Bio-identical Hormones & Migraine
I am tired of women patients and medical colleagues claiming that bio-identical hormones are the kind that have to be made at a “compounding pharmacy” and claiming this type of hormone preparation is the best as it is “natural” and the dose can be tailored to just what a woman needs. Often saliva testing is recommended to check the hormone levels both before prescribing and then during therapy to monitor and then make adjustments to the dose.
I say “Give me a break”! Where is the proof that these products are better (or safer) than bio-identical products that are available by pharmaceutical companies? The term bio-identical has been misinterpreted and misused in recent years. Bio-identical simply refers to the fact that what is being taken is the same as what your own body produces. In the case of hormone therapy for women, we are often referring to estrogen and progesterone when we use the term bio-identical.
Estradiol is the most active and often considered the most important estrogen for women when looking at what our own ovaries produce. During times of estrogen lowering such as menses, post-partum, perimenopause, and menopause, the lower level of estradiol is the main trigger for hormonal migraines that often occur during these times. This level can be raised by giving an estradiol patch such as the Vivelle dot or Climara (name brand estradiol products). This treatment approach is often referred to as “add back estrogen” and is especially ideal when contraception Is not needed or not indicated but a hormonal approach still makes sense given the hormonal trigger for these migraines.
Estradiol comes in patches, gels, sprays and lotions; it can also be inserted as a pellet. These products are all bio-identical and DO NOT NEED TO BE COMPOUNDED OR MADE BY A COMPOUNDING PHARMACY. Since they are made by pharmaceutical companies, they are usually covered by insurance and readily available. As a physician, I know exactly what I am prescribing and can adjust the dose to meet a woman’s needs. There is a lot of flexibility in dosages and preparations. Occasionally, I may order an estradiol level to check a woman’s level if we are unsure whether to go up or down on the dose; however, I usually adjust the dose by how she is feeling and what is happening with her migraines. I order testing by blood and not saliva. I do not feel saliva is a valid measurement of hormone levels and is often hard to interpret. I know many may disagree but that is my opinion. I am also tired of women or compounding pharmacies ordering the saliva testing and then wanting my help in interpreting these results! If a woman or pharmacist orders saliva testing, then let them interpret and figure it out!
Progesterone, also produced by a woman’s own ovaries, is available in a bio-identical product called Prometrium (micronized natural progesterone). It is available as a 100 mg and 200 mg dose and is readily available in pharmacies and usually covered by insurance. I do not see a need for most women to have a compounded progesterone product made up for them. Occasionally, I have women who cannot tolerate Prometrium and we may use a compounded pharmacy to make up a progesterone cream. There are many progesterone creams available over the counter.
Do I ever prescribe a product like Triestrogen/Progesterone or Biestrogen/Progesterone for women in my practice with migraine and hormonal issues? Yes and in a few cases, these women truly feel this is the best way for them to take hormones. I am OK with this but feel it is important to offer these women pharmaceutical bio-identical products such as the Vivelle dot and Prometrium as alternatives to compounded hormones.
I am curious: how many of you feel compounded hormone preparations have worked better for you, including for your migraines, than bio-identical estradiol & progesterone pharmaceutical products like Vivelle dot and Prometrium?
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