Thank you for clearly explaining this! I recently started Duavee and have been worried that it is not as “natural or bio-identical” as the estrogen from soybeans and the progesterone pill I was taking. As someone who is progesterone intolerant and has tried multiple combinations over the years with no luck this is my last chance before giving up on hormones. I feel much better about my current choice! You are wonderful!
This article couldn’t be more timely as I was just trying to figure out what bioidentical meant! Thank you for the thorough and clear explanation. I especially loved the table! Thank you! 💕
1) "it’s pretty hard to see how the concept of “bioidentical” is of any relevance to an individual in menopause who is not pregnant." -- Love it; just love it...
2) Years ago a patient said to me that[something-or-other] was 'natural.' My response was, "so is arsenic." She got it...
Really appreciate this article. I also want to mention that "ethical" is a word I use when I ask people to consider carefully before using Premarin. The PMU mares are kept in small stalls, their entire lives consisting of being bred repeatedly for the purpose of harvesting their urine. As a lifelong horse lover, I declined my doctorʻs offer of a prescription on those grounds. There are organizations that rehome these mares after their "useful" life - and rescue their foals. Wish we could post photos here as I have a great one of me riding a gentle giant PMU foal that might otherwise have been auctioned for horse meat.
I was never offered Premarin, but I had heard this about how it was “harvested” so never considered it. Was coming on here to ask Dr Gunter what the composition is that might make it superior to the other MHTs.
I did a deep dive into the farming here https://vajenda.substack.com/p/premarin-is-extracted-from-horse overall it seems less problematic than the dairy industry. Premarin is comprised of both estrogens and SERMs (selective estrogen receptor modulators), and when given by itself it is associated with a lower risk of breast cancer and breast cancer mortality, likely due to the SERMs. It is available combined with bazedoxifene, and this combination is called Duavee and is ideal for someone with an intolerance to progesterone or progestins or who is high risk for breast cancer, Here is some more information https://vajenda.substack.com/p/duavee-shows-promise-in-breast-cancer
To be clear, I also have problems with confined animal feedlots including dairying operations (I eat both beef and dairy products but from local ranches) - and again, from the perspective of a horse owner this might be not that dissimilar to the life of many horses, but I think there is a certain amount of whitewashing here given the first hand experience I have with foals going to auction and the people who rescue them. There seem to be very good reasons for others to weigh their options and accept Premarin as their best solution. But I do not believe my opinion is based on misinformation.
That's a great explanation of what and how different oestrogens are used in MHT and it cuts through all the BS and pseudoscience. This statement: "However, I know the people who market their “special” hormones as plant-based would have you believe that their formulation begins with plants cultivated in unique microclimates that maximize phytonutrient potency. That harvesting is performed during the narrow circadian window when enzymatic activity peaks, ensuring optimal molecular integrity. And that they use a proprietary extraction process — calibrated to preserve the sapogenin structures and capture the plants’ full spectrum of bioactive constituents. The result is a highly concentrated, clinically inspired blend designed to support the body’s innate cellular resilience and promote balanced hormonal harmony." needs a copyright and mark as satire as I wouldn't be surprised if the Meno-grifters use this to sell their scammy products
This is great and if I only had a dollar for every time one of my friends says "but did you hear about bioidentical hormones"... This is still confusing to me but I think it boils down to synthetic vs the rest, and the rest is what we call bioidentical.
Dr. Gunter. Thank you for such valuable and priceless information. I have a question that I can’t find much information about. So I’m hoping you’ve come across this. I went on MRT due to having bad reoccurring headaches during perimenopause. My headaches went away but I developed De Quervain’s Tenosynovitis on both sides… I’ve found information that is associated with hormonal changes including those experienced during menopause. I’ve mentioned this to several MDs (OBGYNs included) and it appears they don’t know much. Is there any research on this out there?
I’m so confused! I’ve done so much PubMed research, scrolled Reddit Meno threads & regularly revisited its wiki, subscribed to your newsletter for at least a few months now, worked with 4-6 different doctors with varying levels of MHT familiarity over 8 years, and yet… I’m still lost. I’m 58, former smoker w BP issues (usu in the 135/80 range — take 5mg lisinopril), with a family history of breast & skin cancer (27% tyrer cusick), and had endometriosis in my 20s with no recurrence. I seem to be intolerant of progesterone (seems to cause back acne and does not make me sleepy, but acne could be from componded T).
Which versions of E & P are lowest risk of cancer and blood clots again?
Currently on combipatch after fkg around w prempro, then E patch + norethindrone, then E patch + micronized (later compounded) Progesterone. Years before that I tried compounded E&P with little impact on my hot flashes but scared to try anything else bc I was still smoking then.
My head is spinning.
At my last midi appointment, my NP actually suggested a hysterectomy to avoid my problems with progesterone. Already, I’m opting in for double mastectomy with reconstruction later this year. My hot flashes were out of control without MHT. And my libido was nonexistent for at least 10 years before I literally begged for a T rx. That was humiliating.
The acne is likely from the testosterone. I have several posts in my hormone therapy guide on different progestogens. I also review all the data on blood clots. But people who are intolerant of progesterones who have a higher risk of breast cancer and who have an ASCVD score of < 5% and do not have a higher risk of blood clots are ideal candidates for Duavee which has the lowest risk of breast cancer and there is no progesterone of progestins.
Wow- you broke that down like a boss- thank you!!
I cannot stand the abuse of the terminology!
Thank you for clearly explaining this! I recently started Duavee and have been worried that it is not as “natural or bio-identical” as the estrogen from soybeans and the progesterone pill I was taking. As someone who is progesterone intolerant and has tried multiple combinations over the years with no luck this is my last chance before giving up on hormones. I feel much better about my current choice! You are wonderful!
This article couldn’t be more timely as I was just trying to figure out what bioidentical meant! Thank you for the thorough and clear explanation. I especially loved the table! Thank you! 💕
My pleasure!
1) "it’s pretty hard to see how the concept of “bioidentical” is of any relevance to an individual in menopause who is not pregnant." -- Love it; just love it...
2) Years ago a patient said to me that[something-or-other] was 'natural.' My response was, "so is arsenic." She got it...
Hormone chemistry is fascinating. Nerdiest thing I’ve read in years - thank you!
Really appreciate this article. I also want to mention that "ethical" is a word I use when I ask people to consider carefully before using Premarin. The PMU mares are kept in small stalls, their entire lives consisting of being bred repeatedly for the purpose of harvesting their urine. As a lifelong horse lover, I declined my doctorʻs offer of a prescription on those grounds. There are organizations that rehome these mares after their "useful" life - and rescue their foals. Wish we could post photos here as I have a great one of me riding a gentle giant PMU foal that might otherwise have been auctioned for horse meat.
I was never offered Premarin, but I had heard this about how it was “harvested” so never considered it. Was coming on here to ask Dr Gunter what the composition is that might make it superior to the other MHTs.
I did a deep dive into the farming here https://vajenda.substack.com/p/premarin-is-extracted-from-horse overall it seems less problematic than the dairy industry. Premarin is comprised of both estrogens and SERMs (selective estrogen receptor modulators), and when given by itself it is associated with a lower risk of breast cancer and breast cancer mortality, likely due to the SERMs. It is available combined with bazedoxifene, and this combination is called Duavee and is ideal for someone with an intolerance to progesterone or progestins or who is high risk for breast cancer, Here is some more information https://vajenda.substack.com/p/duavee-shows-promise-in-breast-cancer
To be clear, I also have problems with confined animal feedlots including dairying operations (I eat both beef and dairy products but from local ranches) - and again, from the perspective of a horse owner this might be not that dissimilar to the life of many horses, but I think there is a certain amount of whitewashing here given the first hand experience I have with foals going to auction and the people who rescue them. There seem to be very good reasons for others to weigh their options and accept Premarin as their best solution. But I do not believe my opinion is based on misinformation.
That's a great explanation of what and how different oestrogens are used in MHT and it cuts through all the BS and pseudoscience. This statement: "However, I know the people who market their “special” hormones as plant-based would have you believe that their formulation begins with plants cultivated in unique microclimates that maximize phytonutrient potency. That harvesting is performed during the narrow circadian window when enzymatic activity peaks, ensuring optimal molecular integrity. And that they use a proprietary extraction process — calibrated to preserve the sapogenin structures and capture the plants’ full spectrum of bioactive constituents. The result is a highly concentrated, clinically inspired blend designed to support the body’s innate cellular resilience and promote balanced hormonal harmony." needs a copyright and mark as satire as I wouldn't be surprised if the Meno-grifters use this to sell their scammy products
This is great and if I only had a dollar for every time one of my friends says "but did you hear about bioidentical hormones"... This is still confusing to me but I think it boils down to synthetic vs the rest, and the rest is what we call bioidentical.
Dr. Gunter. Thank you for such valuable and priceless information. I have a question that I can’t find much information about. So I’m hoping you’ve come across this. I went on MRT due to having bad reoccurring headaches during perimenopause. My headaches went away but I developed De Quervain’s Tenosynovitis on both sides… I’ve found information that is associated with hormonal changes including those experienced during menopause. I’ve mentioned this to several MDs (OBGYNs included) and it appears they don’t know much. Is there any research on this out there?
I’m so confused! I’ve done so much PubMed research, scrolled Reddit Meno threads & regularly revisited its wiki, subscribed to your newsletter for at least a few months now, worked with 4-6 different doctors with varying levels of MHT familiarity over 8 years, and yet… I’m still lost. I’m 58, former smoker w BP issues (usu in the 135/80 range — take 5mg lisinopril), with a family history of breast & skin cancer (27% tyrer cusick), and had endometriosis in my 20s with no recurrence. I seem to be intolerant of progesterone (seems to cause back acne and does not make me sleepy, but acne could be from componded T).
Which versions of E & P are lowest risk of cancer and blood clots again?
Currently on combipatch after fkg around w prempro, then E patch + norethindrone, then E patch + micronized (later compounded) Progesterone. Years before that I tried compounded E&P with little impact on my hot flashes but scared to try anything else bc I was still smoking then.
My head is spinning.
At my last midi appointment, my NP actually suggested a hysterectomy to avoid my problems with progesterone. Already, I’m opting in for double mastectomy with reconstruction later this year. My hot flashes were out of control without MHT. And my libido was nonexistent for at least 10 years before I literally begged for a T rx. That was humiliating.
… so fkg tired of this!
The acne is likely from the testosterone. I have several posts in my hormone therapy guide on different progestogens. I also review all the data on blood clots. But people who are intolerant of progesterones who have a higher risk of breast cancer and who have an ASCVD score of < 5% and do not have a higher risk of blood clots are ideal candidates for Duavee which has the lowest risk of breast cancer and there is no progesterone of progestins.
Good to know you like Duavee for the progesterone intolerant like myself.
Been sitting on the fence about this medication.
I do not need estrogen for hot flashes anymore but would like bone protection since osteopenia dx
Is Dauvee recommended for bone protection?
Yes, Duavee is an option for prevention of osteoporosis
Thank you so much for your response Dr. Gunter.
That is good information for me to take to my GYN now.
Thanks! Sorry for the rant. (Had to change up my profile name… lol). I am 2 weeks into a monthlong break from the T, hoping for progress. None so far.
Part of my new confusion today was reading in this column how testosterone converts to a Progestin… aaargh, so much science!
In any event, I very much appreciate your expertise and heavy lifting in this underserved area of medicine!
I will look into Duavee.
Best to you
Testosterone can only be converted into progestin in a lab, not in the body
Jen wrote about Duavee here:
https://open.substack.com/pub/vajenda/p/duavee-is-back-on-the-market?r=ge5l1&utm_medium=ios
And also here:
https://open.substack.com/pub/vajenda/p/duavee-shows-promise-in-breast-cancer?r=ge5l1&utm_medium=ios