Hormone replacement therapy (HRT) is commonly associated with women going through menopause and perimenopause. But it has acquired a bad rap in recent years because of the side effects of Premarin and Provera — two of the commonly prescribed HRT drugs out there.
Dr Neal Rouzier was among the first to actively advocate and prescribe “bioidentical hormones” for HRT. And not just to women going through menopause but also men and women of all ages, depending on their needs.
By doing so, he has locked horns with both the medical profession and pharmaceutical industry — mainly because bioidentical hormones mimic the hormones that are naturally produced in our bodies and cannot be patented.
To turn a hormone into a drug, you have to alter the structure of the hormone. The problem with synthetic hormones is that the side effects only turn up after years of taking the drug.
“The public demands safer alternatives [for HRT]. That is why doctors like me are promoting the safe ones, the ones made by your body,” says Dr Rouzier in a recent interview. The medical director at Preventive Medicine Clinic in Palm Springs, California, has specialised in bioidentical HRT since 1997.
In Malaysia, he has teamed up with Accent Wellness Compounding Pharmacy to help train doctors in the region to do what he does. That is because he noticed that many of his patients were from this part of the world. They travelled to the US to be treated for ageing or fertility-related problems such as polycystic ovarian syndrome (PCOS).
Dr Rouzier is neither an endocrinologist nor an obstetrician gynaecologist. In fact, he got into the study of hormones and the effects of natural hormone replacement therapy quite by accident.
“I am surgically trained and I worked at a trauma centre. Who else works at trauma centres? Nurses — hundreds of them. And I was fortunate, or unfortunate, to have befriended many nurses who were miserable from things like menopausal and perimenopausal symptoms, fatigue and premenstrual syndrome (PMS). They asked me to prescribe hormones to help them improve their condition,” he says.
At first, he refused. After all, he had gone to medical school and had been trained in the same way as his colleagues. All he knew was to prescribe Premarin and Provera for most of these symptoms. When the nurses told him that these medications were making them sick or giving them depression, mood swings, weight gain and other symptoms, he offered to prescribe anti-depressants instead.
Working at a trauma centre on 12-hour shifts, most of these nurses suffered from fatigue. When one of them was prescribed natural thyroid hormones by her doctor, she told her colleagues about it. They noticed that they immediately felt better after taking this and begged Dr Rouzier to prescribe it.
“I told them I was not going to prescribe thyroid hormones as their levels were normal and they did not need it,” he says.
He then explains what is “normal”. “They take a thousand women your age, test their blood and plot the results on a graph. And you get this bell-shaped curve. Everyone fits into that range of ‘normal’. Some will be high, some will be low, but everyone that fits into that range is ‘normal’. It may be that everyone in your age group that has ‘normal’ levels does not feel well. And when you bring them to higher levels, they feel better.”
At that time, he was still a product of the system and he did not believe the nurses when they told him that they felt better after taking the hormones. “I told them it had to be the placebo effect.”
These hormones were available through compounding pharmacies, which he knew nothing about. “Estradiol [the most important component of oestrogen] and progesterone were available commercially but only in certain doses. It was either too much or too little. But if you compound them, you can increase it slowly until the symptoms are gone. This is difficult to do with a tablet,” says Dr Rouzier.
This was his introduction to HRT. “There was no course, no books. There was nothing that I knew of that would teach me this,” he says.
Dr Rouzier is fond of quoting a “wise old professor” from medical school, who used to say to the student doctors that if they listened to the patient long enough, the patient would tell them what was wrong. And if they listened even longer, the patient would even tell them how to fix it.
However, most of those in the medical profession were too arrogant to do that. They liked to believe that they knew best in all cases. That is why Dr Rouzier initially told his nurses that the hormones did not work and they had to be imagining that they felt better after taking them.
This was in 1995. “That was how I learnt hormones and that was the start of it. What do women do? They talk to other women and tell their story. Suddenly, the other nurses wanted me to do the same for them. They called me Dr Feelgood,” he says.
“They wanted me to prescribe hormones because they did not feel well. They either had PMS, perimenopause, menopause, fatigue ... a multitude of different issues. I did not know what I was doing, but nobody else knew how to do it either. I was just doing what the nurses told me worked.”
Dr Rouzier decided to do some research to see if there were any studies that supported what he was doing. “I spent six months searching and reading and realised that there were studies and data that show that when you raise hormone levels in men and women, they feel better. So, all I was doing was raising their hormone levels.
“It did not make sense to prescribe hormones if their levels were normal. Their thyroid levels were fine but when I gave them thyroid hormones, they felt better. However, the medical literature says what is normal is not always as good as optimum. Even though your levels are not low, if you optimise them, people tend to feel better.”
As people get older, their hormone levels fall. “And when your raise those levels, people feel better. What do you raise it to? You raise it to the point where they feel better. What number is that? It is different for each person,” says Dr Rouzier.
For instance, the normal level of oestrogen for a menopausal woman is zero. “So, you will suffer the consequences of being normal. It just so happens that the optimal range is where you were when you were younger. When you were 20, your levels were at a certain point. When you are 60, they are much lower. And when you are 80, they are even lower than that. When we bring your levels back up, you feel better,” he says.
“If I tell patients that we are going to optimise their levels, they do not know what that is. But if I say I am going to bring their levels back to when they were 20 years old, they can understand that. If I tell doctors, we are going to bring it back to 20, they say, ‘No, you are not.’ If I tell doctors, we are going to bring it to optimal, they say, ‘That does not make any sense to us because this is normal.’ It is very problematic to get them unstuck from normal.”
Part of the problem lies in the difficulty of telling doctors that what they have been doing for years is not quite correct. “When they come for courses, I ask them, ‘If you are going to continue doing what you are doing, how is that working out for you? They tell me that it is not. Do the patients feel well? No. Do they jump up and down and say thank you? No. Do they tell you they feel so much better? No. What do the patients tell you? They feel lousy.”
Today, bioidentical HRT may not have the endorsement of the medical profession, but many would attest to its effectiveness. Hollywood star Suzanne Somers wrote a book on its impact on her life and it was promoted by talk show host Oprah Winfrey.
“Back when I was treating my nursing staff, there was no Oprah or Suzanne Somers. There were just patients. But the more I realised it, the more I realised that patients were probably undertreated or not treated. So, I gave this Grand Rounds to my hospital staff,” says Dr Rouzier.
A Grand Rounds is a monthly presentation by a doctor to other doctors about something of interest to educate them. When he gave his Grand Rounds, however, 200 doctors showed up. But what was even more interesting, he says, was that 100 nurses did too.
“In the process of my trying to lecture and explain to the doctors what I was doing, they started to challenge and criticise me. And then the nurses got up and challenged the doctors. They told the doctors that they were clueless, that they did not understand women, that they did not understand how to treat women,” says Dr Rouzier.
Not all the doctors were resistant. A couple of the pharmacists and doctors came over to tell him that the presentation had been excellent and he should start teaching courses because “nobody knows this stuff”. So, he did.
Dr Rouzier has a special fondness for the thyroid hormones that started it all. “There are two thyroid hormones in your body — T4 and T3. You have a gland that makes T4 and your body converts it into T3. It is the T3 that is responsible at the cell level for processes such as metabolism and energy.”
For years, he says, doctors used a natural thyroid hormone that included a mix of T4 and T3. “We used it for 100 years and then in came the pharmaceutical industry and they produced just the T4. And the reason they did that was because some people who took T3 got too much of it and had side effects.
“But those who only took T4 found that while there were no side effects, people did not feel as well because the body was not making T3 out of the T4 it was given. The body converts the T4 that the gland produces into T3. But if you just give it T4, it shuts down the production of T3.”
The two feel-good hormones for women, he says, are the thyroid hormones and testosterone. “Oestrogen gets rid of hot flashes, progesterone helps you sleep. But they do not make you feel better. My nursing staff have to work 12 hours straight in an emergency room. If you are over 35, you can’t handle the intensity. But if you are on hormones, it is no problem.”
Are there any side effects from taking testosterone? Rouzier answers rather sarcastically. “Sure, there are. You lose weight. You gain muscle, strength and endurance. You feel better. You function better. You perform better. It is good for your skin, muscles, ligaments, joints, tendons and bones.”
He adds that the most important thing one can do to protect against breast cancer is take progesterone. “The second most important thing that protects against breast cancer is testosterone. If one in seven women are going to get breast cancer, don’t you think they should be protecting against it?”
Testosterone helps improve sexual function in both men and women. “You lose sexual desire after 40. After two kids? Forget it. How do you fix that? Testosterone,” says Dr Rouzier.
He says he has patients in their 70s, 80s and 90s who come into the clinic holding hands, telling him he has saved their marriage. “When there are a couple of thousand patients telling me that I saved their marriage, what does that mean? It means I have given them the means by which they can go back and love one another again,” he chuckles.
What about hormones for men? “It is misunderstood that 50% of the benefit of taking testosterone in men is actually due to the conversion of testosterone into oestrogen in their bodies. It is very much in vogue among doctors who do what I do to block oestrogen in men. But every study shows that when you block oestrogen, you lose half the beneficial effects of testosterone.”
Testosterone in men has the same effect in women: strength, endurance, improvement of well-being, motivation, drive, initiative, work accomplishments, and desire to do new things.
For men, thyroid hormones are not “feel-good hormones”. Dr Rouzier prescribes it as a means of lowering cholesterol. “It works tremendously well. It lowers body fat, which lowers your cholesterol.
“Doctors and the pharmaceutical industry think that everyone should be on cholesterol medication. There is so much force pushing that product that they think it should be in your water.
“I don’t use it because I don’t have to. Thyroid hormones lower cholesterol, and so does testosterone. It will help you lose fat and maintain muscle. It will take your cholesterol down nicely.”
He says people on cholesterol medication still continue to have cardiovascular disease, heart attacks and strokes. “In every study in the last 20 years, taking cholesterol medicine has not improved morbidity or mortality. In every outcome study of testosterone, there has been improvement in both categories.”
Dr Rouzier says oestrogen can even help reverse Alzheimer’s disease. “The drug companies have spent billions of dollars trying to come up with a drug that reverses Alzheimer’s. Everyone has failed. So, what helps?
“In women, it is oestrogen. In men, it is oestrogen. But you can’t give men oestrogen. So what do you give them? Testosterone, which converts into oestrogen.”
How does one go for bioidentical HRT? First, you go for a blood test to determine your hormone levels. There are a number of doctors in Malaysia who have been trained and certified by Dr Rouzier. They can read your bloodwork and prescribe the necessary hormones. Patients are then sent to compounding pharmacies such as Accent Wellness to make up their hormones.
How much does bioidentical HRT cost? According to Accent Wellness managing director Stephanie Yang, it depends on which hormones you require and in what quantities. Most of the older people would be on hormones for life. But if the hormones are used to treat someone younger with, say, PCOS, they can take it until the problem is rectified. Post-menopausal women would probably have to spend an average of RM600 to RM800 a month.