Compounding and Women's Health at Midlife

Back in the “old days” all pharmacists compounded. With limited availabilities of commercial pharmaceuticals, many medications and treatments were personally made up and put together --“compounded” for the unique needs of each individual. Both dosage, medication (singly or in multiple combinations) and delivery system (pill, capsule, sublingual drop or troche, transdermal gel, lotion, cream, etc.) could be personally compounded by the pharmacist.

All pharmacy students still learn compounding in school, but most do not utilize this skill. There are approximately 2,500 compounding pharmacies in the US, compared to +/- 40,000-50,000 “regular” pharmacies. You may locate a compounding pharmacist in your area by contacting the International Academy of Compounding Pharmacists at (800) 927-4227 or at www.iacprx.org, or check with Professional Compounding Centers of America at (800) 331-2498 (www.pccarx.com). There are excellent compounding pharmacies in Davis, Woodland, Sacramento, Gold River and Auburn.

Upon receiving a prescription or consulting directly with a physician and/or the patient, the pharmacist takes the necessary ingredients (frequently bioidenticals derived from plant sources) and compounds (or blends) them to meet the specific needs of the individual.

Many different medications may be compounded (including medications for pain relief and novel ways of giving medications to children). For the purposes of this article, I shall only be discussing those that impact health care for midlife women. These preparations can include estriol, estradiol, estrone, progesterone, testosterone, DHEA, pregnenolone and others.

WHY COMPOUND:

A majority of women do quite well on commercially available fixed-dosage products. Why, then, compound? The reasons are multiple.

Compounding gives the consumer more choice of delivery systems, limited only by the imagination of the pharmacist. Creams, lotions, sublingual, troches or drops, suppositories, salves, gels, capsules, etc. are available.

Compounding can obviously deliver more exact dosing for the individual. Compounding increases the choice of medications, with different isomers and compounds (especially plant-sourced bioidenticals, compounded to be “bioidentical” to the hormone or substance it is replacing) that may not be available commercially.

Compounding gives the patient (in this case the midlife woman) more choice. With more alternatives and the individual counseling each patient receives with the compounding pharmacist, compliance with a therapeutic regimen is more likely with patients who are more involved with their care.

Compounded products are also more likely to be metabolized (accepted into the system) by patients who have had difficulties with commercially available medications.

Additionally, compounding allows for usage of especially designed delivery systems for patients with multiple allergies.

AVAILABLE PRODUCTS FOR WOMEN:

ESTROGENS: The three estrogens natural to women’s bodies--estriol, estradiol and estrone, may be compounded. Estradiol (which is commercially available as well) is adequate for most women, but many do better with a perhaps more physiologic combination of estriol and estradiol (“BiEst”) or all three (“TriEst”). Although concentrations may be individualized, the most common for BiEst is 80% estriol, 20% estradiol, and for TriEst, 80% estriol, 10% estradiol and 10% estrone. A weak estrogen, estriol, may be a “safer” estrogen for long-term use in women, especially for women at risk for breast cancer. Most estrogen products are synthesized in the laboratory utilizing soy as a base, producing the bioidentical hormones.

PROGESTERONE:

Bioidentical progesterone products utilize micronized proges-terone synthesized from wild Mexican yam. It should be noted that the human body cannot metabolize yam directly, so the yam you may see as an ingredient in some over-the-counter creams is not utilizable as such by your system. Bioidentical progesterone is absorbed very well from transdermal cream or lotion and, in larger doses, from a micronized capsule.

TESTOSTERONE:

Tweaking soy in a different direction in the laboratory, scientists produce bioidentical testosterone from the same little soybean. The resulting product is “micronized” (broken down into tiny nano particles to aid in absorption), the same as it is for estrogen and progesterone. The resulting compound may be administered via capsules but, as it is absorbed so well and consistently through the skin, it is usually administered as a transdermal cream, lotion, gel or sublingual (under the tongue) drops or lozenge.

ADRENAL HORMONES:

Pregnenolone, DHEA and cortisol: Some clinicians are finally understanding that chronic stress (physical or emotional) puts undue pressure on the adrenal glands (the “energy glands” of the body, located just above the kidneys) and, like the results of increased wear on the pancreas (which is diabetes) can lead to premature “wear out” and what is known in some quarters as “Adrenal Fatigue”.

Although the causes of fatigue are certainly multiple (and so-called “Adrenal Fatigue” is not #1 on the most likely diagnosis list), when treating fatigued states, especially in patients with Chronic Fatigue Syndrome and Fibromyalgia, evaluation of the adrenal hormones cortisol, DHEA and pregnenolone is warranted. The substances may be accurately compounded and administered via oral or transdermal preparations.

ECONOMIC FACTORS:

Just because a medication is “hand fashioned” does not necessarily mean that it costs more, although this frequently is the case. Because of economic factors and the inability of managed care organizations to make low-cost “deals” with individual pharmacists, many managed care plans (HMOs) do not pay for compounded preparations, although compounding is covered by many PPOs. As in everything else in medicine (as elsewhere), “you get what you pay for...”