April 2021
This month, we talked with compound pharmacist Tara Thompson, PharmD., FAPC, on delivery methods of hormonal treatments, how hormonal imbalances impact the vaginal biome, and her advocacy work in the field of sexual medicine.
Tara Thompson is a pharmacist and patient advocate in the field of sexual health. Tara has been a practicing compounding pharmacist for eight years at Innovation Compounding. She is the VP of Clinical Services in the field of sexual medicine, developing and designing pharmaceutical drug combinations for various sexual health conditions.
Her passion is treating, counseling, and educating patients and providers alike about men's and women's sexual health conditions ranging from vulvodynia and interstitial cystitis to erectile dysfunction and Peyronie's disease.
SHWI: As a leading pharmacist in women’s care helping women to better understand hormonal treatments, what key things would be helpful for physicians in these prescriptions?
Education is always key! Knowing the ins and outs of each hormone that is available to replace – estradiol, estriol, testosterone, progesterone, DHEA, pregnenolone, etc. – is crucial to properly balancing patients' hormones to achieve optimal outcomes. Being educated on the strength and dose of each hormone to use in a woman, and also the frequency to which these need to be applied or taken, is so important.
The route of administration is also vital to appropriately dosing a woman’s hormonal treatments, as there are many different ways women can get the hormone into the body. Some of these routes include vaginal, topical, oral, subcutaneous, or sublingual. There are others, but those are some of the main routes, and depending on your patient’s particular condition or target area of concern, route can make all the difference. Some patients may need a locally-acting treatment, while others need systemic absorption in order to balance their hormones (such is the case to help with vasomotor symptoms like hot flashes and night sweats).
The route the drug is given also relies on the base or carrier the hormone is placed in. Patients may prefer or require different types of bases, and this can increase patient compliance, knowing that you’ve chosen a base or carrier that the patient is comfortable with and prefers.
As a pharmacist who designs drug hormone treatments in different bases and carries, I’ve seen it all! We’ve made vaginal preparations in coconut oil, emu oil, hyaluronic acid gel, vaginal creams, lubes, and ointments, just to name a few. Vaginal suppository bases are also popular because they can act as a lubricant as they melt. As a provider, knowing all your options for hormone drug delivery could be the key factor in producing a positive patient outcome.
SHWI: How does hormonal imbalance impact the vaginal biome?
TT: The vaginal canal is full of hormone receptors and when those are properly saturated (either with the estrogens or testosterone from the woman’s body), the vaginal mucosa and surrounding tissues have everything they need to maintain a healthy environment for the natural flora and biome of the vagina. The pH of the vagina is actually slightly acidic (3.8-4.5), which is different from the pH on our outer skin (around 7-8). This pH provides for a perfect environment for the “good” or healthy and natural bacteria to live, thrive, and work in harmony with each other.
Differing factors, one of which is hormonal imbalance, can throw off this pH level, causing the vaginal biome to go awry. Certain species of bacteria, which thrive in a pH higher than 4.5, can take over, indirectly causing several issues for women, including bacterial vaginosis. This change in pH can also give rise to yeast infections, and urinary tract infections as the vaginal biome is no longer living in harmony at healthy levels.
We see these cases frequently in women who have gone through menopause or surgical menopause (oophorectomy) and no longer produce the estrogens and testosterone from their ovaries. This lack of hormone saturation at the vaginal canal receptors can lead to atrophy over time of the vaginal mucosa, as well as pain and the pH imbalances we talked about earlier.
Hormone treatments at the area, proper balance, diet, using appropriate lubricants, and safe sex practices can all contribute to a healthy vaginal biome and must also be considered in all vaginal and pelvic health conditions.
SHWI: What kinds of other ancillary treatments are helpful for women as they are looking to balance their hormones?
TT: As a pharmacist, I get this question often. I always recommend a woman have a healthy diet and exercise regimen. Also taking necessary supplements can contribute to overall health and wellness. I can spy a woman from a mile away reading the back of supplement bottles that they feel may be the cure to their hormone imbalance – and looking confused.
I am a big advocate in educating women that the key to hormone balance is getting your body right first. Sometimes this can just mean “getting healthy”. Easier said than done, but correcting vitamin and mineral deficiencies – many of which are important co-factors for so many processes within the body – is a great first step.
Exercising to not only keep off unwanted or excess weight, but also for muscle strength, bone health, and cardiovascular benefits can contribute to hormone balance. Likewise, making sure the foods they are allowing to enter their body are worth it – not in terms of calories, but the content of the food itself. Is it providing the nutrients and energy for your body to use and capitalize on? Or are we eating for taste and boredom (yes, guilty!)?
Once we’ve addressed these types of interventions that can be done on their own and depending on the extent of their symptoms, I like to recommend hormone testing, vaginal lubricants (if dryness is present), and I’m also a big fan of the health benefits of probiotics (both vaginal and oral!) as an ancillary treatment.
SHWI: Hormone replacement is delivered orally and transdermally. What would you tell patients and doctors so they could better understand the impacts of both? Are there increased dangers with either approach?
TT: In pharmacy, we call this “route of administration” and it can make all the difference in patient outcomes. A quick background on drug pharmacokinetics will tell you that when given orally, drugs go through GI tract and get absorbed at different rates – going through first pass metabolism in the liver where they are broken down into metabolites. These are then further carried through the bloodstream, exerting their desired actions, before being excreted or cleared in some form or fashion.
Transdermal drugs do not encounter first pass metabolism in the liver because they do not enter the GI tract to be absorbed. Using the transdermal route, drugs are introduced directly into the bloodstream (at differing rates, depending on the drug and carrier), where they exert their actions in their original form before being excreted.
Both routes of administration have pros and cons, but it always depends on the drug. A drug that causes negative GI effects (nausea, GI stress, diarrhea), may be more tolerable by a patient when given transdermally (we see this happen with oral versus topical metformin) – ultimately leading to better patient compliance because they stick with their medication regimen.
However, sometimes we rely on the metabolism of drugs by the liver to produce the favorable action of the drug. Take progesterone for example. When given orally, progesterone passes through the GI and undergoes first pass metabolism in the liver. The major metabolite of progesterone, pregnanolone, is formed from oral progesterone and binds to the GABAa receptor, which brings about a sedative and anxiolytic effect on the patient. Yet, pregnanolone is not formed with transdermal progesterone. It is for this reason that providers usually give women who have trouble sleeping oral progesterone and those who do not have trouble sleeping transdermal progesterone. Regardless of drug, patients may even prefer one route of administration over another due to their lifestyle or difficulty swallowing.
SHWI: If you have any research that you've done or have been involved in that you would like us to share with our audience, please describe your work.
TT: I am currently working on some research which broadens the lens on different types of healthcare providers working together as a multidisciplinary team to treat patients in sexual medicine. We typically see patients whose condition or concern requires several areas of treatment including a provider, pelvic floor therapist, sexual counselor and/or educator, pharmacist and usually others. Everyone included on the team provides a piece of the patients’ healthcare that is so crucial to the success of their therapy and treatment. We are discovering that by bringing in different views and aspects of sexual health experts, we can better hone in on a productive, efficient, and successful treatment plan.
On the advocacy side, a nurse practitioner colleague of mine and I have started a monthly sexual health panel called “justASK!” where we encourage patient listeners to ask their sexual health questions anonymously. We strive to debunk myths and taboos surrounding sexual dysfunction and other intimate topics while providing a safe and confidential space for conversation. Anything goes! Each month we have a different expert in the field of sexual medicine on the show to provide insight to patients in their particular field. We’ve had a pelvic floor therapist, a sexual counselor, physician and midlevel providers in hormone health and sexual medicine, LGBT community providers, and more to come! You can check out some of the interviews here, along with other sexual health resources for patients and providers.
To read more interviews with leading women’s healthcare practitioners, as well as the latest on women's health clinical trials and research, check out The Biome Blog.