Talk to a group of women dealing with menopause symptoms, and it won’t take long before someone brings up the question of hormone replacement therapy (HRT) and “bioidentical progesterone cream” or “natural” hormones vs “traditional” or “synthetic” hormones.
Which is best, most effective, safest? Chances are you’ll get nearly as many answers as questions and still not know for sure.
It’s your health, your comfort, and your quality of life that are at stake here, so at Gennev, we want you to have the facts. Our Director of Health, ob/gyn and epidemiologist Dr. Rebecca Dunsmoor-Su, breaks it down for us.
So that we’re all talking the same language, let’s be clear about our terms.
The term “bioidentical” refers to synthetic hormones that are identical to the ones your body naturally produces. “Natural” hormones come from plant or animal sources, and while not synthesized in a lab, they still have to be processed in a lab in order to become bioidentical (and usable for the body). “Compounded bioidenticals” are treatments that have been created in a compounding pharmacy using bioidentical hormones. It’s these compounded bioidenticals that can be problematic.
A lot of people will assert that “bioidenticals” (meaning “compounded bioidenticals”) are safer than those traditionally prescribed in Western medicine. Sadly, not only are compounded bioidenticals no safer than traditional medications, they’re often actively hazardous to a woman’s health.
According to Dr. Rebecca, the truth is, treatments bearing the bioidentical or natural label are made of the same stuff traditional treatments are made of. “There’s only one place to buy estrogen and progesterone,” Dr. Rebecca says, “and that’s from the pharmaceutical industry.”
So the estrogen and progesterone in compounded bioidentical treatments and in traditional treatments start from the same place – as big crystals of hormone which are then turned into treatments.
The difference is in how those base elements are made into the treatment you pay for.
First, says Dr. Rebecca, it’s important to understand that hormones are healthy and good and safe when prescribed and used correctly. "I do not want to put down compounding pharmacies in general, they are excellent for many purposes. In fact, I use them myself for topical numbing cream for my clinic. I am warning specifically about compounded hormones."
So what’s bad about compounded hormones? The problems occur in the preparations.
“Compounders are literally taking the exact same medications I would prescribe – estradiol and micronized progesterone – grinding it up, mixing it in a cream even though the medication may not be designed for systemic absorption, and telling you to rub it on your body,” Dr. Rebecca says.
If it’s the same medication, why is that a problem?
“There are a couple of problems here,” Dr. Rebecca tells us. “You don’t know how much of the hormone you’re getting, that’s a huge problem. These treatments are not FDA-regulated, and there’s no way to tell how high of a dose you’re getting even from day to day. There’s no way to take a pill, grind it up, mix it with cream, and guarantee consistency of dosage. It’s not possible. Plus, that medication wasn’t designed to be used topically, so it may not even absorb into the skin.”
“Women are being told to rub it on their stomach, their arms, their clitoris, insert it in their vaginas, all sorts of places,” she tells us. “Topical estrogen absorbs through skin really well; we know that, which is why we make absorbable versions. And it can absorb in high doses. So I see women who have gotten a very dose of estrogen one day, and maybe a very low one the next day. Because it’s not consistent, her dosage and her experience with the medication can vary wildly from day to day.”
The situation is even worse when it comes to progesterone. For women with a uterus, if they are given estrogen, they must also have progesterone to avoid developing endometrial cancer. Taking estrogen alone, if you have a uterus, is practically a guarantee of endometrial cancer eventually.
“Women are given progesterone cream by practitioners to prevent cancer – but the cream doesn’t work. Often the progesterone that’s used in these compounded preparations is micronized progestin, because it’s considered ‘bioidentical.’ But micronized progestin is too large, the molecules are too big to be absorbed consistently through the skin. So these women are taking estrogen, rubbing this cream on themselves to prevent cancer, and getting cancer anyway, because the cream doesn’t work. It wasn’t designed to be absorbed.”
There are two forms of progesterone that can be used topically and are typically found in “combined” patches (patches that contain both estrogen and progesterone): norethindrone and levonorgestrel. Even these don’t absorb all that well through surface skin, Dr. Rebecca says, and so the dosage of progesterone has to be quite high.
“Progesterone is absorbed best through the GI tract – so, an oral pill; through the vagina if prepared for that purpose; with a combo patch, though that’s not my favorite, or via an IUD like the Mirena in the uterus. I use these because I know what kind of dosing a woman’s going to get, I know it’s going to be consistent, and I know it’ll be protective against endometrial cancer.”
If you’re given a vaginal cream for your progesterone, be sure it’s not micronized progesterone. “Vaginal progesterone is for pre-term labor prevention and miscarriage prevention – these are the only uses it’s been studied and approved for. We do not have data to support the dosing and use in prevention of endometrial cancer with HRT. The small studies we have are inconclusive, so I would not use it for that reason.”
Dr. Rebecca is quite adamant in her objection to pellets. Why? Because they can have pretty awful side effects, and once the pellets have been implanted, side effects or no, they can’t come out.
Hormone pellets are tiny pellets no larger than a grain of rice that are surgically implanted under a patient’s skin or in muscle tissue. The pellets are intended to give a slow, continuous release of hormone. DHEA testosterone pellets are particularly popular for women hoping to revive their sexless marriage after menopause.
“The problem with pellets is, again, they’re not FDA-regulated, and we’ve seen that they can give an exceedingly high dose of hormone depending on where and how deeply they were implanted. Many women suffer significant side effects as a result, especially with testosterone. Women think they’ll get their libido back, have more energy, feel younger, and they may … but they may also grow a beard, develop acne, have clitoromegaly, where the clitoris grows and becomes very like a small phallus, and develop a deeper voice. Those last two don’t go away when the testosterone does. The small phallus and the deep voice are forever.”
Given all the risks and dangers, why do women still choose compounded bioidenticals?
According to Dr. Rebecca, often women who come to her to get help with menopause symptoms and side effects of poor treatment tell her they simply weren’t told.
“Whether the person giving her the treatment doesn’t know about the risks or is more interested in the profit, I don’t know,” Dr. Rebecca says, “But they just don’t warn women of the risks they’re taking.”
Another reason may be that women have come to be distrustful of standard Western medicine and doctors.
“I understand, I do. Western medicine has not always done right by women; ob/gyns don’t always listen, they don’t always understand the hormonal journey, they’re not always sympathetic. We haven’t done the research into menopause, we don’t have a lot of solutions. It makes sense that women are frustrated. And the flawed WHI study that convinced everyone that HRT is dangerous just compounded the damage.
“Unfortunately, often the only people offering relief are even less trustworthy, and their treatments are less regulated, less understood, less studied than the ones we have. And women are bearing that risk.”
Women need to be their own best advocates while science and Western medicine catch up.
“Get a doctor you can truly trust,” Dr. Rebecca says. “We’ve gotten poorer at judging someone’s credentials and knowledge base and approach, so ask the important questions until you’re confident this person knows what they’re talking about.”
One good measure is to see if they’re certified by the North American Menopause Society (NAMS) for menopause care. All of Gennev’s telemedicine ob/gyns are required to have this certification.
And do your own research. Read Estrogen Matters by Drs. Bluming and Tavris to have a more informed understanding of HRT and the WHI study. Browse NAMS’ resource library. And of course, check out the resources right here on Gennev.
“If you have questions, a menopause specialist ob/gyn is probably your very best bet for answers. You’ll find them in Gennev’s telemedicine.”
Are you considering HRT and not feeling confident about the options? We'd love to continue the discussion. Please join us in our public forums, leave us a note on the Gennev Facebook page, or join our community in Midlife & Menopause Solutions, our closed Facebook group.