Q & A: Bioidentical Hormone Replacement

Schroeder_Elise_webMy health care provider has prescribed bio identical hormone replacement therapy for me. She is recommending I take them sublingually, or under the tongue. Can you explain to me the difference between taking my hormone replacement under the tongue, swallowing it, or using it topically?

Dr. Schroeder’s Answer

Bio identical hormones are commonly produced at a compounding pharmacy.  The pharmacy can make formulas in many different methods. No matter which method you utilize to take your hormones, once they reach your blood stream they are able to travel to all the tissues in your body, including the uterus, breast, skin, and brain, etc.

Oral: Pills that you swallow. When hormones are given this way, they first pass through your digestive system before they enter your blood stream. As they filter through your liver, much of the hormone is metabolized or “digested” into metabolites that are similar but slightly different than the original hormone.  Depending on the hormone, and your condition, these metabolites might be beneficial.  For example, progesterone can be specifically prescribed orally when insomnia is a complaint.  The progesterone metabolites produce a relaxing effect in the brain that can help with sleep.  On the other hand, estrogen given orally can have harmful effects.  Estrogen metabolites produced by the liver have been shown to cause increased blood clotting and increased risk of stroke.

Sub-lingual or Troche:  Drops, lozenges, or quick dissolving tabs placed under the tongue.  Hormones delivered sublingually are mostly absorbed into the blood stream directly from the mouth.  Some portion, however, will be swallowed and therefore be digested or metabolized by the digestive system.

Topical, Creams, Gels, Patches: Hormones applied to the skin as a cream, gel or patch.  When applied to the skin, hormones skip the digestive process.  These hormones are absorbed through the skin and directly into the blood stream. Doses for topical applications of hormones should be much lower than what you would take orally (as a pill).  Patches tend to have the longest acting effect.  When applied, the patch distributes the hormones slowly throughout the day.  The hormones can be more stable when used this way because of this unique ability to be constantly distributed.

Vaginal creams or vaginal ring: Essentially topical hormones.  When applied vaginally, hormones are absorbed directly into the tissue and the blood stream, just like any topical hormone application.  There is a local tissue effect, and this is why vaginal hormones are frequently prescribed to alleviate vaginal symptoms like dryness.

Injections: Hormones are injected with a needle into a muscle. When hormones are given as in injection they are absorbed very quickly into the blood stream.  However, they are usually mixed with a substance that slows the absorption, making it possible to use injections at 2-4 week intervals. Despite this slow release substance, hormone levels tend to be very high right after the injection and then decline sharply, leading to a return in hormone deficiency symptoms.