Bio-identical Hormone Replacement Therapy

Dec 6, 2010

By Trevor Shewfelt, Pharmacist at the Dauphin Clinic Pharmacy

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The information in this article is intended as a helpful guide only. It is not intended to be used as a substitute for professional advice. If you have any questions about your medications and what is right for you see your doctor, pharmacist or other health care professional.

Hormones, hot flashes, breast cancer, Oprah Winfrey, Suzanne Sommers and the Dauphin Clinic Pharmacy. What do these all have in common? Bio-identical Hormones. These have been in and out of the news since 2002. The Canadian Cancer Society recently re-ignited the flame. In September 2010 the Cancer Society sent out a press release about a study in the Journal of the National Cancer Institute. This study said the number of prescriptions of estrogen and progestin fell from 2002-2004 and so did the number of breast cancers.

So then the Society of Obstetricians and Gynaecologists of Canada shot back saying the rate of increase of breast cancer from estrogen and progestin is small and about on the same risk level as being obese after menopause, having the first baby after 30, not breast feeding, not exercising and consuming excessive alcohol.

The Obstetrician/Gynaecologists from Manitoba Ive heard speak treating menopausal symptoms with estrogen and progestins told the family doctors in the audience these hormones were safe. However, they hated the compounded hormone products that pharmacies like the Dauphin Clinic Pharmacy make for patients at the request of their doctor. They also hated Oprah Winfrey and Suzanne Sommers for telling women to go out and get bio-identical hormones.

Then there was a CBC radio program which implied that compounding pharmacies werent regulated and women could buy BHRT without a prescription.

Lets go back to July 2002. The Womens Health Initiative Study, or WHI was being released. A bunch of scientists went on TV, newspapers, radio etc and announced that there was a 26% increased risk in breast cancer and a 29% increased risk in heart attack for women on premarin and provera and their study was stopped because of such a terrible result. Women were scared. The media jumped all over this story. Many women threw their hormone replacement therapy (HRT) in the garbage. Now, almost 9 years later, women are having hot flashes, night sweats, and not sleeping, but are too scared and confused to get treated. What can be done?

First, lets talk about the original study. The study was very well done and designed. However, it only looked at women on premarin and provera. So these results do not necessarily apply to other types of HRT like ones that use estrogen and progesterone. There was an arm of the WHI study in which women were only on estrogen. These women did not have an increased risk of breast cancer. Many women in the WHI study were in their 60s. Usually women start experiencing menopausal symptoms in their late 40s and early 50s. It has been argued that the women in the WHI study were not representative of typical HRT patients because they were too old. Also, the risk of breast cancer discussed in the media was blown way out of proportion. For example only 8 more women than normal out of 10,000 on HRT will develop breast cancer. That isnt much when you consider that consuming 2 or more alcoholic drinks a day or exercising less than 4 hours per week have each been reported to increase the risk of breast cancer to ~35 out of 10,000 women.

So what is a woman with hot flashes to do? Remain calm and lets go over some options. You can choose to just grin and bear your menopausal symptoms. Although this is the safest option, Ive met many women for which this option is unacceptable. When you sweat through multiple sets of clothing every day and cant sleep at night, you get pretty miserable pretty fast. The next option is premarin and provera. I know this is the very combination that was studied in the WHI trial. This is the combination that causes breast cancer and heart disease, right? I believe that premarin and provera arent necessarily evil. I think women were scared unnecessarily away from a treatment that helped many of them. After you and your doctor have a discussion, the two of you may quite logically conclude that an 8 in 10,000 risk of breast cancer is acceptable weighed against the benefit of being able to sleep at night. Your doctor will probably also recommend that you stay on the premarin and provera for 5 years or less. This is because the harm risks increase after 5 years. However, some women may decide to stay on premarin and provera longer. The risk of breast cancer only goes up to ~25 out of 10,000 women after 15 years on premarin and provera. That is still lower than the risk from drinking and not exercising.

What are the alternatives to premarin and provera? One popular, non-hormone, alternative is anti-depressants. No, Im not saying all menopausal women are depressed. Im saying that anti-depressants like effexor do a nice job of controlling hot flashes and night sweats in some women.

Oprah wasnt talking about premarin, provera, or antidepressants, though. She was talking about Natural or Bio-Identical Hormones compounded at a specialty pharmacy like the Dauphin Clinic Pharmacy. The ultimate goal of Bio-identical hormone replacement is to imitate, as closely as possible, the hormones that are naturally produced by the human body.

Unlike what the CBC radio story said, bio-identical hormone replacement therapy products require a prescription from your doctor. Compounding pharmacies like the Dauphin Clinic Pharmacy are regulated by the Manitboa Pharmaceutical Association. If you and your physician wish, a pharmacist at the Dauphin Clinic Pharmacy can book an appointment with you to discuss bio-identical hormone replacement therapy and make treatment recommendations. Your Dauphin Clinic Pharmacy pharmacist can also discuss Saliva Hormone Testing, which is a whole topic unto itself.

One of the nice things about having your hormone therapy compounded is that it will be customized for you. Maybe you prefer a cream to a pill. Maybe you need an in-between dose that isnt commercially available. Those are all things that can be compounded.

The last thing I want to discuss is the safety of compounded hormone treatments. Despite what Oprah, Suzanne Sommers and other celebrities claim, no hormone treatments are 100% safe. We do have some theoretical reasons to think the compounded hormones are safer than premarin and provera, but the studies havent been done to prove that. We have to assume all hormone treatments have the same 8 out of 10,000 risk of breast cancer. We have to assume all hormone treatment should be used for 5 years or less because the Womens Health Initiative study is still the biggest, best study done on the subject. The only reason to choose compounded hormones over commercially available ones is your find them more convenient (e.g. cream over capsules) or the compounded hormones treat your symptoms better. We have no evidence that compounded hormones are safer than commercial ones.

As always if you have any questions or concerns about these or other products, ask your pharmacist.


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