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Bioidentical hormone replacement therapy (BHRT, also known as bioidentical hormone therapy^[1]) refers to the treatment of symptoms and disorders of menopause using hormones that are molecularly identical to endogenous hormones. The term 'BHRT' is commonly used to describe a group of practices including the use of compounded hormone mixtures,^[1] saliva testing, and the attempt to restore certain levels of both hormones in the blood rather than simply aiming to provide symptom relief, which is the goal of standard hormone replacement therapy.^[2][3][4] It is also used to describe a construct within Conventional Hormone Therapy that uses commercially available bioidentical products, with the option of using compounded products if the situation warrants.^[5]

Bioidentical hormones used in BHRT include estradiol and progesterone, which are available both in FDA-approved manufactured products and as pharmacy-compounded products.^[6] In 2002, the Women's Health Initiative ended one arm of its study of conventional hormone replacement therapy (CHRT) due to previously unappreciated risks. This led to a decrease in hormone prescriptions to treat the symptoms of menopause and a search for safer alternatives, spurred in part by popular promotion (such as a book on the topic written by Suzanne Somers^[7] and the discussion of BHRT on The Oprah Winfrey Show^[8]). Advocates have portrayed BHRT as superior due to match to endogenous hormones, the "naturalness" of the hormones, and the safety relative to synthetic hormones, and compounded BHRT as superior due to the individualized approach.^[9] These claims for pharmacy-compounded BHRT's superiority are not supported by research. and the risks and benefits of this form of hormone replacement therapy are unknown.^[3][9][10] The limited research into potency, delivery methods, and conversion of the various estrogens precludes establishing a valid scientific understanding of compounded estrogen products.^[11]

Proponents of BHRT Erika Schwartz, Kent Holtorf, and Deborah Moskowitz have published peer-reviewed articles that state that bioidentical hormones have a better safety profile than non-bioidenticals, and can be more effective^[12][13][14] but the American College of Obstetricians and Gynecologists, the Endocrine Society, the North American Menopause Society (NAMS), United States Food and Drug Administration and the Mayo Clinic have released position statements stating that there is no difference in benefits or risks of hormone replacement therapies using bioidentical molecules compared to those using non-bioidentical molecules, and that compounded hormone products may have additional risks related to compounding. BHRT and CHRT are expected to have the same risks and benefits, and while CHRT and FDA-approved BHRT products have been extensively studied and are heavily regulated, compounded BHRT products are unregulated and lack an accepted evidence base.^{[3][6][15][16][17][18]} Since pharmacy-compounded products are not subject to FDA testing and quality control measures, their potency, purity and safety have been questioned.^[9]

Contents 1 Terminology 2 Uses 2.1 Components and compounding 3 Administration 4 Criticisms 4.1 Lack of evidence for claims 4.2 Safety 4.2.1 Estriol and estrone 4.3 "Natural" claims 4.4 Salivary testing and compounding 5 Wiley Protocol 6 Regulatory status in the United States 7 History 8 Footnotes 9 External links

[edit] Terminology

"Bioidentical" does not have a meaning that is universally recognized and there is confusion regarding its use.^[12] Some groups use it to describe molecules that are identical to those in the body,^[18][19][20] while others also include plant derivation in the definition.^[19] The term has been used in FDA packaging inserts since before 1998.^[12] The FDA states that there is no defined medical or conventional meaning to the term, and that many compounding pharmacies use it "as a marketing term to imply that drugs are natural, or have effects identical to those from hormones made by the body", implications for which there is no supporting evidence.^[19] Manufactured on an industrial scale, the hormones are available as commercial products available in standardized form which compounding pharmacies use to prepare individualized doses and delivery systems based on prescriptions from health care practitioners.^[12]

Patients requesting "bioidentical" hormones may not be clear on what they are asking for. What is sought may be individual or tailored hormone replacements. The marketing and advertising of BHRT has resulted in a significant increase in its popularity. Compounded BHRT has been promoted as a treatment that could improve the symptoms of menopause without the risks of conventional hormone replacement therapy,^{[16][21][22][23][24][25]} though the evidence to support these claims is lacking.^{[3][15][18][26]}

Bioidentical estrogens and micronized progesterone are used to make a variety of FDA-approved products that are used to treat symptoms of menopause:^[6]

Hormone class	Type	Brand names	Preparations	Notes
Estrogens
	micronized 17 beta-estradiol
		Estrace and others	Pill and vaginal cream	Vaginal cream for vaginal symptoms only; sourced from plants; estradiol is bioidentical until ingested and converted in the liver to estrone
		Alora, Climara, Esclim, Estraderm, Vivelle and others	Patch	Sourced from plants
		Estrogel	Transdermal gel	Sourced from plants
		Estrasorb	Topical cream	Sourced from plants
		Estring	Vaginal ring	For vaginal symptoms only; sourced from plants
	Estradiol acetate	Femring	Vaginal ring
	Estradiol hemihydrate	Vagifem	Vaginal tablet	For vaginal symptoms only
Micronized progesterone
	Micronized progesterone USP	Prometrium	Pill
		Prochieve 4%	Vaginal gel
Combined preparations
	17 beta-estradiol and norethindrone acetate	Combipatch	Patch	Estradiol is bioidentical but the progestin is not
	17 beta-estradiol and norgestimate	Prefest	Pill
	17 beta-estradiol and levonorgestrel	Climara Pro	Patch

[edit] Uses

BHRT may be used like conventional hormone replacement therapy (CHRT) to reduce the symptoms of menopause. It is also promoted by some practitioners as providing benefits beyond menopausal symptom relief, and improve quality of life, though there is no evidence to support these claims. BHRT is not expected to offer benefits beyond increased bone density, the only demonstrated benefit of CHRT.^[3] In 2002, the Women's Health Initiative study (WHI), which was designed to demonstrate additional benefits, was terminated prematurely after preliminary data indicated increased risks of breast cancer, heart attacks and strokes in older women given CHRT.^[27] BHRT practitioners recommend the use of compounded products because they more closely mimic the ratio of circulating hormones in a woman's body than do commercially manufactured products.^[3] The early termination and subsequent publicity of these previously unappreciated risks led to a decline in prescriptions for CHRT.^[28] BHRT has since been strongly promoted as a natural alternative with fewer risks than CHRT, though there is no evidence to support this claim.

[edit] Components and compounding

Compounding pharmacies use commercially available bulk drugs to create new formulations that differ in form or dosage from those manufactured on a large scale by pharmaceutical companies.^[15] Typically, compounded preparations of BHs may include estriol, estrone, estradiol, testosterone, micronized progesterone, and occasionally dehydroepiandrosterone (DHEA).^[18] They are promoted as natural, safer, and in some cases more efficacious than CHT, but there are no scientific studies to support these claims.^[18] Estimates from sales of bulk hormones for compounding suggest that more than 1 million women may be using compounded BHRT in the US.^[21]

At one time estriol, considered the least potent endogenous estrogen, was considered a safer alternative than other estrogens, and it was hypothesized that it had a protective effect against breast cancer.^[18] In the 1970s, researcher HM Lemon wrote several articles about estriol, kindling enthusiasm for the estrogen even though several followup studies failed to get positive results.^[5][15] While estriol effects are of shorter duration than estradiol, in some ways estriol has been proven to be a strong estrogen.^[11] Estriol is produced endogenously during pregnancy.^[11] Estriol has never been formally approved by the FDA: it was already part of the U.S. Pharmacopeia (USP) prior to the need for approval, and has been used by compounding pharmacies for decades.^[29] Estriol is only used by compounding pharmacies, and is not used in any FDA-approved manufactured product in the US. The FDA is trying to ban the use of oral estriol in the US, but it is commonly prescribed as part of conventional treatments in other countries.^[15]

Estradiol is the form of estrogen most predominant in the cycling woman.^[11] Estrone is the form of estrogen that predominates in the postmenopausal woman, and is converted from other hormones, including estradiol.^[11] Because of the limited research into potency, delivery methods, and conversion of the various estrogens, it is difficult to establish a valid scientific understanding of compounded estrogen products.^[11]

Supplementation of testosterone to improve libido in post-menopausal women is supported by research. The risk is a potential reduction in HDL levels.^[3] There is no commercial source of testosterone for women in the US except for compounding pharmacies.^[5] There is little published data to support dosing, duration and method of administration, though a growing number of physicians are using clinical results and blood levels to guide their treatment.^[12]

[edit] Administration

Hormones can be administered in a variety of ways, including skin and vaginal creams, pills, topical gels, vaginal rings and tablets, and transdermal patches. Though all preparations are molecularly identical before their use, estrogens administered orally are modified by the liver before entering the blood, while those entering through the skin are not. Creams and gels applied to the skin also enter the blood directly and without modification, but it is not clear how much is actually absorbed.^[6] Pharmaceutical compounding is frequently used to modify the dose, form, and additives of the preparations, based on the instructions from a health care practitioner.

[edit] Criticisms

Bioidentical hormone replacement therapy has been criticized in many peer-reviewed sources for making unsubstantiated claims about being effective against a variety of health conditions, for lacking evidence of safety of the compounds, for marketing itself as more "natural" than conventional HRT and for the frequently-associated practices of compounding and saliva testing. Since bioidentical hormones are in fact used in many FDA-approved, standard hormone replacement therapy preparations, the relative advantages and differences between bioidentical and nonbioidentical hormones has been questioned. The primary differences between conventional and bioidentical hormone replacement therapy as popularly promoted mainly involves the testing of blood or saliva-bound estrogen levels and the use of individualized compounding rather than a standard dose, mixture and application of hormones. Saliva testing has not been shown to accurately measure blood-bound hormone levels, and neither approach has any research to support a relationship to symptom relief. The FDA recommends the lowest dose of hormone that effectively relieves symptoms and does not recommend custom-compounding, blood or saliva testing.^[13][19]

Advocates for BHRT have claimed that commonly compounded BHRT preparations are not commercially available, which is not true. Customized compounding does not actually provide customized results since it is aimed at producing a single hormone profile, which has not been demonstrated to be better than conventional hormone replacement therapy and does not consider rate at which individuals will differ in the activity, metabolism and excretion of the hormones.^[18]

[edit] Lack of evidence for claims

Bioidentical hormones have been advertised, marketed and promoted as being a risk-free panacea that is safer than standard HRT.^[11] Some literature reviews suggest benefits and advantages in the use of BHRT over conventional counterparts^[12][13][14] but there is significant skepticism over the claims made about BHRT and many commentators state that there is insufficient evidence to support the claims made with a lack of randomized controlled trials needed to form firm conclusions.^{[3][9][15][18][26]} The United States Food and Drug Association warned that claims about compounded BHRT products are unsupported by medical evidence, unlike claims made by manufacturers of FDA-approved products.^[24] BHRT has been called a "marketing concept" with no scientific backing by the chief medical editor of Endocrine Today^[6][21] and the FDA stated that pharmacies use the term to imply the drugs are natural and have the same effects as hormones made in the body. It has also been claimed that compounded BHRT can prevent or treat diseases such as stroke, Alzheimer’s disease, breast cancer and heart disease. There is no credible evidence to support these claims. Bioidentical hormones and compounded BHRT are expected to have the same risks and benefits as conventional HRT, though the latter has the benefit of being heavily studied and regulated while BHRT has no scientific data to support claims of safety or efficacy.^{[3][6][15][16][17][18][19]} Despite this a variety of specific claims have been made for the effectiveness of bioidentical hormones and BHRT, with varying evidence to support or contradict them:^[3]

Claim	Evidence
Bioidentical hormones fit precisely in receptors while conventional HRT fit 'cockeyed'; this mismatch causes serious side effects[3]	Synthetic progestins and endogenous progesterones have different binding affinities for different receptors depending on the model and animal used; the differing pharmacodynamics have not been associated with specific side effects[3]
The body is unable to metabolize synthetic hormones[3]	The biological half-life for synthetic hormones is between five minutes and two days[3]
Lack of progesterone causes 'estrogen dominance', resulting in irregular or painful, heavy menses[3]	Oral progesterone is no more effective than placebo at alleviating symptoms of premenstrual syndrome[3]
Progesterone can counter-act stress, increases metabolism and decreases abdominal fat[3]	There is no evidence to support weight loss due to progesterone[3]
'Normal' levels of progesterone protect against breast cancer[3]	The claim is based on a single study of infertile patients during child-bearing years; there is some evidence to support a link between hormonal treatment for infertility and a reduced risk of breast cancer, but these benefits may not translate to women seeking relief from the symptoms of menopause[3]
Progesterone therapy can prevent cardiovascular disease, atherosclerosis and raise good cholesterol[3]	The use of micronized progesterone neither increases nor decreases cardiovascular risks[3]
The side effects reported in the Women's Health Initiative study were due to the synthetic nature of the hormones used[3]	"Cardiovascular benefit has not been proven with micronized progesterone in observational or experimental research...a multicenter, case–control study was conducted in postmenopausal women aged 45–70 years to examine potential differences in cardiovascular risk between the subtypes of synthetic progestins and micronized progesterone...Micronized progesterone and pregnane derivatives were not associated with an increased venous thromboembolism risk, whereas norpregnane derivatives...were associated with increased risk of thromboembolism...Thus, certain progestins are associated with increased cardiovascular risk, whereas pregnane derivatives and micronized progesterone neither increase nor decrease cardiovascular risk in the doses studied"[3]
Proponents claim that bioidentical hormones, in addition to the demonstrated benefit of improving bone mineral density, protect the eyes and skin from drying out, regulating the menstrual cycle, improving mental function, improving blood cholesterol and reduce hot flashes and night sweats associated with menopause[3]	There is no published evidence derived from controlled research that supports claims of beneficial effects for bioidentical hormones as compared to conventional hormome therapy. Risk data have been published for conventional hormone therapy, and CHRT is not recommended to manage any chronic diseases or for the prevention of cardiovascular disease.[3]
Estriol can decrease the risk of breast cancer[3]	Estriol has been shown to cause breast cancer cell growth[3]
Pharmacists use their expertise regarding bioidentical hormones to meet the needs of their clients and improve health outcomes[3]	Compounding is a legitemate practice but there is no evidence that clearly illustrates the benefits and risks of BHRT[3]

In 2006 actress Suzanne Somers released the book Ageless: The Naked Truth About Bioidentical Hormones, which endorsed the use of bioidentical hormones. Ageless mentioned one approach, the Wiley Protocol, specifically. The book was criticized by a group of doctors who, though generally supportive of the use of bioidentical hormones, state that more research is required and object to the Wiley Protocol in particular for its potential danger and its creator being unqualified.^[30] Bioidentical hormones have also been discussed on The Oprah Winfrey Show, with Somers as a guest.^[8]

[edit] Safety

Though bioidentical hormones are often claimed to be safer,^[12] they are expected to carry the same risks and benefits of their non-bioidentical counterparts. There have been no studies that directly compare compounded bioidentical hormones with their non-bioidentical counterparts.^[3] Hormones as used in CHRT have been studied for years and their risk, benefit, and effectiveness profiles are demonstrated through years of research.^[4][19]

The Endocrine Society issued a position statement that bioidentical hormones carry essentially the same risks and benefits as non-bioidentical molecules.^[16] The American College of Obstetricians and Gynecologists in February 2009 re-iterated its position from November, 2005 that there was no proven benefits to safety or efficacy of compounded bioidentical hormones, nor is there any benefit to salivary testing of hormone levels or customized dosing of hormones.^[17] The Mayo Clinic states that there is no evidence that pharmacy-compounded BRHT is safer or more effective than conventional hormone replacement, and that some bioidentical hormones are already available in certain FDA-approved products.^[2] The U.S. Food and Drug Administration has warned several pharmacies about making unsubstantiated claims about the safety and effectiveness of compounded hormone products.^[24] The North American Menopause Association has stated that compounded bioidentical hormones have not been approved by the FDA, so there is no guarantee of purity, potency, efficacy or safety, and they may contain unknown contaminants,^[2] and the Australian Menopause Society has similarly stated that there is no evidence that bioidentical hormones administered using lozenges are any safer than their approved counterparts.^[31][32] The International Menopause Society has stated "There are no medical or scientific reasons to recommend unregistered ‘bioidentical hormones’. The measurement of hormone levels in the saliva is not clinically useful. These ‘customized’ hormonal preparations have not been tested in studies and their purity and risks are unknown."^[10]

BHRT has been linked to three cases of endometrial cancer in Australia, with the authors suggesting the ratio of estrogen to progesterone used was inadequate, leading to endometrial hyperplasia and possibly endometrial carcinoma,^[4] as occurs with unopposed use of estrogen in CHRT, as well as bioidentical estradiol unopposed by progesterone causing proliferation of cells in the breast, increasing the risk of breast cancer.^[33]

Erika Schwartz, founder of The Natural Hormone Pharmacy,^[34] and Kent Holtorf, founder of the Holtorf Medical Group^[35] believe there is an evidence base to support a superior safety profile for the bioidentical hormones estradiol and progesterone when compared to non-bioidentical progestins, improved relief of postmenopausal symptoms, bone density and lipoprotein levels in the blood and promote wellness rather than just symptom relief. Schwartz and Holtorf criticized a 2008 review of literature on bioidentical hormones for addressing only compounded bioidentical hormones, and not reviewing FDA-approved bioidentical products, which they believe added to the existing confusion. They conclude that bioidentical hormones are safer than non-bioidentical hormones when administered correctly, and combination therapy using bioidentical estrogens and progesterone has a better safety profile than regimens including a synthetic progestin.^[12] Deborah Moskowitz, a Doctor of Naturopathic Medicine and employee of a company that manufactures a bioidentical preparation^[36] has also published an article claiming BHRT is superior to CHRT.^[14]

[edit] Estriol and estrone

The hormone estriol is frequently compounded into bioidentical preparations. It is claimed that estriol, along with the also-bioidentical estrone, is a weaker and safer estrogen. These claims are not supported by adequate unbiased research.^[11] The claims about estriol are based on research that is several decades old, using animal models rather than humans and often misrepresent the implications and overstate the benefits of the studies, as well as overlooking the risks.^[18] The custom-compounded preparations promoted by BHRT advocates are not FDA-approved. The FDA has acknowledged that they are unaware of any adverse events connected to the use of estriol but ordered pharmacies to discontinue its use.^[13] Estriol's safety and effectiveness is unknown; the agency's Assistant Director of the Office of Compliance has stated that use of the hormone would require a permit for research and application for a new drug.^[37]

[edit] "Natural" claims

Bioidentical hormones are frequently marketed as being "natural", or more natural than conventional HRT. Women who purchase compounded BHRT are more likely to associate the term "natural" with the idea that the hormones are derived from plant sources.^[18] The source and extraction processes used to create bioidentical and nonbioidentical hormones from plants are exactly the same - most are produced through conversion of diosgenin (extracted from soy or yam plants) into progesterone which is used as a hormone chemical precursor. Natural is also used to refer to the hormones being molecularly identical to those found endogenously. The Harvard Women's Health Watch, published by Harvard Medical School, states that the "natural' part of the marketing of BHRT may be a euphemism for "unregulated" rather than safe and state that the term "natural" can technically be used to indicate any product with an animal, plant, or mineral source, and as such applies to hormones that are not bioidentical, including Premarin (a non-bioidentical hormone extracted from the urine of pregnant horses), as well as to the molecules extracted from soybean and yam sources.^[6]

[edit] Salivary testing and compounding

BHRT is frequently associated with testing of saliva to establish a baseline hormone level, and compounding of the substances by pharmacists, on the advice of doctors, to produce preparations and blood-levels of hormones that are individualized to the patients. There is no research that demonstrates there is any benefit to either of these practices.^{[2][3][4][22][15]} Though promoters of BHRT claim that saliva testing can be used to "customize" the level of hormones for individuals, and tests are used to determine which hormones are supposed to be deficient and require supplementation, there is no scientific basis to support the use of saliva testing as estrogens are secreted in pulses within and across days resulting in varying saliva levels.^[18][25] Certain compounding formulations also attempt to use a single profile for all women, with no evidence that a specific profile is beneficial in all cases and no recognition that women differ in their sensitivity to hormones and rate of metabolization. Customizing based on testing also does not account for much of the effects and synthesization of hormones occurs within tissues rather than in the blood, and therefore blood or saliva levels of hormones may not necessarily reflect actual biological activity.^[18] Other concerns include lack of evidence that samples are stable during storage and transportation, poor reproducibility of results, and considerable variability between assays.^[18][25] There are also no studies that link symptoms with blood or saliva levels of hormones,^[15][18] and no evidence clearly linking progesterone to any changes in the endometrium.^[15] The FDA recommends instead adjusting hormone therapy based on the symptoms of the patient,^[11][17][19] and there is no reason to adjust the dosing or monitor patients receiving BHRT.^[38] Skeptics of BHRT have also pointed out that there is also no certainty regarding what level of hormones should be found in the body.^[6] Although promoted as a way of customizing treatment, hormone therapy does not require customization.^[17] and the use of testing to determine the amount of hormones administered could result in the dose used being higher than the minimum recommended level to alleviate symptoms^[15][18] or the administration of unnecessary hormones to asymptomatic women resulting in greater risks to the patient.^[11][15] In addition, analysis of the material used to promote BHRT suggests that rather than basing hormone doses on saliva results, practitioners are actually adjusting the dose based on symptoms.^[25] Health practitioners customize the care of their patients on an ongoing basis by choosing the medication, dose and administration route individually, using approved medications that have a demonstrated safety record and are not subject to the errors and inconsistencies of custom-prepared combinations. In addition, the different bioidentical preparations result in mixtures with different strengths and practitioners using compounded formulations may be unaware of the total dose of hormones their patients receive.^[11]

Boothby, Doering and Kipersztok summarize the issue as being a poor effort to apply principles of pharmacokinetics to achieve individualized dosing for drugs that do not require it.^[25]

[edit] Wiley Protocol

The Wiley Protocol is a controversial type of compounded BHRT endorsed by T. S. Wiley. It attempts to produce serum levels of estradiol and progesterone that are identical to those of a young woman at the various times throughout the menstrual cycle. In contrast, most bioidentical hormone practitioners instead seek to produce consistent estradiol and progesterone levels that are less than the average levels of a normal menstrual cycle. It has been shown that using serum levels to judge the effects of transdermal progesterone can be misleading.^[39] The Wiley Protocol has been criticized by others for a variety of reasons.^{[23][30][40][41][42]}

[edit] Regulatory status in the United States

In October, 2005, Wyeth Pharmaceuticals (which manufactures a variety of nonbioidentical hormone preparations) filed a Citizen Petition with the FDA, alleging that compounding pharmacies were manufacturing new drugs. The FDA responded with a series of enforcement actions against the primarily internet-based pharmacies that were producing compounded BHRT.^[38] In 2008 seven compounding pharmacies that used the term 'bio-identical hormone replacement therapy' were warned by the FDA to stop making unfounded claims about their safety and effectiveness, which were considered false and misleading by the agency^[24] a warning supported by The Endocrine Society and the American Association of Clinical Endocrinologists.^[43] The FDA considers the word bioidentical to be "a marketing term implying a benefit for the drug, for which there is no medical or scientific basis." The FDA also objected to statements that BHRT was better than approved drugs at treating the symptoms of menopause, and to unsubstantiated claims that it could be used to prevent and treat serious medical conditions and diseases including strokes, Alzheimer's and certain cancers. The inclusion of estriol in bioidentical preparations was also problematic as it has not been tested for safety and effectiveness, and is not approved by the FDA for any use.^[24] The FDA has also expressed concern that unfounded claims made about BHRT mislead women and health care professionals. The agency has no regulatory authority over compounding of products when a licensed practitioner prescribes a compounded product.^[44]

Pharmacy compounding of BHRT is not regulated by the FDA, but is regulated by the boards of pharmacies for each state. Pharmacists can adjust the doses and delivery methods of compounded BHRT according to a doctor's prescription.^[45]

[edit] History

Bioidentical hormones were first used for menopausal symptom relief in the 1930s,^[18] after Canadian researcher J.B.Collip developed a method to extract an orally active estrogen from the urine of pregnant women, subsequently marketed as the active agent in a product called Emmenin.^[46][47] It was supplanted on the market when its maker, Ayerst (later Wyeth Pharmaceuticals) began producing the more easily manufactured conjugated equine estrogens in 1941 under the name Premarin, and by 1992 Premarin was the most widely prescribed drug in the United States.^[48]

In the 1970s, research and reports indicating risks from synthetic conjugated estrogens were published. Investigation determined that the addition of a progestogen to estrogen treatment reduced the risks. As early as 1980, the British Medical Journal recommended oral bioidentical progesterone as an option when side effects from synthetic progestogens necessitated discontinuation of treatment. Starting in 1980, side effects caused by synthetic progestin use prompted more research into bioidentical progesterone.^[12] In May of 1998 the FDA approved Prometrium, an oral progesterone product produced by Solvay Pharmaceutical.^[49]

One of the first proponents of the use of bioidentical hormone therapy was John R. Lee.^[18] He believed that "estrogen dominance" contributed to breast cancer, fibroids, fibrocystic breasts, premenstrual syndrome, osteoporosis, and other conditions. His claims, which lack scientific validation, began a belief in progesterone as a panacea for ills.^[15] Another proponent of bioidentical hormone therapy, Jonathan V. Wright^[50] wrote a number of books on the topic and was one of the developers of the BHRT compound Tri-Est (released in 1982) comprised of 80% estriol, 10% estradiol, and 10% estrone.^[18]

[edit] Footnotes

[edit] External links

• Senate Hearings on Bioidentical Hormones: Sound Science or Bad Medicine? by the United States Senate Special Committee on Aging