A lot of pharmacies put a mortar and pestle on their sign, but seldom use one behind the counter. Most likely, when you hand over a prescription, you’ll get back an amber bottle of pills manufactured by a major drug company.
But pills are a problem for many people, so some patients are returning to the handmade medicines of the past. Known as compounded medicines, they deliver commonly used drugs in alternative forms — gels, pastes, liquids, sprays, lollipops, and tabs that dissolve in the mouth. And they allow drug strengths and dosages to be fine-tuned.
That’s good news to menopausal women who choose bioidentical hormone replacement therapy — BHRT for short. A woman who wants to manage menopause this way can work with her doctor to get personalized treatment based on her own symptoms and chemistry.
“When it comes to hormones, every woman is different,” says Jan Gerber, president and co-owner of Custom Rx, a compounding pharmacy with two locations in Wichita. “With compounded BHRT, we have unlimited options for what dose and combination of hormones to give a patient. There’s a hormone symphony going on, and the body’s systems do impact one another.”
What’s the different between bioidentical and synthetic hormones? BHRT uses hormones that are identical in structure and function to those found in the human body. Conventional hormone replacement therapy uses synthetic hormones that are similar to those that occur naturally. But since they were linked in the ‘90s to cardiovascular risks, they fell out of favor.
“Nobody ever says any of this is without risk,” Gerber said of hormone therapy. “But we want to make sure the body gets what it responds to best.”
Bioidentical hormones can also be measured during therapy with traditional blood tests, which helps doctors adjust dosage levels. That’s where compounded medicines come in.
The pharmacy can mix the exact cocktail the doctor calls for, and deliver it in the most effective form. According to Gerber, many drugs are least effective when swallowed. But hormones are easily absorbed through the skin, which makes transdermal gel a popular choice for women on BHRT.
Custom comes at a price, however. Not all prescription plans cover compounded meds, and those which do tend to put them in the priciest tier. And not all doctors are willing to prescribe them. That’s why Custom Rx seeks to educate physicians rather than marketing directly to consumers.
There’s also a cultural divide between traditional practitioners and those who are more open to alternatives. So women who want to try the BHRT route may have to hunt for a physician willing to prescribe compounds. “It’s a very divided issue. I’ve been doing this over 10 years, and there’s been a big change in the openness and positive response to it,” Gerber said. “But some out there are still very much against it.”
Critics say the customized nature of compounds is what makes them risky. Although the unformulated chemicals in compounds are regulated by the Food and Drug Administration, the final product isn’t. But compounding pharmacists like Gerber say the one-size-fits-all approach is wrong for medicine. As for efficacy, Custom Rx’s wholesalers provide certificates of analysis for their raw materials, Gerber said, and the pharmacy does some random sampling for quality assurance as well.
At Custom Rx, floor-to-ceiling glass separates the reception area from the lab, so visitors can watch the technicians at work. It helps demystify the compounding process, Gerber said. The mortar and pestle have been replaced by high-tech machinery, such as an ointment mill that smoothes the grittiness out of powders in the mix—good news for babies getting compounded diaper cream.
Compounds are essential for patients who need specific dosages and strengths, or who can’t swallow. Most often this means the very young and the very old.
For babies and children, medicines can be converted from pill form to liquid, and administered in very precise doses. Hospice patients can receive pain meds though a gel on their skin or a sublingual tablet, which dissolves under the tongue. Anti-nausea medication can bypass the troublesome GI tract and liver in the form of a troche — a waxy-looking lozenge held between the cheek and gum — or as a gel applied to the inner wrist. Plus, compounding pharmacies can fill a gap when there’s a shortage of a medication, or one is no longer commercially available.
That happened last year when liquid Tamiflu ran short during the H1N1 flu outbreak. Compounding pharmacists began converting capsules to liquid Tamiflu for children. Gerber says that’s what compounding is all about — meeting the needs of those who aren’t served by off-the-shelf products. In the case of BHRT, he said, women are flexing their buying power to get it the way they want it. “It should be evident by the patient response and growth in that area that we’re doing the right thing,” Gerber said. “The patients are demanding it.”
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