Michael Kleerekoper, MD, MACE, has joined the faculty at the University of Toledo Medical School where he is Professor in the Department of Internal Medicine and section chief of the Endocrinology Division. The author of numerous journal studies, Dr. Kleerekoper serves on the editorial boards for Endocrine Today, Endocrine Practice, Journal of Clinical Densitometry, Journal of Women's Health, Osteoporosis International and Calcified Tissue International. Dr. Kleerekoper is also a founding board member of the newly formed Academy of Women’s Health.

Bioidentical hormones

The Annual Scientific Meeting of the Michigan State Medical Society is taking place this week with a potpourri of topics to satisfy everyone’s needs. As an endocrinologist, I made sure that I attended those sessions at which bioidentical hormones were discussed with fervor, both pro and con. This was a hot topic at three separate half-day sessions so I guess there is a lot of interest out there. I am a bit surprised by this because in my clinical practice the number of women and men who have brought up bioidentical hormones is much less now than a year or two ago.

What are bioidentical hormones?

In brief, they are plant-derived chemicals identical or similar to endogenously produced gonadal steroids in humans. They are biologically active, and several are available as FDA-approved therapies. The FDA-approved preparations have all passed safety standards in clinical trials, but this is not so for many of the non-FDA-approved products.

So why all the fuss?

The best way to present this to you is the comment I heard from one of the presenters that, “It is important to optimize testosterone levels in men!” Yes, there are bioidenticals for men too.

Intrigued, I could not resist the temptation to raise my hand and ask how one “optimizes” hormone levels. The response was a very correct listing of the available testosterone replacement options, FDA approved and otherwise, but nothing that could help me optimize testosterone levels for an individual man (or estrogen for a woman). To the best of my knowledge there is no way to do this, but I will welcome any reasoned response readers can share.

Many compounding pharmaceutical companies have the patient provide a saliva sample in which endogenous hormone levels can be accurately measured and then return the appropriate bioidentical that will optimize the patient’s levels. Depending on the company, this is based on either a single sample or multiple samples collected during the course of a single day or collected over many days. The cost of the analyses is not insignificant. For many patients, the clinical response is just fine, but this is not the case for all. My patients on bioidenticals from these companies report that their dosing is adjusted at three monthly intervals based on the saliva test results.

When prescribing estrogen or testosterone, it is clear that one size does not fit all, and dosing must be adjusted based on the patient’s clinical responses over time. This can be very frustrating for both patient and prescriber, but my experience is that a satisfactory dosing schedule can be achieved within two to three months. I need to emphasize that this approach is not based on circulating hormone levels but on the subjective clinical response. It never hurts to listen to the patient, preferably face to face and not with your back turned while you work on the electronic medical record.