Ask Dr. Marie: The Skinny on Bio-Identical Hormones

Feb. 19, 2009— -- The results of the Women's Health Initiative study in 2002 suggesting that the risks of hormones may outweigh the benefits had millions of women stopping their hormones overnight. And just as quickly, hot flashes returned, thermostat settings were lowered, and bedcovers were thrown off in homes everywhere.

Yet two recent segments on "The Oprah Winfrey Show" touting the benefits of hormones have women scrambling to get prescriptions again from their doctors. The hormones Oprah's guests were applauding, called bio-identicals, are shelved under "natural" menopausal hormones and are often made to order and compounded at a pharmacy.

So can the body tell the difference? Are some hormones safe and others not?

Getting to the Bottom of Bio-Identicals

I am intrigued by the interest in bio-identicals, and I find myself asking if there is something special about hormones that are made in the laboratory from plants and compounded by a pharmacy. Or is it the laying on of the pharmacist's hands, by personally mixing the hormone mixture, that makes the difference, much like physicians did less than a century ago?

Or is it the good feeling that comes from believing the cream is being made "just for you" to match your hormones precisely that maybe makes a difference?

Doctors who prescribe bio-identicals often rely on a sample of saliva to estimate the amount of hormone needed -- but in truth, saliva levels and even blood tests for hormones are notoriously unreliable. Not to mention that the quality and dose of a product that is not regulated in any way and made by each individual pharmacy may differ tremendously.

I suspect that women who get great results from bio-identicals are probably benefiting from the transdermal route (any cream applied to the skin is transdermal). I believe this route may be safer than pills because the medicine bypasses the liver.

Their popularity may also be helped by the addition of testosterone to the mixture. After all, most doctor prescribed regimens of hormone replacement therapy do not include testosterone, whereas the bio-identical hormones usually do. Who wouldn't feel better after menopause -- when testosterone levels fall -- with a little testosterone, the hormone of better energy, well-being and heightened sexual desire?

The Truth About HRT

The headlines about HRT have been confusing, but the most recent evidence shows that there can be great benefit from hormones -- at least in the short term -- and that the risks vary significantly for women in different situations. In other words, there isn't a one-size-fits-all answer. A number of studies looking at timing of hormones, dose and method of delivery helps us get a handle on what is best.

Bear in mind that the WHI study examined women who were, on average, 63 years old when they began taking hormones and were mostly overweight or obese -- and therefore likely already had the beginnings of heart disease. They were also not experiencing severe symptoms of menopause, such as hot flashes, and they had not taken hormones in the past 10 years or more; indeed, many had never taken hormones at all.

So the research that led so many women to stop taking estrogen overnight probably did not apply to many younger, healthy women who were taking hormones to treat their sleep disturbance, hot flashes and dry vaginas. But they didn't hear that message from their doctors -- and certainly not from the media at first.

Breast cancer is perhaps the greatest fear of women when deciding whether to take hormones. The women in the WHI study who took estrogen alone in the form of Premarin (they had hysterectomies so didn't need the progesterone) did not have an increased risk of breast cancer.

Women taking the combination of estrogen and the synthetic progestin medroxyprogesterone (commonly called Provera) did have a small increased risk of breast cancer after five years of use. It may be that when it comes to breast cancer, the type of progesterone product and whether you take it in a cyclic or continuous way may be the most important factors. Research suggests that natural micronized progesterone (called Prometrium) is better for your health than synthetic progestin's (such as Provera) and best used cyclically (taking progesterone 10 days each month) rather than continuously (taking progesterone daily) to protect the uterus.

Most women who have had breast cancer should avoid hormones altogether, although occasionally their doctors agree they can try a small amount of vaginal estrogen cream or a tablet.

HRT May Help Some -- but It's No Cure-All

On the plus side, there is no question that estrogen is the most effective treatment for severe hot flashes, sleep disturbances and an annoyingly dry vagina. In an attempt to be fully transparent, I admit that I take a small dose of FDA-approved hormones in the form of a skin patch of natural estrogens changed twice a week and 10 days of natural micronized progesterone each month. Based on the evidence, I believe that I am protecting my heart, my bones and maybe even my brain, colon and eyes.

Unfortunately if libido is a problem, there is no good prescription testosterone for women. I would avoid taking any oral testosterone because of the risk of side effects -- and would prefer a cream or gel much like what the men already have available to them. I do think the proponents of bio-identical hormones prepared by a compounding pharmacy have it right that small amounts of natural testosterone (usually mixed in a cream and applied to the skin) for some women can be useful.

If you want to try some natural remedies for hot flashes, consider soy foods, such as fresh or frozen soybeans, soy milk and tofu (never soy supplements) and black cohosh, a traditional herbal remedy for hormonal problems.

What has been your experience with hormones? Have you tried both bio-identicals and the more traditionally pharmaceutical brands? What were the results?

I know there is so much more to say about hormones. I promise to write much more about hormones, the latest research and the continuing controversy in the weeks to come. As always, I welcome your questions and comments.

Dr. Marie Savard is an ABC News medical contributor. To learn more about Savard's health management system, download free forms and a sample letter to your doctor, visit http://www.drsavard.com and click on "Learn how to take charge of your health."