BHRT: Ignorance Is Not Bliss

The clinical appropriateness of bioidentical hormone replacement therapy (BHRT) has been ignored by many pharmacists, albeit unintentionally. Yet, this therapy may offer patients a significant opportunity and hope for a better quality of life. Perceptive and frustrated women have been seeking help for the age-old problem of hormonal imbalances for years. Perhaps BHRT represents one of the best opportunities for pharmacists to promote recognition of their services while contributing to public health.

There appear to be several reasons why pharmacists have not paid much attention to BHRT. Compounding pharmacists make up only a fraction of practicing pharmacists. These pharmacists generally are well aware of the many women relentlessly seeking help for the symptoms of hormonal imbalance, while other pharmacists may not be.

Evidence-based medicine is the standard that most clinical pharmacists aspire to follow. Historically, evidence-based research concerning BHRT has been sparse. Thus, pharmacists have found it challenging to make recommendations when asked by prescribers for assistance and advice. Among the most difficult questions are those concerning the so-called sex hormones.

It is obvious, however, that women perceive some beneficial effects from BHRT. It is common for women to call several days in advance for their BHRT prescriptions, leaving strict instructions that they will be in at exactly 4:33 ^PM on Friday and to have the medication ready when they walk in.

Studies have been lacking. Pharmaceutical companies, a significant source of funding, have not sponsored them because the subject hormones are not patentable. Since manufacturers also are a significant source of continuing education for pharmacists, there have been few educational opportunities available. After all, it is not usually in their fiduciary interest to sponsor studies on medications that cannot be protected by patents or those that may reduce the market for medications they already sell. Only in the last few years has there been an increase in studies concerning BHRT sponsored by the government and others.

Depending on the practice environment, pharmacists have not given much thought to BHRT. Institutional or hospital-based pharmacists seldom deal with questions or patients involving chronic conditions such as osteoporosis, menopausal, or posthysterectomy symptoms, for example. The average length of inpatient stay is only a few days, and most of these pharmacists do not follow patients on an outpatient basis.

Retail or community-based pharmacists not involved in compounding have little incentive to educate themselves about BHRT, because they dispense only commercially available pharmaceuticals. Historically, time that was allowed for counseling patients has been minimized because it has not been reimbursable. This is an issue for most pharmacists.

Curricula in pharmacy schools probably have not placed as much emphasis on BHRT as on other significant health issues, such as pain management. Why this occurs remains a mystery to some. Both of these issues represent areas where the profession of pharmacy could make significant contributions. Fortunately, curricula are improving.

The science is there, however, and pharmacists can help communicate the knowledge to patients and health care practitioners. Some fundamental concepts that could be emphasized include the fact that progesterone is unique and not the same as medroxyprogesterone or other progestins. The 3 primary forms of physiologic estrogen are estriol, estradiol, and estrone, and they are functionally different from each other and from other sources of estrogens. Another commonly missed concept is that endogenous estrogens work in concert with progesterone, and maintaining the correct balance between them is paramount to therapeutic success and patient well-being.

Outstanding resources for BHRT information are various issues of the International Journal of Pharmaceutical Compounding and its associated Web sites, such as www.ijpc.com and www. compoundingtoday.com. Articles on basic hormone physiology and BHRT hormone compounding and formulas are readily available for study.

If pharmacists really understood the significance and ability of BHRT to improve the quality of life for their family and friends as well as their patients, they would surely make every effort to remove the "ignore" from the "ignorance" surrounding BHRT.

Dr.Vance is a pharmacist consultant with the International Journal of Pharmaceutical Compounding based in Broken Arrow, Okla.