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Bio identical Hormone Restorative Therapy


									Bio-identical Hormone
 Restorative Therapy
  Rebecca Cox, PharmD
  Dorneyville Pharmacy
   November 18th 2009
•   Define and identify Bio-HRT
•   Contrast Bio-HRT to synthetic hormones
•   Address clinical guidelines for usage
•   Outline dosing guidelines
            Bio-identical Hormones
• Exact copies of endogenous human hormones
• Extracted from plants, synthesized in lab
  –   Estrogen: estrone (E1), estradiol (E2), estriol (E3)
  –   Progesterone
  –   Testosterone
  –   DHEA
  –   Pregnenolone
  –   Hydrocortisone/cortisol (adrenal gland)
  –   Thyroid
  –   Melatonin
        Goals of Bio-HRT
• Alleviate the symptoms of low or
  imbalanced sex steroid hormones
• Imitate the body’s natural processes
• Anti-aging
  – Suzanne Somers Books
• Varying receptor affinity/receptivity/and metabolic
• Estradiol - potent receptor binding
   – Traditional symptom management (hot flashes and bone)
• Estriol -
   – Highest levels in pregnancy
   – Weaker than estradiol’s receptor binding in most tissue
      • High affinity in vaginal and bladder tissue
   – Acts as an anti-estrogen/estradiol
   – Binds to ER-ß (prevents breast cancer)
   – Not pharmaceutically manufactured in U.S. (Wyeth Europe)
• Estrone
 Bio-HRT Estrogen Utilization
• Estradiol
• Estriol
• Bi-est * most utilized
  – Estradiol 20% : estriol 80%
  – Estradiol 50% : estriol 50%
• Tri-est
  – Estriol 80% : estrone 10% : estradiol 10%
    Estrogen Verses Conjugated
          Equine Estrogen
•   Premarin®
•   Extracted from pregnant horse urine
•   24 metabolites of horse estrogen
•   High levels of horse estrone and
• Counter-balance of estrogen
• Up-regulates estrogen receptors
• Receptors in uterus, breast, brain, nerves,
  blood vessels, skin, kidney, bone, hair follicle,
• Aids thyroid activity
• Mood enhancement
   Progesterone Verses Progestin
• Clinically superior in side                                                     • Synthetic molecule to mimic
  effect profile and quality                                                        progesterone: only similarity
                                                                                    is effect on endometrial
  of life                                                                           tissue
• Decrease breast cancer                                                          • Increase risk of:
  risks                                                                                    – Breast cancer
                                                                                           – Ischemic heart disease
• No CV risks                                                                     • Decrease HDL
• No effect on HDL
      Holtorf K. MD. "The Bio-identical Hormone Debate: Are Bio-identical Hormones (Estradiol, Estriol, and Progesterone) Safer or More Efficacious
      than Commonly used Synthetic Versions in Hormone Replacement Therapy." Postgraduate Medicine, Volume 121, Issue 1, Jan 2009.
        Estrogen Dominance
• Estrogen ratio higher and out of balance
  with progesterone
• No ovulation, period continues
• Estrogen stored in fat tissue
• Overdosing of estrogen supplementation
• Estrogen like chemicals in environment
         Clinical Application
• If estrogen dominant then use progesterone
• Use progesterone only if mild menopause
  symptoms (1st step)
• Always support estrogen therapy with
• Women secrete 0.3mg a day
• Begins to decline in 30’s
• Aids in muscle tone, energy, mental alertness,
  and libido
• Can replace on a daily basis (in combination
  with estrogen/progest)
• Can replace PRN in higher doses for libido
         Routes of Administration
• Oral
  – Higher doses warranted due to first pass metabolism
  – May be superior in very thin women
• Transdermal
  – Mimics body processes more closely than oral
  – Twice daily dosing superior to once daily dosing typically
  – No increase risk for venous thromboembolism or
    coagulation problems
• Vaginal
• Troche/lozenge (sublingual)
• Prepare Bio-HRT individual prescription
  – Not one size fits all
• Combine hormones into one prescription
• Answer prescriber and patient questions
• Help in dose determination and lab test


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