Incorporating BHRT into Practice

By Dr David Eccleston / 20 Apr 2020

Dr David Eccleston provides his tips for successfully incorporating customised bio-identical hormone replacement therapy into an aesthetic practice

Bio-identical hormone replacement therapy (BHRT) is a field that is fast gaining worldwide traction within the medical and aesthetic industry. According to market research company IMARC Group, the global BHRT market is projected to reach US $6.3 billion by 2024.1

Patients are educating themselves on the options available to them and seeking this treatment from private hormone specialists. However, it has become a natural fit for medical practitioners within aesthetics to offer this service as their existing patient base is generally already interested in ageing treatments and within the appropriate age group, making them the ideal target market. In my experience, BHRT has demonstrated a great way for aesthetic clinics to add more value to existing patients, as well as attracting new patients with this service offering.

About BHRT

Bio-identical or ‘body identical’ hormones have been around since the early 1930s2 and are an important option for women in balancing their hormones. Bio-identical hormones are produced from the chemical diosgenin, which is extracted from plant sources such as Mexican wild yam and soy, and manufactured into micronised form.3 Many prescribers do not realise that synthetic hormones have a different arrangement of carbon, oxygen and hydrogen atoms compared to naturally-occurring hormones in the body; therefore, hormone replacement therapy (HRT) does not behave in the same way as the hormones made by our body. Conversely, BHRT has the same chemical and molecular structure as the hormones produced in the body. As a result, they fit our hormone receptor sites wholly and their effects can be more consistent with the normal biochemistry of the body.4,5

cBHRT vs. rBHRT

There are two types of BHRT: registered bio-identical hormone replacement therapy (rBHRT) and customised bio-identical hormone replacement therapy (cBHRT). Customisation (or the compounding) of hormones offers personalised solutions for treating hormone imbalances and follows a prescription that is based on the individual patient’s diagnosis, symptoms and blood hormone levels that are measured at specific time points.6 cBHRT is classed as ‘off-licence’ prescribing (also known as ‘unlicensed’), which is common across many healthcare sectors. Prescribing unlicensed medicines is a regulated practice that is recognised and guided by the medical, nursing and pharmaceutical professional bodies.7 cBHRT allows different medicines to be combined in a formula that is unique to the patient’s individual prescription. The same approved hormones used in licensed rBHRT are combined in a UK pharmacy registered with and regulated by the General Pharmaceutical Council (GPhC).8 The resulting hormone combination is a named-patient, prescription-specific, quality-assured extemporaneous medicine which can no longer be termed as ‘licensed’ as the ingredients have been combined.

With more demand for a personalised treatment approach, cBHRT made in a regulated compounding pharmacy is becoming more commonly prescribed to patients. The benefit of this personalised approach is that the patient is less likely to experience side effects,5 as they are given the lowest required dose needed to manage their symptoms. It also offers them the opportunity to access a wider range of routes of intake compared to rBHRT, which are typically taken via capsule form for progesterone and gel/patch form for oestrogen, so patients can choose their preferred method. Combining different hormones into a cream, for example, can simplify a regimen and therefore encourage compliance. Personalised treatments also allow the patient a much longer consultation than available on the NHS, meaning that they have time to fully discuss their symptoms and a fully comprehensive medical assessment can be conducted.

cBHRT controversies

It should be noted that there are controversies surrounding cBHRT and, as such, it is not endorsed by the British Menopause Society (BMS) or the Royal College of Obstetricians and Gynaecologists (RCOG).9 The bodies have released a consensus statement highlighting their concerns, which states, amongst other items, that, ‘cBHRT products are not recommended by the BMS as they are not evidence based for effectiveness and safety and because rBHRT options are available’.9

My experience with cBHRT

From personal experience as an aesthetic practitioner, and with a strong medical background including in obstetrics and gynaecology, I could not ignore this treatment. Whilst working both in aesthetics and general practice, I was seeing an increased demand for cBHRT, which led me to seek training. I worked with my team to ensure we were set up to do this to the highest standard and we soon had regular patients. We have now expanded to train our in-house practice nurse to support this popular service and I personally support and oversee every case with her.

The most frequent line I hear from patients after the start of treatment is, “I have got my life back” and, for me, professionally, this has been the most rewarding part of the work I do.

Having built cBHRT successfully into our practice, I want to share the learnings and the key things to consider before incorporating it into your own practice, which requires careful consideration.

Typical patients

I certainly advise that practitioners treat less complex cases to begin with, such as straightforward, menopausal women with no family history of cancer. The majority of patients seeking treatment in my practice are between 40-60 years of age. In my experience, around 80% of the typical patients seeking treatment are either premenstrual, perimenopause, menopause, andropause or suffering with adult acne. I’ve found that perimenopause (the years leading up to menopause) can be the most challenging time for women, as their own hormones are fluctuating wildly, and these patients are most regular in my practice.

Considerations for introducing BHRT into practice

There are many things you as a practitioner need to consider before you can add this treatment to your offering, which are discussed below.

Clinical background

The only legal requirement to be trained to offer these treatments is that you need to be a UK registered prescribing practitioner so that you can prescribe to a UK pharmacy. I believe that prescribing practitioners without experience in women’s health should work with another specialist practitioner with experience in this area, as well as seeking additional training in women’s health, before commencing any BHRT training. In the UK, this can be done through the British Menopause Society or specialist training academies.

Many doctors who graduated post 2000s, around the time of the Women’s Health Initiative (WHI) study which showed an increase in coronary events, stroke, breast cancer and venous blood clots in women taking combined HRT, did not get formal training in menopause management and it is important to understand the essentials before learning how to prescribe hormones.10

Passion for women’s health

I think it is extremely important that practitioners have a passion for women’s wellbeing. Most of the practitioners in my network have built hormone treatments into their practice because of how rewarding it is. When done properly, you can make a huge difference to your patient’s quality of life. To be able to help when I hear the usual complaints of menopause symptoms and other hormone imbalances is incredibly rewarding. Therefore, I would discourage any practitioner who is simply looking to seek financial rewards from offering this treatment.

Regulation and compliance

As BHRT requires the diagnosing and treatment of a medical condition, it is generally a requirement to be registered with the Care Quality Commission (CQC), if you are not already.11 I recommend that you contact the CQC (or the regional equivalent: Health Inspectorate Wales, Healthcare Imporvement Scotland and Regulation and Quality Improvement Authority in Northern Ireland, Health Information and Quality Authority in the Republic of Ireland) before you consider offering this service to check if registration is required, as this is individual to each clinic. You will also need to check whether your current insurance provider will cover you for prescribing cBHRT.

Training in cBHRT

Training is a mandatory requirement for cBHRT to know how to diagnose and treat the typical conditions such as premenstrual syndrome, perimenopause, adult acne and andropause. In considering a training provider, I recommend choosing an accredited course that provides ongoing educational and clinical resources.

I found it useful to choose a provider that offers a network of like-minded peers and access to regular accredited education such as webinars to discuss clinical case studies. My team and I have personally trained with the Marion Gluck Training Academy, and we have found it to be very supportive; however, there are several other options available to practitioners.

 Investment

One of the biggest advantages of building cBHRT into your practice is that there is minimal financial outlay involved, unlike many aesthetic treatment pathways which involve the investment of expensive equipment. If you already have a consulting room and basic medical equipment (including scales and a sphygmomanometer), then it means your route to market is quicker. Obviously, there will be training costs, with the average cost being around £2,000.

Blood testing

You may already take blood tests in your aesthetic or medical clinic if you are also offering nutritional/functional medicine services. In this case, the set up you have will be very similar. Blood tests are generally taken periodically to assess your patients’ current hormone levels. If you cannot take blood in your clinic, you will need to source a local laboratory that offers this service or partner with a phlebotomist.

Most practitioners take blood during the consultation and then send it to the laboratory for analysis – often the laboratories offer a daily courier service. I find this is the easiest for the patient. Some training providers also partner with a blood-testing laboratory and have pre-arranged preferential pricing for cBHRT graduates, which can be useful to consider when choosing a provider.

 Pelvic ultrasound scans and other tests

Another important aspect of hormone treatment is pelvic ultrasound scanning, which is important to ensure the endometrial lining is not thickened prior to and during treatment.12 To provide these scans, you will need to partner with a trusted diagnostics company (radiologist) to refer patients to. As part of the cBHRT consultation it will also be important to know that the patient has had an up-to-date smear test, mammogram and DEXA scan, if applicable. These tests are available on the NHS or may need private referral.

Compounding pharmacy partner

A key element of building cBHRT into your practice is choosing a pharmacy that will supply the hormonal treatments you will be prescribing. Personalised cBHRT is made to dose requirement in a compounding pharmacy. Your pharmacy will become your partner in treating your patients, so you will want to do your due diligence in deciding who to use. As a bare minimum, they must be regulated by the General Pharmaceutical Council.8 We work closely with a compounding pharmacy called Specialist Pharmacy.

Marketing

You will need to consider how you reach your audience for the introduction of this treatment. For most aesthetic practitioners, they already have an existing patient base which they should utilise. The demographic coming in already for aesthetic treatments are often the same who are starting to experience menopausal symptoms. For our practice, marketing involved updating our existing communication platforms, such as our website and newsletters, to include this service. Word of mouth is also an extremely successful marketing channel for many cBHRT clinics. Most of the new patients I see have come thanks to a recommendation from a friend who has rid herself of hot flushes, is sleeping better or is finally able to enjoy sexual intercourse again. This means you need to focus your efforts on providing an outstanding service – something you will already be doing for your other services. As with all references to product claims, it is important to ensure that you are compliant with the guidelines set out by the Advertising Standards Agency (ASA), so it would be prudent to read these before marketing your services.13,14,15

Benefits to introducing cBHRT to practice

Overall, offering this treatment therapy to our new and existing patients has provided:

Added value to our clinic: a competitive advantage in meeting the demands of our patients

New revenue channel: offering additional services to existing patients, and attracting new patients

New patients: attractive to new patients, with a high number driven from referral from current patients who have experienced the treatment

Increased patient retention: long patient lifetime and ongoing servicing of patients’ treatment

Best practice

As mentioned, it is part of our clinical judgement to determine whether or not a patient is outside of scope, so in these cases it is always recommended to refer to a specialist. I believe in providing cBHRT services properly, and, in doing so, we have established a successful practice with lots of excellent patient outcomes. Integrating cBHRT into our service offering has been a natural fit, and many patients want to experience the other treatments we offer. Practitioners must ensure they have the relevant background training and choose a reputable cBHRT training provider that will support them and their team throughout their journey.


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