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As women we hear a lot about HRT. But how much do we really understand? HRT stands for Hormone Replacement Therapy. Depending on the menopause symptoms, one or two female hormones (oestrogen and progesterone) can be replaced by HRT in a continuous or cyclical method and this is often explored to help ease symptoms.

Women choosing to start hormone replacement therapy for the menopause (not to be confused with manopause), often ask if they’d be better off taking ‘compounded’ HRT as opposed to regulated body-identical HRT as they may have heard that it’s ‘safer’, more in tune with what the body produces naturally, and carries a smaller risk compared to conventional or regulated hormone therapy.

It’s essential to understand that both types of hormone replacement therapy are synthesised in a laboratory and are not natural. Compounded bio-identical hormones are produced in independent specialist pharmacies as duplicates of human hormones in cream, pessary or troche form. The production process is unregulated.

Regulated Body-identical HRT contains duplicates of human hormones conventionally produced by pharmaceutical companies. Regulatory authorities are closely involved in allowing these to reach the market, hence they are the safer preferred choice for most menopause specialists.

Compounded HRT 

Contains hormones – estrogen, progesterone and sometimes testosterone, pregnenolone or DHEA. The logic behind ‘compounding’ these is to create a custom-made preparation to treat a woman’s menopausal symptoms. As a result, product quality is highly variable.

Regulated body identical HRT 

Contains estrogen or progesterone / progestogen as a standard preparation. Testosterone may be added for specific indications and there are some particular benefits to this type of HRT. Regulated body identical HRT is produced on a large scale, and the product is standardised.

Benefits of body identical progesterone:
  • Micronised progesterone has been shown not to affect the risk of breast cancer compared to certain synthetic progesterones. Dydrogesteroneis another progesterone with similar benefits
  • Oral micronised progesterone during its metabolism relieves anxiety and brings on sleep – a desirable effect for most women around menopause
  • Compounded bio-identical hormones in a cream form may not have this powerful effect.  Micronised progesterone and dydrogesterone can be safer from the cardiovascular perspective and not affect lipid levels
  • Certain synthetic types of progesterone may produce more side effects (fluid retention and mood changes). Hence, the body’s identical micronised form is often a great choice
Benefits of body identical estrogen:
  • Oral estrogen increases the risk of deep vein thrombosis, whereas transdermal estrogen, a body identical preparation, is safer and does not carry this risk. This makes it useful for a group of women with a history of venous thrombosis.
Menopause societies all over the world do not recommend compounded bio-identical HRT due to the following concerns:
  • The purity, potency and efficacy can be variable as individual specialist pharmacies are not regulated when compared to pharmaceutical grade HRT
  • There isn’t clear evidence that combining hormones by compounding them is the best practice for treating menopausal symptoms
  • The dosage of estrogen for menopausal symptom control could be too inaccurate and is harder to determine in compounded preparations. This can place a woman at risk of side effects. No studies prove that compounded estrogen provides adequate bone protection against osteoporosis
  • Progesterone is the hormone that protects the uterine lining from becoming too thick and opposes the effect of estrogen. There is a concern that progesterone in a cream form in compounded HRT may have erratic / variable absorption placing the woman at risk of uterine cancer
  • Including DHEA, testosterone or other hormones in custom-made compounded preparations runs a risk of side effects
  • Expensive hormone testing (blood or saliva) can often be a part of prescribing ‘bio-identical’ HRT as prescribers want to provide ‘precise/individualised treatment. There is no evidence that these levels are accurate and should not be used to guide treatment. Additionally, the cost of compounded HRT is often higher than regulated body identical HRT

To summarise:

  • Opt for regulated body identical HRT over compounded bio-identical HRT. The former is regulated and has been well studied for efficacy and safety
  • There is insufficient evidence for multiple and expensive bloods and saliva tests
  • Regulated body identical HRT has some advantages over other types of HRT, but further studies are needed

Article written by Dr Charu Narayanan – IMC Katong, 88 East Coast Road, #02-07 Katong Square. Tel: 6342 4440

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