Question: I am 68 years old and have been taking "bioidentical" hormones for several years now — bi-estrogen/progesterone troches, prepared by a compounding pharmacy. When I have stopped them completely my severe hot flashes returned, so I continue to take them. My new gynecologist prescribed Climara Pro, a patch, which worked but then I began to bleed again, which I don't want to do. I do find it almost impossible to lose weight, even cutting out sugar and some carbs. Are either of these products OK to take, or can they both do harm? I'm trying to take care of myself, but this has been a nagging question.
Dr. Vliet's Answer:
Hot flashes are due to falling or fluctuating estradiol, the primary active estrogen made by the ovaries before menopause. The loss of estradiol disrupts the heat regulatory center in the brain and your body doesn’t regulate its temperature normally as it does when estradiol is optimal. That’s why you get the “flash” of suddenly feeling hot and sweaty for no apparent reason related to outside temperature. Or, you may suddenly get a chill of feeling cold and clammy, again for no apparent reason.
The hot flashes and sweats are often worse at night, disrupting sleep and making you feel exhausted in the mornings. You know the drill … keep the room ice cold, fall asleep, then wake up throwing the covers off because you are suddenly roasting.
You experienced relief of hot flashes on the compounded hormones primarily because the small amount of estradiol in "bi-estrogen" may be enough to stabilize the brain heat regulatory center. Then when you stop the compounded hormones, the estradiol falls, and the hot flashes come back.
But this compounded product has some problems. Bi-estrogen contains both estradiol and estriol, a weaker estrogen made by the placenta during pregnancy. Estriol is not recommended for menopause therapy, and contrary to the marketing hype from compounders, actually has adverse effects on the breast as women get older. It also tends to interfere with estradiol binding at brain receptors causing more memory problems, instead of helping short-term memory improve as we see with estradiol.
The progesterone dose compounding pharmacies used in the troches, designed to dissolve under the tongue, is too high compared to the doses for FDA-approved products. Excess progesterone causes more sweet cravings, weight gain, and difficulty losing weight.
Your gynecologist suggested an FDA-approved product, Climara Pro, that contains both estradiol (the bioidentical copy of the estrogen made by the ovary) and a synthetic progestin that is not the same molecule as bioidentical progesterone. Climara Pro is a good product, but I have often seen women have bleeding problems and weight gain because this product has too little estradiol relative to the amount of progestin. For many of my own patients, the best results come when we add slightly more estradiol with the Climara Pro fixed-dose combination to improve the estradiol-to-progestin (E:P) balance.
When the balance of any fixed-dose hormone product (birth control pills, patches, pills, or troches) is shifted toward more progestin and less estradiol, over time it causes the uterine lining (endometrium) to get thinner and thinner, leading to more breakthrough bleeding and spotting. Medically, we call this atrophic lining of the uterus and it is very common with combined hormone products, whether made by compounders or produced by large pharmaceutical companies.
The best way to check out why bleeding is occurring is to have a transvaginal pelvic ultrasound to do an accurate measure of the uterine lining thickness. Less than 5 mm is atrophic (thin), and means that more estradiol is needed. If the uterine lining is greater than about 8 mm, it means there is thicker lining buildup and the treatment is more progestin (or progesterone) and less estradiol. These questions can best be discussed with your gynecologist to get a handle on the best E:P balance for an individual woman’s needs.
In my work with patients, I find women do better with the longer-acting, more sustained products like the transdermal patches than with the short-acting troches made by compounding pharmacies. I also tailor the E:P ratio to the individual woman to achieve the best symptom relief, weight management, energy, zest ... and endometrial protection.
I describe many ways of achieving optimal hormone balance in my book, Women, Weight and Hormones. There is good science to help us find the right hormone balance for older women, but there is also an art to “tweaking” the products. Check out my website, www.herplace.com, for more information.
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