Caution on the use of saliva measurements to monitor absorption of progesterone from transdermal creams in postmenopausal women

Pharmacokinetics and pharmacodynamics of five distinct commercially available hemp-derived topical cannabidiol products

Products containing cannabidiol (CBD) have proliferated after the 2018 Farm Bill legalized hemp (cannabis with ≤0.3% delta-9-tetrahydrocannabinol (Δ9-THC)). CBD-containing topical products have surged in popularity, but controlled clinical studies on them are limited. This study characterized the effects of five commercially available hemp-derived high CBD/low Δ9-THC topical products. Healthy adults (N = 46) received one of six study drugs: a CBD-containing cream (N = 8), lotion (N = 8), patch (N = 7), balm (N = 8), gel (N = 6) or placebo (N = 9; matched to an active formulation). The protocol included three phases conducted over 17 days: (i) an acute drug application laboratory session, (ii) a 9-day outpatient phase with twice daily product application (visits occurred on Days 2, 3, 7 and 10) (iii) a 1-week washout phase. In each phase, whole blood, oral fluid and urine specimens were collected and analyzed via liquid chromatography with tandem mass spectrometry (LC-MS-MS) for CBD, Δ9-THC and primary metabolites of each and pharmacodynamic outcomes (subjective, cognitive/psychomotor and physiological effects) were assessed. Transdermal absorption of CBD was observed for three active products. On average, CBD/metabolite concentrations peaked after 7-10 days of product use and were highest for the lotion, which contained the most CBD and a permeation enhancer (vitamin E). Δ9-THC/metabolites were below the limit of detection in blood for all products, and no urine samples tested "positive" for cannabis using current US federal workplace drug testing criteria (immunoassay cut-off of 50 ng/mL and confirmatory LC-MS-MS cut-off of 15 ng/mL). Unexpectedly, nine participants (seven lotions, one patch and one gel) exhibited Δ9-THC oral fluid concentrations ≥2 ng/mL (current US federal workplace threshold for a "positive" test). Products did not produce discernable pharmacodynamic effects and were well-tolerated. This study provides important initial data on the acute/chronic effects of hemp-derived topical CBD products, but more research is needed given the diversity of products in this market.

Concerns About Compounded Bioidentical Menopausal Hormone Therapy

ABSTRACT

Following the release of the Women's Health Initiative data, women began to use compounded bioidentical hormone therapy (cBHT) in the misguided belief of greater safety and efficacy than traditional hormone therapy. New guidelines recommend government-approved hormone therapy for symptomatic healthy menopausal women younger than 60 years or within 10 years of menopause at the time of initiation. For women requesting bioidentical hormones, those similar to the hormones present before menopause, there are many government-approved hormone therapies with extensive pharmacokinetic, safety, and efficacy data provided with package inserts delineating efficacy, safety, and potential risks. For women requesting non-Food and Drug Administration-approved (cBHT), these cBHTs lack data on pharmacokinetics, safety, and efficacy and are not provided a label detailing risk. Their use should be restricted to women with allergies or dosing or formulations not available in government-approved therapies. Pellet therapy providing women with supraphysiologic hormone dosing raises even more safety concerns.

Safety and efficacy of compounded bioidentical hormone therapy (cBHT) in perimenopausal and postmenopausal women: a systematic review and meta-analysis of randomized controlled trials

IMPORTANCE

More information is needed about the efficacy and safety of compounded bioidentical hormone therapy (cBHT) in the published literature. A thorough synthesis of existing data is not currently available.

OBJECTIVE

To provide a systematic review and meta-analysis of the existing evidence related to the safety and efficacy of commonly prescribed cBHT preparations in perimenopausal and postmenopausal women.

EVIDENCE REVIEW

PubMed, ClinicalTrials.gov, and The Cochrane Central Register of Controlled Trials were searched. Randomized controlled trials (RCTs) comparing cBHT with a placebo or FDA-approved products in perimenopausal or postmenopausal women were eligible. The risk of bias was assessed by the Cochrane risk of bias tool. The primary safety outcome was changes in lipid profile and glucose metabolism, and the primary efficacy outcome was the change of vaginal atrophy symptoms. The secondary outcomes included the change of endometrial thickness, risk of adverse events, vasomotor symptoms, change of serum hormone levels, and change of bone mineral density.

FINDINGS

A total of 29 RCTs reported in 40 articles containing 1,808 perimenopausal and postmenopausal women were included. Two risk factors of cardiovascular disease, lipid profile, and glucose metabolism, were evaluated with cBHT. The results showed that compounded androgen was not associated with change of lipid profile or glucose metabolism. There was no change in endometrial thickness or serious adverse events. There were more androgenic side effects with compounded dehydroepiandrosterone compared with placebo as expected. Other safety measures including clinical cardiovascular events, endometrial biopsy, and risk of breast cancer were not studied. cBHT in the form of compounded vaginal androgen was found to significantly improve vaginal atrophy symptoms (SMD -0.66 [95% CI, -1.28 to -0.04]; I2 = 86.70%). This finding was supported by the association between compounded vaginal androgen and improved female sexual function scores. The changes of serum hormone levels were also evaluated. Despite the variations in absorption from different types of compounded hormones, routes, and strengths, the trends were consistent with published data from FDA-approved products.

CONCLUSIONS AND RELEVANCE

This review found that cBHT used in primarily short-term RCTs is not associated with adverse changes in lipid profile or glucose metabolism. cBHT in the form of vaginal androgens appears beneficial for vaginal atrophy symptoms. There are insufficient RCTs of cBHT to assess clinical risk of breast cancer, endometrial cancer, or cardiovascular disease. Long-term studies with clinical endpoints are needed.

Cortical morphometry and structural connectivity relate to executive function and estradiol level in healthy adolescents

INTRODUCTION

Emotional and behavioral control is necessary self-regulatory processes to maintain stable goal-driven behavior. Studies indicate that variance in these executive function (EF) processes is related to morphological features of the brain and white matter (WM) differences. Furthermore, sex hormone level may modulate circuits in the brain important for cognitive function.

METHODS

We aimed to investigate the structural neural correlates of EF behavior in gray matter (GM) and WM while taking into account estradiol level, in an adolescent population. The present study obtained neuroimaging behavioral and physiological data from the National Institute of Health's Pediatric Database (NIHPD). We analyzed the relationship between cortical morphometry and structural connectivity (N = 55), using a parent-administered behavioral monitoring instrument (Behavior Rating Inventory of Executive Function-BRIEF), estradiol level, as well as their interaction.

RESULTS

Executive function behavior and estradiol level related to bidirectional associations with cortical morphometry in the right posterior dorsolateral prefrontal cortex (pDLPFC) and primary motor cortex (PMC), as well as fractional anisotropy (FA) in the forceps major and minor. Lastly, the interaction of EF behavior and estradiol level related to decreased volume in the right PMC and was linked to altered FA in the right inferior fronto-occipital fasciculus (iFOF).

CONCLUSIONS

The study provides evidence that the relationship between EF behavior and estradiol level related to bidirectional GM and WM differences, implying estradiol level has an influence on the putative structural regions underlying EF behavior. The findings represent a crucial link between EF behavior and hormonal influence on brain structure in adolescence.

Hormone Therapy and Breast Cancer: Emerging Steroid Receptor Mechanisms

Although hormone therapy is widely used by millions of women to relieve symptoms of menopause, it has been associated with several side-effects such as coronary heart disease, stroke and increased invasive breast cancer risk. These side-effects have caused many women to seek alternatives to conventional hormone therapy, including the controversial custom-compounded bioidentical hormone therapy suggested to not increase breast cancer risk. Historically estrogens and the estrogen receptor were considered the principal factors promoting breast cancer development and progression, however, a role for other members of the steroid receptor family in breast cancer pathogenesis is now evident, with emerging studies revealing an interplay between some steroid receptors. In this review, we discuss examples of hormone therapy used for the relief of menopausal symptoms, highlighting the distinction between conventional hormone therapy and custom-compounded bioidentical hormone therapy. Moreover, we highlight the fact that not all hormones have been evaluated for an association with increased breast cancer risk. We also summarize the current knowledge regarding the role of steroid receptors in mediating the carcinogenic effects of hormones used in menopausal hormone therapy, with special emphasis on the influence of the interplay or crosstalk between steroid receptors. Unraveling the intertwined nature of steroid hormone receptor signaling pathways in breast cancer biology is of utmost importance, considering that breast cancer is the most prevalent cancer among women worldwide. Moreover, understanding these mechanisms may reveal novel prevention or treatment options, and lead to the development of new hormone therapies that does not cause increased breast cancer risk.

Treatment of postmenopausal women with topical progesterone creams and gels: are they effective?

Topical progesterone creams and gels can be obtained over the counter and/or by prescription from custom-compounding pharmacies and are used by thousands of postmenopausal women for hormonal treatment. However, the effectiveness of these preparations for protecting the endometrium from unopposed estrogen is controversial, due largely to the very low serum progesterone levels that are achieved. Despite these low serum levels, salivary and capillary blood levels are very high and a protective endometrium has been reported in a limited number of studies. Topical alcohol-based, but not water-based, gels appear to yield luteal-phase serum progesterone levels but studies with these preparations are scant. Long-term studies with percutaneous progesterone creams and gels are likely to provide valuable information for treatment of postmenopausal women with this popular route of administration.

Percutaneous progesterone delivery via cream or gel application in postmenopausal women: a randomized cross-over study of progesterone levels in serum, whole blood, saliva, and capillary blood

OBJECTIVE

This study aims to investigate the distribution of progesterone in venous whole blood, venous serum, fingertip capillary blood, and saliva after its topical application in both cream and gel formulations.

METHODS

Ten postmenopausal women were randomized to receive 80 mg of progesterone cream or gel applied daily for 14 days, crossing over after a 14-day washout. On the last day of each treatment period, venous blood, fingertip capillary blood, and saliva were sampled frequently for 24 hours after the final application.

RESULTS

After progesterone cream or gel application, serum progesterone levels rose gradually, reaching a peak at 9 and 8 hours, respectively; AUC(0-24) h was significantly higher with cream (12.39 vs 8.32 ng h mL(-1), P = 0.0391). Whole venous blood levels followed a pattern similar to that of serum but were considerably lower. Saliva progesterone showed a peak at 1 and 6 hours after cream and gel application, respectively, and C(max) was comparable with cream and gel. Saliva AUC(0-24) h was substantially higher than the corresponding area under the curve for serum or whole blood but did not differ significantly by delivery method (39.02 and 58.37 ng h mL(-1), P = 0.69). In capillary blood, C(max) was reached at the same time (8 h) and was similar with both formulations; AUC(0-24) h was also similar with both formulations (1,056 ng h mL(-1) for cream and 999 ng h mL(-1) for gel) but was dramatically higher than the corresponding areas under the curve for venous serum and whole blood.

CONCLUSIONS

After application of topical progesterone, saliva and capillary blood levels are approximately 10-fold and 100-fold greater, respectively, than those seen in serum or whole blood. High capillary blood and saliva levels indicate high absorption and transport of progesterone to tissues. Reliance on serum levels of progesterone for monitoring topical dose could lead to underestimation of tissue levels and consequent overdose.

Prescribing menopausal hormone therapy: an evidence-based approach

The constantly changing landscape regarding menopausal hormone therapy (MHT) has been challenging for providers caring for menopausal women. After a decade of fear and uncertainty regarding MHT, reanalysis of the Women’s Health Initiative data and the results of recent studies have provided some clarity regarding the balance of risks and benefits of systemic MHT. Age and years since menopause are now known to be important variables affecting the benefit-risk profile. For symptomatic menopausal women who are under 60 years of age or within 10 years of menopause, the benefits of MHT generally outweigh the risks. Systemic MHT initiated early in menopause appears to slow the progression of atherosclerotic disease, thereby reducing the risk of cardiovascular disease and mortality. During this window of opportunity, MHT might also provide protection against cognitive decline. In older women and women more than 10 years past menopause, the risk-benefit balance of MHT is less favorable, particularly with regard to cardiovascular risk and cognitive impairment. For women entering menopause prematurely (<40 years), MHT ameliorates the risk of cardiovascular disease, osteoporosis, and cognitive decline. Nonoral administration of estrogen offers advantages due to the lack of first-pass hepatic metabolism, which in turn avoids the increased hepatic synthesis of clotting proteins, C-reactive protein, triglycerides, and sex hormone-binding globulin. The duration of combined MHT use is ideally limited to less than 5 years because of the known increase in breast cancer risk after 3–5 years of use. Limitations to use of estrogen only MHT are less clear, since breast cancer risk does not appear to increase with use of estrogen alone. For women under the age of 60 years, or within 10 years of onset of natural menopause, MHT for the treatment of bothersome menopausal symptoms poses low risk and is an acceptable option, particularly when nonhormonal management approaches fail.

Use of compounded bioidentical hormone therapy in menopausal women: an opinion statement of the Women's Health Practice and Research Network of the American College of Clinical Pharmacy

Menopausal symptoms affect a significant portion of women. Traditional treatment with manufactured hormone therapy can alleviate these symptoms, but many women and their health care providers are concerned about the risks, such as venous thromboembolism and certain types of cancer, demonstrated with manufactured hormone therapy. Compounded bioidentical hormone therapy has been proposed and is often used as a solution for these concerns. Despite this use, no data are currently available to support the claims that compounded bioidentical hormone therapy is a safer or more efficacious option compared with manufactured hormone therapy. A common misperception is that all manufactured products consist of synthetic hormones and all compounded medications consist of natural hormones; however, in fact, significant overlap exists. Several key stakeholder organizations have issued statements expressing concern about the lack of evidence regarding the efficacy and safety of compounded bioidentical hormone therapy, in addition to concerns regarding prescribing patterns. The Women's Health Practice and Research Network of the American College of Clinical Pharmacy recommends against the consistent use of compounded bioidentical hormones as a safer option compared with manufactured therapy and supports the statements of other key organizations, acknowledging the need for more robust clinical studies to evaluate the potential advantages and disadvantages of compounded bioidentical products compared with manufactured products.

Compounded bioidentical menopausal hormone therapy

Although improvement in long-term health is no longer an indication for menopausal hormone therapy, evidence supporting fewer adverse events in younger women, combined with its high overall effectiveness, has reinforced its usefulness for short-term treatment of menopausal symptoms. Menopausal therapy has been provided not only by commercially available products but also by compounding, or creation of an individualized preparation in response to a health care provider's prescription to create a medication tailored to the specialized needs of an individual patient. The Women's Health Initiative findings, coupled with an increase in the direct-to-consumer marketing and media promotion of compounded bioidentical hormonal preparations as safe and effective alternatives to conventional menopausal hormone therapy, have led to a recent increase in the popularity of compounded bioidentical hormones as well as an increase in questions about the use of these preparations. Not only is evidence lacking to support superiority claims of compounded bioidentical hormones over conventional menopausal hormone therapy, but these claims also pose the additional risks of variable purity and potency and lack efficacy and safety data. The Committee on Gynecologic Practice of the American College of Obstetricians and Gynecologists and the Practice Committee of the American Society for Reproductive Medicine provide an overview of the major issues of concern surrounding compounded bioidentical menopausal hormone therapy and provide recommendations for patient counseling.

Counseling postmenopausal women about bioidentical hormones: ten discussion points for practicing physicians

Bioidentical hormones are compounds that have exactly the same chemical and molecular structure as endogenous human hormones. In contrast, nonbioidentical, or synthetic, hormones are structurally dissimilar from endogenous hormones. Although available for years, bioidentical compounded hormone therapy (BCHT) has gained popularity in the United States only recently. This popularity has paralleled women's rising fears of conventional hormone therapy, especially since the publication of the Women's Health Initiative clinical trials. Although BCHT offers advantages, it is not the panacea of hormone therapy. The claims that BCHT lowers the risk of breast cancer, coronary artery disease, stroke, or thromboembolism are not supported by scientific research. The goal of this review is to present an overview of the available research evidence on BCHT, dispel myths about the use of compounded hormones, and provide helpful tips to answer commonly asked questions about BCHT.

A double-blind placebo-controlled study to evaluate the effect of progestelle progesterone cream on postmenopausal women

OBJECTIVE

To evaluate the effect on climacteric symptoms and quality of life, and the safety of four doses of progestelle progesterone cream administered for 24 weeks to postmenopausal women complaining of moderate to severe menopausal symptoms. Design Single-centre, double-blind, randomized, placebo-controlled study. Population Two hundred and twenty-three healthy postmenopausal women, aged between 40 and 60 years and complaining of severe menopausal symptoms were recruited through newspaper advertisements.

METHODS

Women were randomly allocated to progestelle progesterone cream 60, 40, 20, 5 mg or placebo, to be applied daily for six months. Main outcome measures The primary efficacy variable was the psychological, somatic and vasomotor components of the Greene Climacteric Scale after six months. Secondary endpoints were incidence of hot flushes and night sweats, the nine subscales of the Medical Outcome Survey Short Form-36 (SF-36), serum progesterone, endometrial thickness and histology after six months. Adverse events were sought and recorded and followed up to resolution.

RESULTS

There were no statistically significant differences between any of the treatment groups and placebo for any of the components of the Greene Score. A statistically significant difference between the 20 mg group and placebo was found for the physical functioning (95% confidence interval [CI] 1.7-12.3; P=0.01) and social functioning (95% CI 1.9-16.7; P=0.01) scales of SF-36 after six months. No other statistically significant differences were found between any treatment group and placebo for any of the other secondary efficacy variables. There appeared to be a higher incidence of headache in the groups treated with progesterone cream.

CONCLUSIONS

Progesterone cream was no more effective than placebo for relief of menopausal symptoms.

Double-blind placebo-controlled study to evaluate the effect of pro-juven progesterone cream on atherosclerosis and bone density

Objective

To establish whether treatment for three years with pro-juven progesterone cream affects progression of atherosclerotic plaques or bone density in postmenopausal women.

Design

Randomized double-blind placebo-controlled trial.

Sample

One hundred and thirty-one healthy postmenopausal women aged between 50 and 75 years with at least one asymptomatic arterial plaque visible on ultrasound of the carotid or femoral bifurcation.

Methods

Women were randomly allocated to receive pro-juven progesterone cream, 20 mg twice daily, or placebo, for three years.

Main outcome measure

Rate of change of plaque thickness, intima-media thickness and bone density of lumbar spine and femoral neck.

Results

There was no difference between the groups.

Conclusion

Pro-juven progesterone cream 20 mg twice daily did not affect progression of asymptomatic atherosclerosis or deterioration in bone density over three years.

Advances in the Treatment of Menopausal Symptoms

Vasomotor symptoms and vaginal atrophy are both common menopausal symptoms. Hormone therapy is currently the only FDA-approved treatment for hot flashes. Current recommendations are to use the lowest dose of hormone therapy for the shortest period that will allow treatment goals to be met. Although the reanalysis of the WHI in 2007 by Roussow et al. provided evidence of coronary heart safety for users of hormone therapy under the age of 60 years and within 10 years of the onset of menopause, not all women desire or are candidates for hormone therapy. In this review we present an evidence-based discussion considering the effectiveness of hormonal and nonhormonal therapies for the relief of vasomotor symptoms and vaginal atrophy. Concern exists regarding systemic absorption of vaginal estrogen and possible adverse effects on the breast and uterus. Selective estrogen receptor modulators and estrogen agonists offer benefits through targeted estrogen agonist/antagonistic effects and are being evaluated with and without estrogen for symptomatic menopausal women. Centrally acting nonhormonal therapies that are effective for the relief of vasomotor symptoms include various antidepressants, gabapentin and clonidine. A limited number of clinical trials have been conducted with nonprescription remedies, including paced respiration, yoga, acupuncture, exercise, homeopathy and magnet therapy, and some, but not all of these, have been found to be more effective than placebo. Dietary herbal supplements, such as soy and black cohosh, have demonstrated mixed and inconclusive results in placebo-controlled trials. Potential therapies for vasomotor symptoms and vaginal atrophy require randomized, placebo-controlled trials of sufficient duration to establish efficacy and safety. Agents under investigation for vasomotor symptoms relief include neuroactive agents, such as gabapentin and desvenlafaxine; an estrogen receptor-β-targeted herbal therapy, MF-101; and the selective estrogen receptor modulator, bazedoxifene, paired with estrogen.

Bioidentical hormone therapy: a panacea that lacks supportive evidence

PURPOSE OF REVIEW

In the practice of 'bioidentical hormone therapy', it is our belief that pharmacists are compounding bioidentical hormone therapy with the best intentions. These pharmacists are, however, ill informed regarding the lack of scientific underpinning associated with the efficacy and safety of the practice of bioidentical hormone therapy. It is the purpose of this review to systematically examine the scientific rigor of the arguments posed by the proponents of bioidentical hormone therapy, and to differentiate the practice of bioidentical hormone therapy from the legitimate practice of pharmacy compounding.

RECENT FINDINGS

Most medical organizations have in essence refuted the bioidentical hormone therapy claims as unsubstantiated. The profession of pharmacy needs to address this issue in an authoritarian, scientific way, outside of the compounding issue.

SUMMARY

Bioidentical or natural hormones are expected to have similar efficacy and safety profiles as the commercially available hormonal therapies that have been studied in clinical trials, regardless of whether the active principle hormones are compounded by individual pharmacies or manufactured by large companies. Estriol is a weak estrogen that is not Food and Drug Administration approved for use as a prescription drug in the United States; thus, clinical trials are necessary to demonstrate the efficacy and safety profile for estriol. Further, supplementary clinical trials are necessary to determine whether there are efficacy or safety differences between natural progesterone and synthetic progestin, as studies to date are inconclusive.

Bioidentical Hormones for Menopausal Therapy

'Bioidentical hormones' is a term created by the lay media to refer to chemicals derived from plants that are modified to be structurally identical to endogenous human hormones. These compounds include estradiol, estrone, estriol, progesterone, testosterone and dehydroepiandrosterone when prescribed for menopausal women. Patients assume bioidentical hormones are natural and safer than synthetic hormones with regard to the risk of developing breast cancer and other diseases, but there is little evidence to support this belief. Proponents of this therapy also support the use of salivary hormone measurements to adjust doses of these hormones instead of adjustment based on improvement or lack of improvement in menopausal symptoms. In this review, the rationale behind the use of bioidentical hormones is discussed, along with the evidence supporting the use of compounded and FDA-approved bioidentical products.

Bioidentical hormones for menopausal hormone therapy: variation on a theme

BACKGROUND

Progesterone creams and natural or bioidentical compounded estrogen preparations are being promoted to consumers as safe alternatives to conventional menopausal hormone therapy and as health-promoting tonics. No reliable data support these claims.

SAFETY

Natural hormones, including estradiol, estriol, estrone, and progesterone, can be expected to have the same adverse event profile as conventional menopausal hormone regimens.

SALIVARY HORMONE TESTS

Salivary tests may be used to persuade asymptomatic consumers to use hormones (or symptomatic patients to use higher doses than those needed to mitigate symptoms), a practice that can be expected to result in adverse events.

Bioidentical Hormone Therapy: A Review of the Evidence

Bioidentical hormone therapy (BHT) uses bioidentical hormones (BHs), derivatives of plant extracts chemically modified to be structurally indistinguishable from human endogenous hormones. BHTs are available commercially or can be compounded into different dosages and for different routes of administration. Typically, compounded preparations of BHs may include estriol, estrone, estradiol, testosterone, micronized progesterone, and occasionally dehydroepiandrosterone (DHEA). It is generally accepted that estrogen-based hormone therapies share similar efficacies as well as risks. Many FDA-approved and regulated pharmaceutically manufactured and branded conventional hormone therapies (CHTs) employ BHs. Since the publication of the Women's Health Initiative (WHI) trial results publicizing an increased risk of stroke, venous thrombosis, and breast cancer and no beneficial effect on coronary heart disease (CHD), use of CHT has declined, and there has been increased interest in alternative approaches. This review of the literature related to compounded BHT and the practices of its advocates is to determine if sufficient scientific evidence supports claims of greater efficacy and safety and any additional risks and uncertainties not generally associated with CHTs. Compounded BHTs have been promoted by some as natural, safer, and in some cases more efficacious than conventional hormone therapies, but there is a dearth of scientific evidence to support these claims. Compounded BHTs lack well controlled studies examining route of administration, pharmacokinetics, safety, and a critical, science-based rationale for the mixture and ratios of bioidentical estrogens employed in many preparations. Many advocates of compounded BHTs customize prescriptions based on saliva tests or blood sera levels in direct contradiction to evidence-based guidelines, which support tailoring HT individually according to symptoms. Currently, scientific uncertainties associated with compounded BHTs make their use less preferable to that of CHTs, as CHTs have been and continue to be assessed by clinical trials regarding both benefits and risks and are indicated for use according to evidence-based guidelines.

A study to look at hormonal absorption of progesterone cream used in conjunction with transdermal estrogen

Natural progesterone creams are gaining popularity as a possible treatment for menopausal symptoms, and many women may be using them with estrogen. We planned to evaluate, using an open plan study, the systemic absorption of a combination of transdermal estrogen and progesterone. Women applied transdermal progesterone 40 mg and transdermal estrogen 1 mg daily over 48 weeks. Women were assessed at intervals of 12 weeks. Significant increases in plasma levels of progesterone and estradiol were seen after 12 weeks, although only low plasma progesterone levels were found (median 2.5 nmol/l) and no further increase was noted over the remainder of the study period. A significant correlation was found between plasma levels of the two hormone (r = 0.315, p = 0.045). Women reported significant reductions in menopausal symptoms, as measured by the Green Climacteric Scale, after 24 and 48 weeks of combined treatment. There may be similar mechanisms of absorption of the two hormones, although the doses used in our study produced sub-luteal levels of progesterone. There was no evidence of accumulation of progesterone with time, and further study is needed to assess the efficacy and safety of this combination of hormones.

Transdermal progesterone creams for postmenopausal women: more hype than hope?

Various claims have been made about the benefits of transdermal progesterone creams for relieving symptoms of menopause. Peer-reviewed articles have reported that the creams can raise plasma progesterone levels slightly, but have no effect on vasomotor, psychosexual or mood symptoms, bone metabolism or plasma lipid levels. Currently available progesterone creams can not be recommended for treatment of symptoms associated with menopause.

Percutaneous administration of progesterone: blood levels and endometrial protection

There is controversy about the beneficial effects of topical progesterone creams used by postmenopausal women. A major concern is that serum progesterone levels achieved with progesterone creams are too low to have a secretory effect on the endometrium. However, antiproliferative effects on the endometrium have been demonstrated with progesterone creams when circulating levels of progesterone are low. Thus, effects of topical progesterone creams on the endometrium should not be based on serum progesterone levels, but on histologic examination of the endometrium. Despite the low serum progesterone levels achieved with the creams, salivary progesterone levels are very high, indicating that progesterone levels in serum do not necessarily reflect those in tissues. The mechanism by which the serum progesterone levels remain low is not known. However, one explanation is that after absorption through the skin, the lipophilic ingredients of creams, including progesterone, may have a preference for saturating the fatty layer below the dermis. Because there appears to be rapid uptake and release of steroids by red blood cells passing through capillaries, these cells may play an important role in transporting progesterone to salivary glands and other tissues. In contrast to progesterone creams, progesterone gels are water-soluble and appear to enter the microcirculation rapidly, thus giving rise to elevated serum progesterone levels with progesterone doses comparable to those used in creams.

Bioidentical hormone therapy: a review

OBJECTIVE

The terms "natural" or "bioidentical" hormone therapy (NHT) are used to describe hormone treatment with individually compounded recipes of certain steroids in various dosage forms, including dehydroepiandrosterone, pregnenolone, testosterone, progesterone, estrone, estradiol, and estriol. Based on the results of a person's salivary hormone levels, the final composition of the compounded dosage form is individualized to that specific person. Proponents claim that NHT is better tolerated than manufactured products. This paper is intended to review the concept of NHT and to determine whether there is sufficient scientific evidence to support its use.

DESIGN

A literature search was performed in Medline using the following MeSH terms and key words: drug combinations; progestational hormones; hormone replacement therapy; endometrium; estrogen replacement therapy; climacteric; menopause; estradiol; estrogens; progesterone; drug monitoring; and drug compounding. Current Contents, International Pharmaceutical Abstracts, Cochrane Database of Systematic Reviews, Lexis Nexis, Google, Medscape, MD Consult, and clinicaltrials.gov were searched with key words.

RESULTS

There are a few observational studies and clinical trials comparing conventional hormone therapy with bioidentical hormone therapy. Studies generally lacked adequate study design, including small sample sizes and comparison of inequivalent doses, to prove safety and efficacy. Little evidence was found to support individualized hormone dosing based upon saliva hormone concentrations.

CONCLUSION

Evidence suggests that, although individualized hormonal products may decrease some symptoms of menopause, it seems they have no proven advantage over conventional hormone therapies and their use is not supported by evidence regarding pharmacokinetics, safety, and efficacy.

A holistic programmatic approach to natural hormone replacement

With an unprecedented number of women reaching midlife, the impact of menopause has become a significant public health issue. Recent findings have left women and practitioners questioning traditional hormone replacement therapy (HRT) and searching for reasonable alternatives. Growing numbers of women in this country are choosing to use natural progesterone and estrogen to treat symptoms of menopause. This article describes a program that focuses on education, client participation, and alternative methodology to support individualized HRT therapy using natural compounded bio-identical hormones.