The prior three articles in this series on hormone replacement therapy (HRT) have addressed:

Part 1: Use of the full hormone spectrum and monitoring fluctuating levels.

Part 2: Custom formulation and duration of HRT use.

Part 3: Bioidentical vs. traditional pharmaceuticals and safe use of HRT: Surveillance and protection.

In this last article, various protocols for the use of HRT will be summarized:

1 – Pellets: The use of implanted hormone-containing pellets is an available option for both men and women. Clearly the “pro” here is expediency, as once a hormonal pellet is inserted beneath the skin, it releases hormones continually over the course of months. If this created evenly-sustained levels over time, this “pro” might be considerable, but this is not the case. At the outset, the body levels of hormones are high, often too high, and gradually over months, they dwindle to nothing. As the benefits of a steady level are great, this method, although nearly effortless, does not provide sustained benefit levels. Also, if undesirable effects occur, the ability to make adjustments is very minimal until the pellets “wear off.”

2 – HRT for Men: Other options for men are intramuscular injections or creams, with lozenges a distant third. As with pellets, weekly shots yield fluctuating results. Daily injections hurt; however, absorption issues are bypassed. With a compounded cream, all hormones in the “concert of hormones” (DHEA, estrogen, progesterone, and pregnenolone) can be included, and levels of each can be adjusted readily and independently. When used morning and evening, consistent body levels can be achieved day in and day out. This method provides a comprehensive approach, with steady levels and consistent effect. Sometimes, use of a pharmaceutical drug to prevent conversion of testosterone to estrogen must be included, since with the use of bioidentical products, this natural flux can potentially occur unless prevented, and this can undermine achievement of desired goals.

3 – HRT for Women: For women, other than pellets, options include lozenges, creams, and topical patches. The issue here is: Do we want to recreate a menstrual-cycle-like hormonal pattern or anything close? For some, who have read Suzanne Somers book series, there is a strong wish to recreate the period cycle, although no longer fertile with an egg, but nonetheless still complete with a monthly shedding of a bloody uterine lining . For most who try this once, once is enough, and a less aggressive approach is chosen going forward.

Many variations in usage protocols are available, none clearly being “right” or “wrong.” Two or three estrogens (bi-estrogen or tri-estrogen) are used once or twice daily in combination with progesterone.

a – More estrogen may be used in the morning, as it has an “energizing” effect2

b – Progesterone may be removed from the compounded cream and used only at night, taken orally, to provide maximal sleep benefits.

C – Estrogen may be used the first part of the month and progesterone the latter part to mimic the menstrual cycle.

d – Both estrogen and progesterone may be discontinued or cut in half for several days per month to provide a “time off” from full level HRT. Most women, however, prefer daily use to provide sustained benefits for sleep, mood, cognition, and relief of body pain.

Additionally, clinicians vary widely as to what constitutes “optimal” hormone levels. All customized creams should include any other hormones found to be deficient, such as testosterone.

All protocols have their proponents, and so, after thorough discussion, final choices should be made in a partnership of physician and patient. Such a partnership is the cornerstone of decision making in all of functional medicine.

Since her mentorship with Dr. Robert Atkins, Dr. Robin Ellen Leder has provided functional/holistic medical care to thousands of patients at her Hackensack office, treating a wide variety of hormonal, immunological, metabolic, GI, psychological and auto-immune issues through diet, supplements, and minimal use of medication. She has taken numerous courses in the safe and effective use of bioidentical hormones to achieve long-term health and well-being. Each of her patients is evaluated individually, and ultimately, decisions are made by doctor and patient working as a team. For more information, email [email protected].