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Hormone Replacement for Women

b_DSC_0012Natural Hormone Replacement Therapy

Why are so many enlightened women and men making the move back to nature’s own when it comes to hormonal replacement therapy (HRT)? Why is supplementing and balancing the hormones of women and men, using the exact molecules produced by the human body, attracting so much attention? Perhaps because researched and published benefits can include: energy, sense of well being, strength, stamina, quality sleep, healthy bone and muscle mass, cardiovascular health, and healthier fat to muscle ratios (see references below).

Artificial hormones have side effects associated with them such as mood swings, irritability, migraine headaches, depression, bloating, weight gain, loss of libido, hair loss, increased appetite, increased fibrocystic breast disease, nausea, gallbladder and liver disease, and increased risk of cancer. These problems have been shown in studies to be eliminated or greatly reduced with natural, transdermal HRT. Today’s men and women are seeking the best of both worlds.

Working with your doctor, this method of restoration of the delicate balance of hormones is based on information contained in a detailed personal and family history, and often times blood tests. It enjoys a successful reputation due, in part, to customization and the closeness with which normal physiology is mimicked.

The natural hormones most commonly used for this are testosterone, progesterone, estriol, estradiol, estrone, dehydroepiandrosterone (DHEA), but can also include pregnenolone. Not only are the direct effects of these hormones so necessary for optimal health, but so are the compounds the body converts them into. For example, the adrenal glands use progesterone, DHEA, and the pregnenolones to make the corticosteroids so vital for managing physical, mental, and emotional stress as well as for the activity of a healthy immune system.

b_Lisa Lecture-1Conditions that frequently respond well to hormone therapy include:

More people today are faced with hormonal imbalances because of the many interventions of man with nature. These include tubal ligations, vasectomies, oral contraceptives, hysterectomies, etc.

There is also the effect on our bodies of Xenoestrogens (potent synthetic estrogen-like chemicals) from sources such as every organic chlorinated pesticide used in our food supplies, plastic wrap (a 3 inch by 3 inch piece has been shown to deliver 23mg of this estrogen into frozen meat and several times that when microwaved to thaw it), and beverage bottles we use. They are embodied in our dairy products and animal proteins that are implanted with and fed various hormones.

c_20060831_0016Xenoestrogens are metabolized by the body to some of the most toxic estrogens known to man. They are known to play a larger role in the incidence of prostate and breast and ovarian cancer, infertility, endometriosis, and fibroids than today’s methods of hormonal replacement, natural or conventional. Industrialized countries that have banned the use of these pesticides have enjoyed a significant decline in their incidence of breast and prostate cancers.

Of course there are more people not only living past the age of 45 than ever before, but expecting to operate at full capacity for decades beyond that. While this creates more need for hormonal replacement, it brings to mind the necessity to have HRT that is as safe and effective and side-effect free as possible.

It should, furthermore, meet the specific requirements of the person. It is unreasonable to assume that everyone can respond well to one of a very few choices available in conventional therapy. Some people do better on no hormones, using herbs and nutritional supplements instead. For these reasons, and more in later issues, compounding pharmacists are helping health practitioners customize hormonal replacement therapy for individuals with individual needs.   

Natural Options

b_Lisa Dr KImagine. You have just received a prescription from your doctor for hormone replacement therapy. The doctor explained that benefits includ e reduced risk of cardiovascular disease, osteoporosis and possibly Alzheimer’s. And of course, these are in addition to addressing the many uncomfortable symptoms of menopause.

Fortunately, unlike perhaps your mother or friend, your doctor has written you a prescription for natural hormone replacement therapy. Instead of subjecting your body to the ravages of synthetic hormones and the hormones nature intended for other mammals (often derrived from horse urine), you are about to receive hormones identical to those produced by your body. Your doctor believes you will receive all of the benefits of hormone replacement, without the extensive and diverse complications of artificial hormones foreign to your delicate systems.

Now imagine a pharmacy with the experience of 18 years and thousands of patients to help guide you and your physician through the many intricacies and nuances of natural hormone replacement. In addition, this pharmacy is staffed by NATURAL pharmacists, including two Certified Clinical Nutritionists, who are experts in the dependence between our delicate hormone balance and our diet, nutrition, lifestyle, and exposure to toxins.

This is pharmacy for the 21st Century — the way pharmacy was meant to be. At O’Brien Pharmacy, we treat every patient as the unique individual they are. Just as it takes a shoe store thousands of pairs to satisfy the fit and desire of a specific customer, we literally compound hundreds of different formulas to meet the needs of a specific, individual patient.

Synthetic and animal hormone manufacturers offer a paltry handful of dosage options, with the curious hopes that one might be tolerable. Unfortunately, only a small percentage of patients find the benefits versus the side effects a reasonable trade — studies show most women quickly discontinue synthetic hormone replacement.

Natural hormones are not commercially manufactured because, in most cases, they cannot be patented, and drug companies rely on patents to guarantee profits. By creating a new chemical hormone, a patent can be issued. These modified hormones will produce some expected beneficial effects, but they can also generate many unwanted adverse reactions.

Our process typically begins with a consultation with a natural pharmacist, addressing past and current health status, as well as future health potential. Then, recommendations are made regarding diet, lifestyle, and proper nutritional supplementation. Finally, when appropriate, suggestions are made regarding natural hormone replacement therapy, subject, of course, to the agreement and prescription authorization by the patient’s doctor.

Millions of women have discovered the positive impact that natural hormone replacement can have on their lives. If you are considering hormone replacement therapy, or if you are now using unnatural hormones with less than satisfying results, you owe it to yourself to explore the options of natural hormone replacement.    

What is a Troche?

So you and your doctor have decided to replace your decreasing hormones with natural hormones instead of the synthetic alternatives.  Congratulations!  But don’t stop here.  The next puzzle piece is how to get the hormones inside your body where they can exert their beneficial effects. 

And don’t be too quick to swallow the obvious:  a capsule or tablet.  The problem is, many of the benefits of natural HRT will be lost as the hormones go through the process of digestion.

None of your circulating hormones are secreted into your digestive tract as a means of total body distribution.  Glands typically secrete hormones into the local circulation where, eventually, they reach complete systemic circulation.  This is physiologically natural.  Hormone delivery via the digestive tract is not.

When hormones are swallowed, they are exposed to digestive acids and enzymes and metabolism as they are absorbed through the gut wall.  Then, like virtually everything absorbed by the digestive process, they are carried directly to the liver in what is called first-pass metabolism.

As a total day’s amount of hormones reach the liver in a very short period of time, this does several things.  First, it is just plain hard on the liver.  And if other medications are being taken, this adds to the liver’s burden and increases the risk of liver toxicity, injury and gall bladder disease.

Next, the liver does not know that this rapid rise in hormone concentration is short-term.  It operates on the basis that hormone levels are way too high, and begins to make changes to counteract this effect.  The net result is that it affects the way your body has access to the hormones.  It affects the estrogen and progesterone you might be taking, but also affects other circulating hormones and chemicals as well.  This includes thyroid hormone, cortisol and a substance called antithrombin III that helps to protect you from strokes and heart attacks.

These changes can increase your blood pressure and cholesterol, affect your mood, lower your thyroid and cortisol potential and increase your risk for a stroke or heart attack.

At this time, viable options to swallowing your hormones include injections and transdermal (across the skin) delivery.  Injections have their obvious drawbacks.

However, transdermal delivery of medications has gained rapid popularity during the last 10 or 15 years.  Estrogen, testosterone, nitroglycerin and nicotine are just some of the different medications in a patch form that are applied to the skin for absorption.  Creams, suppositories and troches are other forms of transdermal absorption, all of which bypass the digestive system and first-pass metabolism. 

Creams can be very effective, but because of the extreme variation in skin type (thickness, fat content, water content, etc.), their absorption is erratic and unpredictable.

Suppositories, vaginal and rectal, are very effective and dependable for drug delivery, but lack convenience.

Troches, however, offer another option.  A dosage form dating back to the 1800s, troches have regained tremendous popularity for the absorption of medications, especially hormones.  They are effective because the lining of the mouth is thin and rich in blood supply.

Troches are small lozenges that dissolve between the cheek and gum over a period of about 30 minutes.  As it dissolves, the hormones are gradually absorbed into the blood stream, resulting in physiologically natural hormone blood levels.  Also, because these are bio-identical to the hormones your body has produced, they are efficiently recognized, utilized, metabolized and excreted by the body.  Since your own hormones only last about 8 to 12 hours, your natural hormone replacement should be dosed about every 12 hours to give adequate, even blood levels.

Artificial hormones, however, do not fit receptors exactly and are more difficult for your body to metabolize.  That is why they are usually dosed just once per day.

Because of the tremendous advantages in consistency, effectiveness and the ability to avoid the digestive process, many doctors and patients prefer troches as the primary dosage form for hormone replacement therapy for both men and women.

Hormones In The News

c_digitaleRecent headlines about hormone replacement are both accurate and deceptive.  It is accurate to report that the drugs Premarin and Provera are poor medication choices based on their risks and benefits.  It is deceptive to suggest the same risks and benefits apply to natural or bio-identical hormone replacement.

The stories are old news to those who understand the differences between bio-identical hormones and synthetic hormones, and in fact confirm popular convictions:  Premarin and Provera and other non-human hormones are not safe for humans.  Worldwide research, studies, experience and the drug manufacturers’ own warnings long ago demonstrated the negative effects of these drugs.  Many published clinical trials have already reported that the risk of breast cancer is increased by long-term use of Premarin, and increases even more when Provera is added to the regimen. [J Natl Cancer Inst 1 997 Aug 6;89(15):1110-6]  Many patients intuitively know something is not right with these synthetic hormones.  Now the Women’s Health Initiative Study affirms these convictions.

It is important to understand that the study was not conducted using human (bio-identical) estrogens and progesterone.   The study used only Premarin and Provera (Prempro).  In addition, it is documented that all hormones, when administered in an oral tablet like this study, stress the liver and gall bladder, produce carcinogenic metabolites and have other negative effects on the body, like increased risk of stroke.

The situation is analogous to the history of insulin use in diabetes.   Until the early 1980s, the only insulin hormone available to give to diabetics was from cows and pigs.  While this complex molecule from these animals is almost identical to human insulin, it differs by one or two amino acids.  This seemingly small difference is enough to cause critical long-term problems in human beings.

When drug companies were able to manufacture the exact human insulin molecule in large quantities, it was proclaimed a major breakthrough in health care.  Now, every patient prescribed insulin is given the exact same molecule that is unique to human beings.  Why should hormone replacement be approached any differently?  It only makes sense to use the exact same human molecule (bio-identical).  And every day more and more evidence supports the use of bio-identical hormones and the restricted use or elimination of synthetic or non-human hormones.  It is unfortunate that the lay press, scientific studies and even educated health care providers often group all forms of HRT together as if they were a single medication.  In reality, women’s experiences and clinical outcomes of HRT differ vastly depending on if the hormones are synthetic or bio-identical, and also on the route of administration (troche or cream vs. capsule or tablet).

In addition, unlike mass-produced hormones, bio-identical hormones can be custom-made to match the exact needs of the individual.  Individualized dosing, bio-identical hormones and drug delivery systems that bypass the liver and digestive tract allow for maximized benefits without side effects.  An estimated two million women are now benefiting from bio-identical estrogens and progesterone.

The news reports also neglect the reason 90% of all women take hormone replacement:  to relieve menopausal symptoms like hot flashes, vaginal thinning and dryness, loss of libido, osteoporosis, forgetfulness, anxiety, thinning hair and bladder disorders.  Evidence continues to support bio-identical hormone replacement as a safe and effective option for symptoms of menopause, and is most effective when coupled with dietary, nutritional and lifestyle changes.

Related topics: What is a Troche?  Natural HRT

Essential Truths About the Clinical Practice of Bio-Identical Hormone Replacement Therapy

The reclusive prophet hidden high in the mountains seeks the answer to the meaning of life. A worthy endeavor, but our journey is more difficult and mysterious. Our quest is the elusive answers to hormone imbalance. By the patient seeking relief or guidance, and the practitioner summoned for help, the singular, definitive solution is sought.

But with a skyward glance and a sigh of relief, many practitioners have reluctantly discovered that the simple, truthful answer does not exist. That is not to say we have no rules or guidelines. And in the absence of a lucid, unadorned answer, most of us are grateful for these offerings.

The first rule is, there is no simple answer to hormone replacement therapy. If you are looking for it, stop. The meaning of life will be an easier pursuit. The simple answer will only exist when rule number two is broken by some force or science capable of cloning the human population and eliminating genetic differences.

The second rule is, treat each patient like the individual they are. It is easy to recreate our mistakes of the last 40 years and subject all women to basically the same dose and therapy, regardless and irrespective of their individualized symptoms and desires. The same dose and drug for every patient has more potential for harm than good, and precedes statistics of up to 80% patient withdrawal.

The third rule is, HRT is difficult, and the learning involved for the practitioner is sequestered in time – the time necessary to digest a knowledge base of books, articles, studies, anecdotal stories and your own clinical observation. Do not hurry this building process. It will probably take one year to develop a good foundation, and from there you will find you are constantly remodeling.

The fourth rule is, you will not successfully treat hormone imbalances with hormones alone. Educating the patient on hormones, diet, nutrition, lifestyle and spirit are of paramount importance. The more the patient understands what he or she is doing and why, and the consequences of doing or not doing something, greatly increases the odds of attaining the patient’s goals (after all, we are only here to be of service to the patient, to help them determine and achieve their goals, and not to impose our own objectives and agenda on them).

Time for thorough education should be delineated, and an appointment made. Not all patients will want this. Some will also be looking for the quick, simple panacea to their problems, and they will probably be disappointed. If an appointment is not made, the same educational process is likely spread over weeks and months of phone calls and faxes, in an environment less conducive to learning.

The education process must start with a patient assessment. It is important to know the patient’s familial history including breast cancer, cardiovascular disease and osteoporosis. Physical parameters, chronic and acute conditions, hormonal background and personal goals and desires are also paramount in making a recommendation. These are the things that make this person an individual, and without this in-depth perspective, a basic rule has been ignored.

Start either a computer-based or paper filing system on each patient. You will need it for future reference, and to note changes in symptoms and dosage adjustments. It is also a good place to keep thank-you cards.

After this evaluation, you can now begin to make some recommendations, which may not even include hormone replacement. There are many dietary and nutritional considerations that can positively and profoundly affect the outcome. Generally, this will include a dairy-free and reduced fat and meat diet, with more emphasis on fresh vegetables, legumes and whole grains. Because of modem farming techniques, the best diet will never contain all the nutrients our bodies require. That is why nutritional supplements (high-potency, multi-vitamin/multi-mineral supplements, vitamin A, vitamin C, vitamin E, omega-3 oil and more) are a vital part of the puzzle. You will also find an important role for herbs. The practitioner willing to take the responsibility of helping the patient through this HRT maze should also become educated in diet and nutrition.

Another fundamental aspect of hormone imbalance is exercise. The benefits of aerobic and resistance exercise are well documented in many areas of health and wellbeing, and exercise plays a critical role here as well. It builds stronger, more resilient bones, raises immune system function, lessens depression and anxiety with better mental performance, and can alleviate many symptoms of PMS and menopause.

As the practitioner gains knowledge through experience and reading, you will develop a variety of books you can recommend to your patients to increase their awareness, motivation and understanding of the impact that nutrition and lifestyles will have on their symptoms and overall health. Also, it is often beneficial to have a referral list of doctors, counselors, massage therapists, and other practitioners, for areas outside of your expertise. Look for the professionals that are supportive of these objectives and visit them.

When hormone supplementation is warranted, there are four major points to consider. These come from the belief that if one is going to interfere with the natural aging process at all, it should be done in such a way as to mimic the body’s system as it was created. In that endeavor, only the hormones that are the exact molecules made by the human endocrine system should be used. The human race would not have survived this long if these hormones were dangerous and subjected us to fatal diseases. And it does not look likely that man will develop a drug better suited to our bodies anytime in the near future.

Secondly, those hormones should be introduced into the bloodstream emulating the glands as closely as possible. That is, avoiding the digestive tract and liver. This leaves transmucosal and transdermal as the preferred routes of administration to give the most physiologically normal blood levels, metabolites and protein binding.

Thirdly, a broader spectrum of hormones, at lower doses, offers a more complete, physiologic balance.

Finally, the dose must be individualized to the patient’s needs and goals. When time is given to this end, many more symptoms are abated, fewer side effects are experienced, and poly-pharmacy is reduced or eliminated along with numerous other medical procedures. Forewarn the patient that it can take weeks to reach the proper dose, and as their bodies continue to change, future adjustments might also be necessary.

It is understood that at this point you are working closely with the patient’s physician. Physician involvement is a prerequisite not just in hormone replacement therapy, but in the possible (and, we hope, positive) change in the patient’s other conditions and medications.

With the knowledge gained by dedication and hard work, it is possible to make a significant impact on the lives of patients affected by hormonal imbalances. We can offer them education, understanding, alternatives and options.

 

Beyond The Fear: Hormones That Are Safe

Lisa Everett, Pharmacist, RPh, CCN

(Published in Kansas City Wellness)

News reports warning women of the dangers of hormone replacement therapy (HRT) have
created widespread fear and confusion.  The response to these news reports by patients and their physicians is alarming. Women are discontinuing their hormones and replacing them with inappropriate and harmful prescription drugs.  Here is one woman’s story:

Rebecca was worn out, puffy, and frustrated.  She had not looked or felt this way in years. A year ago, worry over the potential dangers of HRT had pushed Rebecca to discontinue her natural bio-identical hormone
replacement therapy (NHRT).  Bio-identical hormones are natural to the human being because they are identical to the hormone molecules produced by our bodies.

Rebecca made this decision in spite of the fact that she had demonstrated improved health and well-being while taking her NHRT.

After stopping NHRT, Rebecca’s peri-menopausal symptoms returned, including elevated cholesterol, high blood pressure, weight gain, mood swings, anxiety
attacks, hot flashes, and most debilitating of all, insomnia. For these symptoms, her physician prescribed a popular antidepressant for the hot flashes (not depression), a drug to lower cholesterol, another to lower blood pressure, a sleeping pill, and medication to protect her bone density. These medications made her more tired and apathetic, in addition to causing headaches and abdominal pain. With horror she realized her addiction to the sleeping pills and antidepressants. Her blood work-up also revealed elevated liver enzymes, indicating stress or damage to the liver from the barrage of pharmaceuticals.

This increasingly common scenario is reminiscent of the cocktails of stimulants, tranquilizers, antidepressants, and pain pills that were prescribed in the1960s to help women with the symptoms of PMS, menopause, and other hormonal imbalances.  Sadly, we have taken an unnecessary step back in time.

The Perils of Incomplete Reporting
Reports using the blanket terms, “estrogen” and “progesterone” have led many people, even physicians, to think all estrogens and all progesterones are the same.  The truth is:

Important Principles of Safe NHRT

Hormone replacement therapy can be safe and effective without the risks associated with synthetic hormones. Four simple practices help guide a safe approach to natural hormone replacement therapy.  These practices ensure a hormone supplementation that mimics the way our healthy bodies produce, secrete, and utilize hormones. 

Bio-identical hormones enhance lives by improving brain functioning, reducing fatigue, sparking libido, preventing cancer, and more.
Synthetics usually are not as effective and can have the opposite effect from the bio-identical hormones.  Side effects of synthetics often include high cholesterol, facial hair, acne, hair loss, migraine headaches, depression, anxiety, panic attacks, breast cancer, and cardiovascular disease.

Synthetic hormones like birth control pills, Premarin and Provera, can lead to stress-related diseases such as chronic fatigue, fibromyalgia, stomach disorders and cardiovascular disease. In other words, synthetics interfere with the  immune system, whereas bio-identical hormones support it.

The lozenge-like troche is the dosage form most like nature. When placed between the gum and cheek, the troche mimics our bodies by delivering hormones into the general circulation without first passing through the liver. This eliminates many side effects and provides the most consistent hormonal blood levels.

Hormones swallowed in the form of tablets or capsules are problematic because they pass through the walls of the gut and the liver.  Studies have shown that swallowing estrogens, for instance, raises blood pressure, increases triglycerides (an independent cardiovascular risk factor), significantly increases the chance of developing gallstones, increases the formation of clotting factors in the liver (creating dangerous blood clots), and depletes the body of nutrients.

Further, passing hormones through the liver causes weight gain and interferes with growth hormone metabolism, leading to insulin resistance and Type II diabetes.  Liver metabolism and the use of synthetics is also a major cause of hormonally-related migraine headaches. In addition, C-reactive protein increases, which causes inflammation that gives way to cardio-vascular disease, cancer, rheumatoid arthritis, and other inflammatory diseases.  Also, swallowing hormones day after day creates DNA-toxic, carcinogenic hormones in the liver that increase the risk for breast and other forms of cancer. In other words, if someone offers you any kind of hormone replacement, even natural, in a form you need to swallow, run.

Within each of us there exists a delicate balance of hormones. Estrogens, progesterone, testosterone, DHEA, and others normally exist together in our bodies to exert their synergistic, yet opposing effects. There are receptor sites on every cell of the body for every single hormone. If only one hormone is offered to the system, say estradiol, every receptor site tends to pick it up because the chemical structures of hormones are similar and because that hormone is in the highest concentration. Tissues then become too proliferative, often leading to tumor growth. Therefore, all women, even those who have had a hysterectomy, still need progesterone and other hormones to balance their estrogens in order to protect the rest of their bodies. A balanced approach also allows for smaller dosing of individual hormones, a significant contribution to the safety of NHRT.

Each woman is different in her need, production, and metabolism of hormones. Health care practitioners must understand the patient’s medical and social history, risk factors, and needs in order to individualize the dosage. Then they need to monitor symptoms and hormone levels and make adjustments accordingly.

Natural Bio-Identical Hormones Support Health Naturally
Rebecca was lucky. Fed up with the way she felt on pharmaceuticals, she resumed her NHRT and weaned off the medications. Within a few months, she once again enjoyed good health.
Natural hormone replacement can help optimize functioning and prevent disease as we age. In addition, it diminishes our need for other drugs, saving us money and protecting us from harsh side effects. If we follow these principles of NHRT, we can avoid health risks and enjoy physical and emotional well-being, the ultimate benefits of balanced and healthy hormones.  

Copyright 2003, Lisa Everett

Common Formulas

An approximate replacement dose for .3mg conjugated estrogen and 3mg to 5mg medroxyprogesterone acetate (or any other low dose estrogen/progestin): 

Estriol .5mg  
Estrone   .0625mg Total estrogen = .625mg (triestrogen .625mg)
Estradiol  .0625mg  
Progesterone 150mg – 200mg  

 

Approximate dose to replace .625mg conjugated estrogen and progestin: 

Estriol 1mg  
Estrone   .125mg Total estrogen = 1.25mg (triestrogen 1.25mg)
Estradiol  .125mg  
Progesterone 150mg – 200mg  

 

Approximate dose to replace 1.25mg conjugated estrogen and progestin: 

Estriol 2mg  
Estrone   .25mg Total estrogen = 2.5mg (triestrogen 2.5mg)
Estradiol  .25mg  
Progesterone 150mg – 200mg  

 

Of course, since we begin with the highest quality pharmaceutical-grade ingredients, and unlike any other pharmacy, your medication is made by a pharmacist, not a technician! 

Troches are also available in virtually any combination or strength.  Estrogen-only troches are available for cyclic applications, and progesterone-only for PMS, luteal-phase deficiency and other reasons.

Remember, estriol is about 80 times weaker than estradiol.  And, because of metabolism and excretion, these are dosed about every 12 hours.

We can add natural testosterone to each troche in oophorectomized women, or those whose libido has not returned while on HRT (commonly .25mg to .5mg twice daily).  Testosterone is also bone-trophic.

Natural testosterone troches are also available for men, again dosed twice daily, as a possible replacement for injections of synthetic testosterone.  This will reduce the blood level fluctuation seen with injections given at two to four week intervals.

Dehydroepiandrosterone (DHEA), is the precursor to most hormones, and also has its own specific receptors.  It is well known that DHEA blood levels decline with aging and certain disease states.  Many clinicians find it extremely beneficial to add DHEA to patients with auto-immune diseases like systemic lupus erythmatosis, inflammatory bowel disease and rheumatoid arthritis.  It is typically dosed 2.5mg to 5mg twice daily for women and 10mg to 20mg twice daily for men.  This can also be added to any troche formula.

Some clinicians have also found estriol .5mg to 2mg / progesterone 200mg troches dosed three times per day are preferable over SSRIs and other prescriptions for post-partum depression.  Since estriol is a placental estrogen, breast feeding may continue. The hormones are gradually reduced to avoid a relapse.

Literature and clinical experience strongly support the use of progesterone for preterm delivery (premature birth). Progesterone troche 200mg, two to four times daily.

Topical creams and ointments are also available. These can be used for natural hormone replacement, or for local application to the pelvic floor to help normalize tissue, arousal and climax.

Also, it is good to remember blood work is a monitoring tool, but does not always coincide neatly with resolution of symptoms. It is important to note the time blood is drawn relative to the last dose.  Ideally, about 4 hours after a dose will give good blood information; blood drawn immediately after a dose will look to high, and immediately before a dose will look too low.

References for Bio-Identical Hormone Replacement and Route of Administration

This is a representative list and is not meant to be exhaustive.  Balanced interpretation of these and other studies is available in many reference books.

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