A Bioidentical Balancing Act

No woman looks forward to menopause (except, perhaps, for the cessation of menses). The "change of life" brings with it hot flashes, night sweats, mood swings, sleep disturbances, and loss of libido. Menopausal women are often miserable, and those around them may suffer secondhand.

It's no wonder, then, that women seek relief from their symptoms. But since the Women's Health Initiative hormone replacement therapy (HRT) trials ended abruptly in 2002, menopausal women and their clinicians have abandoned conventional HRT in droves. That left a huge void: How could women ease their transition through menopause? What could clinicians offer that was safe and effective?

Into the gap rose bioidentical hormones. Touted by proponents as superior to their conventional HRT counterparts, bioidenticals have seen a surge in use for menopausal symptoms. But not everyone is convinced by these claims—nor by the expanded use of bioidenticals as a veritable "fountain of youth."

Are women succumbing to the allure of feeling younger and more vibrant in their later years? Or are we just waiting for the science to catch up with the not-so-conventional wisdom?

A Question of Quality, Part 1
Stephen Nunn, MPAS, PA-C, has been in practice for 35 years, almost entirely in women's health (obstetrics and gynecology, as well as infertility). And he has a pretty radical perspective on menopause.

"There is nothing natural about it," he says. "If you look back, in 1910, average life expectancy for women in the US was 47. It's only in the past 75 years or so that women have lived long enough to spend a significant amount of their time—a third of their lives—in menopause."

For years, Nunn saw women with menopause and other hormonal issues for whom he couldn't do enough. "Based on the guidelines I was given, I couldn't really effect significant change for a lot of them," he says. "They would come in complaining that they felt a little better, but the available treatment didn't really do the job. And yet we were at what was considered the maximum dosing."

Some of those patients pursued other avenues of treatment—namely, bioidentical hormones—and reported back to Nunn how well they were doing and how happy they were. So when he was looking for a change, Nunn joined (full disclosure) SottoPelle, a Scottsdale, Arizona–based practice dedicated to bioidentical HRT in pellet form.

Although he has a vested interest in promoting bioidentical HRT, Nunn does raise an intriguing point when he notes that the ovary is "the only endocrine organ that gets ignored when it stops functioning." By contrast, he points to the avalanche of new products that address andropause, which is treated long-term.

"I think the quality-of-life issue, as well as the health benefits, say that we really should be treating women with—my bias—bioidentical hormones for the rest of their lives," he concludes.

His viewpoint is shared by independent clinicians. In her Covington, Louisiana, practice, Pamela Egan, FNP-C, CDE, focuses on wellness and preventive medicine. Egan completed a fellowship with the American Academy of Anti-Aging and Regenerative Medicine and will receive her master's degree in Metabolic and Nutritional Medicine within the next six months. Bioidentical HRT is a component of her patient care plan.

"It's all about keeping the body balanced nutritionally and metabolically—that is going to slow down aging, which ultimately will prevent disease," she says. "I have patients who come in and say they can't sleep at night, they're depressed, they have no libido, they have hot flushes. When we get everything balanced, they have much better quality of life. They sleep better, they want sex again, their hot flushes are gone, and anxiety and depression are diminished or alleviated altogether."

Egan isn't a fan of the term anti-aging because, she says, its use in relation to cosmeceutical products has made it "sound a little flaky." What she is trying to achieve with her patients is a lifestyle change through a holistic approach that includes nutrition and weight loss in addition to hormonal balance. "Once people are balanced," she says, "many of them get off their diabetes meds, blood pressure pills, cholesterol pills."

Major medical organizations, such as the American College of Obstetricians and Gynecologists (ACOG) and the American Association of Clinical Endocrinologists (AACE), have a very different position on the role of bioidentical hormones. And this is where a degree of confusion creeps in, because "bioidentical hormone replacement therapy is not really an FDA-recognized term," says Jennifer Hofmann Ribowsky, MS, RPA-C, Academic Faculty/Pre-clinical Coordinator of the Pace University–Lenox Hill Hospital Physician Assistant Program in New York. "It's more a term used for marketing purposes."

That said, bioidentical hormones are essentially plant-derived hormones that are chemically similar or structurally identical to those produced by the body. And there are FDA-approved estrogen and progesterone products that are technically considered naturally occurring or bioidentical.

But traditionally, the term bioidentical hormones has referred to compounded preparations. The reservations, if not downright concerns, of groups such as ACOG and AACE generally relate to two factors: the origins of the bioidentical hormones (FDA-approved products vs compounded products) and how they are used.

Compounding is performed by a licensed pharmacist to specifications prescribed by a health care provider. But compounded products are not regulated by the FDA (they are regulated by the states), and by their nature are not standardized (though the raw materials are US Pharmacopeia–approved products). Therefore, issues of quality—purity and potency—may arise, and there is a lack of safety and efficacy data.

For example, when a clinician prescribes an estradiol patch in a dosage of "0.05 mg per 24 hours," that is precisely what the patient will receive from an FDA-approved product. "It's standardized, so you have that level of comfort that when you're prescribing a certain amount, that's what the patient is getting," Ribowsky says. "That's not always the case with compounded products."

In an August 2012 opinion paper, committees from ACOG and the American Society for Reproductive Medicine concluded that evidence in favor of bioidentical (ie, compounded) HRT was insufficient: "Patients should be counseled that menopausal hormone therapies that are proved to be safe and effective by the FDA are more appropriate for their use than individual pharmacy-compounded preparations."

But in practice, there may be additional considerations. "I leave it up to the patient whether they want compounded bioidentical hormones or FDA-approved bioidentical hormones," Egan says (though she recommends bioidenticals over synthetics). "If a patient doesn't have insurance and has to pay out of pocket, obviously it's financially feasible to get them compounded."

What's Appropriate?
In a 2007 position statement that also recommended "FDA-approved commercially available hormonal preparations," AACE added the proviso that these should be prescribed "following the guidelines published by the various medical societies." This is where the discussion of bioidentical hormones enters the grayest area.

"Estradiol and progesterone are used for the management of vasomotor symptoms that are troubling to the patient, and they should be used within usually the first five years of menopause—the lowest dose, for the shortest amount of time," Ribowsky summarizes. "In terms of being a fountain of youth or a way to stay or look younger, there's not really any support for those types of claims. They're not even studied for that purpose."

Neither Egan nor Nunn refers to a "fountain of youth"; their aim is to keep patients healthy and feeling better. (Although, yes, patients often comment that they feel younger, too.) Both emphasize that patients are monitored and HRT is adjusted accordingly. As Nunn says, the goal is physiologically normal levels—literally replacing lost hormones—not bodybuilder levels.

In terms of safety, Nunn in particular defends estrogen. "If you go back to the Women's Health Initiative study, the one that was 'the estrogen sky is falling,'" he says, "the women who were taking only the [conjugated estrogen] product didn't have an increased risk for breast cancer—only the women who were on the [estrogen plus progestin]. So you really can't blame the estrogen here."

Egan says she doesn't prescribe oral estrogen products because "it's too hard on the liver. The liver methylates it to estrone, which can increase risk for breast cancer."

In terms of cardiovascular risk, Nunn also prefers nonoral routes of administration for estrogen. "If you absorb your estrogen, it doesn't increase your clotting factors, because you avoid the first pass through the liver," he says. "So absorbed estrogen—patches, creams, pellets—doesn't increase your risk for stroke and heart attack."

Even so, patients are encouraged to have regular health screenings, as appropriate. "We certainly have our patients continue to get bone mineral density scans, keep current on their mammograms and Pap smears, and follow all the other things you should do for good health maintenance," Nunn says.

One point on which everyone agrees is the need for additional research to establish what benefits bioidentical HRT offers. The Cochrane Collaboration is expected to publish a review later this year that examines the evidence on bioidentical hormones for vasomotor symptoms; that may shed some light on their safety and efficacy. But Ribowsky, for one, would like to see some head-to-head randomized controlled trials comparing bioidentical HRT with conventional HRT.

"I think when we have studies like that available, we can make recommendations to our patients more clearly and more confidently," she says.

Egan notes that everything she learned in her fellowship was based on available evidence, but wonders if additional research would alter the view of organizations such as ACOG. "I'm just sad to say that the FDA and ACOG are about 20 years behind the times," she says, adding that insurance companies also send her letters requesting that she use conjugated estrogen preparations instead of (FDA-approved) bioidenticals.

"I'm not going to do anything to harm my patients, and we know those drugs cause breast cancer," she adds. "Why would I use those? I think the biggest thing is that we have to identify the difference between synthetic chemicals and the bioidentical hormones in the right form."

No woman looks forward to menopause (except, perhaps, for the cessation of menses). The "change of life" brings with it hot flashes, night sweats, mood swings, sleep disturbances, and loss of libido. Menopausal women are often miserable, and those around them may suffer secondhand.

It's no wonder, then, that women seek relief from their symptoms. But since the Women's Health Initiative hormone replacement therapy (HRT) trials ended abruptly in 2002, menopausal women and their clinicians have abandoned conventional HRT in droves. That left a huge void: How could women ease their transition through menopause? What could clinicians offer that was safe and effective?

Into the gap rose bioidentical hormones. Touted by proponents as superior to their conventional HRT counterparts, bioidenticals have seen a surge in use for menopausal symptoms. But not everyone is convinced by these claims—nor by the expanded use of bioidenticals as a veritable "fountain of youth."

Are women succumbing to the allure of feeling younger and more vibrant in their later years? Or are we just waiting for the science to catch up with the not-so-conventional wisdom?

A Question of Quality, Part 1
Stephen Nunn, MPAS, PA-C, has been in practice for 35 years, almost entirely in women's health (obstetrics and gynecology, as well as infertility). And he has a pretty radical perspective on menopause.

"There is nothing natural about it," he says. "If you look back, in 1910, average life expectancy for women in the US was 47. It's only in the past 75 years or so that women have lived long enough to spend a significant amount of their time—a third of their lives—in menopause."

For years, Nunn saw women with menopause and other hormonal issues for whom he couldn't do enough. "Based on the guidelines I was given, I couldn't really effect significant change for a lot of them," he says. "They would come in complaining that they felt a little better, but the available treatment didn't really do the job. And yet we were at what was considered the maximum dosing."

Some of those patients pursued other avenues of treatment—namely, bioidentical hormones—and reported back to Nunn how well they were doing and how happy they were. So when he was looking for a change, Nunn joined (full disclosure) SottoPelle, a Scottsdale, Arizona–based practice dedicated to bioidentical HRT in pellet form.

Although he has a vested interest in promoting bioidentical HRT, Nunn does raise an intriguing point when he notes that the ovary is "the only endocrine organ that gets ignored when it stops functioning." By contrast, he points to the avalanche of new products that address andropause, which is treated long-term.

"I think the quality-of-life issue, as well as the health benefits, say that we really should be treating women with—my bias—bioidentical hormones for the rest of their lives," he concludes.

His viewpoint is shared by independent clinicians. In her Covington, Louisiana, practice, Pamela Egan, FNP-C, CDE, focuses on wellness and preventive medicine. Egan completed a fellowship with the American Academy of Anti-Aging and Regenerative Medicine and will receive her master's degree in Metabolic and Nutritional Medicine within the next six months. Bioidentical HRT is a component of her patient care plan.

"It's all about keeping the body balanced nutritionally and metabolically—that is going to slow down aging, which ultimately will prevent disease," she says. "I have patients who come in and say they can't sleep at night, they're depressed, they have no libido, they have hot flushes. When we get everything balanced, they have much better quality of life. They sleep better, they want sex again, their hot flushes are gone, and anxiety and depression are diminished or alleviated altogether."

Egan isn't a fan of the term anti-aging because, she says, its use in relation to cosmeceutical products has made it "sound a little flaky." What she is trying to achieve with her patients is a lifestyle change through a holistic approach that includes nutrition and weight loss in addition to hormonal balance. "Once people are balanced," she says, "many of them get off their diabetes meds, blood pressure pills, cholesterol pills."

Major medical organizations, such as the American College of Obstetricians and Gynecologists (ACOG) and the American Association of Clinical Endocrinologists (AACE), have a very different position on the role of bioidentical hormones. And this is where a degree of confusion creeps in, because "bioidentical hormone replacement therapy is not really an FDA-recognized term," says Jennifer Hofmann Ribowsky, MS, RPA-C, Academic Faculty/Pre-clinical Coordinator of the Pace University–Lenox Hill Hospital Physician Assistant Program in New York. "It's more a term used for marketing purposes."

That said, bioidentical hormones are essentially plant-derived hormones that are chemically similar or structurally identical to those produced by the body. And there are FDA-approved estrogen and progesterone products that are technically considered naturally occurring or bioidentical.

But traditionally, the term bioidentical hormones has referred to compounded preparations. The reservations, if not downright concerns, of groups such as ACOG and AACE generally relate to two factors: the origins of the bioidentical hormones (FDA-approved products vs compounded products) and how they are used.

Compounding is performed by a licensed pharmacist to specifications prescribed by a health care provider. But compounded products are not regulated by the FDA (they are regulated by the states), and by their nature are not standardized (though the raw materials are US Pharmacopeia–approved products). Therefore, issues of quality—purity and potency—may arise, and there is a lack of safety and efficacy data.

For example, when a clinician prescribes an estradiol patch in a dosage of "0.05 mg per 24 hours," that is precisely what the patient will receive from an FDA-approved product. "It's standardized, so you have that level of comfort that when you're prescribing a certain amount, that's what the patient is getting," Ribowsky says. "That's not always the case with compounded products."

In an August 2012 opinion paper, committees from ACOG and the American Society for Reproductive Medicine concluded that evidence in favor of bioidentical (ie, compounded) HRT was insufficient: "Patients should be counseled that menopausal hormone therapies that are proved to be safe and effective by the FDA are more appropriate for their use than individual pharmacy-compounded preparations."

But in practice, there may be additional considerations. "I leave it up to the patient whether they want compounded bioidentical hormones or FDA-approved bioidentical hormones," Egan says (though she recommends bioidenticals over synthetics). "If a patient doesn't have insurance and has to pay out of pocket, obviously it's financially feasible to get them compounded."

What's Appropriate?
In a 2007 position statement that also recommended "FDA-approved commercially available hormonal preparations," AACE added the proviso that these should be prescribed "following the guidelines published by the various medical societies." This is where the discussion of bioidentical hormones enters the grayest area.

"Estradiol and progesterone are used for the management of vasomotor symptoms that are troubling to the patient, and they should be used within usually the first five years of menopause—the lowest dose, for the shortest amount of time," Ribowsky summarizes. "In terms of being a fountain of youth or a way to stay or look younger, there's not really any support for those types of claims. They're not even studied for that purpose."

Neither Egan nor Nunn refers to a "fountain of youth"; their aim is to keep patients healthy and feeling better. (Although, yes, patients often comment that they feel younger, too.) Both emphasize that patients are monitored and HRT is adjusted accordingly. As Nunn says, the goal is physiologically normal levels—literally replacing lost hormones—not bodybuilder levels.

In terms of safety, Nunn in particular defends estrogen. "If you go back to the Women's Health Initiative study, the one that was 'the estrogen sky is falling,'" he says, "the women who were taking only the [conjugated estrogen] product didn't have an increased risk for breast cancer—only the women who were on the [estrogen plus progestin]. So you really can't blame the estrogen here."

Egan says she doesn't prescribe oral estrogen products because "it's too hard on the liver. The liver methylates it to estrone, which can increase risk for breast cancer."

In terms of cardiovascular risk, Nunn also prefers nonoral routes of administration for estrogen. "If you absorb your estrogen, it doesn't increase your clotting factors, because you avoid the first pass through the liver," he says. "So absorbed estrogen—patches, creams, pellets—doesn't increase your risk for stroke and heart attack."

Even so, patients are encouraged to have regular health screenings, as appropriate. "We certainly have our patients continue to get bone mineral density scans, keep current on their mammograms and Pap smears, and follow all the other things you should do for good health maintenance," Nunn says.

One point on which everyone agrees is the need for additional research to establish what benefits bioidentical HRT offers. The Cochrane Collaboration is expected to publish a review later this year that examines the evidence on bioidentical hormones for vasomotor symptoms; that may shed some light on their safety and efficacy. But Ribowsky, for one, would like to see some head-to-head randomized controlled trials comparing bioidentical HRT with conventional HRT.

"I think when we have studies like that available, we can make recommendations to our patients more clearly and more confidently," she says.

Egan notes that everything she learned in her fellowship was based on available evidence, but wonders if additional research would alter the view of organizations such as ACOG. "I'm just sad to say that the FDA and ACOG are about 20 years behind the times," she says, adding that insurance companies also send her letters requesting that she use conjugated estrogen preparations instead of (FDA-approved) bioidenticals.

"I'm not going to do anything to harm my patients, and we know those drugs cause breast cancer," she adds. "Why would I use those? I think the biggest thing is that we have to identify the difference between synthetic chemicals and the bioidentical hormones in the right form."

No woman looks forward to menopause (except, perhaps, for the cessation of menses). The "change of life" brings with it hot flashes, night sweats, mood swings, sleep disturbances, and loss of libido. Menopausal women are often miserable, and those around them may suffer secondhand.

It's no wonder, then, that women seek relief from their symptoms. But since the Women's Health Initiative hormone replacement therapy (HRT) trials ended abruptly in 2002, menopausal women and their clinicians have abandoned conventional HRT in droves. That left a huge void: How could women ease their transition through menopause? What could clinicians offer that was safe and effective?

Into the gap rose bioidentical hormones. Touted by proponents as superior to their conventional HRT counterparts, bioidenticals have seen a surge in use for menopausal symptoms. But not everyone is convinced by these claims—nor by the expanded use of bioidenticals as a veritable "fountain of youth."

Are women succumbing to the allure of feeling younger and more vibrant in their later years? Or are we just waiting for the science to catch up with the not-so-conventional wisdom?

A Question of Quality, Part 1
Stephen Nunn, MPAS, PA-C, has been in practice for 35 years, almost entirely in women's health (obstetrics and gynecology, as well as infertility). And he has a pretty radical perspective on menopause.

"There is nothing natural about it," he says. "If you look back, in 1910, average life expectancy for women in the US was 47. It's only in the past 75 years or so that women have lived long enough to spend a significant amount of their time—a third of their lives—in menopause."

For years, Nunn saw women with menopause and other hormonal issues for whom he couldn't do enough. "Based on the guidelines I was given, I couldn't really effect significant change for a lot of them," he says. "They would come in complaining that they felt a little better, but the available treatment didn't really do the job. And yet we were at what was considered the maximum dosing."

Some of those patients pursued other avenues of treatment—namely, bioidentical hormones—and reported back to Nunn how well they were doing and how happy they were. So when he was looking for a change, Nunn joined (full disclosure) SottoPelle, a Scottsdale, Arizona–based practice dedicated to bioidentical HRT in pellet form.

Although he has a vested interest in promoting bioidentical HRT, Nunn does raise an intriguing point when he notes that the ovary is "the only endocrine organ that gets ignored when it stops functioning." By contrast, he points to the avalanche of new products that address andropause, which is treated long-term.

"I think the quality-of-life issue, as well as the health benefits, say that we really should be treating women with—my bias—bioidentical hormones for the rest of their lives," he concludes.

His viewpoint is shared by independent clinicians. In her Covington, Louisiana, practice, Pamela Egan, FNP-C, CDE, focuses on wellness and preventive medicine. Egan completed a fellowship with the American Academy of Anti-Aging and Regenerative Medicine and will receive her master's degree in Metabolic and Nutritional Medicine within the next six months. Bioidentical HRT is a component of her patient care plan.

"It's all about keeping the body balanced nutritionally and metabolically—that is going to slow down aging, which ultimately will prevent disease," she says. "I have patients who come in and say they can't sleep at night, they're depressed, they have no libido, they have hot flushes. When we get everything balanced, they have much better quality of life. They sleep better, they want sex again, their hot flushes are gone, and anxiety and depression are diminished or alleviated altogether."

Egan isn't a fan of the term anti-aging because, she says, its use in relation to cosmeceutical products has made it "sound a little flaky." What she is trying to achieve with her patients is a lifestyle change through a holistic approach that includes nutrition and weight loss in addition to hormonal balance. "Once people are balanced," she says, "many of them get off their diabetes meds, blood pressure pills, cholesterol pills."

Major medical organizations, such as the American College of Obstetricians and Gynecologists (ACOG) and the American Association of Clinical Endocrinologists (AACE), have a very different position on the role of bioidentical hormones. And this is where a degree of confusion creeps in, because "bioidentical hormone replacement therapy is not really an FDA-recognized term," says Jennifer Hofmann Ribowsky, MS, RPA-C, Academic Faculty/Pre-clinical Coordinator of the Pace University–Lenox Hill Hospital Physician Assistant Program in New York. "It's more a term used for marketing purposes."

That said, bioidentical hormones are essentially plant-derived hormones that are chemically similar or structurally identical to those produced by the body. And there are FDA-approved estrogen and progesterone products that are technically considered naturally occurring or bioidentical.

But traditionally, the term bioidentical hormones has referred to compounded preparations. The reservations, if not downright concerns, of groups such as ACOG and AACE generally relate to two factors: the origins of the bioidentical hormones (FDA-approved products vs compounded products) and how they are used.

Compounding is performed by a licensed pharmacist to specifications prescribed by a health care provider. But compounded products are not regulated by the FDA (they are regulated by the states), and by their nature are not standardized (though the raw materials are US Pharmacopeia–approved products). Therefore, issues of quality—purity and potency—may arise, and there is a lack of safety and efficacy data.

For example, when a clinician prescribes an estradiol patch in a dosage of "0.05 mg per 24 hours," that is precisely what the patient will receive from an FDA-approved product. "It's standardized, so you have that level of comfort that when you're prescribing a certain amount, that's what the patient is getting," Ribowsky says. "That's not always the case with compounded products."

In an August 2012 opinion paper, committees from ACOG and the American Society for Reproductive Medicine concluded that evidence in favor of bioidentical (ie, compounded) HRT was insufficient: "Patients should be counseled that menopausal hormone therapies that are proved to be safe and effective by the FDA are more appropriate for their use than individual pharmacy-compounded preparations."

But in practice, there may be additional considerations. "I leave it up to the patient whether they want compounded bioidentical hormones or FDA-approved bioidentical hormones," Egan says (though she recommends bioidenticals over synthetics). "If a patient doesn't have insurance and has to pay out of pocket, obviously it's financially feasible to get them compounded."

What's Appropriate?
In a 2007 position statement that also recommended "FDA-approved commercially available hormonal preparations," AACE added the proviso that these should be prescribed "following the guidelines published by the various medical societies." This is where the discussion of bioidentical hormones enters the grayest area.

"Estradiol and progesterone are used for the management of vasomotor symptoms that are troubling to the patient, and they should be used within usually the first five years of menopause—the lowest dose, for the shortest amount of time," Ribowsky summarizes. "In terms of being a fountain of youth or a way to stay or look younger, there's not really any support for those types of claims. They're not even studied for that purpose."

Neither Egan nor Nunn refers to a "fountain of youth"; their aim is to keep patients healthy and feeling better. (Although, yes, patients often comment that they feel younger, too.) Both emphasize that patients are monitored and HRT is adjusted accordingly. As Nunn says, the goal is physiologically normal levels—literally replacing lost hormones—not bodybuilder levels.

In terms of safety, Nunn in particular defends estrogen. "If you go back to the Women's Health Initiative study, the one that was 'the estrogen sky is falling,'" he says, "the women who were taking only the [conjugated estrogen] product didn't have an increased risk for breast cancer—only the women who were on the [estrogen plus progestin]. So you really can't blame the estrogen here."

Egan says she doesn't prescribe oral estrogen products because "it's too hard on the liver. The liver methylates it to estrone, which can increase risk for breast cancer."

In terms of cardiovascular risk, Nunn also prefers nonoral routes of administration for estrogen. "If you absorb your estrogen, it doesn't increase your clotting factors, because you avoid the first pass through the liver," he says. "So absorbed estrogen—patches, creams, pellets—doesn't increase your risk for stroke and heart attack."

Even so, patients are encouraged to have regular health screenings, as appropriate. "We certainly have our patients continue to get bone mineral density scans, keep current on their mammograms and Pap smears, and follow all the other things you should do for good health maintenance," Nunn says.

One point on which everyone agrees is the need for additional research to establish what benefits bioidentical HRT offers. The Cochrane Collaboration is expected to publish a review later this year that examines the evidence on bioidentical hormones for vasomotor symptoms; that may shed some light on their safety and efficacy. But Ribowsky, for one, would like to see some head-to-head randomized controlled trials comparing bioidentical HRT with conventional HRT.

"I think when we have studies like that available, we can make recommendations to our patients more clearly and more confidently," she says.

Egan notes that everything she learned in her fellowship was based on available evidence, but wonders if additional research would alter the view of organizations such as ACOG. "I'm just sad to say that the FDA and ACOG are about 20 years behind the times," she says, adding that insurance companies also send her letters requesting that she use conjugated estrogen preparations instead of (FDA-approved) bioidenticals.

"I'm not going to do anything to harm my patients, and we know those drugs cause breast cancer," she adds. "Why would I use those? I think the biggest thing is that we have to identify the difference between synthetic chemicals and the bioidentical hormones in the right form."