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Bio-identical Hormones: One Physician’s Experience in Houston-The Woodlands, Texas and Steamboat Springs, Colorado

Posted on 09.16.09 8:01PM under Anti-Aging Medicine, Bio-identical Hormones, BioIdentical Hormones, Colorado, Functional Medicine for Healthy Aging, Houston, Steamboat Springs, Texas, The Woodlands, Vitamins for Healthy Aging, Weight Loss, Women's Health

Over the past several years, the buzz surrounding compounding, or bio-identical hormones (BHRT), grew louder in my ears, like a pesky mosquito that wouldn’t go away. While Suzanne Somers’ books, The Sexy Years and Ageless, provided enlightening information to the public, her media blitz expounding the virtues of BHRT seemed self-serving.

But the ever-present comments from my patients, such as “My friend takes natural hormones and is losing weight,” “My sister sleeps better on bio-identical hormones,” and “Bio-identical hormones are safer than synthetic hormones,” were hard to ignore without understanding these substances.

My first reaction was to dismiss BHRT. As a board-certified specialist, I read my journals and took the appropriate CME courses. The American College of Obstetricians and Gynecologists Committee Opinion from November 2005 emphatically stated that “there is no scientific evidence to support claims of increased efficacy or safety for individualized estrogen or progesterone regimens.”¹

So it would have been easy for me to reject bio-identical hormones. But as a physician, I have an obligation to explore the treatments my patients ask about. Do they actually feel better on bio-identical substances? Do they have more endurance, better sleep and improved libido? I needed to find out, but without the hype and high-priced courses offered by some physicians whose interest may be clouded by monetary factors.

While strolling through the plethora of “hits” from a Google search, past the glut of anti-aging sponsored Web sites, I find one with a genuine feel from Neal Rouzier, MD.² Was this good karma or just plain luck? Who knows, but off I went to Salt Lake City for a two-day weekend course titled, “The Effects of Hormonal Therapies on Quality of Life Issues: The Medical Management of Aging.” I was intrigued, but skeptical.

The upscale hotel accommodations contrasted with the Spartan conference room. Instead of sophisticated PowerPoint slides, Dr. Rouzier uses an overhead projector sans microphone, his voice loud and commanding. And so began a two-day course unlike any other CME seminar I have ever attended. From 8:00 a.m. sharp until almost 6:00 p.m., Dr. Rouzier meticulously covers all the topics with an occasional five minute respite for a bathroom break. Even lunch is a working session, as we cover seminal medical publications. Coupled with practical clinical applications, the course moves rapidly with constant edifications. It’s so enlightening that the two days seem like an hour lecture.

First, Dr. Rouzier presents material on human growth hormone (HGH), a pituitary substance that affects nearly every organ in the body. It’s necessary for proper growth and development. A landmark study by Rudman et al. concluded that diminished secretion of HGH was responsible, in part, for a decrease in lean body mass, expanded adipose tissue mass and the thinning of skin during old age.³

Various publications conclude that physiologic HGH replacement therapy might reverse or prevent some of the inevitable sequela of aging. Dr. Rouzier slowly and methodically walks up and down the conference room with his head slightly tilted downward, a gesture of contemplation, articulately referencing all the good things about HGH in the medical literature. The man, dedicated to the quest for knowledge, reviews a legion of medical publications per week. This is not a show, but a well-organized and researched seminar from a doctor who has practiced using bio-identical hormones for 10 years.

Just as interesting is the next section on testosterone, revealing that its physiologic replacement in men and women increases muscle mass, strength and endurance and decreases fat. It also increases exercise tolerance, as well as libido and sexual performance. Thoroughly, Dr. Rouzier covers a review article from the New England Journal of Medicine on the risks of testosterone replacement therapy and recommendations for monitoring. His survey is honest and fair while raising points about proper use and potential complications.⁴

What about DHEA, a substance patients ask about often? Is it for real? Can a hormone secreted by nerve tissue and adrenal glands result in a shift from a catabolic to an anabolic or protein-building state, reducing cardiovascular risks while improving mood, memory and energy? Articles from the American Journal of Physiology, the Journal of Endocrinology and Metabolism and the New England Journal of Medicine support some of these claims. One article from 1994 concluded that DHEA was associated with a remarkable increase in physical and psychological well-being in men and women.⁵ I lean back in my chair, a bit overwhelmed, but wanting to learn more.

Estrogen and progesterone, those much maligned hormones, suddenly seem amazingly safe and necessary from a bio-identical perspective. These are not just plant-derived hormones, but structures that are chemically identical and, therefore, physiologically beneficial, protecting against heart disease, stroke, osteoporosis, Alzheimer’s and memory disorders. They also can eliminate menopausal hot flashes and vaginal atrophy. Because progesterone is not progestin, a synthetic formulation, it ameliorates PMS and menopausal symptoms while lowering cholesterol, increasing bone density and providing a natural mood calming effect. A study from Hargrove et al. revealed that the combination of micronized estradiol and progesterone offered substantial clinical benefits for women with postmenopausal symptoms and an intact uterus.⁶

Dr. Rouzier is just warming up. His strongest opinions are saved for the controversial section on thyroid treatment, stating that it’s the “most misunderstood hormone.” Expertly, he dissects nearly 40 medical articles about thyroid treatment, emphasizing that bio-identical thyroid—not synthetic—reduces fatigue, improves thinning hair as well as cold intolerance, while promoting weight loss and reducing body fat.⁷ His wrath against the synthetics crescendos as he justifies bringing triodothryronine (T3) levels back to physiological levels, interspersing actual patient lab results on the overhead projector, teaching the correct interpretation of the most clinically useful blood tests.

Does the man ever get tired? I wondered if his Olympian stamina is related to his using bio-identical hormones? Maybe it’s the melatonin he takes, that great sleep promoter and immune enhancer that provides him with Superman endurance? Or could his encyclopedic knowledge be enhanced by pregnenolone, a hormone that may protect against memory loss? His educational program is more than impressive. It’s inspirational. Dr. Rouzier’s enthusiasm is contagious, especially when he relates clinical stories of patients who not only respond to BHRT, but who also stop taking other medications, such as statins, anti-depressants and bisphosphonates. I leave Salt Lake City anxious to begin bio-identical hormone assessment and treatment and to register for his part II and part III courses, further probing the mostly untapped benefits of hormone therapy.

Putting It into Practice

I re-read the 550 pages of Dr. Rouzier’s handout, searching for a way to begin BHRT counseling. How do I start? Will patients be interested in BHRT or satisfied with their current regimen? I don’t know, but the first patient I treat is my wife, who has been on synthetic estrogen and progesterone for several years. While she isn’t thrilled about being a guinea pig, she agrees to have blood levels tested, but remains skeptical to the concept. Eagerly, I wait for the results: an estrogen level pitifully low, the expected, almost nonexistent progesterone level, and testosterone and DHEA values well below optimal range.

“Are you game?” I ask. After some coaxing, she reluctantly agrees. Instead of one pill per day, she now takes three and uses a cream. She finds it inconvenient, but I ask her to be patient and to see what happens.

Surprisingly, most of my patients who take HRT are interested in either changing to BHRT or learning more about it. Even patients who have been off hormones are intrigued by the possibility of improved stamina and sleep, as well as weight loss. Lab tests are ordered, the results reviewed and patient consultations are made with recommendations for estrogen, progesterone and testosterone replacement, along with thyroid and DHEA supplementation, if indicated by suboptimal values and clinical symptoms. It will be a month before I see these initial patients again, so I cautiously watch my wife and wait to hear her take on it.

Just three days after starting her BHRT, she tells me she thinks something is working. I raise my eyebrows. “How so?” A tilt of her head suggests deep thought. “Not sure,” she says, “but I feel different, better, not sure exactly why or how.”

And so it goes with my patients. Most feel better, and many claim to sleep longer, have more energy, fewer hot flashes and/or night sweats. They seem happier, have less vaginal dryness, and most comment on their improved libido.

But not all will be elated, and sure enough, I’m right. Those with no or little clinical response have lab values consistent with minimal changes. Customizing the dosages, as well as the combination of estradiol to estriol and T4 to T3, makes me feel like an internist instead of a gynecologist. Yet, it all makes sense, and even these poor responders return with some improvement and positive feedback. The most difficult patient, my wife, also requires some tweaking to her hormone dosages and combinations until the desired values and clinical responses are met.

Anecdotally, I make an interesting observation. Every patient who takes testosterone seems to have better-looking skin. Is this for real or just my imagination?

“You’re right,” my wife says. “I now have some oil to my skin when before it was dry. My skin feels soft and silky like when I was young.”

I don’t want to get too excited. This seems like the real deal and maybe I should convert everyone to BHRT, but some drawbacks exist. First, because they are bio-identical substances, they cannot be patented by pharmaceutical companies and, therefore, are not regulated by the FDA. As physicians, we have the knowledge and expertise to use bio-identical hormones, but some clinicians feel uncomfortable using non-FDA approved medications.

Second, most insurance companies won’t cover these compounded hormones. Patients usually pay significantly more for them compared to hormones on insurance formularies.

Third, it takes time to find the right combination for each person. Several follow-up visits and repeat blood tests are needed so patients can reach optimal levels and realistic clinical improvement.

While BHRT may or may not slow the aging process, it works well clinically, improving quality of life and well-being. Many of my patients are happy with BHRT, and I’m glad I listened to them. This experience taught me that we need to learn from others. Often, the best ones to teach us are our patients.

For a list of references, go to advanceweb.com/healthyaging and click on the references toolbar.

Randy A. Birken, MD, is a clinical assistant professor at Baylor College of Medicine and medical director of Birken Medical Aesthetics.

For more information, call Liz at 281-419-3231 or email at

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