Foundational Principles of Natural Hormone

Replacement Therapy
Dr. Kristy A. Prouse MD, FRCSC (OB/GYN)
©January 2019 Institute for Hormonal Health Professional Development Division Inc.
Financial Disclosure:
Nothing to Declare

©January 2019 Institute for Hormonal Health Professional Development Division Inc.
Overview:
• Physiology of sex hormone imbalances
• How is symptomatology helpful in diagnosis and
treatment?
• What you need to know about the conventional medical
approach…
• ...and the best way to appproach sex hormone deficiencies
• Conventional HRT vs BHRT: What’s the deal?
• Principles of Prescribing
• The How-Tos of Practical Prescribing: Estrogen,
Progesterone, Estriol
• When is it too much hormone? Symptoms of Over-
replacement
• Troubleshooting dosing of BHRT
• When to refer the complicated patient

©January 2019 Institute for Hormonal Health Professional Development Division Inc.
Physiology of Sex
Hormones

©January 2017 Institute for Hormonal Health Professional Development Division Inc.
Physiology of the Menstrual Cycle

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©January 2019 Institute for Hormonal Health Professional Development Division Inc.
 Estrogen Metabolism
Estrogen Metabolism:

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Cortisol-Sex Hormone Connection

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Classification and
Symptomatology of Sex
Hormone Imbalances

©January 2017 Institute for Hormonal Health Professional Development Division Inc.
 Sex Hormone: Classification Imbalance & Deficiencies

IMBALANCES DEFICIENCIES
• Estrogen Dominance • Estrogen
• Relative Estrogen • Progesterone
Dominance • Testosterone
• Elevated Androgens

©January 2019 Institute for Hormonal Health Professional Development Division Inc.
 Sex Hormone Deficiencies: Symptomatology
LOW LOW TESTOSTERONE (FEMALE)
ESTROGEN/PROGESTERONE
• Hot flashes • Decreased libido
• Memory decline • Decreased arousal/orgasm
• Anxiety • Decreased nipple sensation
• Insomnia • Loss of muscle mass
• Weight gain
• Loss of vitality
• Vaginal dryness
• Painful intercourse • Decreased exercise tolerance
• Decreased libido
• Crawly skin
• Frequent bladder infections

©January 2019 Institute for Hormonal Health Professional Development Division Inc.
Diagnosis

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 Sex Hormones: Diagnosis

• Symptomatology:
Imbalances/Deficiencies
• Physical Examination:
breast and pelvic
• Saliva: historically gold
standard for baseline
• Dried urine spot: baseline
or for those on hormone
replacement
• Bloodwork
underestimates hormone
levels

©January 2019 Institute for Hormonal Health Professional Development Division Inc.
©January 2019 Institute for Hormonal Health Professional Development Division Inc.
Treatment Approach

©January 2017 Institute for Hormonal Health Professional Development Division Inc.
 Sex Hormone Imbalance:Treatment Approach

• Eliminating the Cause

– Dietary/Lifestyle modifications
• Help the body to heal itself
– Dietary/Lifestyle modifications
• Sex Hormone Support
– Herbal Remedies
• Bioidentical Hormone Replacement (BHRT) vs.
conventional HRT

©January 2019 Institute for Hormonal Health Professional Development Division Inc.
 Sex Hormone Imbalance: Treatment Approach
Herbal Remedies

ESTROGEN DOMINANCE ELEVATED TESTOSTERONE

• Indole-3-Carbinol
• Progesterone or Chasteberry
• Calcium D-glucarate
• DIM • Saw palmetto
• Pygeum Bark
LOW ESTROGEN • Fenugreek
• Black cohash
• Nettle Root
• Borage oil
• Evening primrose oil
LOW TESTOSTERONE
LOW PROGESTERONE
• Chasteberry • Maca
• Wild yam • Tribulus Terrestris
• Zinc
• L-arginine

©January 2019 Institute for Hormonal Health Professional Development Division Inc.
 Diagnosis and Treatment
CONVENTIONAL APPROACH INTEGRATIVE MEDICINE APPROACH

• No testing for hormone levels • Always test hormone levels

needed to prescribe • Dried urine hormone testing with
• IF tested (blood)-limitations 4 pt cortisol
• No follow up testing with • Follow up testing recommended
treatment (annually)
• No balancing of estrogen, • Balancing of estrogen,
progesterone, testosterone progesterone, testosterone key
• Progesterone not used if • Progesterone used if deficient
woman has hysterectomy even without a uterus
• Synthetic hormones • Bio-identical hormones only
commonplace
©January 2019 Institute for Hormonal Health Professional Development Division Inc.
BHRT vs CHRT

©January 2017 Institute for Hormonal Health Professional Development Division Inc.
 Definitions
• Bio-identical Hormones: have a chemical structure
identical to endogenous human hormones but are
chemically synthesized such as progesterone, estriol,
estradiol, and testosterone.
• Non-bio-identical hormones: are not structurally identical
to human hormones and may either be chemically
synthesized such as MPA or derived from a nonhuman
source such as CEE.
• Progesterone: our own endogenous hormone.
• Progestins: synthetic chemicals that mimic the effects of
progesterone by binding to progesterone receptors e.g.,
MPA
• Progestogens: an umbrella term for both progesterone
and progestins.

©January 2019 Institute for Hormonal Health Professional Development Division Inc.
 Sex Hormone Imbalances: Treatment Approach

Bio-Identical Hormone
Replacement Therapy (BHRT)

• BiEst (Estradiol/Estriol) TD
• Estriol pv
• Progesterone po/TD
• Testosterone TD
• 7-keto DHEA SL/TD
• DHEA SL/TD

©January 2019 Institute for Hormonal Health Professional Development Division Inc.
 Health Canada Approved Hormones
Type/Source Brand Name Bioidentical?
17 Beta-estradiol/plant (Estrace) po/pv Yes
17 Beta-estradiol/plant (Esclim) TD patch Yes
17 Beta-estradiol/plant (Climara) TD patch Yes
17 Beta-estradiol/plant (Estraderm) TD patch Yes
17 Beta-estradiol/plant (Vivelle) TD patch Yes
17 Beta-estradiol/plant (Estrogel) TD gel Yes
17 Beta-estradiol/plant (Estrasorb) TD cream Yes
17 Beta-estradiol/plant (Estring) vaginal ring Yes
Estradiol acetate (Femring) vaginal ring Yes
Estradiol hemihydrate (Vagifem )vaginal tablet Yes
Progesterone micronized (Prometrium) po Yes
Progesterone (Procheive 4%) vaginal gel Yes

©January 2019 Institute for Hormonal Health Professional Development Division Inc.
 Health Canada Approved Hormones

Type/Source Brand Name Bioidentical?

Conjugated equine estrogens (Premarin )po/pv No
Ethinyl estradiol (Estinyl )po No
Medroxyprogesterone acetate (MPA) (Provera )po No
Norgestrel (Ovrette) po No
Norethindrone (Micronor) po No
CEE and MPA (Prempro) po No
Ethinyl acetate and norethindrone acetate (FemHRT) po No
17 beta estradiol and norgestimate (Combipatch) TD No
17 beta estradiol and levonorgestrel (Climara Pro) TD No

©January 2019 Institute for Hormonal Health Professional Development Division Inc.
 Comparison of Bio-identical Hormones vs.
Conventional Hormone Replacement

Bio-identical Synthetic Bio-identical Synthetic

Progesterone Progestins E2/E3-TD Estrogens
Clinical Efficacy best good Breast protective increased
Physiologic protective negative cancer risk
actions on breast DVT risk none increased
tissue
Risk of breast protective increased
cancer
Risk of CVD protective increased
Risk of DVT none none

©January 2019 Institute for Hormonal Health Professional Development Division Inc.
Prescribing Bio-identical
Hormones

©January 2017 Institute for Hormonal Health Professional Development Division Inc.
Principals of Prescribing BHRT

• Start low and go slow

• Balance
• Physiologic ranges
• Understand downstream
hormones
• Avoid down regulation of
receptors
• Conversion dosing TD->po (x4-5)
• Perform baseline investigations

©January 2019 Institute for Hormonal Health Professional Development Division Inc.
 Baseline Investigations

✓Trans-vaginal pelvic ultrasound (TVUS)

✓PAP smear
✓Mammogram or thermography (>50yo)
✓Bone Mineral Density (BMD)(>50yo)

©January 2019 Institute for Hormonal Health Professional Development Division Inc.
Progesterone
• Used to balance estrogen and to
support cortisol production
• TD or po applications most common
• Prescribed orally for sleep/anxiety
• Given cyclically to menstruating woman
• Given daily (with a day of rest) to post-
menopausal woman
• Initiate dose according to test results
and titrate to symptoms

©January 2019 Institute for Hormonal Health Professional Development Division Inc.
Over-replacement of Progesterone

✓ Slow to wake up or “groggy” in

the morning
✓ Breast tenderness
✓ Cystic acne
✓ Low mood
✓ Swelling in hands and legs
✓ Sluggish bowels/bloating
✓ Hot flashes (body interprets
estrogen as too low)
✓ Insulin resistance and weight
gain

©January 2019 Institute for Hormonal Health Professional Development Division Inc.
Typical Progesterone Dosing
Post-Menopausal

• Compounded progesterone 75-

175mg SR po qhs Monday to
Saturday
**increments of 25mg

• Compounded progesterone
cream 10-30 mg TD qhs
Monday to Saturday
**increments of 5mg

©January 2019 Institute for Hormonal Health Professional Development Division Inc.
 BiEst
• Used to replace estrogen when
objectively deficient
• Combination of estradiol and estriol
(20:80) or (50:50)
• Transdermal application only
• Given daily (with a day of rest) to post-
menopausal woman
• Initiate dose according to test results and
titrate to symptoms
• Must be balanced with progesterone

©January 2019 Institute for Hormonal Health Professional Development Division Inc.
Over-replacement of Estrogen

• Irritability/weepiness
• Acne
• Breast tenderness
• Swelling
• Post-menopausal
vaginal bleeding

©January 2019 Institute for Hormonal Health Professional Development Division Inc.
Typical BiEST Dosing
Post-menopausal

• Compounded BiEST
cream 80:20 (E3/E2) 0.5-
1.75mg TD BID Monday
to Saturday
**Increments of 0.5mg

• Surgical menopause
may require higher
doses to manage
symptoms

©January 2019 Institute for Hormonal Health Professional Development Division Inc.
Troubleshooting Estrogen

• Hot flashes worse at a

certain time of day
• Transition from peri to
post-menopausal dosing
• Timing of switch from
cyclic to daily hormones

©January 2019 Institute for Hormonal Health Professional Development Division Inc.
Estrogen/Progesterone Application Sites
 Estriol for Vaginal Atrophy

• Used for vaginal atrophy resulting in

bothersome vaginal dryness, painful
intercourse or recurrent urinary tract
infections
• Transvaginal application
• Administered in tapering doses at
bedtime
• May be transferred to sexual partner
• May initiate without testing based on
symptoms and physical examination
• Be aware of the modern strategies for urogenital atrophy treatment including
laser therapy and photobiomodulation

©January 2019 Institute for Hormonal Health Professional Development Division Inc.
Typical Vaginal Estriol Dosing

• Compounded Estriol
vaginal cream 0.25-0.5
mg qhs x 2 weeks, then
twice weekly x 2 weeks,
then once per week x 2
months and then as
needed

©January 2019 Institute for Hormonal Health Professional Development Division Inc.
 Delivery Methods

• Carrier bases
• Application site
• Suppositories (E3)

©January 2019 Institute for Hormonal Health Professional Development Division Inc.
 The Complicated Patient: Know when to refer

✓ Post menopausal bleeding

✓ Thickened endometrium on trans-vaginal
pelvic ultrasound
✓ Breast cancer history
✓ Urogenital atrophy unresolved with systemic
and local estrogen
©January 2019 Institute for Hormonal Health Professional Development Division Inc.
Sex Hormone Case Studies

©January 2017 Institute for Hormonal Health Professional Development Division Inc.
CASE STUDY #1

47 yo peri-
menopausal female
not on any hormone
replacement therapy
complaining of heavy
periods with breast
tenderness in the
week before her
period. She is
complaining of new
onset anxiety and
sleeplessness.
Relative Estrogen Dominance

• Test and treat adrenals

• Compounded
progesterone cream 30 mg
TD qhs Monday to
Saturday OR
120mg po qhs Mon to Sat

©January 2019 Institute for Hormonal Health Professional Development Division Inc.
CASE STUDY #2

47 yo peri-menopausal
female not on any
hormone replacement
therapy complaining of
heavy and painful
periods with PMS
symptoms in the week
before her period (28d
cycle).
Estrogen Dominance

• Test and treat adrenals

• DIM or I3C (avoid tumeric
containing compounds)
• ?Compounded
progesterone cream 20mg
TD qhs Monday to
Saturday OR
75mg po qhs Mon to Sat

©January 2019 Institute for Hormonal Health Professional Development Division Inc.
CASE STUDY #3

55 yo post-
menopausal female
not on any hormone
replacement therapy
complaining of hot
flashes, irritability,
awakening between 2-
4am, low libido,
vaginal dryness and
painful intercourse.
Estrogen/Progesterone/Testosterone Deficiency

• Order a 4 pt dried urine or

salivary cortisol and treat
accordingly
• Initiate BiEst cream
0.75mg 80:20 (E3:E2) BID
TD Mon to Sat
• Initiate Progesterone 75mg
po BID Mon to Sat
• Initiate DHEA 10mg TD OD
Mon to Sat

©January 2019 Institute for Hormonal Health Professional Development Division Inc.
CASE STUDY #3

47 yo post-menopausal
female started on
Estrogel 1 pump and
Prometrium 100mg po
by her family doctor
without testing. She is
largely asymptomatic
however with
questioning she does
note occasional breast
tenderness. She has
not had any PV
bleeding and
endometrial thickness
is 4mm.
Over-replacement of Estrogen

• I3C/DIM
• Taper Estrogel
• Switch to BiEST cream at
lower dose 0.5mg 80:20
(E3:E2) TD BID
• Progesterone 100mg po
qhs Mon to Sat
• Retest dried urine with
metabolites in 6 months

©January 2019 Institute for Hormonal Health Professional Development Division Inc.
Conclusion: Foundational Principles of Natural Hormone
Replacement Therapy