Patient autonomy

Patient autonomy key part of medical ethics

Letter to The Straits Times  4 June 2015  (Bolding by HCS)

IN THE article on May 27 (“Just had liposuction? MOH may be calling you soon”), (HCS: See )  it was revealed that those who want to undergo liposuction to improve their looks must also agree to be interviewed by the Ministry of Health (MOH) on the outcome of the procedure.

The four fundamental tenets of medical ethics are patient autonomy, beneficence (to do good), non-maleficence (to do no harm) and social justice.

Patient autonomy includes the patient’s rights to give or withhold consent for treatment, privacy and confidentiality.

These tenets should not be violated or significantly compromised except in the most serious circumstances, and backed by the force of legislation. For example, the Infectious Diseases Act can over-ride certain patients’ rights to privacy and confidentiality in the interest of public health and safety.

Similarly, the Private Hospitals and Medical Clinics Act already empowers the MOH to access patient records for audit purposes without a patient’s consent, in the interest of improving patient safety and clinical quality.

Giving consent for an aesthetic procedure is different from giving consent to be contacted and interviewed by MOH officers post-procedure.

The two are separate and independent events that entail separate and independent decisions by the patient. A patient’s autonomy is compromised when the two decisions are bundled together in one consent form.

We hope the MOH can clarify and explain how it is empowered by legislation to do so and why it has chosen this path of significantly diminishing patient autonomy in its effort to regulate aesthetic procedures.

Wong Tien Hua (Dr)
Singapore Medical Association


MOH’s Reply

The Straits Times  18 June 2015

Patient autonomy in audits: MOH replies

THE Ministry of Health (MOH) thanks the Singapore Medical Association (SMA) for its feedback (“Patient autonomy key part of medical ethics”; June 4).

As SMA president Wong Tien Hua said, MOH has powers under the Private Hospitals and Medical Clinics Act to audit any patient’s clinical outcomes, should the need arise.

Our medical audits enable MOH to monitor and uphold the high quality of care and safety of aesthetic procedures performed in Singapore.

Our intent in including this information in the consent template for medical practitioners and healthcare institutions is to give patients the opportunity to be informed of and to agree to participate in MOH’s medical audits before they undergo aesthetic procedures.

In this way, situations whereby patients are surprised when they are contacted after undergoing the procedure are avoided.

Dr Wong’s letter might have given the impression that the patient must consent to participate in the audit for the treatment to proceed. This is not so. The patient’s autonomy is not compromised in this process: Should the patient not agree to participate in any future audit of his aesthetic procedure, neither the patient nor the doctor is prohibited from undergoing or performing the procedure, respectively.

Before they undergo any aesthetic procedure, we urge the public to exercise due caution by ascertaining that the medical practitioners and healthcare institutions consulted are properly licensed and accredited to perform the desired procedures and treatments.

When in doubt, they should seek a second opinion from their regular family physician or other qualified medical practitioners.

Lim Bee Khim (Ms)
Corporate Communications
Ministry of Health


Three Drugs I Would Not Take

Dr Christiane Northrup looks at hormone replacement in the last section of this blog post – the rest of the post is useful too.

In Western Medicine, drugs are created to treat symptoms as opposed to the root cause of the condition. If you only suppress your symptoms, instead of also addressing the cause, your body will often protest by developing so-called “side effects” to medication or even by developing another dis-ease. This is how our bodies talk to us. But, there is nothing “side” about these effects—they are the direct result of the drugs.

Many of the most popular drugs being prescribed for millions have significant side effects that just don’t outweigh the risks. There are three drugs, which are frequently prescribed to women, that fall into this category—and which I personally would not take.

Statins for Heart Health

Statin drugs are prescribed to lower cholesterol. And the myth is that lowering cholesterol is the key to preventing heart disease. But the latest research has shown that things are far more complex than that. The truth is that statins deplete the body’s CoEnzyme Q10 (CoQ10)—a vital nutrient for producing energy in the cells.Of all the organs, the heart requires the most energy and CoQ10 to function properly. So why take a medication for heart health that depletes a vital nutrient shown to support the heart—as well as every cell in your body?

Low levels of CoQ10 have also been linked to depression and dementia, as well as muscle weakness, fatigue, pain, and nerve damage—all of which are also known side effects of statins.And because your body makes less CoQ10 as you age, taking any medication that lowers CoQ10 is not advisable. Further, fat—and fat in the form of cholesterol—has been vilified as the enemy of a health heart. Actually, sugar is the real culprit, not fat, because sugar causes inflammation. And this inflammation taxes the cardiovascular system and the entire body.

If you want to protect your heart, start by reducing inflammation. This means a healthy diet and supplements that are high in antioxidants. Taking vitamin E has been shown to keep blood platelets slippery (so fewer blood clots) and reduce inflammation.3(See The Wisdom of Menopause for a complete list of heart-healthy supplements and foods.)

Heart health also has an emotional component. If you want to truly heal your heart—or protect it at midlife—you need courage to look closely at any source of emotional pain, and then heal this brokenness with compassion, faith in the Divine, and emotional release. You were meant to have an open heart—to give and receive love, and to live joyfully.

Bisphosphonates for Bone Loss

Your body is constantly renewing itself. Older or damaged cells are eliminated by the body, so that newer, healthier cells can take their place. Your bones go through this cycle, too. If you have decreased bone mass, that means that your body is breaking down bone faster than it is creating new bone.

The most popular treatment is a biphosphonate, such as Actonel, Boniva, or Fosomax. These medications prevent bone breakdown and therefore bone loss. Although this sounds like a good idea, these drugs interfere with the natural cycle of breakdown and restoration.4 The result is older, porous, brittle bone—and brittle bone means an increased likelihood of fractures.5

Bisphosphonates have significant side effects, too, including back pain, joint pain, stomach pain, nausea, vomiting, heartburn, and constipation.6 And some women have suffered osteonecrosis of the jaw—death of bone tissue—a condition that is not treatable7 We’re also seeing atypical fractures of the femur that don’t heal! All because of dense bone that doesn’t remodel and allow in a good blood supply. Many dentists are also seeing an increasing need for root canal surgery because of these drugs.

In about 50 percent of women prescribed a biphosphonate will stop treatment because of these side effects.

Even with these side effects, bisphosphonates may offer some benefit for women over 70 who already have osteoporosis. But I want you to protect your bones much earlier than that! And that means promoting bone health naturally. Be sure to get plenty of calcium, magnesium, and vitamin D. (Studies suggest that to keep your vitamin D levels in the optimal range requires 5,000 IU/day!) I also suggest eating an alkaline diet, getting plenty of weight-bearing exercise, and considering bioidentical hormones or plant hormones (phytoestrogens) that have estrogenic effects.

Premarin, Prempro, and All Other Synthetic Hormones

I’ve been talking about bioidentical hormones for nearly three decades. And it still surprises me when women — and doctors — don’t know the difference between bioidentical hormones and synthetic ones. Bioidentical hormones are created to be an exact match in molecular structure to a woman’s body. That is what makes them “bioidentical.” In contrast, non-bioidentical estrogen, such as the estrogen in Premarin, is bioidentical only if your native food is hay. That’s because it is made from the urine of pregnant horses. Hence the name Pre (pregnant) Mar (mares) in (urine). Progestin is a synthetic form of progesterone that is derived from bioidentical progesterone. The reason for this is that you can’t patent a bioidentical hormone that naturally occurs in nature. And so—to make progesterone marketable—it was changed into a compound not native to the female human body.

For about two decades, Premarin (just estrogen) and Prempro (Premarin plus Provera, a synthetic form of progesterone) were the gold standard for many doctors. And the one-pill-fits-all-women approach was the only option women were given. Then, in 2002, the Women’s Health Initiative Studies showed that women who supplemented with synthetic estrogen or Progestin had more incidences of breast cancer, heart attack, stroke, and blood clots than those who were given a placebo. Once thought to confer heart health and other benefits, women suddenly became wary of these drugs. 9

The best approach for hormone therapy is one that is unique to you. Women can have their levels of estrogen, progesterone, DHEA, testosterone, and other hormones tested. Or simply pay attention to how you feel — which I find is a far more accurate way to assess hormone balance than testing your levels. The results (and how you feel) allow you and your doctor to customize a treatment plan that is right for you. Start with the lowest dose possible and see how you do. Better yet, change your diet to a low sugar, organic food approach. Add a natural herbal remedy such as Pueraria mirifica,maca, black cohosh, ground golden flaxseed, or chasteberry. And if that doesn’t work, then try the bioidenticals.

Remember that hormone therapy can take a few trials and errors. It’s a work in progress — just like you are at menopause.

You aren’t destined to wind up on various preventative medications. My mom is in her late 80s and she isn’t on any medication! Neither is my doctor friend Gladys who likes to say “93 and prescription free.” Before you take any medications regularly, make sure you are informed about all the risks and benefits. Does the drug cause nutritional deficiencies? Are you increasing your risk of cancer or heart disease? If so, seek out some alternatives that won’t put your health at risk.


  1. Langsjoen, P.H., & Langsjoen, A.M. (2003) The clinical use of HMG CoA-reductase inhibitors and the associated depletion or coenzyme Q10. A review of animal and human publications. Biofactors, 18 (1-4), 101-111.
  2. Scott, R.S., et al. (1991). Simvastatin and side effects N Z Med J, 104, 493-495. Laise, E. (Nov 2003). The Lipitor dilemma. Smart Money: The Wall Street Journal Magazine of Personal Business, 12(11), 90-96. Golumb, B.A., et al. (2007) Physician response to patient reports of adverse drug effects: Implications for patient-tergeted adverse effect surveillance. Drug Safety, 30, 669-675. King, D.S., et al. (2003). Cognitive impairment associated with atorvastatin and simvastatin. Pharmacology, 23, 1663-1667.
  3. Stampfer, M.J., et al. (1993). Vitamin E consumption and the risk of coronary artery disease in women. New Engl J Med, 328 20), 1444-1449.
  4. Odvina, C.V., et al. (2004). Severely suppressed bone turnover: A potential complication of alendronate therapy. J Clin Endocrinol Metab, 90, 1294-1301.
  5. Parker-Pope, T. (July, 15 2008) Drugs to buil bones may weaken them. New York Times, available online
  6. National Osteoporosis Foundation,
  7. Ruggiero, S.L. et al. (2004). Ostenecrosisof the jaws associated witht the use of bisphosphonates: A review of 63 cases. J Oral Maxillofacial Surg. 62, 527-534.
  8. Neviaser, A.S., et al. (2008). Low-energy femoral shaft fractures associated with alendronate use. J Orthop Trauma, 22, 346-350.
  9. Writing Group for the Women’s Health Initiative Investigators (2002). Risks and benefits of estrogen plus progestin in healthy postmenopausal women: Principal


HCS has received some queries about the confidentiality of patient records.

While the current debate revolves around aesthetic procedures, HCS is wondering why the same permission was not requested from patients using BHRT and Natural Desiccated Thyroid before, unknown to them, their records were examined and they were contacted by the Ministry of Health.

This was the original article about the new ruling by Salma Khalik in “The Straits Times”.


People who want to undergo liposuction to improve their looks must also agree to be interviewed by the Ministry of Health (MOH) on the outcome of the procedure. This requirement has both doctors and patients up in arms.

Meanwhile, the ministry told The Straits Times that it has interviewed more than 500 patients who have had aesthetic treatments, and “so far, MOH has not needed to proceed beyond the initial interview”.

The ministry has been clamping down on aesthetic treatments recently. From March, all liposuction procedures have had to be done in hospitals or clinics approved for day surgery, removing two in three clinics that had been offering the service.

Read the whole article at:…/just-had-liposuction-moh-may-…

Why is BHRT available in Hong Kong, India, Japan, Australia, Thailand, Malaysia, Switzerland, Germany, Canada, South Africa . . . but under threat in Singapore?

Hormone Choice Singapore has been thinking about the possibilities for us and other people in the region to get access to our therapy overseas. The centres below are just a few that we came across.

However, we keep coming back to the question, why are these supposedly non-evidence based treatments freely available in all these other extremely well-regulated countries but under threat here?

If Singapore refuses to help us, and other patients in the region, we do have other places to go to but we say that with great frustration – and sadness. Singapore is supposed to be “a state of the art” medical centre.

  • Dr Susan Jamieson – Hong Kong – in the 90s, she pioneered the use of bio-identical hormones in women in Hong Kong.   “. . . unwanted side effects were the most common cause of women stopping HRT, however the newer “natural” bio-identical progesterones used in natural or bioidentical hormone replacement therapy (BHRT) fortunately appear to cause none of these symptoms!”

  • Dr. Deepak Anjana Chaturvedi – Mumbai, India – a Physician Endocrinologist, Diabetologist, Antiaging Specialist and Bariatrician based in Mumbai with clientele from all over the globe. “It’s not about one’s calendar age. It’s all about the productive and active age. Bio Identical hormone replacement therapy improves the productive age and hence is an important tool in the field of antiaging.”

  • Dr. Chiaki Kawashima – Tokyo“we use hormones which have identical chemical structures to indigenous hormones and therefore potential side-effects are greatly reduced or entirely absent.”

  • Dr Cabot Clinics – across Australia“The doctors and naturopaths at our clinic have been pioneers in the use of natural bio-identical hormones – we have used them for over 20 years. These natural hormones are wonderful for your skin, energy levels and your sex life. They can also help to overcome fibromyalgia and mood disorders.”

  • Dr Don MacGeachy – Queensland – has been using bio-Identical hormones since 1998. He is considered a leader in this field and has a wealth of experience relating to this topic. “It has always made sense that if we could tailor the hormonal dose to each individual woman by performing blood tests and prescribing the exact bio-identical molecule in correct dosage this would be the most appropriate way to treat menopause and pre-menopause.”

  • Dr Graeme Williams – Sunshine Coast“The art of clinical medicine including detailed history and careful examination, together with lots of communication and compassion is necessary.”

  • Your Health, Leaders in Integrative Medicine – across Australia“Natural Hormone Replacement uses various doses of natural oestrogens (oestriol, oestradiol, oestrone), progesterone, DHEA and testosterone as determined by prior testing for blood levels of the relevant hormones. Often progesterone is indicated in many cases due to oestrogen dominant symptoms and conditions. The aim is to achieve normal physiological levels of these hormones in the right balance for optimum health.”

  • Bumrungrad Hospital – Bangkok, Thailand“Hormone replacement refers to the use of bio-identical hormones that are chemically identical to those produced in a woman’s body. Replacement of estrogen is always done in combination with progesterone, and both have the same effect as natural ones.”

  • Bangkok Hospital – Phuket, Thailand – Royal Hormone Programme The hormone replacement therapies (HRT) at Bangkok Royal Life Anti-Aging Center use only bioidentical hormones, which are synthesized to be identical to the indigenous hormones of the human body. With close follow-up examinations and individualized hormone control, our hormone replacement therapies are of the highest standards of safety and effectiveness.”

  •  Dr Wan Julia Sham Ariffin MD – Allied Healthcare group – Malaysia“She specializes in Bio-Identical Hormones Replacement Therapy, Cell Therapy, Obesity and Fitness. Her main interest is Hormone Modulations, Wellness and Age Management.”

  • Society for Advancement of Hormone & Healthy Aging Medicine Malaysia  – “Conventional medicine treats diseases with patented medicines which is actually a downstream medicine. Healthy Aging Medicine is an upstream medicine where the focus is on prevention, early detection and treatment of age related dysfunction which adds ‘LIFE TO YEARS AND YEARS TO LIFE’.”

  • Society of Anti-Aging, Aesthetic and Regenerative Medicine Malaysia – affiliated with A4M to “Maintain a position stand on Anti-Aging Regenerative Medicine in Ministry of Health in the usage of bioidentical hormones to be allowed only to registered medical practitioners and to be listed under the medical speciality and not to be classified under Traditional and Complementary Medicine.”

  • Dr Jean-Pierre Naim – Geneva – one of the most celebrated international experts in the field of anti-aging “has published numerous works dealing with anti-aging medicine and more particularly on the protocols allowing for the boosting of longevity, on hormone replacement therapy, on the use of bio-identical hormones for aging men and women and on the protocols of telomerase.”


  • Dr. med. Rudolph Weber – Wiesbaden, Germany“We are one of the first gynecological offices in Germany to offer individualized management of perimenopause and menopause symptoms and other hormonal disorders by natural / bioidentical hormones.”

  •  Bioidentical Hormone Replacement Doctors – Clinics Across Canada “Bio identical hormones are extracted from plant sources like soy and wild yams. They possess a molecular structure that is identical or “bio identical” to the hormones produced by our bodies. This is why they will not produce the unwanted side effects caused by synthetic hormones, nor do they increase the risk of any kind of cancer. On the contrary, they are extremely beneficial to the female body undergoing menopause because they provide relief from the uncomfortable symptoms experienced at this stage.”

  • The Compounding Pharmacy of SA – “It’s important that hormone replacement therapy is overseen by a doctor specialising in individual hormone restoration, as each person’s response to hormone treatment is unique. Hormone replacement therapy should follow a customised approach, based on each particular patient’s needs and health concerns. Individual hormone levels can be balanced safely and effectively by using bioidentical hormones customised to each person’s particular requirements.”



Women Empowerment: Dispelling Medical Myths

Dr Helene B Leonetti invites us to share this excellent article, posted 16 June 2014. (Bolding by HCS)

The last fifty years have seen great changes in medicine, and being a part of the journey since 1961, I would like to offer a perspective.  Women’s’ health has been in the forefront of my practice, and there are two issues about which I would like to focus: thyroid health, and hormone replacement therapy.

As we get more and more aware of epigenetics and how everything impacts everything else, we can now almost smugly agree that the dietary, environmental, hormonal, increased toxic load, and emotional connection to thyroid function is real.  Yet, the paltry testing and interpretation of those tests have not changed in these last 50 years.  It is a given that women experience far more thyroid disease than men: perhaps 10:1.  And yet, we continue to measure TSH and occasionally free T4 to assess the health of this power organ located interestingly in the area of the fifth chakra.  The testing so essential includes free T3, reverse T3, TPO and thyroglobulin antibodies, ferritin, iodine, vitamin B12, and vitamin D (25 hydroxyvitamin D).  And the old values of TSH (0.5-5.5 now in some labs lowering the range to 0.4-4.5) is still absurdly too large a spectrum, the higher the number, the more underactive the thyroid.  Those of us practicing functional more integrative medicine desire the range more closely to 0.3-2.0;  yet the endocrine world has yet to adopt these more appropriate levels.  And even with the ideal TSH without looking at antibodies, and the other aforementioned levels, some 2-3 of every ten women I evaluate have abnormal findings.  

Adrenal dysfunction measured in saliva is closely aligned with thyroid function and it, too should be evaluated, because one cannot replace thyroid without addressing adrenal fatigue, which is beyond the scope of this writing. We know that heavy metal intoxication, chronic candida from environmental mold, pesticides, gluten sensitivity all impact thyroid health.  Interestingly, the more physiological T4/T3 preparation, known as Armour thyroid, was replaced with Synthroid (T4 alone) with the expectation that the body would know how to take the inactive T4 and convert it to the active T3.  Our bodies are magnificent and magical and if left to their own devices could do this, providing we give the necessary cofactors to assist liver detoxification and conversion to the active form.  But since we still do not accept the vital role of ingredients provided by pure untainted food and nutrients, we cannot put all the pieces together, and continue the band aid approach to therapy.  The important role of compounding pharmacies comes into play here, as Armour thyroid has gone through some struggles with availability and quality, and so many physicians are choosing to have thyroid compounded from porcine thyroid powder under strict regulations, without fillers and additives, often harmful for patients with multiple chemical sensitivities.

Which is my Segway (sic) into hormone replacement for women.  One must remember history so as not to repeat it, said Santayana.  Back in the 1960s an infamous book written by then president of the American College of Obstetrics and Gynecology, Robert Wilson, MD, titled ‘Forever Feminine’ extolled the benefits of Premarin (pregnant mares’ urine) an estrogen which became not only the largest selling hormone, but drug in the industry.  This well publicized book by the Wyeth Company who sold Premarin was read by millions of women who flocked to their doctors requesting the miracle hormone that would prevent them from becoming dried up sexless hags, aging with little ability to attract a loving partner.  

This drug which was produced by torturing magnificent mares and their fouls (that story told most eloquently by PETA (People for the Ethical Treatment of Animals) became so profitable and ingested by hundreds of thousands of women, and because it was ordered as estrogen alone, approximately four per cent of women developed uterine cancer.   Back to the drawing board, our astute forefathers realized that if a woman still had an intact uterus, she required the other important hormone, progesterone, to balance the stimulatory effects of the estrogen.  Thus was born MPA (medroxyprogesterone acetate) a synthetic progestogen patentable (operative word here) and it was cleverly marketed as Prempro.  The issue here is that synthetic progesterone has many side effects (see the PDR) and many women began complaining, such that many albeit unnecessary hysterectomies were performed so that women needed only to take estrogen.

This is where the medieval solution to this problem originated and continues to his day. We now know that synthetic progestin is actually more carcinogenic than estrogen, and to the credit of the pharmaceutical industry, a more bio identical progesterone capsule, named Prometrium, has been added to the tool kit of my colleagues.  And if estrogen, and a more gentle plant based form which we now have in pills, patches, sprays, gels were always ordered with the more  balancing natural progesterone, I may not be writing this.  But this is not the case.  Despite the fact that God gave women two major hormones, estrogen and progesterone, and to a lesser amount, testosterone, most physicians stay stuck in the 1970s thinking that if there is no uterus, there is no need for progesterone, especially since we are most familiar with the synthetic version.

My final observation: my profession continues to denigrate bio identical hormones, compounded specifically by pharmacists trained to do so, claiming they can be dangerous, tainted, and found to be dose erratic, according to some critics.  Yet for 25 years I have measured hormones in the saliva, and along with a comprehensive thyroid panel, AND most importantly, my patient’s story, I have been able to formulate small, appropriate doses of these hormones, preferably administered through the skin or in the vagina, thus avoiding first pass through the liver and avoiding cytokines and clotting factors which can be affected by estrogen pills.  And the one size fits all hormones provided by the pharmaceutical industry cannot come close to addressing each patient’s unique biochemistry.  

It is time that we release our egos and righteous indignation about whether we are in the conventional or alternative camps of medical practice.  We are here to serve our patients, and when we integrate the best of both worlds, those whom we serve benefit.  I just had back surgery: not angel dust or acupuncture, though I certainly gave those attention: this is a metaphor for how we need us all.

Helene B Leonetti, MD

Hormone optimisation therapy for you?

Dr Amir Farid Isahak

This article taken from The Star online 13 April 2013

The acronym, HOT, which stands for hormone optimisation therapy, is about increasing levels of hormones which are within the ‘normal’ but low range, especially if accompanied by symptoms.

In my previous four articles, I explained the roles of one dozen hormones that are evaluated and corrected by wellness and anti-ageing doctors.

I have mentioned that when you go for your “executive profile” blood tests, only one hormone (TSH or T4) is tested. And when this is normal, you are told that you are okay.

Well, in fact, many other systems may be going haywire inside you. For example, for the sex hormones, most men past 50 don’t have a clue that they are andropausal (male menopause), unlike their female (menopausal) counterparts who know their status because their once regular menses have ceased.

In fact, many men in their 40’s already have low testosterone, some low enough to be defined as andropause.

How can you know that your body is healthy and working well if you don’t have a clue about the levels of all the important hormones in your body? For example, many of my patients were shocked to learn of their low HGH (growth/youth hormone) or testosterone levels. Without testing, they would not have a clue.

Many unhealthy men are also walking around with excess oestrogens, with some having more oestrogen (oestrodial) than their menopausal wives!

An anti-ageing hormone assessment would include at least 10 of the hormones mentioned in the last four articles. In future, when we understand more about the other hormones (and when testing becomes cheaper), many more will be included. The more of these hormones are corrected or optimised (if necessary), the better your health.

HRT – Hormone Replacement Therapy

I will not discuss the details of hormone therapy, but only the concepts. You should always get the advice of your doctor, and never self-medicate with hormones as the subject requires much understanding, and the wrong treatment can cause more problems for you.

In general, therapy should only be carried out by doctors who understand the subject well, after careful evaluation, and with regular reviews/follow-up.

Most of you are familiar with the term HRT, which means hormone replacement therapy. It should mean the replacement of any hormone (eg thyroid for hypothyroidism, insulin for diabetes), but the term has been hijacked by gynaecologists to become synonymous with female sex hormone HRT or simply female HRT.

Female HRT is further divided into ET/ERT (oestrogen therapy/replacement therapy), PT/PRT (progestogen therapy/replacement therapy, usually only in younger women with “oestrogen dominance”), and EPT/EPRT (combined oestrogen+progestogen therapy/replacement therapy, which is most common for menopause).

“Replacement” implies using something to replace what is deficient or absent. For women who undergo natural menopause, the decline is gradual and HRT is “optional” after weighing the pros and cons (made very confusing since even the experts disagree).

However, women who have their ovaries removed for whatever reason before natural menopause (ie surgically-induced menopause) should go on HRT because the oestrogen deprivation is sudden and drastic, and the residual oestrogen production by other tissues (eg fat) can be extremely low.

There is little controversy in the replacement/replenishment of thyroid hormones, insulin, cortisol and other hormones when these are deficient.

The controversy arises in female HRT because of unexpected adverse results after long-term studies; in the use of natural or “bio-identical” hormones as a solution to this; and in replenishing other hormones in patients who have “low normal” levels who want to improve their health.

Synthetic and horse oestrogens

All the studies, including the WHI (Women’s Health Initiative, US) and The Million Women Study (UK), which alerted the world that female HRT was not safe, only studied women who were on synthetic and/or horse hormones.

Although their conclusions are still being debated now, these studies virtually halted HRT.

It is a pity, because menopause carries many health risks, and women were deprived of the right solution.

Two to three decades ago, when I was a full-time gynaecologist, we did not have much choice of female HRT drugs. And the ones most promoted, and therefore the ones we were most familiar with, used CEE or conjugated equine oestrogens (ie oestrogens obtained from pregnant mare urine) as the oestrogen component.

The drug insert and reference books listed the active ingredient as CEE. However, since all this controversy, I notice that it is not listed as CEE anymore, but as “natural oestrogens”, which hides the fact that it comes from the horse, although it is indeed from nature!

It does provide some benefits, and is still widely used by doctors after 70 years in the market.

When female HRT was first introduced, doctors only used synthetic and/or horse oestrogens. Soon, they realised that the women were getting uterine cancers. So they added progestins (synthetic progestogens) in combination with the oestrogens. This combination reduced the womb cancers but increased the number of breast cancers instead.

Nobody of course bothered to study the bio-identical oestrogens and progesterone (natural human progestogen) because the drug companies cannot patent them.

Now we have other choices (apart from conventional synthetic/horse hormones) to treat menopausal problems, including herbal medicines, selective oestrogen receptor modulators (SERMs), selective tissue oestrogenic activity regulator (STEAR), and natural bio-identical hormones (for more on the subject, please refer to Hormones for health, Fit4life, Feb 17, 2013).

BHRT/ BIHRT – Bioidentical HRT

The controversy over BIH (bio-identical hormones) and their use in HRT (BIHRT or BHRT) continues unabated. The Malaysian Menopause Society (MMS) is bringing down Dr Tobias Johannes de Villers, the President of the International Menopause Society (IMS), to explain its stand against BIH, while the Society for Anti-Aging, Aesthetic & Regenerative Medicine Malaysia (SAAARMM) will also bring international experts to explain the benefits of BIH at their respective congresses in KL within the next few weeks.

Ironically, while MMS officially rejects BIH, its latest newsletter (April 2013) carries advertisements of both bio-identical and horse-derived hormones side by side.

Here I quote the position statement of the A4M (American Academy of Anti-Aging and Regenerative Medicine), the world’s largest medical anti-ageing organisation, which is adopted by our own SAAARMM: “It is the position of the A4M that the use of hormones in ageing patients to replenish these levels to a youthful physiologic state, when conducted by qualified physicians trained in the practice of treating age-related hormonal decline, constitutes a legitimate and important life-enhancing, life-extending medical application.

“Bio-Identical Hormones have the same chemical structure as hormones that are made in the human body. The term ‘bio-identical’ indicates that the chemical structure of the replacement hormone is identical to that of the hormone naturally found in the human body. In order for a replacement hormone to fully replicate the function of hormones, which were originally naturally produced, and present in the human body, the chemical structure must exactly match the original.

“Thus, BIHRT is a method by which replaced hormones follow normal metabolic pathways so that the essential active metabolites are formed in response to the treatment. It is the molecular differences between bio-identical and non-bio-identical that may prove to be the defining aspect in terms of their safety and failure to make this differentiation could be misconstrued.

“Regrettably, a number of articles recently appearing in various newspapers and magazines have falsely suggested that BIHRT is unsafe and ineffective.

“The goal of BIHRT is to optimise function and prevent morbidity with ageing and to enhance quality of life. With proper modification, adjustment and titration by an experienced anti-ageing physician, the benefits of BIHRT far outweigh the risks.” (Extracted from

I fully endorse the above statements and have found BIHRT most useful in my own practice. There are many other doctors who have achieved better results with BIHRT compared to synthetic or horse HRT.

HOT – Hormone Optimisation Therapy

Now I would like to introduce a new acronym, HOT, which stands for hormone optimisation therapy. While the term hormone optimisation therapy is not new, I would like to stress that HRT was meant to replace/replenish severely deficient hormones (as in andropause, menopause and hypothyroidism) while HOT is about increasing levels of hormones which are within the “normal” but in the “low normal” range, especially if accompanied by symptoms.

What about those with “low normal” levels but who do not have symptoms? Well, actually, many don’t complain because they don’t realise or don’t know what they are missing.

Often, the deterioration in health occurs gradually, and there is a large overlap of symptoms attributed to other problems such that the patients may not complain about it, and doctors may not know if the “low normal” hormone levels are causing or contributing to sub-optimal health.

Many patients with “low normal” hormone levels (eg testosterone) report improved health and wellbeing after hormone optimisation (ie therapy to increase levels from low-normal to average or higher levels).

Anti-ageing doctors may be accused of over-treating if this concept is not understood by other doctors who just go by the lab results. Many people don’t realise that they should and could be much healthier than they are, if only they get their hormones checked and optimised.

Even if you live a healthy lifestyle, have adequate sleep, manage stress well, eat a healthy diet (plus supplements as necessary), exercise regularly (including building muscles and of course doing some qigong) and maintain your ideal weight, you should still check and optimise your hormones to achieve the best of health.






Combined hormone replacement therapy and risk of breast cancer in a French cohort study of 3175 women.

French study shows that when bioidentical hormones are used there is no increased risk of breast cancer

de Lignières B, de Vathaire F, Fournier S, Urbinelli R, Allaert F, Le MG, Kuttenn F


The largest-to-date randomized trial (Women’s Health Initiative) comparing the effects of hormone replacement therapy (HRT) and a placebo concluded that the continuous use of an oral combination of conjugated equine estrogens (CEE) and medroxy-progesterone acetate (MPA) increases the risk of breast cancer. This conclusion may not apply to women taking other estrogen and progestin formulations, as suggested by discrepancies in the findings of in vitro studies, epidemiological surveys and, mostly, in vivo studies of human breast epithelial cell proliferation showing opposite effects of HRT combining CEE plus MPA or estradiol plus progesterone. To evaluate the risk of breast cancer associated with the use of the latter combination, commonly prescribed in France, a cohort including 3175 postmenopausal women was followed for a mean of 8.9 years (28 367 woman-years). In total, 1739 (55%) of these women were users of one type of estrogen replacement with systemic effect during at least 12 months, any time after the menopause, and were classified as HRT users. Among them, 83% were receiving exclusively or mostly a combination of a transdermal estradiol gel and a progestin other than MPA. Some 105 cases of breast cancer occurred during the follow-up period, corresponding to a mean of 37 new cases per 10 000 women/year. Using multivariate analysis adjusted for the calendar period of treatment, date of birth and age at menopause, we were unable to detect an increase in the relative risk (RR) of breast cancer (RR 0.98, 95% confidence interval (CI): 0.65-1.5) in the HRT users. The RR of breast cancer per year of use of HRT was 1.005 (95% CI 0.97-1.05). These results do not justify early interruption of such a type of HRT, which is beneficial for quality of life, prevention of bone loss and cardiovascular risk profile, without the activation of coagulation and inflammatory protein synthesis measured in users of oral estrogens.


Natural (Bio-identical) vs. Synthetic HRT – Kent Holtorf

A review of the medical literature demonstrating how natural hormones are superior to their synthetic counterparts. The conclusion is clear that bio-identical hormones are a safe alternative to Premarin and medroxyprogesterone acetate (MPA), marketed as Provera. The natural bio-identical hormones are very different from their synthetic versions, often having completely opposite physical and cellular effects. Thus, it is critical that women be given the information that these natural hormones do not have the negative side effects of the synthetic hormones and in no way pertain to the conclusions reached by the Women’s Health Initiative (WHI) study. Natural hormones are a safe and more conservative approach to hormone replacement therapy that does not carry the risks associated with Premarin and Provera.


Hormones in wellness and disease prevention: common practices, current state of the evidence, and questions for the future – Erika T. Schwartz & Kent Holtorf,

This article attempts to clarify some of the confusion and controversy surrounding estrogen, progesterone, testosterone, growth hormone, and thyroid hormones and discuss their roles as supported by the present state of evidence in disease prevention and aging as they apply to the primary care practice.




The Truth About Hormone Therapy – Erika Schwartz, Kent Holtorf and David Brownstein

The Wall Street Journal March 16, 2009

An interesting study of “how special interests, a confused medical establishment, and opportunists can combine to complicate the issue and deny patients access to safe and effective treatments”.

Evidence?  (bolding by HCS)

There are 25 years of scientific research with hundreds of studies in the U.S. and Europe that have demonstrated that bioidentical hormones, estradiol and micronized progesterone, are equally or more effective than synthetics — and safer. Yet mainstream medicine has buried its head in the sand and refused to take these studies seriously.

The article concludes:

Sadly, seven years after the WHI study finding Premarin/Provera unsafe, the hormone-replacement debate can be summed up in three words: confusion, ignorance, misinformation. Meanwhile, millions of women have embraced bioidenticals, leaving their conventional physicians looking stubborn and foolish.

The medical establishment must stop kowtowing to drug companies and start serving women’s best interests — and that involves widely prescribing bioidentical hormones. This will lead to healthier, happier women and, in the long run, help reduce America’s skyrocketing health-care costs.