Management of perimenopause and male andropause with bioidentical hormone replacement therapy – Dr Bill Reeder

Another very interesting letter written by Dr Bill Reeder in New Zealand to General Practitioners regarding the use of bioidentical hormone replacement therapy.

The summary, reproduced here, bolding by HCS, is succinct:

Summary

The overarching factor is that with diminished quality of life, and it can vary from nuisance level to serious, hormone replacement can be very effective.

The answer to these questions, which to me is logical, then is to replace using safe, physiological dosing, transdermal where possible, bio-Identical hormones. 

And maintain healthy patient surveillance using meaningful lab methodology. 

I always recommend patients be their own advocates and read as widely on the subject as they can. We doctors guide, council and at best we do no harm.

(See below for full letter.)___________________________________________________________________________

                                                     Dr Bill Reeder                                                                       

Integrative and Biomedical Medicine

458 Airport Rd Hamilton 3282 New Zealand

Tel 64 7 856 8568 Fax 07 859 1212 wjr@medcom.co.nz

 Dear Doctor,

Management of perimenopause and male andropause with  Bio-identical Hormone Replacement (BHRT) 

Firstly, bio-identical means exactly the same molecular structure steroid as human – so not a derivative or equine sourced.

There is some confusion about the ‘natural’ word. Bio-identical hormones have a plant derived source and then synthesised into human hormones. So are most pharmaceutical hormones but they are analogues or altered. Pharmaceutically compounded hormones (BHRT) are not natural’ i.e. from humans, they’re still synthesised but remain bio-identical. Most, but not all are used as a transdermal form – for good reason.

One of my several special interests is bio-identical hormone management. It is controversial for a number of reasons for some critics of the treatment: 

  • “Its not an ‘approved’ or ‘guideline’ medicine”. 

* Most drugs by their synthetic nature and non-human occurrence    require extensive RCT testing and approval processes. ‘Bioidentical Replacement Hormones’ (BHRT) have already been ‘proven’ biologically. That’s common sense. Moreover, these natural hormones have been used by many doctors world-wide for at least 2 decades now. There is no evidence of any higher risk than in the non-treated population when prescribed correctly.

* What is up for discussion is long term exposure to even natural hormones. Are we designed to have minimal hormones at mid-life for some safety reason or is it just that we are living beyond fertility use by date. Its unlikely that continuation of low dose replacement would be harmful when used according to natural cycles and in appropriate dosage.

  • Unfamiliarity with the method.

 *There are no drug reps or promotional materials. Information is via doctor personal education, international conferences, workshops etc.

  • There are no large RCTs.

*No pharmaceutical company or other agency is willing to fund  the high expense for no return. No RCT’s – means just that – the large trials haven’t been done – it does not mean the treatment may not be effective.

*There are good data nevertheless.

  • BHRT hasn’t been proven to be of benefit? 

*Actually there is good data and clinical experience showing effective benefits.

*In my own experience using BHRT over 18 years, I have no doubt at all of the efficacy and safety. I listen to the patients, they know.

  • Studies show the risks of past HRT – particularly the 2002 WHI data.

*Bio-identical hormones are NOT the same as the hormones used in the WHI studies. Here the estrogens were equine (horse) species derived and the ‘progesterone’ was synthetic MPA progestin – neither has been in the human before. Progesterone (the only form in the human) is NOT a ‘progestin’. Whilst the biochemical steroid composition may appear similar, the effects can be very different just as estrogen and testosterone – with their subtle substitutions, have totally different physiological responses.

*Cohort WHI studies actually showed that using natural progesterone instead of MPA (progestin) was not associated with the risks in the WHI data (CEE and Progestin).

*Its very salient to examine even the WHI data itself – in fact the risks even with oral HRT were extremely low considering the benefits. Its just that the reporting method as % risk rather than absolute was emotive and caused panic. 25% increase in breast cancer is far more compelling than expressing as about 7 chances in 10,000 risk.

For example, ask a woman whose life has turned upside down from menopause the question of risk acceptance using standard pharmaceutical HRT in two ways – consider the reaction to the question put different ways:

  • You have a 25% increased risk of breast cancer – is that OK?
  • Or, you have about 7 more chances in 10,000 of breast cancer risk – is that OK?

Same thing, different perspective.

Women I pose this question to, usually respond quite differently to the use of HRT. Using bio-identical products the risk is almost certainly minimised further the gains in QOL very significant.

 

Advantages in using BHRT.

This communication is meant to be brief so the discussion is limited for that reason. There are many publications on the subject of ‘natural’ hormone supplementation for women and men.

  • It replaces deficient levels with the exact same human substance.
  • The dosing is low, never reaching physiological levels of younger fertile women – those levels are not necessary to resolve menopause or andropause symptoms. This is in line with WHI later recommendations.
  • Most BHRT hormones are in transdermal cream applications. Hence avoiding liver first-pass. The evidence for the benefits over oral routes, especially estrogens, is well documented in mainstream literature. It appears not so well established a need for progesterone or DHEA, which seem to be safe orally. It’s the first pass through liver that’s important for E2 and E3 – conversion to 16-OH metabolytes is variable as is reduced safe methylation and likely the source for unwanted risk.

Is there a place for single unopposed hormone replacement?

  •  With intact uterus, micronized oral progesterone is used to reduce risk of endometrial neoplasia as with traditional estrogen treatments.
  • Post hysterectomy – we still advocate the addition of progesterone as the philosophy is to mimic nature as close as possible. Also we may add testosterone and DHEA where these are sub-optimal. There is ample evidence of improved QOL in so doing. Hard data on prevention of disease is less robust as there is little gain in this research.
  • Some women have hormone ‘imbalance’ for example estrogen dominance as evidenced by symptoms and lab workup. She may do very well on transdermal progesterone only.
  • Some women may have very low testosterone and clinical symptoms supporting this – she may respond to gentle T supplementation for libido, muscle strength, vitality and so on.

So are there risks?

Nothing is guaranteed in medicine. It is good practice to screen for risk factors, to ensure ‘healthy woman’ ongoing screening. I ask patients on BHRT to ensure they work with their GP for regular checks. There is still some belief that long term exposure to estrogen may enhance risk of BCa. The data on this when considering protection with concomitant progesterone, healthy diet, exercise etc. is still being worked on. It is still a very small risk. As always, consider the risks to benefits.

Testosterone replacement for men.

Another large discussion point, which I will not cover other than to say, similar principles apply. The major criticisms are again not supported by the literature:

  • Testosterone supplementation especially bio-identical does NOT cause prostate cancer. Sure, if PCa occurs, and statistically it does as we age, then T replacement is contra-indicated.
  • T does not cause or aggravate heart disease – in fact it is PROTECTIVE.
  • Recent literature has pointed to higher risk of cardiac events for older men on T replacement. It appears to contradict other studies. This year there have been criticisms of the study with major flaws in design. We await further analysis. To date T appears protective when used in sufficient dose to place T in the upper protective centiles.
  • So for men the data on testosterone replacement efficacy is well established.
  • What formulation is less clear. As a general rule in integrative medicine, we prefer to use exact biological equivalents where possible. So T is available as actual testosterone, applied transdermally. Six months use will determine efficacy. Some men will prefer the injectables when T creams are not effective.

Ongoing surveillance

  • As mentioned above, serum levels are useless when using transdermals. Urine is better. In fact I have access to a US lab that can determine what we do with our testosterone metabolically – DHT, aromatising to E2 etc.
  • Must watch for excess aromatisation to estrogens and treat.
  • Regular prostate checking especially in first 12 months.
  • CBC for Hb.

When we look at the long list of potential loss of vitality symptoms for men as we age and lose testosterone production, as evidenced by the loss of vitality, depression, increased abdominal size, metabolic syndrome, libido etc – it seems to me astounding that go to lengths to avoid this area of management. Women have long understood the huge benefits of HRT for them.  

I’m sure if a drug was produced to make men feel younger and vital again, as testosterone does, it would be a block-buster – even if it had side-effects and some risk.

 

What a strange profession we are in sometimes… 

Summary

The overarching factor is that with diminished quality of life, and it can vary from nuisance level to serious, hormone replacement can be very effective.

The answer to these questions, which to me is logical, then is to replace using safe, physiological dosing, transdermal where possible, bio-Identical hormones.

And maintain healthy patient surveillance using meaningful lab methodology.

I always recommend patients be their own advocates and read as widely on the subject as they can. We doctors guide, council and at best we do no harm.

Dr Bill Reeder

Biomedical Clinic

Hamilton

See original document at:

http://www.hormonechoicesingapore.com/wp-content/uploads/2014/09/Bioidentical-Hormones-Thyroid-Report-for-Doctors-Bill-Reeder.pdf

 

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