Bioidentical hormone replacement therapy (HRT) for women refers to either the replacement of estrogen in postmenopausal women, or the replacement of progesterone in women who have a uterus or have not had a hysterectomy.
This therapy also makes it possible to replace testosterone in women who are in perimenopausal or menopausal and complain about a decrease in libido and energy.
Unlike synthetic hormones, bioidentical hormone replacement therapy administered via subcutaneous implants involves the use of bioidentical estrogen (17B-estradiol), which has a molecular structure identical to the hormones produced by the ovaries.
Hormone replacement therapy for women using subcutaneous pellet implants can also be performed with a low dose of bioidentical testosterone. This procedure can be done at the same time as HRT for estrogen.
Hormone replacement therapy can also be administered orally.
For HRT, does it matter how the estrogen is administered?
In short, yes. Here’s how the various types of hormone replacement therapy affect treatment:
If the medication is administered orally, it must be taken every day. Additionally, it must pass through the liver, which increases the risk of hypercoagulability and thrombophlebitis. It can also cause nausea and digestion issues. Finally, oral medication can increase inflammatory markers, SHBG, triglycerides and blood pressure.
If using transdermal or vaginal administration, the medication must be applied once or twice a day. There’s also a risk of skin irritation. Moreover, about 45% of women don’t absorb it sufficiently. There’s also a risk of transmission to others.
At one time, it could be injected, but this method is now rarely used because of its inconsistent release in the body.
If hormone replacement therapy is administered subcutaneously using pellets or implants, this method guarantees a steady release of hormones over the course of several months. Patients may feel some discomfort during the insertion or if rejection occurs. However, there are very few restrictions during the recovery period in the days following the implantation.
If the medication is administered orally, it must be taken every day. Additionally, it must pass through the liver, which increases the risk of hypercoagulability and thrombophlebitis. It can also cause nausea and digestion issues. Finally, oral medication can increase inflammatory markers, SHBG, triglycerides and blood pressure.
If using transdermal or vaginal administration, the medication must be applied once or twice a day. There’s also a risk of skin irritation. Moreover, about 45% of women don’t absorb it sufficiently. There’s also a risk of transmission to others.
At one time, it could be injected, but this method is now rarely used because of its inconsistent release in the body.
If hormone replacement therapy is administered subcutaneously using pellets or implants, this method guarantees a steady release of hormones over the course of several months. Patients may feel some discomfort during the insertion or if rejection occurs. However, there are very few restrictions during the recovery period in the days following the implantation.
What are the benefits of bioidentical hormone replacement therapy for women using implants?
- It’s a physiological replacement therapy
- It uses bioidentical hormones
- It’s biologically active
- It gets absorbed directly
- It’s effective because it maintains stable blood levels
- It doesn’t have peaks during the day
- It has minimal side effects
- It’s practical because it lasts for 3 to 4 months
- It can lower cholesterol and triglyceride levels
- It can improve sensitivity to insulin
- It’s not associated with weight gain
- It’s the best method for improving bone density
- It doesn’t increase inflammatory markers and SHBG
- It doesn’t increase the risk of breast cancer
- It doesn’t create a risk of blood clots, thrombophlebitis, heart attack or stroke
How does bioidentical hormone replacement therapy using subcutaneous implants work?
- An estrogen pellet is made of pure estradiol.
- The pellets are compressed using thousands of pounds of pressure, then sterilized by E-Beam (not autoclave).
- They’re manufactured by a specialized pharmacy.
- Quality control is performed by an independent pharmacy.
- They become effective about 10 days after implantation and can last between 3 and 4 months.
- Their absorption isn’t based on a predetermined duration, but rather on the person’s heart rate and blood pressure. This means the duration of the implant’s efficacy can vary depending on how much physical activity the woman engages in. Active women, especially runners, will benefit from the treatment for about 3 months, whereas women who are less active will draw less estrogen from the pellets and cause them to last closer to 4 months.
What’s the process for women to be considered for hormone replacement therapy?
- You’ll have an initial consultation with a urologist at one of our clinics. You’ll discuss your medical history and current symptoms. At the end of the appointment, if you’re a candidate for this procedure, you’ll be given a referral for blood work.
- A follow-up appointment will be scheduled one month later. If the results confirm that you’re a candidate for hormone replacement therapy, a nurse will explain the bioidentical hormone treatment. You’ll also be asked to fill out a questionnaire about your symptoms. This appointment should take about 30 minutes.
- You’ll then schedule an appointment to have the implants inserted.
What can you expect during hormone replacement therapy using pellet implants?
- First, you’ll be greeted by a nurse. The dosage of estrogen and/or testosterone you need will be determined using a computer program. The amount is based on your blood test results and symptoms.
- You’ll lie on your side or on your stomach, and a local anesthetic will be administered by your urologist at the implantation site and in the subcutaneous path above the gluteal fold. The urologist will then make a small incision and insert a trocar through which the estrogen and/or testosterone implants will be inserted into the subgluteal fat. The urologist will finish the procedure by applying bandages as needed.
- A nurse will apply pressure to the site for 7 minutes. During this time, you’ll be given instructions and recommendations for your recovery.
- A blood test will be scheduled for 6 weeks after the initial procedure.
- A follow-up phone call with a nurse will be made after 2 months of treatment to re-evaluate your symptoms and blood test results. If the test results show that your prescription needs to be adjusted, your urologist will make the necessary changes. It’s always a good idea to book your follow-up in advance.
- At any time during your treatment, you can call the clinic to schedule a phone consultation with a nurse if you have questions or feel that your treatment may need to be adjusted.
What are the disadvantages of bioidentical hormone replacement therapy using pellet implants?
- It’s a procedure that requires local anesthesia
- There may be some discomfort when the implants are inserted
- There’s a minor risk of bleeding and infection
- There’s a minor risk of implant rejection
- You’ll need to avoid exercise, especially physical activity involving the legs, for 48 hours
- This treatment isn’t covered by RAMQ or most private insurance plans
What steps need to be taken to prepare for the procedure?
No special preparation is required prior to this procedure.
What steps should be taken following an implantation procedure for bioidentical hormone replacement therapy for women?
- The insertion site will be covered with two layers of bandages. The external layer can be removed any time after 24 hours. It should be removed as soon as any blood soaks through. Remove the 2nd layer (the foam tape) 3 days after the procedure.
- We recommend placing an ice pack over the insertion site for 20 minutes every two hours for the first 24 hours.
- Don’t take a bath, sit in a hot tub or swim in a pool for 3 days. You can shower, but don’t scrub the area until the incision has fully healed (about 7 days).
- Don’t engage in exercise that could affect the area around the incision for the first 3 days. This includes running, using an elliptical and doing squats or lunges.
- The sodium bicarbonate in the anesthetic may cause swelling around the area for 1 to 3 days. This is normal.
- The implantation site may be uncomfortable for 2 to 3 weeks. If you experience itching or redness, you can take Benadryl for relief (50 milligrams orally every 6 hours). However, you must be careful, as this may cause drowsiness.
- You may experience bruising, swelling and/or redness around the implantation site. This can last anywhere from a few days to 2 to 3 weeks.
- You may notice some pink or red discolouration on the outer bandage. This is normal.
- If the incision begins to bleed, apply firm pressure to it for 5 minutes.
- If the bleeding doesn’t stop after applying pressure or if there’s pus around the wound, call a nurse at our clinic using the phone number provided on your post-operative care instructions.
References
Rahmani, A. & al. (2022). Sexual Function and Mood Disorders Among Menopausal Women: A Systematic Scoping Review. The Journal of Sexual Medicine, 19(7), 1098-1115.
Davis S. R. & al. Global Consensus Position Statement on the Use of Testosterone Therapy for Women. J Clin Endocrinol Metab, October 2019, 104(10):4660–4666
Breast Cancer Incidence Reduction in Women Donovitch G., Cotten M. Breat Cancer Reduction in Women Treated with Subcutaneous Testosterone: Testosterone Therapy and Breast Cancer Incidence Study. Eur J Breast Health 2021; 17(2): 150-156