Hormone Replacement Therapy: The Evidence and the Clinician’s Dilemma

Victor S. Sierpina, MD

Alvah Cass, MD

Daniel Freeman, PhD

Bio-identical Hormones

• Hormones that are identical to those produced in the human body (may be synthetically produced)– Estrone, estradiol, estriol (Ortho-

Est,Estrace, Estraderm, Climara)– Progesterone (ProGest, Fem-Gest,

Progonol)– Testosterone– DHEA

Natural Progesterones?Compounding Pharmacies

• Mexican Wild Yam• (Must add UPS Progesterone to topical

cream to be bioavailable)

• Compounding pharmacies: Bi-Est, Tri-Est, Micronized Progesterone

• 800-927-4227; www.iacprx.com… • www.womensinternational.com…

Ovarian Steroidogenesis

Altered and“Natural Hormones”

• Conjugated or otherwise modified from the original structure

• May have multiple components, bioactivity, bioavailability, metabolites

• Premarin®, conjugated equine estrogen has 90 different hormonal components

Differences in Function/Structure

Testosterone Estradiol

Differences in Structure

Methylated ProgesteroneProgesterone

Basics of Menopausal Care

• Regular exercise• Social support• Meditation, relaxation, sleep • Quit smoking/alcohol• Dietary phytoestrogens

– Soy– Celery, fennel, parsley– Nuts, seeds– Flaxseed

Phytoestrogens

• Soy• Black Cohosh

• Dong Quai• Red Clover• Chaste Berry Tree• Licorice• Evening Primrose Oil• Ginseng

Botanicals

• Cimcifuga racemosa (Black cohosh) 1-2 g tid; 2 mg bid (27-deoxyacteine)

• Angelica sinensis (Dong quai) 1-2 g tid• Glycyrrhiza glabra (Licorice) 1-2 g tid• Vitex agnus-castus (Chaste berry)1-2

g tid• Ginseng 500-1000 mg/d

Conclusions

• Jury still out on safety of HRT

• Bio-identical HRT has not been evaluated in clinical trials

• Are risks of HRT due to the hormones, their metabolites, methods of administration

Conclusions

• Botanical medicines useful to treat menopausal sx

• ? Effect on osteoporosis, CV dz

• Progesterone alone may tx both menopausal sx and osteoporosis (controversial for osteoporosis when used alone)

BOTTOM LINE

– HRT for menopausal sx is likely safe for up to 4-5 yrs

– Longer use (10-15 yrs) may create increased risk for some women

– Don’t HRT as CV tx or preventive– Individualize risk/benefit ratio and choice for

each pt.