Many menopausal women suffering interminably from hot flashes, night sweats, and sleeplessness are now opting to take bioidentical hormones. These products—which can be anything from prescription drugs to cosmetic creams to drugstore supplements—are chemically identical to the estrogen and progesterone made by a woman's ovaries. Thus, they're safer than traditional pharmaceuticals in which the hormones are derived from a horse's urine or synthesized in a lab, right? Well, perhaps. Some European studies are suggesting this may be true, but the evidence is far from definitive. In the meantime, most experts agree that bioidentical hormones are a reasonable option to bring needed relief from menopausal symptoms—provided you follow some sensible guidelines.
1. Take the smallest dose for the shortest period of time. Like traditional hormone therapy, bioidentical hormones should be used only to help ease a woman's menopausal symptoms, most doctors say. They shouldn't be a lifelong proposition taken to ward off wrinkles, heart disease, osteoporosis, or any other hallmark of aging, stresses Adriane Fugh-Berman, a physician and associate professor in the complementary and alternative medicine master's program at Georgetown University Medical Center. If you're having only vaginal symptoms like dryness or painful intercourse, she says you can probably get away with a low-dose topical application of estrogen. Bioidentical estradiol is available in a cream (Estrace), gel (Estrogel), or vaginal ring (Estring, Femring), all of which are approved by the Food and Drug Administration as safe and effective drugs. You'll still, though, need to take progesterone pills to protect against endometrial cancer.
2. Stick with FDA-approved products. There are a host of estrogen and progesterone supplements and creams for sale without a prescription in drugstores and on the Internet, but it's probably wise to stay away from all of them. These over-the-counter products are like taking a roll of the dice—you never know what you're going to get, says Isaac Schiff, chief of obstetrics-gynecology at Massachusetts General Hospital in Boston. Women concerned about getting too much estrogen in a prescription pill can taper the dose down by using an FDA-approved gel or cream, Schiff says. Plus, you'll be treating your symptoms under a doctor's supervision, so you know the dose you're taking is appropriate for you.
3. Skip the saliva test. Some doctors insist on measuring a woman's hormone levels in her saliva or blood to determine how much estrogen or progesterone she needs, but most experts say these tests are worthless. "Menopausal symptoms often don't correlate with a woman's individual levels of hormones," says Fugh-Berman. "Some women can have high levels of estrogen and severe hot flashes, whereas others can have undetectable estrogen levels and have no symptoms whatsoever." And, she adds, there are no established "optimal hormone levels" that women should have after menopause, so no test can tell you if your levels are too high, too low, or just right. "If you're not having menopausal symptoms," she adds, "you shouldn't be taking any hormone therapy."
4. Take progesterone only in pill form. There is an FDA-approved bioidentical progesterone gel, and compounding pharmacies can make creams and suppositories. But experts say it's not a good idea to use these products because it's impossible to tell how much gets absorbed through the skin into your blood. If not enough is absorbed, says Fugh-Berman, women taking estrogen may not get the protection they need from endometrial cancer. Progesterone pills, on the other hand, deliver a reliable dose to counter estrogen's effects. Note: A woman who has had a hysterectomy would not need progesterone, since she no longer has a uterus.
5. Be wary of compounded products. Compounded preparations aren't regulated by the FDA and can vary widely in potency. One study found that only 1 in 10 compounding pharmacies provided progesterone vaginal suppositories that were within the potency range required by similar FDA-approved products. That means those taking progesterone to protect against endometrial cancer might be putting themselves at risk. They also could be getting higher doses of estrogen than they bargained for if they get products that are more potent than what's on the label.
Corrected on 03/30/09: An earlier version of this article misstated the hormone therapy protocol for women who have had hysterectomies. They do not need progesterone along with estrogen.