Perimenopause has been challenging for me. Overcoming these challenges required finding the right medical doctor and a variety of other health care providers that have played a key role in my menopausal journey. In addition to my doctor, my health care team includes a dietitian, a pelvic floor specialist, a psychologist, and a pharmacist. I know, the last one surprised me too. I used to think that who filled my prescriptions was irrelevant, but having a trusted pharmacist in perimenopause has become invaluable.
Lauren, my pharmacist, has had a significant impact on my knowledge, confidence, and wellbeing. I would encourage everyone, particularly anyone going through perimenopause, to find a pharmacist to add to their health care team. They are a hidden gem in our health system. And in a system under strain, the support of clinical pharmacists can be significant for patient outcomes.
Investing In My Healthspan
I was connected to Lauren years ago through a doctor. I thought it didn’t matter where I got my prescriptions filled, until I called in for my first refill. Lauren was engaging, asked me how I was feeling, and if I thought the medication that was prescribed was accomplishing the goals I had for the medication. Pardon?!
In that conversation, Lauren recommended tweaks, alternatives for consideration, and made me feel like I had agency in this process. Lauren also made me realize that there was value in me understanding the medications I was taking, and their impact on my physical and mental wellbeing.
At first I thought this might be a one-off experience or just something that happened with new patients in the pharmacy. However this approach to patient care has continued for years. And it has been an important part of my perimenopausal journey as I continue to strive to be my best self and invest in my healthspan.
Progesterone – A Perfect Example
I recently started taking a pharmaceutical oral micronized progesterone to help with premenstrual dysphoric disorder (PMDD) and sleep disturbances. Note that the use of progesterone for these purposes is off-label. Although use of 300 mg of oral micronized progesterone nightly compared to placebo does improve sleep as per the North American Menopause Society (NAMS) 2022 hormone therapy position statement.
After trying other prescriptions, and a wide range of lifestyle changes that continue to be part of my solution, progesterone has been a lifeline for me.
Small Things Can Make a Big Difference
Recently the pharmacy filled my prescription with a different generic brand of progesterone called Reddy-Progesterone. Teva-Progesterone is the generic brand the pharmacy normally uses to fill my prescription, but they were out of stock. I took the new generic on night one and couldn’t fall asleep. On night two, same thing. On night three, I didn’t take any progesterone and was able to get to sleep. Same for night four, but I woke up in the middle of the night which is my perimenopausal sleep issue. On night five I took just 100 mg of the Reddy-Progesterone and again, no sleep. I called Lauren.
Here Is What I Learned
While the active ingredients (hormones) in the generic versions of Prometrium (the brand-name drug) are the same, the fillers are different. Lauren explained that although rare, I could have an intolerance to one of the fillers in the Reddy-Progesterone that is not in the Teva-Progesterone. For example, one of the differences between the two generic drugs is that Reddy-Progesterone uses peanut oil and Teva-Progesterone has only a small amount of peanut oil mixed with fractionated coconut oil, or medium-chain triglycerides (MCT). It may also have been that I wasn’t absorbing the active ingredient properly due to the composition of the capsule. Regardless, something was off.
Lauren suggested that she send over a small amount of the Teva so that I could test and see if it really is the switch in generic brands that was causing the sleep issue. Efficient, practical, and no fuss.
That night I took my regular dose of Teva-Progesterone and slept really well. Lauren put a note on my file to only fill my prescription with Teva and not the other generic brands. My drug plan doesn’t cover Prometrium.
Other Interesting Facts About Progesterone
- In Canada there are 5 generic brands of oral micronized progesterone and each of them have at least some peanut oil in their preparation.
- Prometrium, the innovator brand or brand-name drug, is now made with sunflower oil in Canada.
- Prometrium is often not covered by drug plans as there are less expensive generic options as listed above.
- Some drug plans will accept Prometrium with special consideration from the prescriber when a patient has a peanut allergy or an intolerance/poor response as described above.
What Can A Pharmacist Do For You?
Lauren graciously agreed to chat with me about their philosophy of practice and how she and her team are involved in patient care. Here is a recap of our conversation.
M: What Is Patient-centered Individualized Care?
L: In pharmacy practice, but especially for women’s health in menopause, we always want to give patient-centered individualized care, which means that we create treatment plans and we set treatment goals in collaboration with the patient. That is who we are there to help, that’s who’s needs we want to address. They probably have some goals in mind, based on health conditions they want to treat or things they want to improve in their life. They want to see measurable improvement – maybe hot flash reduction, improvement in vaginal dryness, or improvement in energy or better sleep quality. And for sleep quality: is it sleep onset, duration, or waking up fewer times in the night? We try to hone in on what the patient wants to see improvement on. It’s never a one-size-fits-all approach.
And not all drugs in fixed commercial doses are appropriate for all patients. Sometimes we need to go to compounded products to find regimens that are best suited to a patient’s needs. For example, we might be customizing a progesterone dose to help balance sleep without having next-day fatigue or dizziness. Commercially prepared oral micronized progesterone products, often referred to a bio-identical progesterone, are only available in a 100 mg capsule, but the right dose for a patient might be 25 mg.* This allows us to address issues like sleep disruption and low mood, while reducing the risk of side effects.
Allergies and intolerances to fillers in commercial preparations are also reasons for using compounded preparations, as these drugs can be made without the additives or fillers that are problematic.
M: How Do You Create Individualized Treatment Plans?
L: Usually the patient or practitioner approaches the pharmacy team. They might have a prescription with a dosage range for example, take 1 to 3 capsules. The pharmacist will recommend to the patient how to start the drug and increase or decrease accordingly while monitoring for side effects and evaluating what improvements have occurred.
The pharmacy team can also make suggestions for dose adjustments to the patient’s doctor based on lab work and patient feedback on how they are feeling on the new medication. For example, when a patient is put on thyroid medication and they are is still feeling sluggish, having cold intolerance, or metabolism and weight gain issues, we can make suggestions for dose adjustments to the doctor by interpreting the labs in conjunction with the patient symptoms. This can save time and is a great example of how we work closely with patients and practitioners to create individualized treatment plans and help patients find the right solutions.
Pharmacists Often Have A Little More Time
M: I have very much appreciated when I have called in for a renewal and you’ve taken time to ask me questions about the medications, how I am feeling on them, and if I have considered other options, as an example. I think that is something that is typically overlooked, but incredibly valuable.
L: That is a great point. We often have a little more time. There is so much to cover in doctors’ appointments, they just don’t have time to discuss all the options or even review the full treatment plan, e.g., start gradually and if noticing this issue cut back. We can take the time to fully explain how to monitor the impact of a new drug, how to know if it’s working, what to watch out for in terms of side effects, and help balance efficacy with safety. And we can suggest complementary therapies to help manage side effects.
M: Can You Tell Me More About Finding The Right Solution?
L: Finding the right solution means digging a little deeper to better understand the full picture. We ask questions like:
- What is the patient using the drug for?
- What are their goals and expectations?
- Are they taking what they should be taking?
- Could they be taking something they don’t need?
- Do they have an unmet need that they should be taking medication for?
- Is the medication doing what we want it to do and if not, why?
- Is the dose too low? Is it the wrong medication? How can we change this?
Working with the patient to identify their expectations is especially important for things like Antidepressants. Some good questions to ask patients are:
- How will you know if it’s working for you?
- What changes are you wanting to see?
- Are you looking for improvement in mood, more motivation, more drive?
- What did you discuss with your doctor about what to watch out for?
Side Effects and Safety
And then we are reviewing side effects and safety. Explaining the kinds of side effects this medication could cause and what the patient should watch for. We explain things like signs that the dose is too high, or how to know if you are having a drug interaction. And sometimes side effects aren’t avoidable, so we go through how you can improve or manage the side effects.
For example, if progesterone is causing next-day fatigue, we could also review lifestyle factors. Things like cutting down on or avoiding alcohol, or other sedating medications or substances, that would have additive side effects to help reduce the risk of having an issue from your prescription.
M: What Other Care Options Do You Provide?
L: Pharmacists can also help determine if the addition of non-drug therapy may be beneficial, and can make recommendations for managing menopause using complementary alternative therapies. These may include supportive supplements for sleep, anxiety, stress, stamina, headache prevention, hot flashes, and healthy estrogen metabolism. Examples include: melatonin, magnesium, L-theanine, adaptogens, GABA, Co-enzyme Q10, B vitamins and herbal products.
We can also provide non-prescription preparations for vaginal dryness, vaginal lubricants, and probiotics for digestive and vaginal health. Pharmacy staff can also help patients with basic dietary and nutritional advice, as well as provide recommendations to allied health providers such as dietitians, naturopaths, nurse practitioners, and psychologists.
M: Compounding vs Pharmaceutical Products: How Do You Address Safety Concerns?
L: There are several commercial products that are fantastic options. Examples include EstroGel which comes in fixed strengths and Estradot which has a lot of dose options. Prometrium (oral micronized progesterone) and generic versions of this drug, are all great options, however they only come in 100 mg capsules in Canada.
Sometimes a patient may need an intermediate dose, or they may have allergies or intolerances, or they may need a special formulation like a sustained-release progesterone. And that is where compounding can provide the best solution for that patient.
All of the compounding ingredients are regulated by Health Canada, while the final preparations are regulated by the respective regulatory bodies in each province or territory. In Alberta, where we are located, there are very strict regulations for compounded medications. The facility must be approved by the Alberta College of Pharmacy and continuously show excellent quality and safety. This means preparations must be made consistently at the doses expected, and be free of impurities and contaminants. Our pharmacy conducts random, internal audits every 3-6 months. The Alberta College of Pharmacy audits us every 1 to 3 years.
When considering a compounded product, it is important to look for a pharmacy that has a membership with a professional compounding association like PCCA (Professional Compounding Centers of America) or MEDISCA.
The Bottom Line
Pharmacists are medication management experts and one of the most accessible health care providers in our system. Most of us just don’t think of them in that way.
A pharmacist should be on everyone’s care team. In case you aren’t yet convinced, here are a few other reasons why Lauren is my trusted pharmacist in perimenopause:
- Lauren is a phone call away and makes finding the right solutions more efficient.
- Lauren is an expert, and her in-depth knowledge is appreciated by patients and practitioners.
- Lauren delivers my prescriptions free of charge, even when I am out of province.
- Lauren is an active listener.
- Lauren believes that all patients should ask questions, understand the details of their medications, and take charge of their health.
Thank you, Lauren, for helping me thrive.
*Progestins, created in a lab by manipulating chemical structures to work like progesterone, are available in different doses. The molecular structure of progestins is different than progesterone. Oral micronized progesterone has the same molecular structure as the progesterone our bodies make and is often marketed as bio-identical. This term can be misleading as it implies the drug is ‘natural’ when it is also manufactured in a lab. Progestins and progesterone belong to a class of drugs called progestogens. The team at Women Living Better has done a great job of explaining the differences.