What are bioidentical hormones?

A few weeks ago, my sister sent me an article in the New York Times called “Treating the Incredible Shrinking Vagina,” about the vaginal atrophy that can happen when we lose our hormones in menopause.

Here’s how it starts, as a letter to an OBGYN:

So, vaginal atrophy. What’s that about? I (very tentatively) asked my general practitioner about how the whole “vagina after menopause” thing works and she was basically “yeah, that’s right, it will atrophy.” So what can be done about it, if anything? Frankly, I’m a bit sad.

— Shrinking Violet

My sister is nowhere near menopause. But I imagine that she was just a little bit panicked by the idea of a ‘shrinking vagina’, and she was perhaps a bit relieved when I told her “I treat this all the time!”

I love the fact that the author is writing about such potentially uncomfortable topics in a publication like the New York Times. We need to talk about these things. The author discusses some of the medical treatments that are available, and also lots of lifestyle-related ways of addressing vaginal atrophy. She talks about vaginal estradiol, which can be a life saver for many women. But I was so disappointed to see this disclaimer at the end of the article:

“A word of caution

Some health care providers and pharmacies advertise “bioidentical” hormones for use after menopause. This is a marketing term, not a medical term. “Bioidentical” has been used to describe hormones that are chemically identical to what the ovary makes or for hormones derived from a plant source. These products are often marketed as “more natural” or “safer” than pharmaceutical options, but they are not.”

This is incredibly misleading. “Bioidentical” is very much a medical term. In fact, it refers to the biochemistry of the hormones themselves. The author even refers to a bioidentical hormone - estradiol - in her article. Bioidentical simply means identical to the body - the same, identical hormone that the human body makes. Here’s an example:

Estradiol bioidentical.png

That’s right, the estradiol made by a drug company is exactly the same estradiol that is made by a human, male or female. (Women and men both have two other forms of estrogen, called estriol and estrone. These are slight variations on estradiol, which are found in much lower amounts, so in most people estradiol is our primary form of estrogen and is the one that is most commonly used as a medication.)

Now, estradiol is available as a prescription medication in many forms. It is available as a pill (generic estradiol tablets), as a patch (Vivelle-Dot is one brand, and it is also available as a generic), as a cream (Estrace is one brand name), and even as vaginal tablets (Vagifem). All of these medications are available through your regular pharmacy - Walgreens, Walmart, etc.

The same is true for bioidentical progesterone - Prometrium (brand) or generic progesterone are available from just about every pharmacy in America.

The author is right that there is some confusion about bioidentical hormones, but there is no need to perpetuate this confusion. Many people think that bioidentical hormones are only available from a compounding pharmacy, but this is incorrect. A compounding pharmacy is a pharmacy that can make medications in many forms and in many dose strengths. Because compounding pharmacies make medications from raw materials in many forms, they can be customized to exactly the dose the patient needs. This gives us much more flexibility in dosing, rather than relying on the few doses that are commercially available. When compounding pharmacies make medications for hormone replacement, they typically use bioidentical forms of the hormones, because that is what the market demands, but there is no requirement that compounded hormones be bioidentical.

I tailor my prescriptions to the individual patient’s need, based on both symptoms and test results. Sometimes I use bioidentical hormones that are available commercially, through a regular pharmacy. But sometimes, if a patient needs a dose that’s not available commercially, or needs their prescription to be without additives or dyes, I’ll prescribe a compounded medication. This is one way that we can individualize medicine. Sometimes we’ll use commercially available forms of hormones just for cost savings, if they’re covered by a patient’s insurance. But either way, in my office, hormone replacement is always bioidentical.

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