Bioidentical Hormone Replacement Therapy (BHRT)

‘Bioidentical hormones’ is a term used for the steroid or sex hormones in the human body used to treat low hormone levels or imbalances.

As we age, we experience many physical and emotional changes within our bodies as our sex hormone production is reduced. Both the female menopause and the male andropause can cause symptoms such as a lack of energy, sweats or hot flushes, mood swings, reduced libido, vaginal complaints for women, difficulty sleeping, and issues with bone density or osteoporosis. Both men and women can benefit from a treatment known as Bioidentical Hormone Replacement Therapy (BHRT). Bioidentical hormones have the same chemical structure as those that occur naturally within our own bodies. They are derived from plant sources and synthesised in a laboratory to create molecules identical to our own hormones. Some conventional Hormone Replacement Therapies (HRT) use bioidentical hormones whereas others may contain progestins, which mimic the action of our natural hormones and can cause unpleasant side effects.

Following a consultation and various tests, your clinician can tell you what the results indicate and prescribe BHRT accordingly. If using compounded medication, this prescription will be individualised to meet your specific needs. Hormones must be prescribed, as they are regulated as medicines. Expect to pay around £300 - £600 for the initial consultation and testing and then approximately £40 - £80 per month for compounded medication.

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What are Bio-identical Hormones and how do they work?

Bio-identical hormones have the same chemical structure as those that occur naturally within our own bodies. They are derived from plant sources, such as diosgenin which comes from wild yams and betasitosterol from soya bean plants. These are then manufactured into products which can be taken orally or through creams and skin patches.

Some people also market the treatment as BODY-identical hormone replacement therapy.

As bio-identical hormones have an identical chemical structure to our own hormones, the body does not reject them, nor consider them to be foreign in any way, and the way that they are handled by the body is the same as for your naturally occurring hormones. For this reason, bio-identical hormones are often referred to as ‘natural’, due to their likeness to the natural molecular structure of our own hormones, (and not because they come from sources found in nature).

Synthetic hormones, used in conventional Hormone Replacement Therapies (HRT), which are synthesised by pharmaceutical companies, have a chemical structure that is similar, but not exactly the same, as the hormones produced by our bodies. These chemical differences can mean that synthetic hormones act differently in the body and can produce different effects, as well as some unwanted side effects. Bio-identical hormones can therefore be beneficial to those who have a hormone imbalance or who have previously tried other treatment options, including conventional HRT, and have experienced unwanted side effects; or are concerned about any associated health issues.

HRT has been around since the 1930s and their use to alleviate menopausal symptoms has been commonplace in the UK since the 1960s. The hormones used may be derived from the urine of other pregnant mammals such as Premarin® (progesterone) which is taken from mares (female horses). Oestrogens can also be synthesised from other sources, and some have been chemically altered from plant based extracts.

BHRT has only been used within the NHS to treat women for menopausal symptoms if there is a medical reason why they cannot receive the conventional HRT hormones prescribed for this condition. They have been used for approximately 20 years in Europe.

Sadly, there is a lack of large scale, long-term clinical study evidence to support BHRT, even though it is true that there is no evidence that these bio-identical hormones cause the same side effects as conventional HRT. The rise in interest in bio-identical hormones was linked to the 2002 reports on HRT risks and side effects which caused a stampede away from HRT. Research into the long-term effects of HRT has been linked with many side effects such as an increase in uterine, ovarian and breast cancers and heart disease. The latest study published in 2016 seemed to suggest that the warnings released in 2002 underestimated the detrimental effects of HRT. It is not yet clear whether these side effects are due to their structure or the medicated dosage, or in the way that they are metabolised within the human body.

Not surprisingly this meant that doctors and their patients were reluctant to use HRT to treat menopausal symptoms such as hot flushes, sleeplessness and tiredness. Up until 2002 is was not unusual for women to be given HRT when the menopause commenced, and well beyond, in a very long term course of treatment. Currently, the guidance is for the lowest dose possible for the shortest amount of time. The risks of developing any of these side effects reduces once the HRT course is completed. The other problem with conventional HRT is that the pills come in certain predetermined dosages and can only be prescribed in this way by a GP.

Bio-identical hormones are not synthesised or extracted from other animals but come direct from plant sources. They do however have to be processed to make them suitable to be delivered into the human body; to make them absorbable so they can have their effect on their target cells and be broken down metabolically. They can also be prescribed to an exact measure for each patient and made up by a pharmacist to that individual prescription. Therefore, they are becoming a more widely available option for private clinics to offer to their clients.

A BHRT programme starts with a consultation and a saliva, urine or blood test to determine if there are any hormone deficiencies. As hormone levels in the human body fluctuate, a hormone level check is only a moment in time and any deficiency should be carefully considered and monitored, along with a discussion of symptoms or problems being experienced over time.  

What are the different types of Bio-Identical Hormones?

A variety of BHRT products can be prescribed to reduce imbalances found in specific hormone levels, in both men and women. There are both branded products and those compounded by pharmacies to your bespoke prescription. The hormones being replaced within BHRT treatments include:

 Oestrogen (main female sex hormone) measured through the specific levels of the oestrogen hormones estrone, estradiol or estriol. The amount of estradiol varies during a menstrual cycle, but drops to a very low level after menopause. Not all of the oestrogens have the same effect, and the exact replacement prescription should contain an appropriate amount to treat your situation and symptoms. This will treat the symptoms of hot flushes, vaginal dryness, urinary concerns, as well as improving skin and hair health. It is also used preventatively against osteoporosis, certain age-related eye concerns, as well as strokes and heart disease.

 Progesterone (female sex hormone). This will treat mood swings and depression and can also help with difficulty sleeping. It is used preventatively against breast and uterine cancers, ovarian cysts and heart disease.

 Testosterone (main male sex hormone). Regulating this hormone in men is used to improve energy, increase libido, help mood swings and depression and protect against heart disease. It is also important for women, and improves libido and energy levels, as well as muscle and bone strength.

 DHEA (Dehydroepiandrosterone) – a precursor to the sex hormones, produced in adrenal glands, the testicles or ovaries and the brain. It is used in treatment to stimulate the immune system, decrease cholesterol and body fat (particularly visceral fat), reduce the risk of heart disease and improve mood and well-being due to its antidepressant effects.

• Pregnenolene (a precursor to other hormones). This is used in treatment to repair cells in the brain and nerve tissues, particularly for memory enhancement.

 Melatonin – this is the hormone which not only regulates other hormones but also maintains the body’s circadian rhythm or sleep pattern. This will treat difficulties with sleeping and help regulate normal sleep patterns, as well as the depth and quality of sleep achieved. In turn, this has an effect on energy and mood. It also has powerful anti-oxidant effects.

Clinics may refer to BHRT replacements by brand names or have their own compounds formulated, but you should make sure that you know which hormones they contain. It is much easier to research the effects of these hormones in the human body and to then understand exactly why they are being prescribed to you.

What should you do before undertaking Bio-Identical Hormone Replacement Therapy?

This depends on why you are considering this treatment. If it is to treat the symptoms of the menopause, then an appointment with your GP would be a sensible place to start. If you are not satisfied with the origin of the conventional HRT available, or you are concerned about possible side effects, then a private consultation for BHRT may be useful. Bear in mind that this will usually entail a consultation fee, even if you decide not to proceed, and a long-term cost if you do. BHRT is rarely available free through the NHS.

If the reasons are concerned with anti-ageing or feeling younger, then research clinics that specialise in this type of BHRT treatment and ask about their experience and results.

Many bio-identical hormone products are available online. Most experts state that these are not high dose enough to achieve desirable results, and obviously, self-medication is never recommended. Attending a clinic for a consultation would always be preferable to self-selection from the Internet.

Which problems can Bio-Identical Hormones treat?

Oestrogen and progesterone are used to treat menopausal symptoms such as hot flushes, mood swings, vaginal dryness, tiredness, disturbed sleep, reduced libido and loss of bone density.

Testosterone can be used to treat andropause (male menopause).

DHEA can be used to stimulate the immune system to treat tiredness or fatigue, depression and memory loss.

Melatonin can be used to improve sleeping patterns.

It is claimed that BHRT can improve general health, well-being and vitality.

What happens during a Bio-Identical Hormone Replacement Therapy programme and treatment?

Careful discussions regarding your reasons for wanting Bio-Identical Hormone Replacement Therapy are very important. You must also make sure that this treatment can deliver what you want. The duration of the treatment is also important. Any potential risks from hormone supplementation increase with the length of treatment. Taking the current medical advice for conventional HRT - the lowest dose for the shortest period of time – may be advisable to apply to BHRT too. There is currently limited data to confirm that long-term use of bio-identical hormones is any different, so caution may be pertinent. Your practitioner should be able to answer all these questions.

A medical history should be taken to make sure that there are no reasons why you shouldn’t undertake treatment. You will be asked to sign a consent form which means that you have understood the potential benefits and risks associated with the treatment programme and any associated tests.

Photographs (if there is an anti-ageing solution or alleviation of visible medical symptoms being sought), and possibly questionnaires to establish mood or symptom rating scores may also be taken by the practitioner for comparison later.

The initial consultation will lead to a blood, urine or saliva test and some cells may be taken from the inside of your cheek, with a swab, to check telomere length, which can be analysed to assess internal-ageing. Your DNA strands are protected by a cap called a telomere. There is a lot of research which indicates that these telomeres shorten as you get older and your DNA may then start to deteriorate. Telomere length can be used to measure your internal age. These tests may be offered as part of a general health check rather than for any specified symptoms.

The next consultation will take you through all the indicators that have been examined and measured by the tests. These may include hormone levels such as oestrogen, progesterone, testosterone as a comparison to your chronological age; thyroid and adrenal hormones; cholesterol levels; vascular health; telomere length etc. It would seem to be common sense that before embarking on any hormone replacement therapy you should begin by establishing if there is any deficiency that matches up with the symptoms that you are describing. The tests performed and the indicators measured may vary from one clinic to another so it’s important to get a thorough evaluation.

The clinician can tell you what these test results indicate and prescribe BHRT accordingly. This prescription will be individualised for your body. Hormones must be prescribed, as they are regulated as medicines, but other dietary supplements which may be recommended alongside might be available over-the-counter from a pharmacist. It is worth asking about this as it could make a huge difference to the price that you pay for the overall treatment programme.

BHRT may be taken orally, as a tablet or lozenge, or topically as a cream or patch which may be delivered through the skin or through the genital region.

How long will BHRT treatment take?

This is an ongoing treatment programme and how long it will last for should be decided between you and your clinician. You will need to attend follow up consultations to re-test for the indicators and to assess the next prescriptions and supplements. The clinic usually books you in for your next appointment about 6 weeks into treatment and once your hormone levels are steady you may only have to revisit every 6 months to obtain a new prescription.

There should be no down time, but you should be made aware of any side effects that might occur and what to do if they happen, as well as details about informing your practitioner. Some side effects may require you to contact your clinic or even to stop taking your medication. Your clinician should advise you on these circumstances, and if you are in doubt then contacting the clinic would always be the best course of action.

What are the risks and potential complications from taking Bio-Identical Hormones?

This is a very complicated area and you should feel fully informed before you undertake this treatment. Your individual situation and your personalised prescription and medical history should be taken into consideration. The most common complications seem to be a change in mood, similar to experiencing pre-menstrual tension or PMT, or skin problems such as acne. Long term effects have not yet been established by any large sample medical study.

DHEA (dehydroepinandrosterone) is one bio-identical hormone available to both men and women. It is a pre-cursor hormone produced naturally by the adrenal glands and can lead to the production of testosterone and oestrogen (both hormones are naturally occurring in both sexes). The side effects may occur because of an imbalance between the male and female hormones and may cause the opposing secondary sexual features such as an increase in facial hair, lowering of the voice or thinning of the hair on the head in females. Adrenal imbalance is referring to low levels of this hormone which peaks at around the age of 20 years and then declines.

Incidentally, most of these hormones would show up in a drug test and are therefore not suitable for those competing in sport at a serious level.

What should you do after BHRT?

It is advisable to make notes in a diary or through an electronic system, and to keep a good routine for taking the therapy. BHRT treatment must be taken regularly, and it is worth taking a few minutes to note down how you are feeling every day at the same time, reflecting on the previous day, so you can build up a pattern of the progression of your treatment and how it is affecting you, both positively and negatively. The effect of these hormones can be complex, and in some cases unpredictable, but certainly variable from person to person. Contact your clinic if anything concerns you and use your diary notes as reference for your discussions. You may need to return for a consultation or further tests.

Who should not have Bio-Identical Hormone Replacement Therapy?

A full medical history should be taken before commencement, but typically BHRT is not considered to be necessary for people under 30 years of age; those taking conventional HRT or contraceptive pills; those who are pregnant or breast feeding or wanting to become pregnant; those taking other medications such as blood thinners, anti-convulsion medication; those with diabetes, liver or heart problems; deep vein thrombosis or hormone dependent cancers. You must share any concerns about your medical situation with the clinician at your initial consultation.

Who can administer Bio-Identical Hormones?

Only doctors or prescribing nurses can prescribe a course of BHRT as they are a regulated prescription only medicine. However, other medically and non-medically trained practitioners at a clinic may be able to take the blood, saliva or cheek cell tests and take a medical history from you.

Is Bio-Identical Hormone Replacement Therapy available on the NHS?

It is usual practice for the NHS to only provide conventional HRT to women experiencing the symptoms of the menopause. It is worth discussing this with your GP before embarking on BHRT through a private clinic to find out if you would be suitable for conventional HRT or if you are happy with what it offers.

BHRT is sometimes available on the NHS, as these plants-derived hormones can be used when there are contra-indications for conventional HRT. Again, you will need to discuss this with your GP.

However, even if that is the case, the general practitioner (GP) or a specialised consultant will prescribe a milligram (mg) dose of the bio-identical hormones, rather than a measured or individualised dose prescribed following tests through a private prescription.

It is highly unlikely that anyone considering BHRT for any other reason would be able to access this free of charge on the National Health Service.

We would however always recommend that you visit your General Practitioner before embarking on private treatment for menopausal or andropausal symptoms. As well as their advice and guidance they may also be able to refer you to a local specialist private clinic who can treat you.