Functional Medicine Bioidentical Hormone Replacement Therapy (BHRT) Workup
A comprehensive BHRT workup should include thorough hormone testing, evaluation of symptoms, and consideration of appropriate bioidentical hormone formulations, with treatment decisions based on laboratory findings and clinical presentation rather than salivary hormone testing alone.
Initial Hormone Assessment
The recommended hormone panel for BHRT workup should include:
- Morning cortisol and ACTH levels 1
- TSH and free T4 1
- Comprehensive electrolyte panel 1
- For females: FSH, estradiol, and progesterone 1
- For males: LH and testosterone 1
- DHEA levels (if low libido or energy concerns) 1
Imaging and Additional Testing
- Consider MRI of brain with pituitary/sellar cuts for patients with multiple hormonal deficiencies or new severe headaches 1
- Standard-dose ACTH stimulation testing for indeterminate cortisol results (AM cortisol between 3-15 mg/dL) 1
- Bone mineral density testing for patients with estrogen deficiency 1
Treatment Approach
Estrogen Replacement
- 17β-estradiol is preferred over ethinylestradiol or conjugated equine estrogens 1, 2
- Transdermal delivery is recommended, particularly for patients with hypertension 1
- Typical dosing: Transdermal estradiol patches 0.05 mg/day applied twice weekly 2
Progesterone Replacement
- Required for women with intact uterus to prevent endometrial hyperplasia 1, 2
- Micronized progesterone (200 mg daily for 12-14 days per month) is preferred due to safer pharmacological profile 1, 2
Testosterone and DHEA Supplementation
- Consider DHEA replacement for women with low libido and/or energy after other hormones are optimized 1
- Androgen treatment should be limited to 24 months with evaluation at 3-6 months 1
- Women should be informed that androgen treatment has limited supporting data and unclear long-term health effects 1
Monitoring Protocol
- Initial follow-up at 3 months after starting therapy 2
- Annual clinical review thereafter, focusing on compliance 1, 2
- No routine monitoring tests required unless prompted by specific symptoms 1
- For androgen therapy: evaluate treatment effect after 3-6 months 1
Important Considerations and Cautions
Evidence-Based Approach
- Limited evidence supports individualized hormone dosing based on salivary hormone concentrations 3
- Compounded bioidentical hormones have no proven advantage over conventional FDA-approved hormone therapies 3
Contraindications
- Active liver disease 2
- History of breast cancer 1, 2
- History of coronary heart disease 2
- Previous venous thromboembolism or stroke 2
Risk Management
- Combined estrogen/progestogen therapy increases breast cancer risk when used >3-5 years 2
- Venous thromboembolism risk is highest in the first year of use (RR 3.49) 2
- Transdermal estradiol has lower thromboembolism risk compared to oral formulations 1
Special Populations
Women with Premature Ovarian Insufficiency (POI)
- HRT is indicated for symptom relief and may have cardiovascular and bone protection benefits 1
- HRT has not been found to increase breast cancer risk before the age of natural menopause 1
Women with Endometriosis
- Combined estrogen/progestogen therapy can effectively treat vasomotor symptoms and may reduce disease reactivation risk 1
Women with Migraines
- Migraine is not a contraindication to HRT 1
- Consider changing dose, route of administration, or regimen if migraines worsen during HRT 1
By following this structured approach to BHRT workup and treatment, clinicians can provide evidence-based hormone replacement therapy that addresses symptoms while minimizing risks.