Is Bioidentical Always Best?
Most menopausal women who take hormone therapy, assume that bioidentical estrogen is the most natural, and therefore the safest. That is not always true.
Words should have precise meanings. That is especially the case in medicine where communication is about 90% of doing a good job.
I still remember the first time a patient told me she wanted a “natural birth”. I wanted to give her what she wanted, but I didn’t know what she meant by natural. Was she hoping that she wouldn’t need an epidural? Did she not want any drugs? Maybe she was letting me know she hoped to deliver vaginally? To me, a natural birth is – as it occurs in nature. Meaning the obstetrician stays home and reads the newspaper and the laboring woman lets the baby pop out in a grassy field someplace, bites off the umbilical cord, and gets back to work. OK, I knew that wasn’t what she wanted, but I honestly did not know what she meant.
When I was pregnant, I was very careful to tell my obstetrician precisely what I wanted- an epidural with my first contraction, or ideally, before my first contraction, and then she should feel free to do whatever she needed to do to get my baby safely delivered including forceps, a c-section, a plunger, a winch… no questions asked. There was no ambiguity about my priority.
My frustration with imprecise or misleading words carries over to the menopause world as well. At the top of the list is the constant misuse of the term Hormone Replacement Therapy “HRT”. But I have already ranted about that.
Today’s rant is on the word- “bioidentical”
Ask someone what comes to mind when they hear the term “bioidentical hormone therapy” and you will get answers like
Bioidentical hormones are safer than the synthetic hormones you get from a regular pharmacy”
“Those are hormones that come from plants, so they are better for you”
“They’re the best- but most doctors can’t prescribe bioidenticals, you need to go to a hormone doctor for that”
“Bioidentical hormones don’t cause cancer since they are the same as the hormones in your body”
Ask someone what comes to mind when they hear the term “synthetic hormone therapy” and you will get answers like
“Synthetic hormones are the ones that are bad for you, but that’s the only kind most doctors can prescribe”
“Those are the ones that cause breast cancer and are really dangerous”
“You mean horse urine hormones? Lots of side effects. Also, they torture the horses.”
“Hormones made in factories. I would never take a synthetic hormone”
NEWS FLASH!
All estrogen, including bio-identical estrogen, is SYNTHESIZED
Stick with me. I am going to explain that in a bit. But first, I’m going to focus on the term “Bioidentical.”
Bioidentical was originally not a medical term
The term “bioidentical” is an accepted part of the medical lexicon, but that was not always the case. It was originally not a medical or scientific term. Prior to the year 2000, the word bioidentical didn’t appear in textbooks or journals. I never heard it when I was in medical school. It didn’t exist.
“Bioidentical” was a term made up by savvy market research gurus in the late 90s to describe hormones distributed by compounding pharmacies. The use of the word “bioidentical” was brilliant. It was catchy, it sounded natural, and it also sounded different than the hormones produced and distributed by commercial pharmacies.
Bioidentical sounded infinitely more appealing to put in your body compared to estrogen derived from horse pee. And it worked. A multibillion-dollar compounded bioidentical hormone industry was launched by an actress and continues to thrive today. And, many, if not most women and clinicians, believe that bioidentical is always best when it comes to menopausal hormone therapy.
But that is not necessarily true. The following information is not my opinion, these are facts that any scientist will confirm. And today, for the sake of brevity, I am just going to focus on bioidentical estrogen. Other types of bioidentical post-menopause hormones are prescribed equally often.
*This would also be a good time to mention that I have no financial ties or sponsorship with any pharmaceutical company that makes postmenopausal hormone therapy.
I wish I did. I would be able to take a lot more vacations.
There are three general categories of menopausal systemic estrogen
Synthetic Estrogens
Synthetic estrogens are entirely produced in the laboratory. If you have ever used birth control pills, you have taken synthetic estrogens. Synthetic estrogen is found in many forms of menopausal hormone therapy.
Examples are Femhrt™ and Jinteli. ™
Conjugated Estrogens
Conjugated estrogens are mixtures of different types of estrogens. Some are plant-derived. Some are derived from pregnant horse urine. Some are entirely synthesized in the laboratory.
Examples include Premarin™, Cenestin™, and Enjuvia™ .
Bioidentical Estrogens
Bioidentical estrogen is structurally identical to the estradiol made in ovaries. Bioidentical estradiol is found in both commercial and compounded products. The bioidentical estrogen you get in a compounded estrogen is identical to bioidentical estrogen in an FDA-approved commercial product.
Bioidentical estradiol is extracted from plants in a chemical factory. The powdered form of estradiol is then sold to compounders and commercial pharmacies. It’s the same stuff.
There are several issues with compounded hormones- many of which I covered in my podcast on pellets. Not going to go there today. And to keep it simple, in this post, when I refer to a bioidentical estrogen, I refer to commercially produced FDA-approved bioidentical estradiol.
Examples include Bijuva™, Femring™, and all commercially produced transdermal patches and gels. Examples are Climara™, Minivelle™, Evamist™, Divigel™ and Estrogel. ™
Pretty much every post-menopausal woman who takes hormone therapy, or is thinking about taking hormone therapy assumes that bioidentical estrogen is the most natural, and therefore the safest and the most effective form of estrogen. That is not necessarily true.
The Four Big Myths About Bioidentical Estrogen
Myth #1-Bioidentical estrogen is completely natural
Myth #2-Bioidentical estrogen is safer than other forms of estrogen
Myth #3-Bioidentical estrogen is more effective than other forms of estrogen
Myth #4 Bioidentical estrogen is less likely to cause breast cancer than other forms of estrogen.
Myth #1-Bioidentical estrogen is completely natural
The word “natural” means “as found in nature.” Every single plant-derived estrogen product requires a multistep chemical process to extract and convert estrogen precursors from a plant source into estradiol powder which can be used to make an estradiol cream, spray, patch, or pill.
Every plant-derived hormone preparation, whether it comes from a compounding pharmacy or a large commercial pharmacy, is synthesized in a laboratory to a usable form.
Bioidentical estrogens don’t always come from plants. They can also be synthesized entirely in the laboratory or extracted from animals.
The chemical structure of the molecule, which is chemically identical to the estradiol humans naturally make, not the originating source, determines whether a hormone is bioidentical.
The only thing that is truly natural is to eat the plant or drink the horse urine.
As far as plant-derived estrogen being more human-like than conjugated equine estrogens, as a reminder- humans are closer to horses than plants, and at least 10 of the estrogens conjugated from horse urine are identical to human hormones.
So, all bioidentical estrogen is synthesized. But, even if bioidentical estrogen was completely natural, that in no way assures that it is safer or better for you. Millions of products use the term “natural” because it implies safety. Natural soap, natural food, natural supplements, and natural hair dye. You name it, someone has come up with a “natural” version.
But “natural” does not equal “safer.” We can all name many things that are natural but also unsafe. Arsenic, anthrax, and strychnine come to mind.
Natural does not mean more effective. Don’t get me started on the billion-dollar industry of worthless “natural” supplements that promise to eliminate your hot flashes.
While I am on the topic of horses, the myth that horses are tortured and made to stand for days at a time for urine collection is not true. This is a highly regulated industry. As my friend Dr. Risa Kagan says, “Those horses are treated far better than most people treat their children.” Here is a link to documentation of the treatment of horses.
Myth #2-Bioidentical estrogen is safer than other forms of estrogen
The thing that increases the safety of estrogen more than anything else is how it gets into your body. Oral estrogen is metabolized by the liver. Transdermal estrogen is applied to the skin using a patch, cream, or gel and absorbed directly into the bloodstream.
Oral estrogen increases the risk of developing a blood clot. By avoiding the trip through the liver, transdermal estrogens do not increase the risk of gallstones, blood clots, stroke, pulmonary embolism, or deep vein thrombosis. A transdermal estrogen decreases triglycerides. An oral estrogen increases triglycerides.
Transdermal estrogens are generally safer than oral estrogens. It so happens, that all transdermal estrogens are bioidentical.
The fact that they are TRANSDERMAL, not bioidentical, is what makes them safer.
There are almost 50 different hormone therapy protocols in terms of the type of estrogen, the type of progestogen, the dosage and if it is transdermal, oral or vaginal.
When you compare risks and benefits, sometimes a plant-derived bioidentical comes out on top, and sometimes conjugated estrogens or synthesized estrogen comes out on top.
As an example, the risk of stroke with oral estrogen is the same whether it is a plant-derived bio-identical or a conjugated equine estrogen. In some studies, conjugated equine estrogen, Premarin™, does a better job than bioidentical estradiol when it comes to increasing insulin sensitivity.
Myth #3-Bioidentical estrogen is more effective than other forms of estrogen
Synthetic estrogens, plant-derived estrogens, animal-derived estrogens, and bioidentical estrogens all bind to estrogen receptors and mimic the action of estrogen. All forms of estrogen will make your hot flashes go away, will improve vaginal symptoms, and will benefit bone health.
The dose, not the type of estrogen, is what has the biggest impact on symptom relief, If you are using an oral estrogen and still having flashes, the general approach would be to increase the dose, not change to a different product. So, no, bioidentical estrogen is not more effective. In some cases, women don’t absorb a transdermal product so it is less effective. Not because it is bioidentical, but because it is transdermal.
When it comes to symptom relief, it doesn’t matter if estrogen is synthesized from plants, horse urine, or in the laboratory.
The dose and route of delivery matter.
Myth #4 Bio-identical estrogen is less likely to cause breast cancer than other forms of estrogen.
This is the one that is the biggest surprise to most people. Both bioidentical estrogen and conjugated equine estrogens will decrease the risk of developing breast cancer.
In the WHI, conjugated equine estrogens (Premarin™) when used without a progestogen decreased the risk of breast cancer by 23% and reduced breast cancer deaths by 40%.
Bioidentical estradiol also appears to decrease the risk of breast cancer, but all of the data is observational, and therefore not as convincing. But the point is, estrogen, regardless of the source, decreases the risk of breast cancer, and it may even be that estrogen derived from horse urine is the most protective.
A few months ago, on my podcast, I interviewed Dr. Jim Simon, the author of a landmark paper, A Contemporary View of Hormone Therapy which compares the safety of different types of estrogen. There is no paywall so anyone can access it.
I think you get the point. It’s important not to fall into the “natural is always better” trap.
Words like “natural” and “bioidentical”, do not inform me as to effectiveness or safety. That’s marketing, not science.
I have two criteria that dictate what hormone therapy I recommend to someone. Given a woman’s medical history and goals, what is HER safest option, and what would be HER most effective option?
So, to bring this full circle. Is natural childbirth, meaning no intervention, always the safest way to go? No, sometimes an appropriate intervention is life-saving for both the baby and the laboring woman.
And if you are curious, I got my epidural with my first contraction and beyond that, had a very natural birth. Whatever that means.
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This is excellent and well written. Most people are not aware of the fact that estrogen decreases the risk of breast cancer. Even combination HRT, estrogen plus progesterone, has a role for women despite a small increase risk after five years of use. And natural is not better. Thanks for taking the time to write this informative article.
This is a must read! Very articulate, accurate and interspersed with humor and sarcasm- LOVED IT! This article needs to be downloaded, printed and available at all OB/GYN offices waiting rooms for people to read. (And for the OB/GYN to read…)