Obesity and Insulin Resistance: The Case for Compounded Estrogen Hormone Replacement Therapy
Anne is a 48-year-old woman who is menopausal. Fed up with hot flashes, insomnia, and, most recently, weight gain, she approaches her neighborhood pharmacist about her over-the-counter options. Like many women, she is somewhat nervous about hormone replacement therapy and prefers a more natural approach.
This is a perfect opportunity for the pharmacist to discuss new research that shows that estrogen replacement might actually be beneficial to her long-term health.
Estradiol, the dominant form of estrogen, has long been thought of as contributing to weight gain, insulin insensitivity and glucose intolerance, and heart disease. This and the increased risk for reproductive cancers has led the American Congress of Obstetricians and Gynecologists (ACOG) to end their recommendations that women take supplemental estrogen to minimize the risk of developing health complications.
However, physicians have also observed that weight gain and diabetes are significantly more common in women as they age, especially right after menopause when estrogen levels begin to decline dramatically. This fact led some researchers to consider the idea that when it comes to the increased risk of obesity, diabetes and heart disease, “estrogen deficiency, rather than estrogen excess, is a more likely causative factor.”1
As one of the primary providers of bio-identical and compounded hormone replacement therapy, compounding pharmacists must be aware of the potential health implications of both estrogen deficiency and estrogen supplementation.
Role of Estrogen in Obesity and Insulin Sensitivity
Weight gain despite attempts to lose weight is one of the most common complaints among post-menopausal women. Most weight gain occurs because of an increase in visceral adipose tissue (VAT), or fat tissue that is found in the abdomen and surrounds the vital organs.2 This is also, unfortunately, one of the most dangerous places to gain weight, as an increase in VAT is linked to diabetes and other metabolic diseases.
It has been suggested that an environment of estrogen deficiency may lead to an increase in circulating free fatty acids.3 This boosts adipocyte production and insulin insensitivity in the liver and muscles. Muscle cells are unavailable to use glucose properly, leading to weight gain. However, with estrogen supplementation, the muscles are more able to properly use and regulate free fatty acids for energy use.
Adipose tissue itself is an endocrine organ, producing molecules called adipocytokines, which include the interleukins and tumor necrosis factors. These markers are pro-inflammatory and may lead to insulin resistance. Premenopausal women have lower levels of adipocytokines. Further, estrogen may have anti-inflammatory properties, reducing the risk for diabetes, obesity and heart disease.
Counseling Women About Hormone Replacement Therapy
There is a large role that pharmacists can play when it comes to helping women deal with the complexities of hormonal changes after menopause. Hormone replacement therapy (HRT) is still controversial; not all providers agree about the safety and efficacy of estrogen supplementation after menopause and not all women trust these medications either.
Women still suffer from many physical and emotional discomforts during menopause, leading them to look for safer alternatives to hormone replacement therapy, but with the same benefits. As a result, many patients elect to go the “all natural” route, turning to bioidentical hormone therapy.
As compounding pharmacies are the leading provider of bio-identicals, pharmacists are in a position to provide appropriate counsel regarding the cost, safety, efficacy, and what to expect from therapy. They can also discuss the risks and benefits of bioidentical hormone therapy with both patients and women considering these drugs. It also encourages a discussion about other health risks related to aging and estrogen loss, as well as home remedies for menopausal side effects.
Finally, a knowledgeable compounding pharmacist can encourage women to speak with their physician about initiating HRT therapy and can provide customized dosing for their patients. Hormone replacement therapy is not currently recommended by ACOG for use in minimizing health risks like heart disease and diabetes. However, this study suggests that providers at least consider opening the discussion with their patients about the potential benefit of HRT in certain populations.
The FDA currently does not promote safety or efficacy of compounded bio-identical hormones, even though they may be an effective option for many women. Recognition and regulation of these drugs will increase patient safety and effectiveness, as well as allow the tracking of negative side effects. This ultimately promotes the legitimacy of these products and makes it a viable option for many more women.
Most importantly, pharmacists need to be aware of latest research regarding HRT and the potential risks and benefits they offer to their patients. In addition, for pharmacists interested in performing research, their role in providing these medications presents an opportunity to perform and publish research related to menopause, cardiovascular and hormonal health, and HRT therapies.
The use of HRT is still somewhat controversial amongst physicians and the women they treat. Rising concern about the risk of reproductive cancers has deterred many women from using these therapies, despite their effectiveness at treating menopausal symptoms. Pharmacists can play a key role in helping women understand the benefits of HRT and the potential preventative role they play in heart and insulin health.
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- “Estradiol: The Emerging Evidence for a Protective Role Against Insulin Resistance and Obesity,” Jul/Aug 2015, https://www.ijpc.com/Abstracts/Abstract.cfm?ABS=4005 ↩
- “Estrogen Deficiency and the Origin of Obesity during Menopause,” March 6, 2014, http://www.hindawi.com/journals/bmri/2014/757461/ ↩
- “Effects of Estrogen on Free Fatty Acid Metabolism in Humans,” June 1994, http://www.ncbi.nlm.nih.gov/pubmed/8023922 ↩