COMMENTARY

Bioidenticals: Another All-Natural-Is-Good Myth

Charles P. Vega, MD

Disclosures

September 26, 2013

In This Article

Introduction

The concept and practice of hormone therapy (HT) have changed dramatically over the past decade, and both patients and providers have sought alternative treatments for the symptoms of menopause. Bioidentical therapy has become increasingly popular as a treatment option over conventional HT. This treatment uses a different mix of hormones intended to copy the exact molecular profile of natural sex steroids, and proponents of bioidentical therapy claim that it is at least as effective and safer compared with conventional HT. Are they right? The current review discusses this issue.

Background

Menopause is a natural process but still produces severe levels of impairment among many women. In a study of 140 women with vasomotor symptoms related to menopause, quality of life was significantly lower compared with menopausal women who did not have hot flashes.[1] The severity of vasomotor symptoms, but not the frequency of hot flashes, was associated with quality-of-life ratings. Another study found that younger women with a negative affect and other concomitant medical conditions were most likely to suffer bothersome hot flashes.[2] African American women reported higher rates of bothersome hot flashes compared with white women.

The most popular HT, containing conjugated equine estrogens, with or without progestins, is effective in the management of vasomotor symptoms of menopause. In an analysis of data from the Women’s Health Initiative (WHI) study, HT was associated with a 28% relative improvement in the relief of hot flashes compared with placebo.[3] Night sweats were also significantly improved with HT, at the cost of a higher rate of breast tenderness. Moreover, lower doses of HT, which have been favored since publication of the results of the WHI research, appear to be similarly efficacious as higher doses in improving women's symptoms.[4]

Nonetheless, it was the negative results of the WHI in 2002, in particular related to breast cancer, that led to a dramatic change in prescribing patterns for HT. Between 2001 and 2003, the number of outpatient visits completed with a prescription for HT fell by one third to two thirds of previous levels.[5,6]

Physicians were partly responsible for the severe reduction in the use of HT, as the treatment strategy rapidly evolved from one of preventive therapy for a number of diseases to one that addressed women's symptoms only. However, there was also an obvious shift in the attitude of women toward HT, marked by a sense of injustice and mistrust at the hands of the medical system and physicians themselves. In one study that surveyed women in 2003, all respondents had heard about the results of the WHI, and 52% reported that it affected their use of HT.[7] Women who had stopped HT were less likely to trust their physician after making the change.

Given the risk, albeit rare, of severe adverse events associated with the use of HT, both patients and physicians have sought alternatives. (One of these alternatives, the new formulation of the serotonin reuptake inhibitor paroxetine, was reviewed in the July 2013 issue of Best Evidence Review.[8]) While the popularity of this nonhormonal therapy remains to be seen, there is no doubt of the broad interest in bioidentical HT to improve menopausal symptoms.

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