I recently attended a 3-day long (intense) conference on integrative endocrinology, hosted by University of South Florida (Personalized Medicine Certification). This is the 4th organization from which I have received training on hormone therapy replacement and I always learn something new (the others were IFM, A4M, and AAMP).
When it comes to hormone replacement therapy, which is a hot topic right now, I consider 4 things:
- Will HRT help symptoms and improve quality/duration of life?
- Will it be safe for the patient to use?
- I have EMR templates for medico-legal coverage about use of HRT
- Does the patient have financial restraints that will affect the choice of treatment? In these cases, I consider non-compounding treatments and as of this past weekend's conference, I will be listing out the "Ok vs better vs best" treatment (not something that was taught at the conference, but a culmination of all my education so far on HRT use).
Note: Every organization that I have received training from has their own studies and own approach. There doesn’t appear to be a consensus across organizations (beyond always using bioidentical treatments).
Here are a few clinical pearls on using progesterone as a treatment that I gleaned from the conference:
Some points on use of progesterone:
- Transdermal progesterone can be 5x more potent than oral (Dr. Smith mentioned a case where someone was put on 400mg of topical progesterone and developed insulin resistance)
- Just a reminder that progestin and Provera are NOT bioidentical progesterone!
- You can use topical progesterone in men for a variety of reasons (e.g. 1-5mg applied over carotid arteries to help induce sleep)
- Compounded Progesterone E4M or oil-based are better than immediate release (since 95% of immediate release is destroyed in the upper gut)
- A patient must have a healthy gut to have a good response to bioidentical hormone therapy!
“Nevers”
- Never give estrogen therapy without progesterone in a woman with a uterus, and VICE VERSA (news to me)
- Do not use serum to monitor progesterone levels when prescribing HRT (over-estimation of dose will show up in serum due to metabolites)
- Never use a dose that is more than what the body would naturally make
- Topical progesterone does not protect the endometrium (since not enough progesterone enters the bloodstream to flow to/through the endometrium) (2005 article)
When side effects happen (e.g. paradoxical effect, bloating, depression, anxiety), causes could be:
- Too much progesterone
- Progesterone converting to allopregnenolone
- Toxins
- If using Prometrium (which is the only bioidentical form of progesterone that may be covered by insurance), a histamine reaction from the smidge of peanut oil in this can be the reason for adverse effects
- Adjuvants in non-compounded formulas.
Stay tuned for next week’s topic: Estrogen replacement!
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