A provider’s perspective on compounding pharmacies

In 2002 the world of hormones in women’s health care was pretty much turned on its head by the publication of the findings of the WHI(Women’s Health Initiative). This was a major study that implied that the findings of multiple previous(and I mean MULTIPLE)studies  underscoring the benefits of hormone replacement treatment were essentially overturned, which started a veritable firestorm in the prescribing of HRT for peri and postmenopausal women(please see our various previous posts on this if you are unfamiliar with this study and the conversations surrounding it).

Fortunately, I have practiced in Portland, OR since 1990.

Our beautiful city of Portland aglow with the light of the gloaming hour

Our beautiful city of Portland aglow with the light of the gloaming hour

Portland is unique in that we have a major medical center(OHSU), a naturopathic college, a Chinese medicine(including accupuncture) college, and a chiropractic college. Having this variety of educational settings in one city sets the stage for intelligent, although sometimes contentious, conversations and sharing of ideas.  Even so, the reaction across the city mirrored that across the country when the news of WHI’s findings first hit the presses causing a bit of panic in the offices of clinics caring for women. After all, millions of women were on HRT so to suddenly tell them that these prescriptions could no longer be filled was HUGE, to say the least.

Thankfully, a group of pro-active internal medicine doctors and cardiologists pulled together a ‘damage control’ symposium of providers, which I attended. During the symposium , lively dialogues ensued . Providers sifted through the study and compared its findings to those of previous ones and concluded that taking women off of HRT cold turkey was premature and irresponsible. Caution, of course, was advised but  absolute crisis was averted. In the process, providers like myself began to investigate safer approaches to the synthetic HRT combinations found to be of greater risk than benefit in the WHI.

So in 2002 I was faced with how to continue responsible, safe and quality care of my patients already on some sort of hormonal therapy and how to address the thousands more who would soon be entering the same phases of life.  I began to seek alternative approaches to helping women through the long and often difficult transition from monthly cycles into the relatively ‘foreign lands’ of peri and menopausal realities.

Most of my patients stay informed by reading the paper and listening to the news and we sort through the latest info together

Most of my patients stay informed by reading the paper and listening to the news and we sort through the latest info together

One of my patients at that time told me about a special she had seen on KOPB(our local public TV station) on ‘bio-identical hormones’. This was before the time of TEVO so I called the station and was able to reach the sponsor, a local compounding pharmacy.  I was put in touch with their top compounding pharmacist and asked her if she would be willing to meet with me and explain what this was all about. We met for several hours and I was amazed not only at her depth of knowledge of hormones, testing and treatment but by her willingness to share this with me and take the time to mentor me into this new paradigm of medical treatment. Soon I began to attend conferences put on by PCCA(Professional Compounding Corporation of America) and I quickly began to apply these new concepts to the care of my patients.

From that point on, I became aware of the value compounding pharmacists had to providers in terms of education and forming long-term relationships. Prior to that time, I occasionally would call a pharmacist to discuss a particular patient and their medications, but due to the nature of most large pharmacies, it is difficult for pharmacists in those settings to form personal relationships with the large number of clients that they served. Much of the information I could glean from these interactions was generalized and generic.  I had entered an entirely different world of medicine: one based on a broader team approach(between the patient, myself and the compounding pharmacist) and a more functional/integrative approach to health and wellness.

After immersing myself into learning as much as I could about hormone imbalances, testing and treatments, I began to specialize in this realm. I no longer used the ‘guess and treat method’ but now was testing and treating(primarily relying on saliva testing) and the results were remarkable. The majority of my patients made remarkable progress in terms of alleviation of their symptoms and feelings of wellness and balance. Along the way, I often would confer with the pharmacist about treatment regimens and I developed a strong collaborative relationship with him or her.  We often would brainstorm about how best to treat a particular patient, which resulted in improved outcomes and happier patients.

In addition, not only did I learn about the various hormonal preparations that were available, but I also learned how common drugs(such as Ibuprofen , ketoprofen which are anti-inflammatories, or Neurontin, which is used for neurological pain such as that caused by shingles) could be formulated into a transdermal cream, which allowed the drug to be delivered right where it was needed , at a lower dose and with less effect on the liver. Truly my prescribing world had opened up wide and I was better able to meet the needs of my patients.

In terms of what I look for when working with a compounding pharmacist and their pharmacy, here is a list of my essential criteria:

1. Knowledgeable, approachable and personal pharmacist. This is first and foremost: someone who stays abreast of the latest research, technology, medications, guidelines and standards in the field.

2. A pharmacy that meets the testing and safety measures of the various governing and regulatory bodies(obviously there is some controversy about which testing agencies are best and essential as evidenced by the comments to Candace’s last blog post: bottomline: testing and adherence to safety guidelines is of the upmost importance to providers and patients)

3. A clean room equipped with hoods to decrease the risk of contamination to medications , as well as exposure to the pharmacy techs working with the formulations made by the compounding pharmacy

Safety hoods in a clean and well-equipped compounding pharmacy

Safety hoods in a clean and well-equipped compounding pharmacy

4. Ongoing continuing education of the staff

5. A knowledgeable and courteous staff and one that is available quickly to answer my or my patients questions and concerns(one pharmacy I work with has no voicemail on their phone, which means a live person ALWAYS answers: that is an important personal touch that I know I greatly appreciate, as do all of my patients

6. Reasonably quick turnaround time. Patients who take medications, particularly hormones, sometimes run out of their meds at the most inopportune times and often need them quickly. I gravitate towards pharmacies that can fulfill prescriptions within 2-3 days at most times.

The cloud cast by WHI in 2002 contained a silver lining for me. I  re-evaluated the way I cared for my patients with hormonal balances and how I dealt with all of the health care needs of my patients.  I moved towards a more functional, integrative approach to medicine which opened me up to the world of compounding pharmacies.  I now provide better care of the women who trust me to help them achieve health and balance and I feel fortunate to have a team that I can rely on as well.

Stay tuned for more information on how you can find an excellent provider, laboratory and pharmacist to form your own team.

A votre santé !

Candace and I have formed a long-term friendship and working relationship over our combined interests in helping women find hormone balance safely and effectively

Candace and I have formed a long-term friendship and working relationship over our combined interests in helping women find hormone balance safely and effectively

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