Bio-identical hormones should be prescribed in a way to bypass the liver or we will eventually see the same stroke issues the WHI study revealed with oral synthetic hormones. We are not meant to eat hormones! So HRT is best delivered through the skin (transdermal) or under the tongue (sublingual).
I rarely prescribe the exact same hormone regimen to any two of my patients. Each woman is different and each prescription reflects her individual needs. That being said, there are some rules of thumb I follow to insure the best outcome.
First all, patients must take a break from their hormones. Why? Because the receptor sites that allow the hormone into the cells will eventually become resistant to the hormone. You can get away with up to ten months of continuous hormones before your hypothalamus wonders why this “pregnancy” is never ending. Then you become resistant to the hormones and need higher and higher dosages to get the same effect.
Women are asked to break for 3-5 days per month to mimic a natural menstrual break. It takes 72 hours to clear hormone receptor sites. Initially taking this 3 day break from HRT will induce break through bleeding—just like the birth control pill—but eventually once a woman is truly menopausal the bleeding will cease completely. Unless she wishes to menstruate for the rest of her life, which is entirely possible with high dose hormonal regimens.
For Premenstrual Women:
Progesterone is the hormone of choice. Low dose at the beginning of symptoms through the menses usually helps with moodiness, menstrual cramps, and irregularity. Sublingual estrogen can be used to prevent menstrual migraines.
For Perimenopausal Women:
Estrogen is prescribed a little higher in the first half of the month, lower in the second half when progesterone is added. Usually these two hormones are enough to improve libido, but if not, low dose testosterone is added with two small peaks a month to mimic the natural cycle. All three hormones are stopped for 3-5 days each month.
For Menopausal Women:
If your periods have stopped completely and your FSH is over 30 for at least 6 months, then estrogen and progesterone are prescribed together, the same amount all month long except the three days off. Testosterone is added if needed after a couple of cycles. Since DHEA can be converted into testosterone and many menopausal women have adrenal deficiency, DHEA may also be prescribed. While transdermals are the preferred route for most hormones, DHEA is best delivered under the tongue since the skin will hog up the hormone leaving little for systemic use. Estrogen vaginal cream is added to relieve vaginal dryness and stress incontinence until the systemic estrogen can take over (usually 6 weeks)
I do not agree with high dose hormone replacement. The levels of hormones produced by young women are safe for them because they have the means to safely metabolize the hormones. Most older women do not have the means to metabolize the hormones safely. Although they can take lots of IC3 indoles (the active ingredient in cruciferous vegetables) and lots of EPA (fish oils), keep their weight down and drink alcohol in moderation, there is no guarantee at preventing estrogen dependent cancers.
For I believe reversing age related metabolic enzyme activity takes a multi-pronged approach. A holistic approach to hormone replacement therapy includes complete neuro-immune-endocrine and metabolic evaluation. Functional medicine testing is available to assess genetic and metabolic capabilities of an individual. There is no one size fit all prescription for hormone replacement or anti-aging therapies.