Hormones act as messengers between body systems to regulate physiology and behaviour, thus affecting a person's quality of life, for example, the hormones that regulate digestion. The endocrine system controls the response of the various glands in the body and the release of hormones at the appropriate times. Gastrin stimulates gastric acid secretion in the stomach, while secretin stimulates sodium bicarbonate secretion in the small intestine. Furthermore, somatostatin is released to stop acid secretion when the stomach is empty. Cholecystokinin is the hormone that stimulates the contraction of the gallbladder to release bile (Waterman, 1960).
Stress, growth, movement, reproduction and mood are also controlled by hormones (Hayashi and Sato, 1976; Fernández-Guasti et al, 2012).
Hormone imbalance and quality of life
Hormones play a huge role in a patient's quality of life and when they become imbalanced, the effects can be wide-ranging. Imbalances can develop as a result of endogenous or exogenous change, leading to modifications in hormone homeostasis. These changes can be physical (e.g. aches and pains or sleeplessness) or mental (e.g. being unable to cope under stress or being irritable).
Furthermore, hormones play an important role in the skin's health and appearance, and imbalanced hormone levels can accelerate skin ageing. There are various receptors in the skin including those for progesterone, androgens and thyroid, which control many physiological processes, thus ensuring blood circulation, collagen structure, moisture and skin cell regeneration (Zouboulis, 2004; Schmuth et al, 2007).
Hormone imbalance can be a root cause of skin degeneration, as hormones control the largest endocrine organ, which is the skin. Acne can be caused by elevated testosterone, inflamed blackheads by excess of testosterone and dehydroepiandrosterone). Progesterone helps to moisturise the skin, tighten the connective tissue and is responsible for remodel collagen. Low progesterone levels will be expressed with dry, flaky and eczema-prone skin and cellulite. Oestrogen imbalance may result in thin skin, wrinkles, acne and inflammation, since oestrogens promote cell division and skin growth, as well as retaining collagen (Verdier-Sévrain et al, 2006).
Results of disrupted hormones
Disrupted hormonal balance can have various effects on the body, such as weight gain, polycystic ovary syndrome, menstrual cycle disturbances, pregnancy issues and skin-related problems, such as acne, hair loss and skin pigmentation (Meek et al, 2013; Ndefo et al, 2013).
As the body ages, hormone levels naturally decrease and metabolism slows down. At this stage of life, there is often an elevated risk of specific types of diseases or medical conditions. For instance, many women experience sharp declines in the natural production of the primary sex hormones oestrogen and progesterone, which is associated with several health risks, including heart disease, certain types of cancer and osteoporosis (Griffiths, 1995; Cauley, 2015).
The influence of oestrogen and progesterone on collagen synthesis has been reported in tissues such as the vagina, paraurethral tissues, tendon, skin and cervical tissues (Stevenson and Thornton, 2007; Hansen et al, 2009; Nallasamy et al, 2017).
While ageing is inevitable, how the body ages can be improved and, by maintaining optimal hormone levels, overall wellbeing may be guaranteed.
Sex hormones and sleep
Oestrogen and progesterone are sex hormones that regulate sexual development and reproduction, but as levels drop during the ageing process, they also begin to affect quality of life. While some hormones can be responsible for some sleep disorders (e.g. hypersomnia and insomnia) (Terán-Pérez G et al, 2012), they can also seem to protect from sleep-disordered breathing, which can cause fatigue and a reduced ability to function adequately, whereas testosterone may predispose to it. On the other hand, thyroxine has long been known to stimulate respiration (Saaresanta and Polo, 2002).
Oestrogen replacement therapy can improve sleep-related problems, which at times, are a result of the menopause, most likely by alleviating vasomotor symptoms such as night sweats (Moe, 1999).
Bioidentical hormones
Bioidentical hormones are identical to hormones produced endogenously. They originate from natural sources, such as soya and yams. They are not present in nature as such, but need to be modified from natural material in the laboratory to become bioidentical. This means that they are not natural, but rather, synthetic molecules from a natural source. The real difference between bioidentical hormones and synthetic hormones is that the final structure of the molecule is exactly the same as the endogenous hormone in the case of the former.
Impact of lifestyle and diet
Before contemplating whether a patient needs hormone replacement therapy (HRT), it may be useful to consider ways of improving lifestyle. Maintaining a healthy lifestyle and diet may help improve a patient's hormonal health and allow them to feel their best.
The following lifestyle measures can help reduce some menopausal symptoms:
» In specific clinical settings, the choice of the transdermal route of administration of oestrogens and the use of bioidentical progesterone might offer significant benefits «
Synthetic hormones versus bioidentical hormones
In the UK, the use of bioidentical hormones, particularly progesterone, oestradiol and estriol, has recently been debated intensely. Of special concern is their relative safety compared with traditional synthetic and animal-derived versions, such as conjugated equine oestrogens (CEE), medroxyprogesterone acetate (MPA) and other synthetic progestins.
Typically, traditional HRT refers to the replacement of hormones that are naturally diminishing with synthetic and semisynthetic hormones. Some HRT, such as with marketed progestins, is completely synthetic. Others, such as with conjugated equine oestrogen, are semisynthetic and derived from an animal source.
The British Menopause Society (BMS) subcategorises the term bioidentical hormone therapy (BHRT) in two sections: compounded BHRT and regulated BHRT, supporting the use of bioidentical hormones, in particular progesterone, but maintainis its position against compounded BHRT due to the lack of evidence of their efficacy (BMS, 2019).
Although there is no clear evidence of compounded BHRT being safer than or equally safe as bioidentical hormones, there is a rising demand of these treatments based on years of collected scientific and anecdotal data.
Bioidentical hormones and safety
The differences in the actions, risks and benefits of various hormones depend on numerous factors, including method of administration, absorption, bioavailability, metabolism, receptor affinity, receptor specificity and molecular structure (Huber et al, 1999; Leake, 1999).
If hormone levels deviate above (excess) or below (deficiency) their normal ranges, this can cause serious health disturbances. Medical professionals should always be involved in monitoring their patients on BHRT to ensure optimal ranges are maintained.
In the UK, bioidentical hormones are readily available and approved, and they have been prescribed for a few years now. It is believed that, due to the fact they are identical to human hormones, they might cause minimal side effects when taken at individual appropriate levels.
Bioidentical hormones can help with serious health conditions; for instance, the incidence of breast cancer seems to be lower in women treated with oestradiol and micronised progesterone (both bioidentical hormones), rather than with synthetic progestins (Campagnoli et al, 2005). Furthermore, synthetic progestins have potential anti-apoptotic effects and may also increase the conversion of weaker endogenous oestrogen into more potent oestrogens. They also have the completely the opposite effect to bioidentical progesterone as they promote atherosclerotic plaque formation, prevent the plaque-inhibiting and lipid lowering actions of oestrogen and can significantly increase insulin resistance (Holtorf, 2009).
While all types of HRT are safe and effective and confer significant benefits in the long term when initiated in young post-menopausal women, in specific clinical settings, the choice of the transdermal route of administration of oestrogens and the use of bioidentical progesterone might offer significant benefits and added safety (L'hemite et al, 2008).
Based on the data from research conducted by Simon (2012), which is now included in the American guidelines (Goodman et al, 2011), the use of transdermal oestradiol and micronised progesterone could reduce, or possibly even negate, the excess risk of venous thromboembolism, stroke, cholecystitis, and possibly even breast cancer associated with oral HRT use (Simon, 2012).
Hormones and differences between countries
Bioidentical hormones are approved and used, not just in the US, but also in the UK. They are also approved and used across many European medical jurisdictions. Bioidentical hormones may be preferred over standard HRT due to their physiological benefits and safety profile.
17B-estradiol
In the US, 17B-estradiol is Food and Drug Administration (FDA) approved for menopausal symptoms as it is in the UK and may have cardioprotective effects and fewer adverse effects on blood pressure than conjugated equine oestrogens.
Estriol
Estriol is not FDA approved, but it is widely used in Europe and is effective in relieving menopausal symptoms.
Progesterone
Progesterone is approved by the FDA for the management of menopausal symptoms and for the prevention of endometrial hyperplasia; however, it should always be used orally to oppose oestrogen.
Testosterone
Testosterone is FDA approved in combination with oestrogen for the management of vasomotor symptoms. While some bioidentical testosterone is licensed in the UK, the forms and doses are limited and only available for men.
Dehydroepiandrosterone
Dehydroepiandrosterone is not FDA approved, but some small-scale studies indicate that it may improve bone mineral density. It is treated as over-the-counter medication in the US and is a controlled drug in the UK. Similar to dehydroepiandrosterone, melatonin and pregnenolone do not require a prescription in the US, but do in the UK. This is another example of differences in regulations and the safety profiles of certain medications in different countries.
Benefits of personalised dosage
In the UK, there are two main suppliers of tailor-made medications that account for approximately 1% of all prescriptions, but make up more than 75 000 different formulations (Wilkinson, 2018). Furthermore, personalised medication is mainly made by specials manufacturers who support the NHS to meet the individual clinical needs of a patient when a suitable licensed medicine is not available.
Prescribing licensed bioidentical hormones will suit many patients across the UK. However, there will be some for whom the available strengths are not appropriate for their needs or who prefer a different dosage form. Hormones can be combined so that one cream or one capsule can be taken instead of many. Allowing a clinician to alter individual elements of a patient's prescription to achieve precise dosing can be beneficial for patient safety and experience.
Compounding pharmacies
Customised compounding of medicine has been practised by pharmacists since the earliest days of pharmacies. Compounding pharmacies are as old as the pharmacist profession and were the sole providers of medication in the UK until the NHS came into being, followed by the advent of high-volume pharmaceutical manufacturing. When the large pharmaceutical companies appeared, it changed the way medications were made as they were able to manufacture medicine on a large scale to serve many patients (Malerba and Orsenigo, 2015).
In the present day, compounding pharmacies are used to create individualised medicines when an approved drug is not available or appropriate for the patient or must be altered in some manner (for example, strength or route of delivery). Traditional pharmacy compounding provides a valuable service that is an essential element of the UK and US's healthcare system (Gudeman et al, 2013).
Compounding pharmacies, which are regulated by the General Pharmaceutical Council in the UK, should inform their clinicians and patients, both verbally and with leaflets that go out with every compound, about ingredients, potential side effects and how to report any problems.
Conclusion
Bioidentical hormones play an important role in regulating the body and maintaining homeostasis, and may be a new, effective hormonal treatment for skin ageing.
The decline of hormone levels plays an essential role in the ageing body, yet, with careful management, medicating with hormones can combat the signs and symptoms of ageing in both men and women. Often, aesthetic practitioners will see patients seeking to combat the overt signs of ageing. By adding knowledge of hormones to their portfolio, this means they can treat patients from the inside as well as the outside.
As with any treatment or medication, there are risks, so training is essential when working with hormones. The practitioner must be aware of interactions, side effects and health risks and should monitor their patient closely, as well as providing their patient with the necessary information to perform their own risk assessment. However, by correctly personalising the dose of medication for the patient's situation, these risks may be lowered.
Compounding with bioidentical hormones is commonplace in the US and becoming more customary in the UK. Practitioners should choose their pharmacy carefully, ensuring that preparations are made to high-quality standards, that sufficient patient information is provided and that there is suitable advice and support available to both the practitioner and the patient when needed.