Hormone Replacement FAQ

Why take hormones at all?
Health is a holistic goal, and hormonal health put simply, is a large and significant factor of that big picture. Hormone replacement therapy (HRT) was developed to replace the hormones the ovaries made during the reproductive years in a woman's life, and hence reduce or eliminate menopausal symptoms.The goal of hormone therapy is not only to relieve these symptoms, but also to protect the body from other harmful side effects of aging such as osteoporosis and memory disorders such as Alzheimer's disease.

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What are Bio-Identical Hormones and where do they come from?
The ovaries, testicles and the adrenal glands manufacture a series of hormones known as steroids that are all derived from cholesterol. Since the early 1960s, chemists have been able to synthesize all of these molecules starting either from cholesterol or from plant sterols found in nature.
 
Bioidentical hormones are primarily derived from a plant oil called diosgenin, which is very similar in chemical structure to cholesterol. Diosgenin is extracted primarily from soybeans and wild yams, but is also found in several thousand other plants worldwide. The human body cannot convert this compound into steroid hormones. Diosgenin has to be chemically altered in a lab to exactly match the human steroid hormones. Since the manufactured molecules exactly match the chemical structure and effect of hormones that occur naturally in the human body, they are called bio-identical.

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What are the hormones or combination of hormones commonly used with BHRT?
While there is no set combination or dosage of hormones that works for every woman, an HRT regimen may commonly include any combination of the following:

• Estrogens separately
  • Estradiol - E2
  • Estriol - E3
  • Estrone - E1
• Biest Formula (E2/E3)
• Triest Formula (E2/E3/E1)
• Progesterone
• Testosterone
• DHEA - Dihydroepiandrostendione

  Estrogens
  Estrogen is non-specific term most often used to describe a family of three hormones naturally produced in women, but a small amount is also present in men. During puberty estrogen is responsible for inducing the distinguishing changes in girls that result in the female sex characteristics common in women. The three predominate natural estrogens that exist in women and their approximate relative amounts are:

• Estradiol = E1 (10%)
• Estriol = E2 (80%)
• Estrone = E3 (10%)

  Estradiol(E2) is the most active and potent form of estrogen, and is responsible for over 400 functions in the female body. It is 12 times more potent than estrone and 80 times more potent than estriol. Estradiol is primarily produced by the dominant ovarian follicle during a woman's reproductive years, and has been referred to as the estrogen of youth. It is most abundant in young women in their teens and twenties, and is important in helping women look and feel young. Women in this age group do not have wrinkles, or sagging skin. At this time in women's lives, the incidence of cancer, stroke, heart disease and any other chronic diseases is minimal. These are some of the logical reasons medical professionals have sought to provide estradiol supplementation during menopause.

  Estrone (E1) is the dominant form of estrogen during menopause. In general estrone can function in a woman's body much like estradiol does, but it is considered much weaker in its effects. Estrone is produced in small quantities by the stromal tissue of the ovaries, but is primarily synthesized outside of the ovary by the peripheral conversion of androstenedione (a testosterone derivative) in adipose (fat) tissue. After menopause estrone levels often increase, possibly a result of increased conversion of androstenedione to estrone due to increased body fat. It has been found that because obese women have more fat, they may produce more estrone, which possibly explains why they often report fewer menopausal symptoms. Unfortunately, the more fat tissue a women has after menopause, the more estrone they are exposed to which puts them at a higher risk for breast cancer.

  Estriol (E3) is the weakest and least active form of the three major estrogens. In fact, it is 1,000 times weaker in its effect on breast tissue than the other forms, but actually found in the highest concentration in premenopausal women (80%). In non-pregnant woman, estriol is synthesized in the liver from both estradiol and estrone. High levels of estriol are produced by the placenta during pregnancy and appear to protect the body against certain forms of cancer. When taken by itself in relatively high doses, estriol does not increase endometrial proliferation, and has been suggested to be less carcinogenic than estradiol and estrone in animal studies. Unlike conjugated estrogens or estradiol, estriol is not converted into estrone, which is an estrogen that has been linked to cancer.

  For years, doctors in Europe have been prescribing estriol as a safe and effective alternative to 100% estradiol or Premarin for years. They have discovered estriol is the estrogen most beneficial to the vagina, cervix and vulva. Over time they have found it especially helpful and the safest estrogen to use for women with disabling postmenopausal symptoms, such as vaginal thinning, painful sexual intercourse, recurrent urinary tract infections, and urinary incontinence.

Biest
Biest is a combination of two estrogens: estriol and estradiol. It is most commonly compounded in a ratio of 80:20, estriol (E3) to estradiol (E2). The key to the success of any bio-identical hormone replacement therapy (BHRT) program is the balancing of the body's natural hormone levels so that they will mimic the normal physiologic hormonal levels for that specific person. Through patient education, people have developed their own ideas on how they wish their BHRT program to be structured, and often times a particular bio-identical hormone combination is a matter of patient preference.

Healthcare practitioners often prefer the biest combination for the following reason. When a woman enters menopause, estrone (E1) becomes dominant as the ovaries stop producing estradiol (E2). Estrone (E1) at this time is produced by the adrenals and in the fat tissue of the body. Because it can be produced in the fat tissue of the body, depending on an individual (overweight) and diet, its levels can remain high. It would then make sense if we have an abundance of estrone (E1) at menopause we might choose to supplement with only estriol (E3) and estradiol (E2) (thus bi-estrogen) to maintain proper balance of the body's natural hormones.

Triest
Triest is a combination of three estrogens: estriol, estradiol and estrone. It is most commonly found in a ratio of 80:10:10, estriol (E3), estradiol (E2), and estrone (E1). Although this combination isn't as popular it does contain all of the three major circulating estrogens. It is slightly weaker in its effect when compared to biest, but this can be compensated for by increasing the strength or by slightly changing the ratios. As with biest, the use of a particular combination of natural estrogens seems to be a patient or practitioner preference or philosophy. The argument for the use of a triest is simply balance. If a triest formula does a better job to obtain this balance then we will provide this option.

Progesterone
When female hormones are mentioned, most women immediately think of estrogen. However, progesterone is the other important female hormone necessary for a normal monthly menstrual cycle.It is primarily produced by the ovaries during the latter two weeks of the menstrual cycle, but smaller amounts are also secreted by the adrenal glands. While progesterone has a significant role in generating a regular monthly menstrual cycle, the primary function of this hormone is to perform tasks necessary for reproduction.

The meaning of the word progesterone is found in it's origin. Pro (supporting) + gesterone ( gestation or pregnancy) Progesterone literally means, "for gestation" or the hormone of pregnancy. For example, it stimulates the growth of a cushiony endometrial lining that serves as a nest for the fertilized egg, prepares breast tissue for the secretion of breast milk, and generally maintains the advancement of pregnancy. If pregnancy does not occur, progesterone levels drop sharply, which signals the uterus to shed this lining.

While progesterone is a key hormone of the reproductive system, it also plays a very critical role in maintaining a woman's day-to-day health. Progesterone serves an important role in brain function and is often called the "feel good hormone" because of its mood enhancing and antidepressant effects. Optimum levels of progesterone can influence feelings of calm and well being, while low levels of progesterone can mean feelings of anxiety, irritability and even anger.

Studies have found that progesterone acts as opposition to the estrogen levels in a woman's body, relieving and balancing out some of the intense and sometimes negative effects of estrogen. This phenomenon known as "estrogen dominance" occurs when a women has plenty of estrogen in her body but lacks adequate levels of progesterone. Unopposed estrogen can actually produce many symptoms associated with menopause as well as increase the risk of endometrial and breast cancer.

Around the time of menopause estrogen will fall 40% to 60% and progesterone levels will essentially fall to zero, which results in irregular menses, hot flashes, vaginal dryness, weight gain, fluid retention, headaches and mood swings. By opposing these effects, progesterone can improve sleep, calm mood swings, eliminate water retention, increase the body's ability to use fat, stimulate new bone formation, normalize sex drive, as well as improve numerous other afflictions that aging women battle daily. For this reason, progesterone is often preferred over estrogen as the "initial" hormone replacement treatment for menopausal symptoms.

Finally, it is important to realize that there is a difference between progesterone and a "progestin". Many of the available commercial products such as Provera (medroxyprogesterone) are in fact progestins. These molecules are structurally somewhat similar to a progesterone, but in the body may have drastically different actions. The body does not recognize a progestin, and therefore it is treated as a foreign molecule. In fact, studies have found that the progestins can actually blunt many of the beneficial effects that estrogen has in the body.

Testosterone
Testosterone is secreted by the male testes and is the main androgenic hormone in the plasma of men. Although it is usually considered a male hormone, women also synthesize testosterone in small amounts by both the ovary and adrenal glands.

Testosterone works differently in the bodies of men and women, but it plays a very important role in the overall health and well-being of both sexes. Often called the "hormone of desire" because of its powerful effect on libido, testosterone is important in building strong muscles, bones, and ligaments as well as increasing energy and easing depression. What has not been recognized until recently is the invaluable role of testosterone in a woman's post menopausal, sexual, psychological and physical well-being. By the time a woman goes through menopause, her testosterone level has dropped to about half of what it was when she was younger. This dramatic decrease in testosterone level can cause loss of interest in sex, fatigue, irritability, depression, aches and pain in joints, thin and dry skin, osteoporosis, loss of muscle mass and tone and an increase of fat to muscle ratio.

Men produce about 20 times more testosterone than women per day. As a man ages, testosterone levels also drop, resulting in many of the same symptoms as a woman experiences and potentially many more, since testosterone has much the same beneficial and protective effects in a man that estrogen has in a woman.

As with all of the hormones, testosterone must be dosed properly to be effective without causing unwanted side effects. The dose in women is generally one-tenth that used in men. Because testosterone is not effective when it is taken orally it is usually prescribed as a topical gel, cream or as a sublingual tablet.

DHEA
Short for dehydroepiandrosterone, DHEA is the primary androgen produced by the testes in men and the ovaries of women, and it is also synthesize by the adrenal glands and brain in both sexes. It is called a precursor hormone or foundation hormone because it is produced in large amounts in the body and because other steroid hormones are made from DHEA, including estrogen and testosterone. DHEA was once believed to be inert in the body, but recent interest in its therapeutic effects has grown.

From age 25 to 30 DHEA declines at a rate of about 2 percent a year; we begin to feel the result of this decline in our mid-forties. By 80 years of age our DHEA level is only 15 percent of what it was when we were twenty-five. This drop in DHEA levels correlates dramatically with the signs and symptoms associated with aging.

Research indicates DHEA may protect against cancer and heart disease by lowering blood cholesterol and preventing blood clots. DHEA may also improve memory, strengthen the immune system, prevent bone loss, and prevent fatigue, depression, diabetes and autoimmune disease. It also may enhance feelings of well-being, increase strength, alleviate symptoms of menopause, reduce body fat, and enhance libido.

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What is Estrogen Dominance?
Estrogen dominance is a term coined by John Lee, M.D., in his first book on natural progesterone (What Your Doctor May Not Tell You About Menopause). The name refers to a prolonged state of estrogen excess (particularly in relation to progesterone) common to the waning of reproductive hormones with age, but exacerbated by exposure to the plethora of synthetic "xenohormones" such as synthetic HRT, pesticides and pollutants in our environment. Even a woman with low estrogen levels can have estrogen dominance symptoms if her body has exhausted it's ability to produce progesterone naturally. According to Dr. Lee, many of the most common and unwanted symptoms of menopause and the years preceding it (peri-menopause) are causally connected to this condition.

The scientific literature is clear that an excess of estrogen or estrogen activity at the cell level is a root cause of breast cancer. We know too, that hormone imbalances triggered by the use of synthetic hormone combinations ( Premarin, Prempro, Premphase, Provera) can have deadly consequences. The most recent definitive study, The Womens Health Initiative Trial, was abruptly cancelled in July 2002 when it showed a greater risk vs. benefit for a majority of diseases it was thought to be preventing:

• A 41% increase in strokes
• A 29% increase in heart attacks
• A 26% increase in breast cancer
• A 22% increase in total CVD
• A doubling of the rate of blood clots
• A possible contributor to Alzheimer's disease

Symptoms of Estrogen Dominance: When estrogen over stimulates the brain and body the following symptoms may occur:

• Decreased sex drive
• Irregular or abnormal menstrual periods
• Water retention and bloating
• Breast swelling and tenderness
• Headaches
• Mood swings
• Problems with sleep

According to Dr. Lee, most of these symptoms can be relieved with natural, bioidentical progesterone, which is available over the counter in a 2% cream. It protects against breast cysts, is a natural diuretic, a natural antidepressant, and can stimulate bone building which may help protect against osteoporosis. In one study 83% of menopausal women got relief from hot flashes with bio-identical progesterone cream.

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What is the difference between synthetic and bio-identical hormones?
In wake of the WHI results finding a greater risk then benefit with "synthetic" hormone replacement therapy (HRT), there is a lot of talk about "natural" hormone replacement (NHRT). However, the term "natural" can be confusing when used in connection with hormones. When we say a hormone is "natural," we are referring to the structure of the hormone. However, the definition of "natural" has different meanings to different people. When medical professionals speak of natural hormone replacement therapy (NHRT), they typically use the phrase to reference the act of supplementing the body with hormones containing a chemical structure that is identical to the hormone naturally produced by the body.

A "natural" hormone does not mean that it is an organic product purchased in a health food store. In fact, many "natural" hormones are synthesized in laboratories using pharmaceutical-grade products. The important thing to remember is that for a hormone to be considered "natural" its structure must be an exact replica of the structure of the hormones your body produces. Thus, the term "Bio-Identical" more accurately reflects the nature of this form of hormone replacement therapy or BHRT. An important note to make here is that the Food and Drug Administration (FDA) considers bioidentical hormones to be natural regardless of their source, and as a result they cannot be patented.

A "synthetic" hormone, on the other hand, may have a structure similar to, but not exactly the same as, a hormone produced by your body. However, these chemical differences can mean that the synthetic hormones act differently in your body and produce substantially different effects. "Natural" and "synthetic" hormones should not be considered the same or used interchangeably. The important point to remember is the structure, not the source, determines whether a hormone is bioidentical or synthetic.

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What are the benefits of Bioidentical Hormone Replacement?
Bio-Identical hormones have proven time and time again, both in clinical practice and in research, to be better tolerated than synthetic hormones, with fewer side effects. Reduces or relieves symptoms associated with menopause including:

• Helps to protect against endometrial and breast cancers
• Protects against heart disease
• Guards against artherosclerosis
• Protects against osteoporosis and promotes bone building
• Improves concentration and memory
• Reduces symptoms of depression
• Promotes fat burning for energy
• Increases energy
• Prevents vaginal thinning and dryness
• Lowers incidence of urinary tract infections
• Eliminates or reduces hot flashes
• Reduces sleep difficulties and night sweats
• Enhances sex drive and libido
• Improves blood flow
• Improves skin elasticity and prevents thinning of the skin
• Protects against fibrocystic breasts

• Increased anxiety, depression, and mood swings

Are bioidentical hormones safer than synthetics?
European medical studies suggest that bio-identical hormones are safer than synthetic versions, and its use in the world over the past 10 to 15 years has created a large and positive anecdotal base. This evidence doesn't mean bioidentical hormones are perfect, and we never recommend that a woman think of a drug as completely safe. As with any prescription medication, the pros and cons of using BHRT must be carefully weighed after a thorough consultation with your health care provider.

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What are the forms of BHRT available?
One of the biggest assets to bio-identical hormone replacement is that they are available in a variety of dosage forms. Since bio-identical hormones are formulated by compounding pharmacists, each dose can be compounded to each person's specific needs, whereas synthetic hormones are limited to a few doses. Slow release capsules, vaginal creams and transdermal creams/gels are our most commonly used products. We also offer sublingual (under the tongue) lozenge/troches and vaginal suppositories which are also effective ways to administer these hormones. We invite you to discuss these options with our pharmacists.

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What are the goals of BHRT?
The ultimate goal of any BHRT is to provide an adequate supply of the deficient hormone in a form as close as possible to the original hormones, resulting in normal physiologic effects. BHRT can:

• Alleviate the symptoms caused by the natural decrease in hormone production
• Give the protective benefits originally provided by naturally occurring hormones
• Re-establish a hormonal balance

How do I get started on BHRT?
The Bio-Identical Hormone Replacement (BHRT) program at Cox Pharmacy was created to take the guesswork out of prescribing natural hormone replacement therapy and to provide the tools and expertise necessary to help you and your health care provider monitor results.

1. Patient Education
   At Cox Pharmacy we believe the more health knowledge you have the more power you have over your health. We recommend that you first educate yourself about conditions related to hormone imbalance such as menopause or andropause and their relative treatment options. The following reading material is suggested for patients as well as health care providers. You might start with Dr. John Lee's book "What Your Doctor May Not Tell You About Menopause," or "HRT Solutions" by Marla Alhgrimm. If you are looking for a short yet informative and easy to read book about BHRT try "Natural Hormone Replacement" by Dr. Jonathan Wright MD. Many women may relate to Suzanne Somers book, "The Sexy Years" which has brought bioidentical hormones onto center stage. You can also reference books written by other BHRT experts such as Drs., Susan Rako, Eugene Shippen, and Christiane Northrup. We also offer seminars that provide an in-depth review of the BHRT.

2. Evaluation Form and Testing
   For those that are familiar with BHRT and would like to proceed with our BHRT program please drop by either location and pick up a BHRT information packet. In this packet is additional information about BHRT and a confidential BHRT evaluation form that we request you complete. At your request, we can also mail, fax or email these forms to you. This form reviews the following: current/past medical history, current/past medications, diet, exercise, current symptoms, and much more. Then, based on the information you provide, a pharmacist will determine if it is necessary for saliva hormone testing. While saliva hormone testing is effective at detecting deficiencies and imbalances it isn't always necessary for successful hormone replacement outcomes.

   Cox Pharmacy is an approved distributor for ZRT Laboratories Test Kits, which we distribute freely for our patients interested in testing their hormone levels. You can take the kit with you and collect the saliva sample in the privacy of your home. Then you fill out the accompanying material and choose which hormones levels to be measured. ZRT Laboratories tests are priced according to the number and type of hormones you request be tested. You send the saliva sample directly to ZRT Lavoratories in a pre-paid mailer and the results are returned to us in two to three weeks. One of our pharmacists will then contact you to review your levels in reference to an initial evaluation or ongoing hormone replacement management.

   Please call ahead if you are planning on picking up a test kit! (918) 456-2233. These can also be mailed to you from the pharmacy at your request.

3. Consultation
   Once we have your completed confidential BHRT evaluation form and saliva test results (if available), one of our pharmacists will be happy to conduct a comprehensive hormonal consultation and evaluation. At this visit, we will review your personal history, family history, current medical situation as well as signs and symptoms associated with hormone imbalance. Then we will provide additional information concerning the principles of bioidentical hormone replacement, answer all your questions and discuss all your health care concerns and goals. Finally our pharmacists will make appropriate hormone dosing recommendations, explain the remaining steps necessary to initiate BHRT and the process of ongoing BHRT management. Some fees may apply so please call for more information at (918) 456-2233.

4. Prescription
   BHRT requires a prescription so we will put together a customized plan complete with dosing recommendations, saliva test results, and your confidential evaluation. You are welcome to take this plan with you, but most of our patients prefer we fax or mail this information directly to their health care provider. We recommend that you initiate and maintain your BHRT program through your current health care provider, for she/he is aware of your general state of health and will monitor other conditions beyond hormonal imbalance. Most practitioners are receptive to the BHRT plan we prepare, but we can also help you find a health care provider that works with BHRT.

   Once your health care provider has reviewed your BHRT plan, he or she will contact our pharmacists to approve or deny the recommendation. If your physician requires additional information we will be happy discuss these issues with them directly. All this is done to take the hassle out of patients having to go back and forth between the pharmacist and the physician. Once the approval for therapy is given, hormone replacement can begin.

5. Follow-Up and Ongoing BHRT Management
   BHRT is not a quick fix and requires monitoring and tweaking during the first 3 months to one year to ensure a patient's continued hormonal balance. To maintain this balance ongoing BHRT management is essential because as you age your body changes and your hormone requirements change too. Our pharmacists are there to listen to you and discuss any changes that you may be experiencing. When changes need to be made to your therapy we can contact your physicians and recommend the appropriate adjustments. Finally, in addition to taking your BHRT prescriptions, we promote the important contribution of healthy lifestyle choices and proper nutritional supplements to achieve optimal results.

If you are currently on or considering the use of Hormone Replacement Therapy (HRT) and you think individualized BHRT makes more sense than a one-size fits all approach, then please visit our pharmacy to receive free information or call (918-456-2233) to schedule a private consultation with one of our pharmacists.

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Important Notice about Our BHRT Program:
Any form of hormone replacement can be contraindicated in certain patients. Please consult with your medical practitioner before proceeding with any hormone regimen, including over-the-counter products. BHRT is not recommended for every patient and can carry significant side effects if prescribed and/or taken in an unbalanced manner. These effects can include blood clots, strokes, and certain kinds of cancer, among others. Balance between hormones and balance in lifestyle and nutrition is the key to successful BHRT program.

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