ROLE OF BIOIDENTICAL HORMONES IN MANAGEMENT OF MENOPAUSE (1).pptx

bioidentical hormones in menopause

1. ROLE OF BIOIDENTICAL HORMONES IN MANAGEMENT OF MENOPAUSE DR.JHEELAM MUKHOPADHYAY HEALTH WORLD HOSPITAL DURGAPUR

2. MENOPAUSE

3. Conventional Hormone Therapy ( What We Learned From WHI,2002) Ref:Hersh AL, Stefanick ML, Stafford RS. National use of postmenopausal hormone therapy: annual trends and response to recent evidence.  JAMA . 2004;291:47-53   McIntosh J, Blalock SJ. Effects of media coverage of Women's Health Initiative study on attitudes and behavior of women receiving hormone replacement therapy.  Am J Health Syst Pharm . 2005;62:69-74

4. Menopausal s/p TREAT OR NOT TREAT D EBILITATING S/P MILD S/P GOAL IS TO IMPROVE QOL TRADITIONAL MHT NATURAL /BIOIDENTICAL

5. MOTIVATIONS FOR CHOSING BIOIDENTICAL HORMONES

6. BIOIDENTICAL HORMONES

7. COMPUNDED BIOIDENTICAL HORMON THERAPY ( Santen RJ, Allred DC, Ardoin SP, et al. Postmenopausal hormone therapy: an Endocrine Society scientific statement.  J Clin Endocrinol Metab . 2010;95:s1-s66 

8. Ref:( US Food and Drug Adminstration (FDA) FDA Web site Compounded menopausal hormone therapy questions andanswers .  http://www.fda.gov/Drugs/GuidanceComplianceRegulatoryInformation/PharmacyCompounding/ucm183088.htm )

9. ACOG CLINICAL CONSENSUS ON COMPOUNDED BIOIDENTICAL HORMONES Safety and Efficacy of Custom-Compounded Hormone Therapy Accuracy of Hormone Level Testing Patient Counseling Marketing Further Research

10. CLAIMS ABOUT CBHT C laim  1: C ompounded  BHT I s  S afer  T han  FDA-A pproved  HT safer, more efficacious, or less likely to cause breast or uterine cancer than FDA-approved HT   C laim  2: C ompounding  P rovides  I mproved  D elivery and  T olerability of  HT meet the individualized needs + delivered in an alternative form  C laim  3: C ustom  CBHT C ontains  S afer  I ngredients  T han  FDA A pproved  HT diosgenin from plants such as soy and yams C laim 4: S alivary  T esting  S hould  B e  U se to  P rovide  “P ersonalized  T herapy ” C laim  5: C ompounded  BHT H as a  L ower  B reast  C ancer  R isk  T han  FDA-A pproved  HT C laim  6: C ompounded  BHT H as a  B etter  E ffect on  B ones  T han  FDA-A pproved  HT

11. Counseling Postmenopausal Women about Bioidentical Hormones: Ten Discussion Points for Practicing Physicians   1: “Bioidentical” Does Not Mean “Natural”   2: “Custom-Compounded HT” is Not Synonymous with “BHT 3: FDA-Approved Products Offer Certain Advantages Over Custom-Compounded Preparations   4: The Concept of an “Absolutely Safe” Hormone is a Myth 5: CHT is a Broad Term That Includes Both Bioidentical and Non bioidentical Hormones

12. Cont …   6: Benefits of “Individualization” and Monitoring with Testing Hormone Levels Have Not Been Established 7: Estriol is a Weak Estrogen But Not Necessarily a Benign Estrogen 8: Bioidentical Progesterone and Synthetic Progestins Are Structurally Dissimilar and Functionally Different in Non endometrial Tissues  9: The Use of DHEA and Testosterone Therapy among Women is Controversial 10: Adrenal Fatigue Does Not Mean Adrenal Insufficiency

13. APPROACH TO PATIENT CARE D efinitive information about CBHT to their primary care physicians A cknowledge the use of the bioidentical formulations without appearing to be judgmental or dismissive P hysician is in full agreement about the need for the formulations, their dosage, and indication and is familiar with the compounded product E ducate the patient about currently available FDA-approved BHT products L owest efficacious dose  F or the shortest period A nnual evaluation

14. Alternatives to hormone therapy Non-hormonal prescription drugs (off-label use): Antidepressant SSRIs: fluoxetine, paroxetine, escitalopram SNRIs: venlafaxine and desvenlafaxine Hypnotic Eszopiclone Anticonvulsant Gabapentin Antihypertensive Clonidine Neuropathic pain drug Pregabalin

15. Alternatives to hormone therapy (cont’d) Complementary & Alternative Medicine Soy isoflavones Traditional Chinese medicine Herbs Black cohosh Cranberry St. John’s wort Valerian Vitex Over-the-counter hormones (dietary supplements) Topical progesterone Melatonin

16. Phytoestrogens are estrogen-like chemicals found in plants. In fact, bioidentical hormones often start out as phytoestrogens extracted from different sources like wild yams, cactus, and soy plants and peanut oil. Professionals in medical labs then convert these to bioidentical forms of estrogen ,progestogens and other hormones . Phytoestrogen

17. Phytoestrogens are non-steroidal diverse group of plant derived substances or metabolite that induces biological responses in vertebrates and can mimic or modulate the actions of endogenous estrogens usually binding to estrogen receptors . Data regarding the use of isolated phytoestrogen's ability to alleviate menopausal symptoms, their potential reduction in breast cancer risk and potential increase in bone mineral density are positive. Phytoestrogens consumption provide relief from perimenopausal vasomotor symptoms such as hot flushes, night sweats and has good effect on skeleton and cardiovascular system as well. International Journal of Current Research, Vol. 08, Issue, 06, pp.32585-32591, June, 2016 ROLE OF PHYTOESTROGENS AS AN ALTERNATIVE TO HORMONE REPLACEMENT THERAPY IN POSTMENOPAUSAL WOMEN

18. J Menopausal Med. 2023 Aug 31;29(2):73–83.

19. Adv Nutr . 2023 Sep 25;14(6):1633–1643 .

20. Labs Ordered The following baseline labs should be ordered prior to treatment. • (FSH) •(LH) • Estradiol • Progesterone • (DHEA - S) • (SHBG) • Testosterone • Vitamin D • Vitamin B12 Topical creams, patches, oral progesterone, oral estradiol, vaginal creams and rings, and pellets. Topical progesterone, vaginal rings, and pellets

21. Sample Treatment Options E2 treatments : Climara patch (0.025 mg once a week) or Vivelle - dot (0.0375 mg two times per week), and Avoid oral estrogen; patch is preferred. Ideally add compounded Estriol for cancer protection to E2 • Oral Progesterone (100 - 300 mg one tablet by mouth every night), • Topical Testosterone 2% (5 mg/1 gram one click once a day) 1 click = 1.25 mg, 2 clicks = 2.50 mg. One hormone holiday is permitted one day a week.

22. Bioidentical treatment approach : Bi - est • woman is newly menopausal : Biest (50/50) (5 mg/ 1 gram one click once a day) can be given, which is 50% E2 and 50% E3, and • Later in menopause : 80/20: 80% of the safer estrogen known as estriol (E3) and 20% of estradiol (E2). • Topical Biest (80/20) 5 mg/1 gram sig: 1 click qday (1 click = 1.25 mg), Disp 30 grams • Bi - est (80/20) 2.5mg/1 gram sig: 1 click qday – (1 click =0.625mg) • Bi - est (80/ 20) 0.25mg/gram cream sig; apply 1 gram • Bi - est (80/ 20) 0.25mg/gram Sig; apply 1-gram qday (4clicks) daily Disp #30 grams R3 • Bi - est (50/50) 5mg / 1 gram Sig: 1 click qday (1 click = 1.25mg) • Bi - est (50/50) 2.5mg/1 gram Sig: 1 click qday – (1 click =0.625mg) • Bi - est (50/50) 0.25mg/1-gram cream Sig: apply 1 gram (4 clicks) daily disp 30 grams R3 • Bi - est (50/50) 0.25mg/1ml cream Sig: apply 0.5ml (2 clicks) qday disp 30 grams R3 – (Common dosing)

23. Progesterone Progesterone SR 50 - 200 mg 1 tab po qhs (optimal dose 100 - 200mg) Prometrium (100 - 300 mg one tablet by mouth every night) (Brand Progesterone), Assess peanut allergies due to its component of peanut oil. Progesterone topical cream 10 - 50mg daily (average 20mg qday ) Sig: 20 mg qday Topical Progesterone (100 mg/1 gram 2 - 4 clicks once a day) Example: 1 click = 25 mg, 2 clicks = 50 mg.

24. Testosterone Topical testosterone for female dosing is not available through westernized pharmacy. Topical Testosterone 2% (5 mg/1 gram one click once a day) 1 click = 1.25 mg, 2 clicks = 2.50 mg. • Topical testosterone is effective for stimulating clitoral orgasms, vaginal atrophy, and lichen. Vaginal treatment approach for women who have been in menopause for 10 years (safer treatment) apply to perineum help increase bladder tone

25. Take home massage ( Treatment Options……………………………… “ Start low and Slow ”) Listen Support Build trust Respect and validate