Incorporating BHRT into Practice

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 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 1930s 2 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 naturallyoccurring hormones in the body; therefore, hormone replacement therapy (HRT) does not behave in the same way as the hormones made by our body. Conversely,

is generally already interested in ageing 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 namedpatient, prescription-specific, qualityassured 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.

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.

I would discourage any practitioner who is simply looking to seek Typical patients financial rewards from offering I certainly advise that practitioners treat less complex cases to begin with, such as this treatment straightforward, menopausal women with no family history of cancer. The majority of patients seeking treatmentin my practice are between 40-60 years of age. In my Initiative (WHI) study which showed an Information and Quality Authority in the experience, around 80% of the typical increase in coronary events, stroke, breast Republic of Ireland) before you consider patients seeking treatment are either cancer and venous blood clots in women offering this service to check if registration premenstrual, perimenopause, menopause, taking combined HRT, did not get formal is required, as this is individual to each andropause or suffering with adult acne. training in menopause management and it is clinic. You will also need to check whether I’ve found that perimenopause (the years important to understand the essentials before your current insurance provider will cover leading up to menopause) can be the most learning how to prescribe hormones. 10 you for prescribing cBHRT. challenging time for women, as their own hormones are fluctuating wildly, and these Passion for women’s health Training in cBHRT patients are most regular in my practice. I think it is extremely important that Training is a mandatory requirement for practitioners have a passion for women’s cBHRT to know how to diagnose and treat Considerations for introducing wellbeing. Most of the practitioners in my the typical conditions such as premenstrual BHRT into practice network have built hormone treatments into syndrome, perimenopause, adult acne There are many things you as a practitioner their practice because of how rewarding and andropause. In considering a training need to consider before you can add it is. When done properly, you can make provider, I recommend choosing an this treatment to your offering, which are a huge difference to your patient’s quality accredited course that provides ongoing discussed below. of life. To be able to help when I hear the educational and clinical resources. usual complaints of menopause symptoms I found it useful to choose a provider that Clinical background and other hormone imbalances is incredibly offers a network of like-minded peers and The only legal requirement to be trained to rewarding. Therefore, I would discourage access to regular accredited education such offer these treatments is that you need to be any practitioner who is simply looking to seek as webinars to discuss clinical case studies. a UK registered prescribing practitioner so financial rewards from offering this treatment. My team and I have personally trained with that you can prescribe to a UK pharmacy. I the Marion Gluck Training Academy, and believe that prescribing practitioners without Regulation and compliance we have found it to be very supportive; experience in women’s health should work As BHRT requires the diagnosing and however, there are several other options with another specialist practitioner with treatment of a medical condition, it is available to practitioners. experience in this area, as well as seeking generally a requirement to be registered additional training in women’s health, before with the Care Quality Commission (CQC), Investment commencing any BHRT training. In the if you are not already. 11 I recommend that One of the biggest advantages of building UK, this can be done through the British you contact the CQC (or the regional cBHRT into your practice is that there is Menopause Society or specialist training equivalent: Health Inspectorate Wales, minimal financial outlay involved, unlike many academies. Healthcare Improvement Scotland and aesthetic treatment pathways which involve Many doctors who graduated post 2000s, Regulation and Quality Improvement the investment of expensive equipment. If around the time of the Women’s Health Authority in Northern Ireland, Health you already have a consulting room and basic medical equipment (including scales and a sphygmomanometer), then it means

Benefits to introducing cBHRT to practice your route to market is quicker. Obviously,

Overall, offering this treatment therapy to our new and existing patients has provided: there will be training costs, with the average • Added value to our clinic: a competitive advantage in meeting the demands of our cost being around £2,000. patients • New revenue channel: offering additional services to existing patients, and attracting Blood testing new patients You may already take blood tests in your • New patients: attractive to new patients, with a high number driven from referral from aesthetic or medical clinic if you are also current patients who have experienced the treatment offering nutritional/functional medicine • Increased patient retention: long patient lifetime and ongoing servicing of patients’ services. In this case, the set up you have treatment will be very similar. Blood tests are generally

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 again. This means you need to focus your

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 cases it is always recommended to refer 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 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 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

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 with a compounding pharmacy called

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.

Dr David Eccleston

qualified in 1987, training further in dermatology, ENT, ophthalmology, obstetrics and gynaecology, before entering general practice. He founded The Oakley Partnership Private Medical Practice in 2014. Dr Eccleston is also the clinical director of Medizen cosmetic dermatology clinic in Birmingham. Qual: MB, ChB, MBCAM

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