A number of methods available for treating menopausal symptoms are considered ‘natural’. They include maintaining a healthy lifestyle through diet, exercise and stress reduction; the use of herbal medicines like dong quai, black cohosh and licorice; and the use of phytoestrogen (plant) products which contain flavones. While many women find these natural therapies helpful, they are not the same as natural Hormone Replacement Therapy (HRT).

Even though natural therapies are healthy choices and sound practices, it is important to remember that diet and exercise do not raise hormone levels. The only way to truly impact hormone levels is to take hormones. In this bulletin we are going to focus on natural HRT — the practice of supplementing declining hormone levels with natural, bio-identical hormones. Natural hormones do raise hormone levels. We will also present an overview of the natural, bio-identical products on the market today.

For many years conventional HRT has consisted of a standard prescription of hormones — most commonly

0.625 mg of Premarin® (animal-derived) and 2.5 mg of Provera® (synthetic). Premarin is a combination of estrogens derived from the urine of pregnant mares. Provera is synthesized in the laboratory from natural progesterone, then modified for reasons of product patenting.

As women seek education about options available to them as they enter menopause, and as their demand for more natural products increases, a ripple effect has been created throughout the pharmaceutical industry. The result has been a number of new natural, bio-identical pharmaceutical products.

Natural hormones are derived from chemical precursors found in plants. Soybeans and wild yams are the most common sources of these chemicals. For a soy or yam precursor to be converted into a hormone, it must be done in a laboratory. Therefore, natural hormones, like their synthetic and animal-derived counterparts, can be pharmaceutical compounds.

Natural hormones are identical in molecular structure to the hormones the body makes, thus they are called bio-identical. When a bio-identical hormone circulates through your system and binds with a receptor, the fit is the same as if your body had produced that hormone.

Animal-derived and synthetic hormones are similar to human hormones, but they do not have the same molecular structure. When one of these binds with its receptor, the fit is not exact, sometimes resulting in side effects. Natural hormones have been growing in popularity because they are very effective and often without the side effects that can come with the use of synthetic or animal-derived hormones.

For many years natural, bio-identical hormones were only obtainable from compounding pharmacies which make prescriptions by hand and formulate them to suit an individual’s needs. Now, however, pharmaceutical companies are developing an ever-increasing number of natural hormone products. There are a variety of oral preparations, transdermals (patches, creams, and gels applied to the skin) and combination products (containing more than one hormone) from which to choose. Some natural hormones like progesterone and DHEA can be purchased over the counter, without a prescription, from your local health food store, via the Internet or through a catalogue.

By definition, estrogen is not a single hormone; it is a category of hormones which includes estradiol, estrone and estriol. The one most commonly used in the treatment of menopausal symptoms is estradiol, but estrone and estriol are also prescribed.

Estrace®, a commercial pharmaceutical product made from natural, bio-identical estradiol, is predominantly used in tablet form but is also available as a cream. Estrace tablets come in three dosage strengths — 0.5, 1 and 2 mg, however estradiol may be obtained from a compounding pharmacy in any dosage your doctor chooses to prescribe.

Natural, bio-identical estradiol is also present in a variety of commercial patches — Climara®, Alora®, Estraderm®, FemPatch®, Menorest® and Vivelle®. Patches range in doses from 0.025 to 0.1 mg. They are applied to different locations on your torso (your choice) and changed every 3 to 7 days.

Estring® is a pharmaceutical estradiol product in the form of a ring. Inserted into the vagina, Estring is very effective for vaginal dryness and atrophy.

Prometrium® and Crinone® are natural progesterone pharmaceutical products. Prometrium is oral micronized progesterone in a peanut oil capsule. For individuals allergic to peanut oil, certain compounding pharmacies use safflower oil. Prometrium comes in 100 and 200 mg doses. If you need a dose that is either smaller or larger, a compounding pharmacy can formulate one for you. Crinone is a micronized progesterone vaginal gel that comes in two strengths, 4% and 8%. Compounding pharmacies can formulate a variety of topical and sublingual progesterone products to suit your individual needs.

Progesterone creams are widely available in a variety of strengths over the counter. Some of the most popular are ProGest®, AngelCare®, Woman Wise® and Balance®. (To obtain a list of some of the progesterone creams available, call Aeron LifeCycles.)

The commercial combination products, Prempro® and Premphase® combine Premarin and Provera. To date, there are no pharmaceutically manufactured combination products of estradiol and natural progesterone, however bio-identical estrogen products can be formulated by a compounding pharmacy to include progesterone.

Tri-Est and Bi-Est are natural estrogen combination products. Tri-Est is a combination of estradiol, estrone, and estriol. It comes in a 10-10-80% formulation that is designed to match the body’s ratio of each hormone and can be prepared by a compounding pharmacy in oral, gel, and cream forms. Bi-Est is a similar product but does not include estrone and is 20% estradiol and 80% estriol.

More and more women are using Bi-Est because it does not contain estrone (already plentiful in postmenopausal women) and because there is some research to indicate that estriol is the weaker and safer form of estrogen. Both Bi-Est and estriol alone can be formulated into a vaginal cream. Because of the numerous estradiol receptors in the vagina, these products work well addressing vaginal atrophy and incontinence.

Until recently, the only commercial testosterone products available contained methyltestosterone, a synthetic form of testosterone, in dosages only appropriate for men. Current studies, however, clearly show that testosterone is also an important hormone for women. Now, because of its increased popularity, there has been a rush by both pharmaceutical companies and compounding pharmacies to meet the demand. The estradiol-testosterone combination patch Estratest® provides dosages appropriate for women, but does not contain natural, bio-identical testosterone. Presently, bio-identical testosterone can only be purchased from compounding pharmacies, formulated as tablets, capsules, creams, gels, or sublinguals. A major pharmaceutical company, however, is currently developing a low dose bio-identical testosterone patch for women.

Because every woman is a hormonal individual, there can be an element of trial and error involved in selecting an HRT protocol. Saliva testing is a powerful tool that can take the guesswork out of HRT. A baseline saliva test helps determine which hormones are needed (if any), and follow-up testing measures your response to your prescription. Saliva testing can tell whether or not you are within your particular target range. It can also help your doctor determine why you might be experiencing symptoms by showing whether your dose takes your hormone levels above or below your target range.

If you are not happy with a particular hormone delivery system and want to change, a saliva test will help your doctor quickly establish the most suitable new dosage for you. Switching from a patch to an oral delivery system can mean having to completely renegotiate the amount of hormone you are taking because each is utilized differently in the body.

Oral hormones pass through the liver before the body uses them making as much as 90% of the hormone unavailable. Patches, on the other hand, deliver hormones through the skin and directly into the bloodstream without passing through the liver, therefore, a transdermal dosage can be as much as ten times lower than that of an oral preparation.

Our knowledge of hormones and how they work in the body is expanding very rapidly. Sometimes it is difficult for healthcare practitioners to keep up with the large volume of the latest research. In our next bulletin we will present some guidelines for talking to your doctor about natural, bio-identical hormone replacement therapy and hormone level testing.