Bioidentical Hormone Replacement Therapy:

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Bioidentical Hormone Replacement Therapy:

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Bioidentical Hormone Replacement Therapy:Myth vs FactWhat you really need to knowMark D Filidei, D.O.Director of Integrative MedicineAmen Clinics


The two main principles of Bio-identical Hormone Therapy (BHRT):1) Use of natural (human bio-identical) hormones: exactly like those produced in the body

2) Physiological replacement to levels of a young adult


Many doctors are unaware they are prescribing BHRT!VivelleEstraceEstradermFemringFemtraceClimaraAloraPrometrium


BHRT-The main playersThyroidEstrogenTestosteroneProgesteroneDheaGrowth Hormone


Hypothyroidism is an epidemicThe Colorado thyroid disease prevalence study:25,000+ participantsCONCLUSIONS:“The prevalence of abnormal biochemical thyroid function reported here is substantial and confirms previous reports in smaller populations. Among patients taking thyroid medication, only 60% were within the normal range of TSH. Modest elevations of TSH corresponded to changes in lipid levels that may affect cardiovascular health. Individual symptoms were not very sensitive, but patients who report multiple thyroid symptoms warrant serum thyroid testing. These results confirm that thyroid dysfunction is common, may often go undetected, and may be associated with adverse health outcomes that can be avoided by serum TSH measurement.”


Signs and Symptoms of Low Thyroid Fatigue Increased sensitivity to cold Constipation Dry skin Unexplained weight gain Puffy face Hoarseness Muscle weakness

Elevated blood cholesterol level

Muscle aches, tenderness and stiffness

Pain, stiffness or swelling in your joints

Heavier than normal or irregular menstrual periods

Thinning hair

Slowed heart rate


Impaired memory


Standard ranges for thyroid testing (Labcorp):Free T4 0.82-1.77Free T3 2.0-4.4 >3.50




With co-morbidities use:

fT3/rT3 >20





D1 (but not D2!) is suppressed and down-regulated by: Physiologic and emotional stressDepressionDietingWeight gain/Weight LossInsulin resistance and DiabetesObesityInflammationAutoimmune diseaseSystemic illness

Chronic fatigue syndrome


Chronic pain

Exposure to toxins, mold, heavy metals, and plastics



Thyroid hormone replacementT4 only (most common) Synthroid, levothyroxineNatural thyroid (




, NP thyroid) contains natural ratios of T4 and T3


only (






The Three Forms of EstrogenEstrone: Produced in peripheral tissues; implicated in some cancers (breast, uterine)Estradiol: Secreted by ovaries; most active form, supports cognitive function and mood, higher levels associated with youthful appearance. Deficiencies associates with osteoporsis, dementia, heart deseaseEstriol: safest and weakest form of estrogen; may have anti-cancer effects, useful for vaginal dryness and MS (reverses brain lesions)



Signs of Low Estrogen (From Unleash the Power of the Female Brain)Weight gainBladder incontinence and infectionMood changes/depressionInsomniaLow libidoHeart palpitationsOsteoporosisPainful intercourseFoggy headednessIrritabilityFatigue


Hot flashes



Signs of Excess Estrogen (From Unleash the Power of the Female Brain)PuffinessHeavy bleedingFibrocystic breastsLow libidoCravings for carbohydratesWeight gain around the hipsVaginal or oral yeast (thrush)Mood swings/easy to tearTender breasts

Headaches or migraines


Benefits of Estrogen replacementHelps reduce/eliminate menopausal symptomsCan help maintain bone densityAnti-Aging benefitsMay decrease risk of Alzheimer’s and and

other brain related problems

Supports cognitive function and mood

(serotonin function)


Estrogen enhances brain function“Authors suggested this study supports previous results showing that the effect of estrogen therapy on mood may be independent of antidepressant effects mediated by alleviation of vasomotor symptoms and that estrogen therapy may be of benefit to perimenopausal women experiencing moderately severe depression.” Short-term use of estradiol for depression in perimenopausal and postmenopausal women: a preliminary report. Am J Psychiatry. 2003





in a therapeutic dosage alters brain activation patterns in postmenopausal women in specific brain regions during the performance of the sorts of memory function that are called upon frequently during any given day. These results suggest that estrogen affects brain organization for memory in





of estrogen on brain activation patterns in postmenopausal women during working memory tasks.

JAMA. 1999 Apr 7;281(13):1197-202


Premarin Pregnant Mare Urine

Conjugated estrogens, from the urine of pregnant mares (50% equine hormones, not found in humans)







Natural Estrogen ReplacementBi-Est: 80% estriol, 20% estradiol in oral or transdermal formEstradiol only

Transdermal is recommended to avoid “first pass effect” and coagulation issues of oral use

Should always be balanced with natural progesterone in women with an intact uterus


Estrogen MetabolismEstrogens convert into several metabolites. Estrone, for example, may convert into three different forms:• 2-hydroxyestrone, protective against cancer• 4-hydroxyestrone, promotes cancer• 16-alpha-hydroxyestrone, promotes cancer In women on HRT, the 2/16 ratio should be >2. Lower ratios are associated with breast and ovarian cancer.


March 30, 2013, 9:54 p.m“Study upholds breast cancer mortality for hormone replacement” Though it was generally agreed that woman who took the two hormones to curb their hot flashes and night sweats upped their chances of developing the disease, many studies suggested that the cancers the women developed were less likely to be deadly.A new analysis of data from the Women's Health Initiative now casts doubt on those findings

. The study, published Friday by the Journal of the National Cancer Institute, concludes that the prognosis for cancers related to hormone replacement therapy is just as dire as for other breast cancers.

As a result, women who turn to the treatment are more likely to die of breast cancer than their peers who don't take hormones



“The new findings apply only to women who take estrogen and progestin, a synthesized form of the natural hormone progesterone. Women who have had hysterectomies can take estrogen alone, a regimen that doesn't seem to increase breast cancer risk. But those who still have a uterus must take both estrogen and progestin to avoid developing endometrial cancer.

And hidden much further down in the article we find this:


Hormone therapy for Breast Cancer Survivors?“We observed lower risks of recurrence and mortality in women who used HRT after breast cancer diagnosis than women who did not” …the results suggest that HRT after breast cancer has no adverse impact on recurrence and mortality”J Natl Cnacer Inst 2001 May

“Continuous combined HRT was associated with reduced risk of death from primary


and all cause mortality.”

Med H


2002 Oct

“Over a mean follow up of 30 months 17 of 214 users experienced recurrence (4.2% per year), compared with 66 of 623 controls (5.4% per year). HRT did not seem to affect breast cancer recurrence risk”



Oncology 2001 April

Estrogen replacement therapy apparently does not increase either recurrences or mortality rates. Adding progesterone may even decrease recurrences. Women with early breast cancer should be offered hormone replacement therapy…




Gynecol. 1999


Hormone replacement therapy after breast cancer: 10 year follow up of the Stockholm randomised trial.“The number of new events did not differ significantly between groups, in contrast to previous reports. The increased recurrence in HABITS has been attributed to higher progestogen exposure. As both trials were prematurely closed, data do not allow firm conclusions. Both studies found no increased mortality from breast cancer or other causes from HRT. Current guidelines typically consider HRT contraindicated in breast cancer survivors. Findings suggest that, in some women symptom relief may outweigh the potential risks of HRT.”


J Cancer 2013 Jan


Synthetic ProgestinsProvera (medroxyprogesterone acetate) most popular “progesterone” drugDozens of adverse effects: decreases blood flow to heart, lowers HDL, and causes edema, weight gain, insulin resistance, insomnia, and, if taken in early pregnancy, birth defects


Natural ProgesteroneProtects against estrogen’s proliferative effects on endometrium Helps alleviate PMS symptomsReduces fibrocystic breast diseaseMay elevate libido and moodMay promote bone formation


Natural progesteroneSupports GABA - a major calming neurotransmitter“natures Valium”Levels drop with low thyroid, chronic stress, vitamin deficiencies and refined sugar


Symptoms of low progesteroneAnxiety/depressionPoor sleep

Fibrocystic breasts


Premenstrual headaches

Postpartum depression


Progesterone ReplacementOral micronized progesterone, 100-300 mg at bedtime

Transdermal natural progesterone creams, 1/4-1/2 teaspoon daily


both OTC and prescription


Testosterone for Women (?)Yes! Declines with age, just like in men Increases libido, elevates mood and energy level Improves ratio of fat to muscle Replacement: Natural testosterone in transdermal cream or gel. Implanted pellets.


Testosterone for MenLevels fall gradually with age; ”Low T” syndromeLow levels herald andropauseSymptoms include loss of libido, fatigue, depression, loss of muscle mass, osteoporosis,



“I lost my mojo”

Testosterone replacement


be used for men with history of prostate cancer if they are disease free.


Testosterone ReplacementInjections: 200mg wk, 100mg 2x/wk SQ or IMTopical in gel or cream: 50-100mg/dayTroche

Implanted pellets

Avoid oral testosterone

HCG injections


DHEA –adrenal hormonePrecursor hormoneLow levels associated with depression, weight gain, heart disease, diabetes, autoimmune disorders, immune dysfunction, obesity, cancer, osteoporosis, memory lossReplacement improves sense of well-being, mood, memory, immune function, and in women libido


DHEA“DHEA was associated with a remarkable increase in perceived physical and psychological well-being for both men (67%) and women (84%)...Morales, AJ et al. Effects of replacement dose of dehydroepiandrosterone in men and women of advancing age. J. Clin. Endocrinology and Metabolism, 1994; 78(6):1360-1367.


DHEA"... an increase in DHEA-S of 100 mg/dl was associated with a 36% reduction in mortality from any cause and a 48% reduction in mortality from cardiovascular disease."Barrett-Connor, et al. A perspective study of dehydroepiandrosterone sulfate, mortality and cardiovascular disease. NEJM, Dec. 11, 1986; 315(24):1519-1524.


DHEAAverage doses: 5-25 mg women 25-50 mg menCheck blood levels of DHEA-S to determine optimal dose

Use with caution in patients with hormone-sensitive cancers, such as breast or prostate cancer*


DHEA may protect against breast cancerDehydroepiandrosterone (DHEA) has a protective role against cancer…These results suggest that the mechanism of DHEA actions against breast cancer involves the inhibition of cell proliferation and the suppression of migration, indicating that DHEA could be useful in the treatment of breast cancer. Eur J Pharmacol. 2011 Jun 25The DHEA metabolite 7β-hydroxy-epiandrosterone

exerts anti-estrogenic effects on breast cancer cell



. 2012 Apr;77(5


Human Growth HormoneAfter 6 months of treatment: Increase in muscle mass (8.1%)Reduction of body fat (14.4%) Increase in bone density (1.6%)

Rejuvenation of skin (7.1%)

Rudman, D et al. Effects of human growth hormone in men over 60 years old.



J Med

, July 5, 1990; 323(1): 1-6.


Human Growth Hormone“The effects of 6 months of hGH on lean body mass and adipose-tissue mass were equivalent to the changes incurred during 10 to 20 years of aging.”Rudman, D et al. Effects of human growth hormone in men over 60 years old. New Engl J Med, July 5, 1990; 323(1).


Human Growth HormoneSpeeds healing after surgery and recovery from severe illnessExcellent therapy for heart failure: increases cardiac output and exercise capacityGiven by SQ injectionOral “Secretagogues”do

not reliably increase IGF-1

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