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Hormone Testing

Hormone Testing

A comprehensive review of laboratory testing for hormones is beyond the scope of this article, but testing can be a useful tool in hormone prescribing decisions. Saliva and serum tests are both effective for measuring baseline hormone levels and determining hormone deficiencies. However, to monitor the therapeutic benefit of prescribed hormones, patient symp­toms and well-being is generally the best guide. The role of laboratory testing is limited primarily to determining baseline hormone levels prior to initiation of therapy. There is no evidence that testing can be used prior to determine a specific hormone dose for a patient. For women supple­menting with hormones, tests may provide qualitative data to help deter­mine whether unresolved symptoms are a result of excess or insufficient supplemented hormone.

Physiologic Doses

Most BHRT/Bioidentical hormone replacement therapy prescribers agree that physiological doses of hormones are preferable. Unfortunately, there is little agreement as to what constitutes a physiologic dose. Many believe that use of the lowest dose required to relieve or prevent symptoms is the most prudent course given the increased risk of hormone-related cancers during the postmenopausal years. Researchers; L’Hermite and Simoncini concluded their review: “Low doses of physiologic bioidentical hormones, as well as their systemic administration, exert probably the least risk, and as a precaution, might be preferred.” However, many antiaging prac­titioners routinely recommend higher doses of bioidentical hormones, believing that overall health is improved by restoring the hormone levels of youth. Another subset of antiaging practice recommends cyclical use of high doses of hormones to produce a monthly bleed. Thus, there are many possible interpretations as to what constitutes a physiologic dose.

The limitless dosing options available with compounded bioidentical hormones are a contributing factor to the ambiguity around optimal doses. With commercially available hormone preparations, the dose options are defined and limited. However, with custom compounded bioidentical hormones, some doses are common but none is considered standard. Thus, it is difficult to conduct or locate research in support of specific dosing protocols for compounded bioidentical hormones. And, although some contend that the broad therapeutic range for sex steroid hormones obviates the need for highly individualized dosing, the majority of women express satisfaction with custom compounded hormone products.

Oral versus transdermal progesterone

Although transdermal estradiol is clearly preferable to oral, conjugated equine estrogens, CEE the advantages of transdermal progesterone are less clear. A 2003 paper by Leonetti found that progesterone cream had an antiproliferative effect on an estrogen-stimulated endometrium, this is a positive finding but these results have not been confirmed by other researchers. Other researchers: Hermann and Nafziger compared progesterone exposure from an over-the-counter progesterone cream to oral micronized progesterone. They found no differences in the 24-hour progesterone exposure between progesterone cream and oral progesterone (as measured by the area-under-the curve from whole blood samples), indicating that whole blood progesterone levels from an over the counter proges­terone cream are equivalent to those achieved from oral micronized progesterone. However, the Hermann study did not compare clinical effects for transdermal versus oral progesterone. From a patient preference perspective, progesterone cream is favored over oral micronized progesterone by 77% of patients.

In summary, current research indicates that oral administration of conjugated equine estrogens is associated with increased potential for harm compared to trans­dermal estradiol. Oral estrogens undergo first-pass metabolism by the liver, producing estrogen metabolites that may accumulate and increase the risk of coagulation and cancers. To date, there are no studies comparing the transdermal and oral forms of BiEst and TriEst.


Research supports the 3 common principles of bioidentical hormone replacement therapy, (BHRT):

  • Use of bioiden­tical hormones
  • Optimization of hormone deliver
  • Use of physiologic doses

It appears that some bioidentical hormone options are safer than their non-bioidentical and synthetic analog counterparts. For example, it may be more breast-friendly to use estriol with estradiol, and there is evidence that progesterone is more breast-, heart-, and brain-friendly than synthetic progesterone analogs. In terms of the clinical efficacy of bioiden­tical hormones, Mahmud in his 2010 paper reported on the results of a bioidentical hormone protocol (including BiEst and progesterone) given to 189 women over a 12-month period. He found that 60% of women who had experienced menopausal weight gain lost weight on the bioiden­tical hormone protocol (average of 14.8 pounds) and 90% experienced improvement in mental symptoms. Mahmud reported that “complica­tions described with traditional HRT did not develop in this population.

Despite these positive research findings, bioidentical hormones cannot be considered completely risk-free. All forms of hormone replacement should be considered to have the potential to increase the risk of hormone-related disorders. Therefore, patient follow-up to monitor benefits or adverse effects is essential regardless of the type of hormone used. In addition, anyone prescribing hormones to postmenopausal women is well-advised to keep abreast of current hormone research.

L’hermite M, Simoncini T, Fuller S, Genazzani AR. Could transdermal estra­diol + progesterone be a safer postmenopausal HRT? A review. Maturitas. 2008;60:185-201. Wren B. Transdermal progesterone creams for postmenopausal women: more hype than hope? Med J Aust. 2005;182(5):237-238.Leonetti HB, Wilson KJ, Anasti JN. Topical progesterone cream has an anti-proliferative effect on estrogen-stimulated endometrium. Fertil Steril. 2003;79(1):221-222.Leonetti HB, Wilson KJ, Anasti JN. Topical progesterone cream has an anti-proliferative effect on estrogen-stimulated endometrium. Fertil Steril. 2003;79(1):221-222.Hermann AC, Nafziger AN, Victory J, Kulawy R, Rocci ML Jr, Bertino JS Jr. Over-the-counter progesterone cream produces significant drug exposure compared to a Food and Drug Administration-approved oral progesterone product. J Clin Pharmacol. 2005;45:614-619 
















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