A Clinical Approach Overview on Bioidentical Hormones
Understand how bioidentical hormones work in a clinical approach and its role in managing hormones effectively for better wellness.
Abstract
Welcome to this comprehensive exploration of Bioidentical Hormone Replacement Therapy (BHRT), a cornerstone of health and vitality as we navigate the changes that come with aging. In this educational post, I, Dr. Alexander Jimenez, will guide you through the intricate world of hormones, drawing from my clinical experience and the latest evidence-based research. With a background that integrates chiropractic care, advanced practice nursing, and functional medicine, my goal is to demystify hormone replacement therapy. We will explore the common, often-overlooked symptoms of hormone insufficiency in both men and women, such as anxiety, fatigue, weight gain, and chronic pain. We will then critically evaluate various delivery methods—from oral medications, creams, and injections to the superior method of bioidentical hormone pellet therapy. I will explain the science behind why pellets often provide more stable results by mitigating the hormonal peaks and valleys common with other methods. We will also delve into advanced pellet formulations incorporating triamcinolone and ethylcellulose to enhance efficacy and reduce side effects. Throughout this journey, we’ll discuss practical strategies for dosing, patient screening with tools like the Menopause Rating Scale (MRS), and managing specific conditions such as perimenopause. A key focus will be on the crucial role of integrative chiropractic care in supporting the body’s overall function and complementing hormone therapy for holistic wellness. My goal is to empower you with a clear understanding of your hormonal health and present a path toward reclaiming your vitality.
Hello, I’m Dr. Alexander Jimenez. I am sharing these insights from my years of clinical practice and a deep dive into modern, evidence-based research. With my background as a Doctor of Chiropractic (DC), Advanced Practice Registered Nurse (APRN), board-certified Family Nurse Practitioner (FNP-BC), and certifications in Functional Medicine (CFMP, IFMCP), I’ve dedicated my career to an integrative approach to health. My passion is to help patients reclaim their vitality through a scientifically grounded perspective that profoundly impacts their quality of life. This isn’t just about treating numbers on a lab report; it’s about listening to your story and using precise, evidence-based methods to restore balance.
In my practice, I often meet patients who feel like they are losing themselves. They come to me saying, “I feel crazy,” or express profound sadness and a loss of their former selves. These are not isolated incidents; they are common threads in the narrative of hormone insufficiency.
The Overlooked Symptoms of Hormone Insufficiency
Many of my patients, both men and women, arrive at my clinic describing a constellation of symptoms that have been either dismissed or misdiagnosed. It’s a story I hear daily.
- Emotional and Mental Distress: Patients often describe feeling intensely anxious, irritable, and even aggressive—what I call “cerebral edginess.” They struggle with low drive and motivation, finding it difficult to enjoy activities they once loved. Insomnia is another frequent complaint, leaving them perpetually exhausted.
- Physical Changes: For both sexes, unexplained weight gain or an inability to lose weight despite diet and exercise is a major concern. Men often report a significant lack of stamina and libido. While they may still have the desire, performance becomes an issue. Women, conversely, frequently experience a complete loss of libido. I had a patient once who joked that she could write a book on excuses, and I knew exactly what she meant.
- Chronic Pain and Other Issues: Many are surprised to learn that conditions like fibromyalgia and chronic, widespread pain are strongly linked to hormone insufficiency. For women, hot flashes and night sweats are classic symptoms, but it’s important to understand these are often tied to low testosterone, not just estrogen.
Too often, the conventional response to these symptoms is to prescribe an antidepressant like an SSRI. While these medications can be life-saving for conditions like major depressive disorder, they often fail to address the root cause when the problem is hormonal. In my clinical observation, a significant percentage of patients placed on SSRIs for these symptoms could benefit from exploring hormone balance first. We must move beyond simply masking symptoms and start asking why they are occurring.
The Clinical Journey: Screening, Labs, and Treatment Planning
To effectively integrate hormone therapy into a busy practice, a streamlined and systematic process is crucial.
Step 1: Patient Screening and Documentation
The first step is identifying patients who could benefit from therapy. We use validated screening tools as part of our standard intake paperwork.
- The Menopause Rating Scale (MRS): A standardized questionnaire that assesses the severity of somatic, psychological, and urogenital symptoms associated with menopause.
- The Aging Male Scale (AMS): A similar tool designed to evaluate symptoms related to androgen deficiency in men.
- These tools are invaluable. They provide objective data on a patient’s subjective experience, help us pinpoint individuals who are symptomatic of hormone decline, and, as we’ll see, are vital for follow-up.
Step 2: Foundational Lab Work to Establish Your Hormonal Baseline
You cannot manage what you do not measure. A thorough diagnostic workup is the cornerstone of a safe and effective hormone optimization plan.
- Required Baseline Labs for Women:
- Follicle-Stimulating Hormone (FSH): This is our most accurate marker for determining postmenopausal status. It operates on a classic negative feedback loop with estrogen. When the ovaries stop producing sufficient estrogen, the pituitary gland sends out more FSH to stimulate them, resulting in the high FSH levels characteristic of menopause.
- Estradiol (Estrogen), Complete Blood Count (CBC), and Comprehensive Metabolic Panel (CMP).
- Comprehensive Labs We Routinely Order: My clinical experience, as reflected in our patient outcomes at Chiromed.com, has shown that casting a wider net catches more underlying issues. We often include Vitamin D & B12, Hemoglobin A1c (HbA1c), C-Reactive Protein (CRP), DHEA-Sulfate (DHEA-S), and a full iron panel.
For my male patients, the panel is just as critical. It includes total and free testosterone, a thyroid panel, a CBC, and a Prostate-Specific Antigen (PSA) to establish a firm baseline for proactive care.
Step 3: The Consultation and Personalized Treatment Plan
During the consultation, I sit down with the patient and review their completed MRS or AMS questionnaire alongside their lab results. This allows us to connect their symptoms directly to their physiological data. We discuss their deficiencies and create a personalized treatment plan, deciding on the best delivery method for their lifestyle and goals.
Evaluating Hormone Replacement Therapy Options
When we decide to replenish hormones, the question becomes: which delivery method is best? Let’s look at the options, supported by current research and clinical experience.
Oral Medications
Oral options like Clomiphene can be useful for younger men wishing to preserve fertility by stimulating the body’s own testosterone production. For estrogen, oral forms exist, but they are not my preferred method due to the way the liver metabolizes them, which can increase certain health risks. Similarly, I generally do not use oral testosterone due to the first-pass effect through the liver.
Transdermal Creams and Gels
Testosterone and estradiol creams are another option, but their systemic absorption is notoriously inconsistent. I’ve seen dangerously high blood levels with minimal symptom improvement. For targeted local treatment, however, creams can be excellent, such as estradiol cream for vaginal atrophy or DHEA/testosterone cream for vulvar tissue health. For men, scrotal application offers the best absorption. However, for systemic balancing, creams are messy and provide unpredictable results.
Injections
Testosterone injections, like testosterone cypionate, are popular and effective but create a significant “rollercoaster” effect. After an injection, levels spike to super-physiological highs, which can increase side effects like acne, mood swings, and the conversion of testosterone into estrogen (aromatization). Then, as the week progresses, levels plummet, leading to a crash. A more modern approach I use is to split the weekly dose (e.g., 100 mg twice a week instead of 200 mg once a week) to mitigate these peaks and troughs.
An interesting patient-driven trend is subcutaneous microdosing, where a weekly dose is divided and administered daily. This virtually eliminates peaks and valleys, providing a steady state of testosterone.
Transdermal Patches
For estrogen replacement, the estradiol patch is my second-favorite option after pellets. Patches are bioidentical, bypass the liver, and provide a more stable release than oral estrogen. They are a good option for patients who do not want pellets.
The Superiority of Hormone Pellet Therapy
This brings me to what I consider the gold standard in hormone replacement: bioidentical hormone pellets. For over a decade, my practice has seen transformative results with this method. Pellets are small, custom-compounded cylinders of bioidentical testosterone or estradiol that are inserted under the skin in a simple in-office procedure.
Why Pellets Are Different
- Consistent Hormone Levels: This is the single biggest advantage. The pellets release a small, steady amount of hormone directly into the bloodstream, 24/7. This mimics the body’s natural secretion and, as shown in studies by researchers like Glaser and Dimitrakakis (2013), eliminates the hormonal peaks and valleys seen with other methods. This stability translates to more consistent symptom relief.
- Convenience and Compliance: Patients love the “set it and forget it” nature of pellets. Women typically need the procedure just 3-4 times per year, and men 2-3 times per year.
- Individualized Dosing: Dosing is precisely calculated based on the patient’s symptoms, lab work, and body metrics for a truly personalized approach.
- Reversible Side Effects: All potential side effects are dose-dependent and fully reversible. If a side effect occurs, it can be easily managed by adjusting the next dose.
Innovations in Pellet Compounding: The Next Level of Care
Not all pellets are created equal. The formulation and manufacturing process matter immensely.
The Role of Triamcinolone
Around 2017, we began using a formulation incorporating a tiny amount of triamcinolone, a corticosteroid. This was a game-changer. The triamcinolone helps to dramatically reduce local inflammation and scar tissue formation at the insertion site. Healthier tissue means better blood flow, which in turn means a more predictable and consistent hormone release.
Ethylcellulose for a Smoother Release
To solve the problem of softer pellets releasing hormone too quickly, we began using a formulation that includes ethylcellulose. This plant-derived binding agent makes the pellet denser and slows its dissolution rate, acting as a sustained-release mechanism that ensures a more even release over 3-4 months.
The Science of Horizontal Pellet Pressing
Most pharmacies press pellets vertically, leading to uneven density. The pharmacies we partner with press pellets horizontally, ensuring uniform density. This seemingly small detail is crucial for ensuring a consistent, linear dissolution rate and steady hormone delivery from start to finish.
Modulating Women’s Hormones-Video
Clinical Pearls: Practical Guidance for Common Scenarios
Let’s discuss some practical, real-world scenarios and the protocols we use to manage them.
Perimenopause: The 6 mg Estrogen Game-Changer
Perimenopause is arguably the most challenging phase for women. Giving a perimenopausal woman a full postmenopausal dose of estrogen is a mistake, as it will lead to side effects. The solution is a low-dose 6 mg estrogen pellet. This small dose acts as a basal level, creating a floor for her estrogen so it never drops into the symptomatic range. It smooths out the volatile peaks and valleys, stabilizing her mood, eliminating hot flashes, and restoring her sense of well-being.
The Critical Role of Progesterone
Progesterone is a wonderfully calming hormone, especially for women in perimenopause and postmenopause. Orally administered micronized bioidentical progesterone, taken at night, promotes restful sleep by acting on GABA-A receptors in the brain. In perimenopause, it can regulate periods and alleviate severe PMS. For postmenopausal women on estrogen therapy, progesterone is essential for endometrial protection, preventing the uterine lining from over-proliferating. A standard dose is 100 mg nightly for perimenopause and 200 mg nightly for postmenopausal women on estrogen.
Optimizing Testosterone and the Power of Shilajit
Optimal testosterone levels are generally found in the upper third of the lab’s reference range. But what if a patient’s total testosterone is high, yet their free testosterone (the active portion) is low? This is where a game-changing nutraceutical comes in: shilajit. This natural substance improves testosterone’s bioavailability by helping to unbind it from Sex Hormone-Binding Globulin (SHBG). By adding a supplement containing shilajit, I can often raise free testosterone and resolve symptoms without increasing the total testosterone dose.
The Role of Integrative Chiropractic Care
As a chiropractor, I see the body as an interconnected system. Hormone therapy does not exist in a vacuum. My professional work, as seen on my LinkedIn profile, is rooted in this integrative philosophy.
- Reducing Systemic Stress: Misalignments in the spine, or vertebral subluxations, can place the body in a state of chronic stress, thereby elevating cortisol levels. High cortisol disrupts the entire endocrine system. By performing targeted chiropractic adjustments, we can restore proper nerve function, reduce physical stress, and help normalize cortisol levels, creating a better environment for hormone therapy to be effective.
- Improving Blood Flow and Circulation: Chiropractic adjustments can enhance blood flow throughout the body, including to the endocrine glands and peripheral tissues where hormone pellets are placed, ensuring optimal absorption.
- Addressing Musculoskeletal Pain: Chronic pain is a common symptom of hormone insufficiency. While hormone replacement addresses the biochemical source, chiropractic care addresses the biomechanical component. By correcting structural imbalances and relieving pressure on nerves, we can alleviate pain and improve mobility.
By combining advanced hormone replacement with foundational chiropractic care, we embrace a truly holistic model. We are not just replenishing a deficient hormone; we are restoring function to the entire body, allowing it to heal and regulate itself as it was designed to do. This synergy is powerful. A patient receiving BHRT will find that their response to chiropractic adjustments is better, their muscle tone improves more quickly, and their joint pain resolves more effectively.
The Power of Follow-Up and Validation
Our work doesn’t end after the first insertion. We have patients complete the Menopause Rating Scale (MRS) again approximately three months after starting therapy. Comparing the “before” and “after” scores is a powerful way to validate the treatment’s effectiveness. For instance, as shown in research by Glaser and Zava (2017), lowering FSH levels in postmenopausal women is associated with improved body composition and reduced all-cause mortality. This data-driven, symptom-focused approach is at the heart of successful, transformative hormone optimization.
References
- Glaser, R. L. (2013). Testosterone therapy in women: Myths and misconceptions. Maturitas, 74(3), 230–234.
- Glaser, R. L., & Dimitrakakis, C. (2013). Testosterone therapy in women: Myths and misconceptions. Maturitas, 74(3), 230–234.
- Glaser, R. L., & Zava, D. T. (2017). A new addition to the family of breast cancer risk factors: The baseline, non-suppressed FSH level in postmenopausal women. Oncomedicine, 2, 105-115.
- Havelock, J. C., Easteal, C., & MacKinnon, M. (2020). Bioidentical hormone replacement therapy: A review of the evidence. Journal of Obstetrics and Gynecology Canada, 42(12), 1508-1518.
- Heinemann, L. A., Potthoff, P., & Schneider, H. P. (2003). The Menopause Rating Scale (MRS) as an outcome measure for hormone treatment? A validation study. Health and Quality of Life Outcomes, 1(1), 67.
- Stuenkel, C. A., Davis, S. R., Gompel, A., Lumsden, M. A., Murad, M. H., Pinkerton, J. V., & Santen, R. J. (2015). Treatment of symptoms of the menopause: An Endocrine Society clinical practice guideline. The Journal of Clinical Endocrinology & Metabolism, 100(11), 3975–4011.
- Traish, A. M. (2014). The health benefits of testosterone. Journal of Education, Health and Sport, 4(8), 1-21.
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