BHRT Collaborative Care Program

 At The Medicine Store we understand that each patient is unique as an individual and in their health needs.  To meet these needs, we will work with you and your physician within the TRIAD of care to address your health concerns.  This is one of the wonderful benefits of bioidentical hormone replacement therapy (BHRT).  We can customize your prescription to meet your specific needs.  This care program is truly individualized care.  The term Bioidentical indicates that the hormones we compound with are the same chemical structure as the hormones we naturally make, this unlike other products used traditionally for hormone replacement that are often made with synthetic hormones (chemicals that have had the chemical structure altered in some way by the manufacturer).  We also can make the strength and combination of hormones in your compound to match your unique needs, we are not limited to strength A, B, or C as commercial products are.   

The TRIAD of care consists of patient, physician, and pharmacist.  It is important that we gather information from you, the patient, and your physician concerning you medical/health history.  We, as pharmacists, will then make a recommendation to your physician regarding the BHRT prescription(s) that we feel will best address your health concerns.  If your physician agrees with our recommendation, he/she will sign the prescription and fax it back to us allowing us to fill the compounded prescription for you.  The consultant pharmacists at The Medicine Store have completed extensive training and education in regards to hormone replacement therapy.  Our education also focused extensively on human biochemistry.  However, it is important to understand that we, as pharmacists, cannot prescribe medication, so you, the patient, will want to ensure your physician or other healthcare provider is familiar with BHRT, that they feel you would be a good candidate for BHRT, and that they are willing to consider a recommendation for BHRT from your pharmacist.  Ultimately, our role is to use our education to make a recommendation to your physician, we also will take time to do a thorough consultation with you.  It is, however, very important for you to keep your physician informed and to convey any concerns you have during this process to your physician as well as to the pharmacist.  

PATIENT INSTRUCTIONS: 

  • BHRT Evaluation Form: On initial visit, the pharmacist will fill out a BHRT Evaluation Form to obtain baseline symptoms and health history information in order to compile an initial recommendation.  We prefer for this visit to be in-person. 
  • Symptom Journal: The pharmacist asks that once started on BHRT that you write down the date and any symptom/side effect concerns you experience while on BHRT.  The pharmacist will follow-up with you 6 to 8 weeks after starting BHRT and it is helpful if you have kept a symptom journal so that we can make any adjustments necessary to get you balanced.  **If you have any significant concerns before the 6-8 week follow-up call please feel free to contact us and/or your physician.   
  • It is very important to be patient when first starting BHRT.  It can take up to 6 months for hormones to become balanced, although some improvement is usually seen sooner than this.  You will have the best experience if you go into this with the understanding that it takes time for us to figure out what is best for your body and that this is not going to be an “overnight” fix.  We are a team (patient, pharmacist, and physician) and if we work together we will have the best outcome. 
  • Labs: To ensure that you are getting the most from your bioidentical hormone regimen we ask that you have lab work performed.  In some cases we will ask that your physician order blood/serum labs and in other cases we can give you a saliva test kit that you can collect at home and send in to the saliva lab.  Depending on the situation we may or may not recommend that baseline labs be drawn before starting BHRT, however, we will ALWAYS request that either your physician order serum/blood lab work or you send in saliva labs 3 months after starting BHRT and at least every 6 months to once a year thereafter.  It may also be needed sooner than the one year mark if there are any significant dosage changes to your hormone therapy.   
  • Please be sure to forward any lab results you receive to the pharmacist. 
  • The lab tests that we will request to be ordered by your physician or collected via saliva may include: Estradiol, Estrone, Progesterone, Free and total Testosterone, Vitamin D, DHEA, and possibly morning cortisol.  If you have other medical conditions (eg. Hypothyroidism or hyperthyroidism) we may recommend additional labs be drawn. 
  • DO NOT STOP YOUR CURRENT BHRT DOSE in order to have labs drawn.  
  • Serum/blood labs MUST be drawn EXACTLY 5-6 hours after your most recent BHRT dose.  This timing is VERY important to get accurate lab results.    
  • For saliva labs closely follow the instructions provided in the saliva kit in regards to how much time after your last BHRT dose should pass before you collect your saliva
  • Well Woman Exam, Pap Smear, Mammogram 
  • Before starting BHRT we require you, the patient, to confirm you are up to date on all pertinent wellness screening exams.   
  • The pharmacist will be happy to review the current guidelines with you to determine which exams are necessary for you and how frequently they should be repeated. 
  • If you have any unexplained bleeding while on BHRT it is imperative that you notify the pharmacist and/or physician  
  • In many situations bleeding can be normal, but we want to be notified of any bleeding you experience in order to make that determination. 
  • When to request refills of compounded medication 
  • Because BHRT is very specific to each individual patient, we need ample time to prepare each compound in the lab.  Please try to call your compound refill in at least 5 business days before you are out of medication.  More time is needed if you are out of refills or if you want to discuss a possible dosage change because of symptoms or labs. 

DOSAGE FORM/SALIVA VS. SERUM (BLOOD) LABS: 

  • Compounded hormone replacement can come in several possible dosage forms such as topical creams, troches, oral capsules, vaginal creams, etc. 
  • For Estrogen replacement we prefer a non-oral dosage form (eg. a topical cream) in order to completely bypass the first pass metabolism of the liver.  Naturally, hormones are released directly from glands in our body into the bloodstream and do not go through the G.I. tract.  We try to mimic this natural physiology as much as we can which is why we prefer non-oral dosage forms when possible.   
  • Hormone levels can be monitored via serum (blood) or saliva. There are different situations where one method of monitoring is better than another. 
  • At The Medicine Store, we believe that topical hormone replacement does not show up well in serum, but more accurately is reflected by testing saliva levels. Usually when we measure serum labs on a topical hormone user, the levels come back lower than expected.  Once serum levels start going up with a topical hormone user it actually indicates that the topical dose is too high.  Serum labs are useful for troche hormone administration, but not topical.  It has to do with how topical hormones are distributed throughout the body.  It is not known how they are distributed, but there is some thought that it could be via the lymphatic system.  The way to think about it with topical hormone replacement is we want to soak the sponge (get the levels back to normal at the tissue level) but we don’t want the sponge to be overly soaked to the point that it starts dripping out (if the tissue becomes overly soaked, it will start spilling over to the serum and will show up on serum labs, but this is overly soaked).  Some believe that if topical hormones do not show up in serum labs that they are not being absorbed and are not getting to the tissue level.  This can be refuted with saliva labs though.  If a person has his/her saliva labs tested at baseline and then again after being on topical hormone replacement, the saliva lab levels go up.  This indicates that the topical hormone is, indeed, being absorbed topically and getting to the tissue level.  ZRT laboratories is an excellent resource for understanding when to use saliva vs. serum.  For patients that we recommend topical hormone replacement, we will ask that they collect saliva labs.  We provide the saliva kit which can collected at home then be mailed to the lab. 

COST 

  • The cost of each compounded hormone prescription usually ranges from $55-$85 each time it is filled. 
  • Cost of labwork (saliva or blood/serum) 
  • Insurance coverage and cost of blood/serum labwork is very variable.  However lab results are an essential part of this program.  The consultation pharmacist can try to help determine the most cost effective and appropriate lab collection option for you. 
  • Saliva labs are not usually covered by insurance and the standard order is $130. 
  • The initial consultation fee with the pharmacist is $100. 
  • This includes the 6-8 week follow-up and the 3 month lab review. 
  • Any phone calls lasting greater than 15 minutes or additional appointments outside of the included follow-ups will cost $30/15 minute block of time. 
  • Brief questions lasting less than 15 minutes will be free of charge, as always.  In fact, we want to you to feel comfortable to voice any questions or concerns you have. 
  • However, if you need to speak with the pharmacist for more than 5 to 10 minutes, you will need to schedule a one-on-one phone or in-person consultation and there is a fee of $30/15 minute block of time for this service. 

PROFESSIONAL GRADE SUPPLEMENTS RECOMMENDED WITH BHRT 

      (ask about our professional grade Wellness Works vitamin and supplement line). 

  • Multi-Vitamin 
  • Several vitamins and nutrients are required to fuel basic biochemical pathways for hormone conversion. 
  • Quality Probiotic 
  • Probiotics can help with immune and gastrointestinal health. 
  • Omega-3-Fatty Acids (Fish Oil) 
  • Fish oil can have anti-inflammatory properties, can be cardio protective, and can be beneficial for brain health. 

Thank you for trusting us to be a part of your healthcare team. We look forward to working with you to get you feeling your best! 

BHRT Collaborative Care Program 

I have read and agree to all terms of The Medicine Store’s Collaborative Care Program: 

Signature of patient:______________________________________________ 

Date:______________________________________ 

Printed name of patient:________________________________________