As an advanced compounding pharmacist and PCCA (Professional Compounding centres of America) member I have been well equipped and privileged (over the last seven years) to develop a clientele of more than a five hundred women who use BHRT (Bioidentical Hormone Replacement therapy). In addition, the vast majority (over 75% in my opinion and experience) derive substantial benefit and an increased quality of life as a result. The following paragraphs will attempt to detail the differences between topical and oral BHRT dosing and why one route of administration is generally preferred over the other for a variety of reasons.
Topical Dosing is the preferred method of delivery for at least four very good reasons:
1) Since first pass metabolism (which includes: saliva, stomach acid, intestinal enzymes and finally liver destruction of hormone molecules occurs with orally given meds) is missed when we topically dose this translates in our ability to give fewer molecules or mg of hormones to achieve similar results as oral dosing. In other words, we get the job done with fewer molecules floating around in our body when we dose topically through the skin (this is just intelligent and no doubt safer). There have been recent studies that suggest the chance of blood clots are greatly reduced with topical dosing compared to oral dosing.
2) Secondly, since a cream is being used we can now place it in a tube along with a very accurate needleless syringe and titrate the dose from low to high based on symptom response or resolution. This is especially useful for the biestrogen creams as the net estrogen signal is what caused a lady to grow the lining of her uterus each month and is thus proliferative or a cellular go/grow signal in nature. We do not want to over do any dosing of a molecule that is a cellular go/grow signal. I compare this to the analogy of hemming a pair of pants or buying a pair of shoes specific to that individual and not just willy nilly picking a mg dosage and hoping it works for everyone. For example, the body may downregulate (remove) receptors if too high a dose is perceived by that persons genetic type (as we all vary by genetics). If down regulation occurs then at that point the "waters have been muddied" and we can double or triple the dose and we get many of the same symptoms as we would if we were to have too little hormones. Hence, the importance of creams for: using less molecules and for the ability to titrate from low to high dosage based on an individuals genetically determined response. This way we treat the person and not just place them arbitrarily into a lab range somewhere.
3) Thirdly, topical dosing does seem to dove tail nicely with saliva testing. I would like it made clear that I do not take sides between saliva and blood testing as I simply can tell more from both then either type of test alone. One needs to know the pharmacokinetics of each dosage route and then the corresponding scales between the two testing methods become much clearer to understand.
4) With oral dosing a higher dosage as mentioned above is needed to get the molecules past first pass metabolism unchanged. In addition, there is concern that since this higher mg dosage has to go through the liver that it may be "harder" on the liver period. At the very least, as mentioned above there does seem to be a higher blood clot risk orally versus topically according to studies (and this applies to drug company hormones as well). One advantage of oral dosing that I can think of is that if you have a very nervous or "high strung" menopausal lady then by the giving of oral progesterone the "spray" of metabolites once past the liver and into the general circulation do seem to have a calming affect.... much more so than topical dosing would.
Therefore, and in conclusion, topical BHRT dosing is without question the smarter way to start with. That being said, if we try all the angles with topical dosing and a lady is still struggling with her genetically specific set of symptoms I will as a last resort offer her oral, sustained release,compounded, BHRT capsules. Should a lady have eye sight problems (eg cataracts) or hand problems (eg arthritis) that would make measuring her cream impractical for her and then of course we would offer the easier and quicker (but not smarter) oral capsules to take.
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