What Is bHRT?

Bioidentical hormone replacement therapy (BHRT) refers to HRT for women using artificial, lab-made hormones, derived from plant sources. Bioidentical hormones are chemically identical to endogenous hormones and have a similar binding ability to human hormone receptor binders. This makes their absorption easier in the body.

The most common steroid hormones falling under the BHRT umbrella include estrone sulfate, estropipate, 17β-estradiol, estriol, progesterone, testosterone, and dehydroepiandrosterone (DHEA).

Bioidentical hormones are NOT natural hormones (as marketed by several pharmacies). ‘Natural’ or ‘herbal’ hormones are synthetic hormones that come from natural sources like yams and soybeans but they undergo significant processing to be approved by the US FDA. Their efficacy and safety profiles are debatable and need further research.

Moreover, there are compounded hormones available in pharmacies sold under the compounded bioidentical hormone therapy (cBHRT) umbrella, formulated entirely by pharmacists, which is again not standardized and can be misleading information.

What Is Estrogen? Why Is It Important?

Estrogen is a steroid hormone secreted by the ovarian follicles in the first half of the menstrual cycle when the egg (ovum) is maturing and about to undergo ovulation. Estrogen levels in women reduce with every menstrual cycle and there comes a point when there are no more eggs left in the ovaries and menstrual cycles cease completely. This phase is called menopause which women in their mid-forties and early fifties go through for as much as a decade.

The lack of estrogen in women (and the other sex hormone, progesterone, secreted by the ovaries) leads to hot flashes, mood swings, anxiety, depression, severe mental health issues and genito-urinary concerns which can cause significant disturbances in daily life, especially for chronic cases. HRT for women can help alleviate menopause symptoms. Though the efficacy of HRT initially was debatable, it has been accepted and bioidentical formulations of estrogen have been validated and approved by the FDA.

Estrogen As A Bioidentical Hormone

The rapid decline of endogenous estrogen levels in women can be replenished by bioidentical estrogen. There are three main forms of bioidentical estrogen, namely Estrone sulfate and estropipate (E1), 17β-Estradiol (E2), and Estriol (E3) that mimic natural estrogen for menopause syndrome. E1 and E2 in BHRT have cleared the required safety and efficacy parameters, and are available in the market on being approved by the FDA. E3 is not FDA-approved yet but is used widely in Europe.

17β-Estradiol is the most used bioidentical estrogen and has been validated in multiple studies. It is prescribed to manage multiple menopausal symptoms like hot flashes, vulvovaginal atrophy, and osteoporosis. It has further been studied to have a cardioprotective and an anti-hypertensive effect as well. 17β-estradiol with drospirenone (a synthetic form of progesterone) was used in clinical trials as an HRT therapy for menopause in women with angina and hypertension respectively, to demonstrate this. Not only this, clinical studies have proven its anti-depressant properties as well. 

Estrone sulfate, estropipate, and estriol have been studied in comparatively smaller clinical trials albeit with successful results. Two large-scale clinical trials in HRT studies to alleviate menopause symptoms in women have been the Woman Health Initiative (WHI) study and another Danish study and both have concluded that prescribing HRT involves analysis of a complex dataset and is to be only prescribed on an individual basis depending on age and medical histories. This said multiple beneficial, isolated studies have successfully demonstrated the management of vasomotor, physiological, and genito-urinary symptoms with BHRT, balancing estrogen levels in the body.

The golden rule which remains is – any form of HRT should only be prescribed for symptomatic management (as approved by regulatory bodies) and not as a cure for any condition. It is not a magic potion to cure any illness but more of a temporary pain reliever!

What Are The Benefits Of Estrogen In bHRT?

Clinical trial data highlights the benefits of bioidentical estrogen (estradiol) as a part of HRT for menopause, to manage different symptoms in mostly vaginal or transdermal formulations (as patches or gels) instead of oral pills. The key to reaping the maximum benefits from the best hormone therapy for menopause is to start early and start on a lower dose, with gradual increases as and when prescribed.

Estrogen has specific receptors in the body which keep on depleting with postmenopausal age. Hence the sooner (after the onset of chronic menopause syndrome) the body is supplied with estrogen, the better it will be able to cope with everything and show the desired results. On the other hand, a decade-long wait (for women in their sixties) will only result in reduced efficiency and lead to more risks.

Dosing and duration are crucial in achieving the optimal benefits like,

•  Improved bone health: Estrogen with or without progesterone helps prevent bone loss in postmenopausal women and helps in bone mass development in later stages of menopause. Estrogen therapy for menopause, when carefully monitored, can be as good as drugs like bisphosphonates which are tailor-made to treat bone loss and osteoporosis. Furthermore, estrogen in combination with progestogen (a synthetic form of progesterone) can also help in preventing hip and vertebral fractures. Level B evidence in clinical trials (which have been proved but have a slight chance of changing over time) also show that estrogen exerts a protective effect in arthritis and reduces rates of arthroplasty.
• Mood-booster: Mood swings, hot flashes and anxiety are the holy trinity of menopause syndrome in women. Estrogen alone or in combination with progesterone balances the body’s hormone levels and can calm the heat, anxiety, and mood swings that come with perimenopause and continue with menopause. A plausible explanation behind this is to do with the serotonin and norepinephrine levels which are lowered with reducing estrogen levels. However, if there is a history of anxiety or clinical depression in the family, or the woman has undergone hysterectomy or oophorectomy, a mental health professional will need to prescribe appropriate medication in addition to estrogen therapy for menopause, as per the patient’s health conditions.
• Improved urino-genital health: Estrogen formulations, especially vaginal gels and patches have shown to improve vaginal dryness and atrophy, and boost mood and energy levels. This cumulatively improves a person’s libido. More importantly, estrogen also makes the urinary tract less prone to infections as it rejuvenates the vulvo-vaginal passageway.
• Cognitive benefits: Estrogen is known for its neuroprotective functions as well. Estrogen promotes synaptic and dendritic spine density, has a positive impact on cholinergic responsivity and hence helps in neurotransmission. Estrogen levels also impact verbal articulation, and improve cognitive functions in patients with Alzheimer’s Disease.
• Overall health benefits: balancing estrogen levels in the body post menopause improves energy levels, muscle atrophy and muscle mass generation, sleep cycles and has a protective effect against some forms of cancer, largely breast and prostate cancer. However, the treatment regime is dependent on age, dosage, and duration.

Should You Be Taking Estrogen?

If you are a woman in your mid forties or early fifties who is suffering from vasomotor, physiological, and/or genitor-urinal issues as commonly seen with menopause, please consult your ob-gynae or your general physician. If your symptoms are severe, the ob-gynae will prescribe you hormonal or non-hormonal therapy depending on the severity. The duration of hormone therapy is most likely to be between 3-5 years.

Please do not neglect your symptoms if you see a pattern and if your daily life is getting affected. Estrogen, BHRT or any form of HRT can be the best hormone therapy for menopause only when initiated at the right time.

Also, if you are a woman who has had a history of hearts attacks, thromboembolism, stroke, breast cancer, uterine cancer, dementia, or liver disease, or you are over sixty years of age, please take a second opinion before resorting to any form of hormone therapy.

FAQs

Does a doctor prescribe bioidentical hormones in the first go?

The doctor will only prescribe hormone therapy. The prescribed drugs may or may not be bioidentical hormones; it totally depends on the patient’s profile. Please note that the US FDA does not recognize the term “bioidentical” separately, but all approved bioidentical formulations are recognized as commercially available hormones made in the laboratory from plant sources with a structure closest to the ones secreted by the pituitary gland.

What is the main difference between bioidentical hormones and compounded bioidentical hormones?

Bioidentical hormones or any commercially synthesized pharmaceutical hormones must undergo a set of clinical trials to confirm their safety and efficacy data to get the US FDA’s approval. They have strict quality control measures which ensures negligible variation between different batches. Most insurance companies also cover their costs for fixed doses. However, this is not the case with compounded formulations. Compounded formulations are not regulated, and are dependent on human calculations and are more prone to errors. There are no FDA approved compounded medications.

Between salivary tests and serum tests, which is better for hormone level detection?

Serum tests are always preferred over saliva tests. This is because salivary assays are not standardized as much as they should be. The results from salivary tests are not convincing enough as the levels of hormones in saliva are very low. Having said that, even serum hormone tests are at best a crude guide to what one can expect. You will need accessory tests to ensure your health parameters. 

Is there any treatment for high estrogen in females?

High levels of estrogen can be due to multiple factors like obesity or PCOS (polycystic ovarian syndrome), early menopause, or if the body produces less progesterone (a condition known as estrogen dominance). Initiating hormone therapy for low estrogen treatment can also lead to an initial increase in estrogen levels. The physician can either modify the dosing of estrogen or can introduce aromatase inhibitors or gonadotrophin-releasing hormone antagonists as protective measures, depending on patient health.