Bioidentical Hormone Pitfalls
Bioidentical Hormone Pitfalls
Jake Ames, MD, HMD
Puerto Vallarta, Mexico
There are times when a physician who is an expert in prescribing bioidentical hormones will have trouble getting a woman’s hormones balanced. Usually men do not have this problem.
Hormone Subdermal Pellets
See my other hormone blogs. Estradiol and testosterone pellets are so small that once they are inserted, they usually cannot be found if the dosage was incorrect. Estradiol pellets gives a woman a 2:1 estradiol to estrone level, which she had before menopause unless she was obese. The 2:1 ratio of estradiol (E2) to estrone ratio (E1) protects women the most from breast cancer. The best estradiol creams can do is a 1:1 E2 to E1 ratio. Oral and sublingual estradiol should not be given to women because they will consistently cause a poor E2 to E1 ratio.
Always error on the side of too little estradiol. Women can always take subdermal estradiol cream to supplement extra estrogen if they are having estradiol deficiency symptoms (hot flashes, brain fog, dry skin and hair, vaginal dryness, decreased libido). Women should have the following hormone blood tests 5 weeks after hormone pellet insertion since the hormones peak in 4-6 weeks: Estradiol, Estrone, free and total Testosterone, FSH, Progesterone, DHEA-sulfate (optional), Pregnenolone (optional). If you put your patient on DHEA and pregnenolone, then test their levels. Estradiol lowers FSH more than estrone. An incorrect E2 to E1 ratio can make a woman feel terrible. Do not check for total estrogens, check E2 and E1.
Testing Follicle Stimulating Hormone (FSH) is the test to see if your patient received enough estradiol. At 5 weeks post estradiol pellet insertion, the FSH should be lower than 20 mIU/mL. Lower than 5 mIU/mL may mean that your patient received too much estradiol especially if she has symptoms of excess estrogen such as swollen, painful breasts, hand and feet edema, and PMS. A few of my patients need the FSH around 10 mIU/mL.
The testosterone range should be above the lab’s reference range. Always treat your patient, not the lab value. If your patient is over 70 years old or has not been on hormone replacement therapy (HRT) for years, start out with a lower dose testosterone pellet. My other hormone blog talks about dosing the pellets.
Low Cobalt
I’ve never seen a patient with optimal RBC cobalt. Most of my patients have zero levels of cobalt testing their RBC cobalt. If your patient is low on cobalt, she will urinate out her hormones to quickly. I learned about this from my colleague Jonathan Wright, M.D. I usually put women on 100 mcg daily of cobalt chloride. I check RBC cobalt and hair analysis cobalt a few months later.
Hormone Allergies
Allergies to hormones and their metabolites are more common than you think. You need to check 100% of your patients for allergies to hormones and hormone metabolites. The most common steroid hormone allergy is to progesterone. After progesterone it is estradiol and estrone, then testosterone. I rarely see patients allergic to DHEA, DHEA-sulfate, Pregnenolone and Pregnenolone sulfate. It is important to check for all of the metabolites of steroid hormones. Using kinesiology, you can just ask the patient’s subconscious to see if they are allergic to hormone metabolites. If the answer is yes, then check individual hormone metabolites. See my allergy blog. I can usually cure women of their hormone allergies in one to three 5-minute treatments.
Hormone Creams
In general hormone pellets are superior to topical hormone creams. You will have some women and men resistant to hormone creams. They just don’t get absorbed. I do not like Versabase creams. I use the hormone creams from Womens International Pharmacy. (12012 N 111th Ave
12012 N 111th Ave, Youngtown, AZ 85363-- Phone
800.279.5708). I have found their creams absorb the best.
Still, on some days hormone creams may be absorbed 40%, another day 70%, another day 20%. The subdermal hormone pellets give you a steady-state hormone level.
Do not use Biest. There is no true science behind this. Some physicians prescribe 80% E2 and 20% Estriol (E3). I did this for years. What Estriol (E3) does, it interferes with E2. I do use E3 in some women who have or had breast cancer. But using different ratios of E2 and E3 is just nonsense. What convinced me of this was giving women E2 pellets. The E2 pellets protect women the most from getting breast cancer.
Breakthrough Menstrual Bleeding
This I hate the most! Sometimes I wish all of my female patients had a hysterectomy (sorry women). What causes dysfunctional uterine bleeding? Common causes are too much estradiol and/or not enough progesterone. Sometimes women need more estradiol to stop them from having periods, but in general, women need more progesterone and less estradiol. If a woman is in the perimenopause phase of her life, you may have to cycle her progesterone. I usually have them take progesterone (P4) on days 15-25. The first day of your period is day 1. Women who have gone through menopause years ago, I do not cycle their progesterone. They have E2, P4, and testosterone (TE) daily. If menstrual spotting or periods persist for a few months, you need to order an endometrial biopsy and pelvic and vaginal ultrasound. The radiologist will look for endometrial and endocervical polyps, leiomyoma’s (fibroids), endometrial and ovarian cancer. Rarely, I put a woman on a birth control pill during her perimenopause phase. See my other hormone blog on dosing hormones.
Hypothyroidism and Iodine Deficiency
I have a blog on hypothyroidism. Basically, my good friend, David Brownstein, M.D. has written many books. Start out reading his books on thyroid hormone, salt, and iodine. Most of your patients’ who are hypothyroid will have type II hypothyroidism. Mark Star, M.D. explains this well in his book, “Hypothyroidism Type 2: The Epidemic.” At least 40% of my patients have Type 2 hypothyroidism. If your patient is low on thyroid hormone, then this must be treated first! Always treat the patient, not the lab. The lab is just a guide to help you.
These are the main problems that you will experience at times with women on hormone replacement therapy.
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