The latest trend in the management of menopause is bioidentical hormone replacement therapy (BHRT). Natural hormones have been gaining in popularity as an alternative to conventional treatment, especially after the Women’s Health Initiative raised concern about increased risk of heart disease, breast cancer and dementia associated with synthetic estrogen and progesterone. Much misinformation and misunderstanding has made bioidentical hormones a tricky topic, but reviewing the basics will help clarify the confusion.
Biochemistry and Physiology
“Natural” is an ambiguous term with many different interpretations. “Bioidentical” more precisely describes hormones that originate from plants and exactly match hormones made by the human body. They are derived from one of two botanical origins: diosgenin extracted from the Mexican wild yam, or beta-sitosterol extracted from soybeans. These plant derivatives are similar to cholesterol, which the human body uses to make steroid hormones including estrogens, progesterone, and androgens such as testosterone and DHEA (dehydroepiandrosterone). Diosgenin and beta-sitosterol are chemically altered in the laboratory and after various enzymatic reactions they are biochemically identical to human hormones in both structure and function.
Natural Versus Synthetic
Bioidentical hormones are consistent with our normal physiology. Because they are duplicates of human hormones, our bodies are designed to recognize, utilize and eliminate them efficiently after they have served their purpose.
Changing the three-dimensional structure of a hormone changes the biological effects in ways that are not completely understood. Because the structure of synthetic hormones is foreign to the body, they may be metabolized differently, producing harmful break-down products that take longer to excrete. This increases risk of unpredictable and undesirable side effects, and exposure to potentially carcinogenic molecules. The widely held belief that natural hormones are safer than synthetic hormones makes good theoretical sense.
Supplementation with bioidentical low-dose estrogen balanced with progesterone probably has limited impact on the risk of breast cancer, but long-term studies are needed before experts will know for sure. Until then, some women should be especially cautious. Those with a personal or family history of breast cancer should not take exogenous hormones. Women who know they have the gene mutation predisposing them to breast cancer, and those who have had benign breast disease with atypical hyperplasia, should also skip hormone replacement therapy, natural or not.
The Top Tier
Bioidentical hormones are just one of many natural choices for managing the symptoms of peri-menopause. Therapeutic choices can be categorized into three tiers of treatment. The best place to start is the least amount of intervention, or the bottom tier in the range of therapies. This includes diet, exercise, lifestyle changes and stress management. When more support is needed, supplementation with nutritional and botanical medicines is the next step up. The top tier, or most drastic intervention, is bioidentical hormone replacement therapy. When other options are not successful in resolving severe symptoms, BHRT is a last resort.
The unique needs of each woman can be met when bioidentical hormones are compounded. After laboratory tests determine endogenous hormone levels, a doctor or pharmacist formulates a prescription to provide only what is missing in precise amounts. Compounded BHRT may include estrone, estradiol, estriol, progesterone, testosterone and DHEA formulated into oral slow-release capsules, transdermal creams or gels, sublingual drops or vaginal suppositories and creams. Individualized prescriptions can provide the symptom relief that peri-menopausal women have been unable to find through other treatments.
It is always best to take only necessary medications, whether natural or conventional. Women who choose hormone replacement therapy should only take the minimum amounts needed to maintain optimal hormone levels in the body. Those interested in bioidentical hormones should talk to their doctor about their symptoms, treatment options and compounded prescriptions.