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Bio-identical hormone replenishment protocols

Bioidentical Hormone Replenishment Protocols

Guidelines

  1. Treat any underlying adrenal fatigue or stress
  2. Take a good symptomatology history to assess hormonal deficiencies / excesses (see attached symptom questionnaire)
  3. Assess energy patterns (see attached energy sheet) to assess possible hormonal deficiencies
  4. Rule out any hormonal cancers
  5. For example : cancer markers : PSA for prostate
    Ca125 for ovarial
    Ca15-3 and CEA for breast
    Breast evaluation ex. Sonar, mri, mammogram
    Ovarial and endometrial sonar|
    Prostate examination in men (digital or sonar or biopsy when needed)

  6. Establish high risk patients for breast cancer
  7. Example : family history, especially 2 family members
    Early menarche (<11)
    Late menopause (>49)
    No pregnancies/children
    Excessive alcohol use
    Stress

    For alcohol use and breast cancer risk reduction suggest folic acid supplementation

    For people at high risk for breast cancer consider :

    a) estrogen metabolite testing to ascertain 2:16oh estrone
    b) I3C/DIM supplementation
    c) Omega 3 fishoil
    d) Estriol, progesterone natural bioidentical
    e) melatonin

  8. Do lab work to assess the hormonal status
  9. Remember that labwork should confirm what you probably already know from history taking!

Female Hormone Deficiency Treatment

we suggest to use transdermal estrogen gel in the following forms :

a) estradiol on its own
b) or combinations of estradiol and estriol in a ratio of 20-50 : 80-50

For progesterone replacement we suggest transdermal or vaginal natural bioidentical progesterone or oral micronized progesterone

We advise to use combinations of estrogen and progesterone, EVEN IF the uterus has been removed

Never give estrogen therapy without first giving progesterone

The order in which to replace hormones is :

Adrenal hormones followed by progesterone, followed by estrogen, testosterone, thyroid, and only once all hormones are balanced consider the need for growth hormone

Progesterone Replenishment Therapy

Premenopausal women : use days 15 to 26

Postemenopausal women : use days 1 to 26

SYMPTOMS SEVERE : associated adrenal stress / fatigue and estrogen dominance

Moderate hot flashes and night sweats

Anxiety

Breast tenderness

Weight gain (belly, hips thighs, buttocks, love handles)

Palpitations

Irregular frequent heavy periods

Labs : <25% lowest value on the test

Treatment options and dosages :

a) Progesterone transdermally 25-30mg/ml +- dhea 5 to 10mg/ml
Give dose in the morning
b) micronized progesterone per mouth 250mg before bed
c) progesterone vaginally in the morning (100mg/ml …give ¼ ml / d)

SYMPTOMS MODERATE : mild fatigue

Hot flashes, mostly night sweats

Periods frequent and heavy flow

Unable to lose weight

Anxiety

Labs < 50% of the lowest range

Treatment options and dosage :
a) progesterone transdermally 20mg/ ml
b) micronised oral progesterone 200mg
c) Progesterone vaginally am 80mg/ml …apply ¼ ml

SYMPTOMS MILD : night sweats
Periods more frequent, not heavy
Symptoms worsen last 2 weeks of the cycle

Labs <75% of the lowest range

Treatment options :
a) progesterone transdermally 15mg/ml
b) oral micronised before bed 150mg
c) progesterone transvaginally 60mg/ml 1/4ml)

Symptoms With Normal Lab Values :

Labs normal

Treatment suggested : progesterone transdermally 10mg/ml

General advice with progesterone

Take into account :
a) degree of adrenal fatigue ( include a bit of dhea ex 5mg/ml, with 25mg /ml progesterone
b) degree of adrenal stress …if cortisol is high consider oral progesterone as only 10% converts to cortisol, cortisol is usually high in these people and progesterone may convert to cortisol if given transdermally
c) also consider oral progesterone in cases of severe insomnia or anxiety, since transdermal progesterone does not cross the blood brain barrier that readily and oral progesterone does with good gaba receptor activation
d) women with a history of estrogen dominance, need more progesterone P:E dosage >300:1 (salivary), >20:1 (blood)
e) Progesterone adjustment...
If progesterone excess occurs (decreased sweating, tender breasts, chemical sensitivities, cold body temperature, heart burn, elevated blood sugar or insulin, depression, weight gain) then lower the dose
f) in general oral doses in excess of 300mg oral progesterone , or excess of 50mg transdermally are not required

The transdermal bio-availability (absorption) of testosterone and progesterone varies between 30-60% of the dose applied depending on the patient, when incorporated into PLO (pluronic organogel) bases. If not in PLO, then the absorption varies from 2-20%. It is for this reason that the correct dose should be titrated according to symptom resolution primarily (and monitoring for adverse reactions), and according to blood levels secondarily.

Progesterone:

It takes approximately 2 weeks of continuous daily dosing of 30-60mg of progesterone daily for steady-state progesterone levels to be attained (ie blood levels to reach steady levels, neither increasing nor decreasing).

Absorption half-life: 25-50 hours

Protein binding: 96% to 99%

Metabolism: Hepatic to metabolites

Half-life elimination: 5-20 minutes

Excretion: Urine, bile, faeces

Estrogen Replenishment

Severe Symptoms

Younger and more severe hot flashes

Periods ceased or markedly less frequent

Fatigue, dry skin, mouth, vagina

Mood swings, osteopenia, severe depression

Lack of energy after 6pm

Treatment Options

Groups 1/2/3

  1. Younger BI-EST (estradiol :estriol) 50/50 or 40/60 or 20/80
    active transdermal cream 2-2.5mg/ml)
    surgical menopause (At least 1mg/ml estradiol)
    ESTRADIOL ON ITS OWN 1mg/ml at least
    Pellets E2 50mg placed 4 monthly
  2. Menopausal age BI-EST (estradiol : estriol 40:60) transdermal
    cream having at least 0.75mg
    estradiol/ml
    ESTRADIOL (at least 0.75mg/ml)
    Pellets E2 25mg q4 monthly
  3. Elderly BI-EST ( estradiol : estriol 20:80 or 40:60 or 50:50)
    Having at least 0.5mg.ml estradiol OR ESTRADIOL ON ITS OWN (at least 0.5mg/ml)
    Estrogen dominance (PMS, PELLETS 12.5mg q4 monthly Dysfunctional uterine bleeding, cysts, fibroids, fibrocystic breasts)

Moderate Symptoms

  • Severe hot flashes and night sweats, GROUP 1 : as group 2 severe symptoms
  • Mild fatigue periods now lighter and more infrequently, mood swings GROUP 2 : as group 3 severe symptoms
  • Depression with apathy
  • Hairloss crown of head GROUP 3 : half previous group dose
  • Droopy, dry skin

Symptoms Mild

  • Some hot flashes GROUP 1 : as group 2 moderate symptoms
  • Night sweats
  • More periods in frequency but not heavy GROUP2 : as group 3 moderate symptoms
  • Irritable
  • Depressed GROUP 3 : ½ the dose of group 1

Testosterone

IN WOMEN

:

½ of women’s testosterone is from the peripheral conversion of dhea to testosterone (ie adrenals)

High androgens : (women = dhea + testosterone)

  • Seen in adrenal stress (high dhea)
  • Also seen in insulin resistance
  • Also polycystic ovarian syndrome
  • Obtain ovarian ultrasound to rule out polycystoc ovarial syndrome
  • If ultrasound normal consider adrenal stress or fatigue
  • Consider : Saw palmetto, metformin, progesterone cream 2% if progesterone is low, cruciferous vegetables, calcium-d-glucorate for detoxification, chaste tree berries, vit b6,mg,licorice, inorganic sulphate to optimize detoxification
  • Low androgens : seen in menopause
  • Seen in adrenal fatigue

Treatment Options Of Low Testosterone

a) testosterone cream transdermally or transvaginal : 0.1-0.3mg/ml transdermally or transvaginally 1/4ml am
A good starting dose is to use a 0.25% cream applied to upper chest or outer upper arm in a femal
Male dose requirements vary from 25-200mg/d (2.5%-20%)
DHEA 5-10mg/ml applied am as a cream
OR preferabley per mouth as a capsule since this way the dhea can be sulphated in the liver before going systemic
DHEA strating dose in a women should be 10mg, doses can be increased up to a maximum of 50mg if required
DHEA strating dose in a male is 25mg, maximum dose ias 100mg

b) testosterone pellets average dose 75-125mg (100-112.5mg pellets)

Testosterone:

  • Distribution: Crosses placenta; enters breast milk
  • Protein binding: 98% bound to sex hormone-binding globulin (40%) and albumin
  • Metabolism: Hepatic; forms metabolites
  • Half-life elimination: 10-100 minutes
  • Excretion: Urine (90%); feces (6%)

Andropause

Before replacing testosterone discuss the risks

a) PSA elevation / prostate cancer
b) Increased prostate size
c) Gynecomastia
d) Erythrocytosis (elevated hemoglobin and blood clots)
e) Elevated LDL cholesterol
f) Odoema
g) Sleep apnoea might worsen

Determine lifestyle : nutrition, exercise, sleep

  • Adrenal issues ?
  • Estrogen dominance ?

Do not start testosterone if :

  1. there isn’t a testosterone deficiency
  2. a history of prostate cancer
  3. active prostate infection
  4. obstructive benign prostate hyperplasia
  5. A PSA of >4

Estrogen Dominant Therapy

  • lower abdominal fat
  • avoid alcohol
  • medications : aromataze inhibitors : arimidex, chrysin
  • increase elimination of estrogen : I3c/Dim combinations
  • Consider removing medications that may interfere with testosterone production (statins, SSRI’s steroids,alcohol, beta blockers,etc)

Written by : Dr Craige Golding
MBCHB (cum laude), FCP(SA)
ABAARM : American board certified in antiaging and regenerative medicine
FAAFM : fellow in antiaging and functional medicine

 
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