed over time, which often results in adrenal insufficiency.  At that point, supportive methods ranging from hormonal support to steroid support, depending on the degree of severity, to lifestyle interventions as stated above can be employed to help the adrenals heal (and to help you feel better!).

In another example, if someone is found to have a disproportionate amount of estrogen in relation to their progesterone, also known as “estrogen dominance,” we optimize liver detoxification pathways to help it eliminate the excess estrogen more efficiently.  This process can be supported with things like B-vitamins.  We also look at reducing exposure to estrogenic compounds on a consistent basis, such as plastics or soy.  Further, fatty tissue contains an enzyme called aromatase that converts testosterone into estrogen, so in males who have a disproportionate amount of estrogen we must monitor estrogen levels when we consider testosterone replacement therapy.

Similarly, one can increase their intrinsic production of testosterone by building lean muscle mass.  Certain vitamins and herbs can also support your intrinsic testosterone production.  There is even a certain pose, known appropriately as “power pose,” which measurably raises blood testosterone production!  Just stand with your arms in a “V” formation over your head (or think the “Y” move from the YMCA dance), with your chin up and hold for 2 minutes to produce this effect.  Bonus:  this move reduces blood cortisol levels at the same time!  The relationship between your body, your mind, and your physiology cannot be overstated, and these aspects are vital to consider when undergoing treatment for hormone imbalance.

Diagnosing and treating hormone imbalance is a comprehensive process in which you and your doctor will work together to determine how to best address your needs.  It is one that can take time to achieve your ideal balance, but one that can be highly rewarding, both in terms of overall health and quality of life.

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