Mary’s Question: Hi. I just started estriol cream a couple of weeks ago. I am fifty-three years old and have been told I have PCOS for the past twenty years with a history of absent periods, heavy facial hair growth, and moodiness, and PMS. I have managed my PCOS through diet change, supplementation, and exercise. And I am told I am quite healthy. I began taking the estriol cream for bladder urgency and frequency and for the mucous membrane support for vaginal dryness. Sex had become very painful. I am experiencing some really wonderful positive benefits from the estriol. And in some ways, I realize I have probably been short of this for many many years likely due to the malfunctioning of my ovaries with the PCOS. The skin over my shinbones that has always been flaky no matter how much I moisturize, now, is soft, smooth, and supple for the first time in many years. The skin on my elbows, knees, and heels is softening. And it seems to have helped my skin tremendously. Even my facial hair is coming in much lighter. It seems to be reducing my belly fat in some ways. It is kind of a miracle. And I wish I had known about this years ago. The possible deal-breaker here is that I have become so painfully constipated over the past few weeks. And the estriol cream is the only thing that has changed. I also take bioidentical progesterone in a troche form which I have been taking for about ten years without a problem. The estriol is the only thing that has changed. The only time I can remember being this consistently constipated over a long period of time was during my two pregnancies. Any thoughts?

Short Answer: For constipation, the common advice is to drink more water and eat more fiber. However, for some, this does not work. It may seem strange to think that bioidentical hormones could impact digestion, but it is certainly possible for either progesterone or estrogen to cause someone to become constipated. We look at constipation as being a liver issue. Taking hormones can put a slightly extra burden on the detoxification capacity of the liver, which can slow down digestion.

PYHP 103 Full Transcript: 

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Dr. Maki: Hello, everyone. Thank you for joining us for another episode of the Progress Your Health Podcast. I am Dr. Maki.

Dr. Davidson: And I am Dr. Davidson. 

Dr. Maki: So how is your summer going? 

Dr. Davidson: My summer is going great, although it is already August. So I feel like it is almost over. 

Dr. Maki: Yes. 2020 has been such a roller coaster. But yes. Weather is good. We are surviving everything. 

Dr. Davidson: How is your summer going? 

Dr. Maki: Well, it is a rhetorical question, because I know exactly how your summer has been, because mine has been pretty much the same as yours. So I cannot complain. But you are right. It is going by way too fast. I cannot believe it is already August. But we still have a couple of months of nice weather before the rain comes. 

Dr. Davidson: And even then here in Washington, it is still really beautiful. 

Dr. Maki: Oh, yes. Yes. Yes. The rain is not as bad as it sounds. I will take the rain over the snow any day. I will take the rain over the cold any day. And we still get out, and we still do a lot of hiking. Even in the wintertime, we spend a lot of time outdoor. So you bet. That makes it fun. 

So on this one, we are going to do a question that just came in, one of the comments in the website, as I thought this would be kind of an interesting one, one of these kind of secondary, very female-specific problems that tend to come up from time to time, quite frequently, actually. 

Dr. Davidson: So I am going to go ahead and read the question. This is from Mary. It says, “Hi. I just started estriol cream a couple of weeks ago. I am fifty three years old and have been told I have PCOS for the past twenty years with a history of absent periods, heavy facial hair growth, and moodiness, and PMS. I have managed my PCOS through diet change, supplementation, and exercise. And I am told I am quite healthy. I began taking the estriol cream for bladder urgency and frequency and for the mucous membrane support for vaginal dryness. Sex had become very painful. I am experiencing some really wonderful positive benefits from the estriol. And in some ways, I realize I have probably been short of this for many many years likely due to my malfunctioning of my ovaries with the PCOS. The skin over my shinbones that has always been flaky no matter how much I moisturize, now, is soft, smooth, and supple for the first time in many years. The skin on my elbows, knees, and heels is softening. And it seems to have helped my skin tremendously. Even my facial hair is coming in much lighter. It seems to be reducing my belly fat in some ways. It is kind of a miracle. And I wish I had known about this years ago. The possible deal-breaker here is that I have become so painfully constipated over the past few weeks. And the estriol cream is the only thing that has changed. I also take a bioidentical progesterone in a troche form which I have been taking for about ten years without a problem. The estriol is the only thing that has changed. The only time I can remember being this consistently constipated over a long period of time was during my two pregnancies. Any thoughts?”

Dr. Maki: Oh, yes. So this one, again, women being constipated, of course, is a very common problem. But the fact that she added the estriol in and then it kind of started after that is a little bit not typical for the most part. We would expect her to be constipated before the estriol and/or the progesterone, and the bioidentical hormones actually helping that situation. So I thought this would be an interesting one for us to kind of hash it out a little bit.

Dr. Davidson: Yes. And we are all unique individuals. So what might work for somebody or somebody might have a different symptom compared to the person next to you. Everybody is different. But like Dr. Maki said– and I can even attest for myself. Hopefully, this is not too much TMI. But constipation is really common in females. I do not know if it is so common in males. I always laugh with my female patients saying, “Men can go to sleep. Men can go to the bathroom. And men can lose weight very easily.” Whereas, ladies, we have a tendency to go the other way on that.

But I will just say, just from personal history with constipation, that is not fun. But she is having so many positive benefits from this estriol that really in terms of constipation, we could probably find some other resource to help her with that while she can still continue to use the estriol.

Dr. Maki: Yes. Right. Well, it brings up a couple of things. She mentions that she was really constipated during her pregnancies. Of course, as we all know, when a woman is pregnant, her hormone levels are just through the roof, lots of estrogen, lots of progesterone. 

So it makes sense, not only from all the hormonal change at pregnancy, but also there is a lack of space, especially as the growing baby is getting bigger, there comes the space issue. Obviously, I have never had any children myself. But we have talked to a lot of patients. And they have all kind of talked about constipation, when you are pregnant, it is kind of par for the course.

But the fact that she has added in the estriol – and, now, that constipation is coming back – makes me think about liver function. What is going on with her liver? Granted, there is probably some bowel changes from adding in that estriol. But it makes me think that actually – and she does not say what the dosage is; I would be really curious to know what the dosage is – that a lot of times, even though you added anything that it made it worse, it is just an indication that she needs more of it to actually help to kind of alleviate some of that.

But, like I said, there are some other tips and tricks you can do to curb the constipation in the meantime.

Dr. Davidson: Exactly. Estrogen is an amazing hormone, the best hormone in the whole world. And there are three different estrogens: the estrone (E1), estradiol (E2), and then estriol, which we are talking about here, (E3). And it is very gentle.

So what I am thinking with that estriol, it really does not sound like a coincidence if nothing has changed, and she is getting this terrible constipation from just adding this in the last few weeks. It has got to have some connection there.

But, like I was saying, estrogen is a little funny. And sometimes, if you give more, the symptoms go away. And then sometimes, if you give less, the symptoms go away. Estrogen has to be right smack in that nice little balance to get the goals that you are looking for, if that makes sense.

Dr. Maki: Yes. Right. Yes. For example, I had a patient last week. I started her on some estrogen cream. And when the body gets a taste of that estrogen, that is what makes a woman woman. As you say, it is the best hormone. I would beg to differ. I think maybe testosterone might be a little better. But I am biased in my own way.

But when the body gets a little bit of that hormone, it wants more of it. So the cells tend to soak it up very rapidly. And now, your body is asking for more of that hormone. That is why sometimes when you think you should actually cut back, because it made something worse, it is actually an indication to lean into that, and use more. 

That is what it made me think when I read this question, that instead of cutting it back or getting rid of it, add a little bit more, try to palliate that constipation in the short term. We will talk about some of those ideas here in a minute. 

But she is fifty-three. She never used it before. She has had some wonderful benefits. And for a woman – and this is something that I say all the time; I know you do the same – it is not about using too much. It is making sure, like you just said, that you actually have enough. 

And I think that, even from a practitioner’s perspective, there is a lot of fear using estrogen because of cancer and everything like that. But the estrogen itself is not something to be afraid of. You just have to make sure you have enough of it or to do what you really want it to do.

Dr. Davidson: Yes. Exactly, to have that balance. And you had mentioned about the liver function. Mary, obviously, is very healthy. She has even been told she is very healthy. She works on her diet and her lifestyle and supplementation. But when you are breaking down estrogen, as you break down any hormone, it turns into different metabolites that it could be that her liver just needs a little help to process these estrogen metabolites that it did not have to deal with a few weeks ago before she started all these.

Dr. Maki: Yes. Right [clears throat]. Excuse me. I would probably assume as well, too. She is not our patient. If she was, we would not probably be talking about her, because that would probably not be appropriate necessarily. But the fact that this is just a random question and we are all here for educational purposes, we are just trying to educate, right? We are not giving any medical advice or anything like that. 

But if she is our patient, we would, like you said, do some palliative things. Certainly, everyone knows there are different forms of magnesium. You can use magnesium citrate, magnesium hydroxide. There are a few things you can use to basically create a kind of an osmotic laxative effect, osmotic meaning kind of basically water. You bring water into the colon by using some of those minerals. Vitamin C can do the same thing. And now, you kind of hydrate the large intestine. And it makes it easier to actually have a bowel movement. You are not, yes, making it so difficult. Or you are skipping multiple days in a row.

I mean I have had. I know you have as well. Women, over the years– and they will sometimes only go to the bathroom one or two times a week or two or three times a week, when literally you are supposed to go every day, if not, multiple times a day. 

That is where I think, you said earlier, where men and women are completely different. It is very unusual to hear a man that is constipated. But it is very common to hear that a woman is constipated.

Dr. Davidson: And like you said with that magnesium, I mean I laugh with patients, because I take magnesium every night. Magnesium is literally a girl’s best friend. We all like diamonds. But magnesium is a girl’s best friend. 

And like you had said, I like the citrate, in particular, because I do think that is also a nice additive for bone density. But it does help the large intestines pull in that water, so the stool becomes, I guess you could say, more liquidy or more fluid-bound, so it is easier to come out the next day. 

It is not like a stimulant like some of the over-the-counter medications for constipation, even some herbs or stimulants, which can cause a lot of cramping and some bloating. But the magnesium I think is a nice, really safe alternative.

Dr. Maki: Yes. Even some of the colon formulas, some of the detox products, they will put Senna or Cascara Sagrada which are actual herbal laxatives. And those things should not be used on an ongoing basis, maybe once in a while, maybe temporarily.

And most of the time, when we look at chronic constipation, it is either a liver issue, right? That is why this one kind of brings up liver for me. She added in something different, even though more than likely that estriol dosage is probably just a couple of milligrams. I am actually surprised that it had such a dramatic impact. But again, that still makes me think about the liver function, in general, because she added in this new variable that was not there before.

Coffee, alcohol, all those things are always putting pressure – daily dietary pressure – on the liver which then can slow down. If you think of the digestive tract, mouth to anus, it is kind of like a conveyor belt. The liver is kind of the rate-limiting step. It controls how efficiently that conveyor belt moves. If you put too much pressure on the liver, then that conveyor belt does not usually work as efficiently as it should. And now, things get slow down. As a result of that, people get constipated.

Dr. Davidson: And we are exposed to a lot of stressors in our life, fumes, car exhaust. So working on your liver or doing a nice liver support can help anyone. This might be a good thing to use with women that have constipation when they are taking estrogen or estriol. 

Dr. Maki: Yes. Right. Even hemorrhoids, hemorrhoids is a really common problem. And there is not really a lot of good treatments for that. But the same thing, if you have hemorrhoids, the approach to that – or, at least, part of the approach – is to fix your liver.

Now, when I say fix the liver, there is not necessarily a disease there, right? You can do blood work. And liver enzymes are normal and all that kind of stuff, at least, most of the time. Sometimes it is not. Maybe somebody has some kind of minor liver thing going on. But you help to improve what they call the functional capacity of the liver making sure all those enzymes of the liver has to deal with in process and hormones and food and all those different things. You are just helping the efficiency of the liver. So now, again, that can very well just able to work effectively. 

And if you got hemorrhoids, people think that hemorrhoids are related to the constipation. But I think the hemorrhoids are somewhat a result of the constipation. But you can have hemorrhoids and not be constipated. And you can be constipated and not have hemorrhoids. It can kind of go both ways. One does not necessarily cause the other. 

But the liver is a central component of both of those, at least, in my opinion. If you can look at the physiology, you will understand how the physiology works. And we are not going to get into that right now. But it certainly plays a role there.

Dr. Davidson: And in talking about detoxification when you are thinking estrogen, estrogen metabolites, that doing some DIM or – what is it – the Indole-3-Carbinol, it is a great way to help with estrogen metabolites. And they are all basically derived from cruciferous vegetables. So that can be another option to help with women that have that constipation from estrogen. 

Dr. Maki: Yes. And the other thing, people automatically– if you go to your doctor because you are constipated, the only thing they tell you is to drink more water and to consume more fiber.

Now, the water part, maybe true, right? But all we ever really tell our patients is as long as your urine is clear, right, there is no yellow to it. Maybe the first or your morning urine is a little yellow. Then as you start drinking water through the rest of the day, then your urine is going to be basically a clear color. Then you know that you are not dehydrated, and you are probably not necessarily overly hydrated. I do not think that people have to worry too much about being overly hydrated, maybe in some circumstances.

But the fiber component, you start using psyllium husk which is what most fiber products are. If you are already constipated, that usually just makes it worse. You want to be a little careful with consuming all that fiber, because you want things to be moving before you add all that fiber in except maybe some gentle plant fibers like some cooked vegetables or figs or dates, things like that. But the psyllium husk, it can be like a big blob of– it just does not work very well. It does not have that kind of cleansing process. It can just kind of make things more backed up than you really want them to be. 

Dr. Davidson: We have mentioned about the magnesium. That is bringing the water into the large intestines. A lot of doctors will recommend trying to almost, in some ways, make the stool a little bit greasy. So I will say, “Hey, take some coconut oil in the morning.” Sometimes that can be enough to kind of get a little bit more of that greasiness. I hope that is not a weird way of saying it. 

But for the stool, a lot of them, doctors, will recommend MiraLAX which you do not want to take a bunch of MiraLAX. But the goal behind that is to kind of lubricate the stool where I think you can just do that from good essential fatty acids or medium chain triglycerides like coconut oil or MCT oil.

Dr. Maki: Yes. And not to mention, too, when you consume fat like that, whether it is butter or coconut oil or olive oil or avocados, you are forcing the liver to release bile. And bile, by itself, is a wonderful laxative. In some ways, that is where it really makes it easy. And that is why people that have gall bladder problems, they might be constipated before they get their gallbladder out. They are really constipated after the gallbladder is removed, because that bile surge is no longer there anymore. 

Based on her overall statement, Mary, I am sure her diet is probably fairly good supplementation. So she was able to kind of whittle it down to this one variable. But she kind of refers to it as being a deal-breaker. If her lifestyle is that good, some of those dietary things are not there – not too much coffee, not too much alcohol; there is not a lot of pressure on her liver – then she should be able to remedy that with a couple of things we have already said.

Dr. Davidson: No. I think that is a great thing, because, like you said, estrogen, like I said, it is the best hormone in the world. So we would not want to necessarily take that away and then lose some of the benefit. At the same time, like you said, finding some healthy tips and some ways around it. 

And we have lots of women that are constipated that are still menstruating. So you cannot take their estrogen away from them, because they are actually making it. There are lots of little tips and ways. 

And I really appreciate Mary sending that question out, because sometimes I think we see a lot of these symptoms all the time. But when we got the question, I was like, “Oh, yes, of course. Right.” But we do not put it together to talk about it on our podcast. 

Dr. Maki: Or we take it for granted sometimes, because we are always dealing with these kind of challenges. But yet, this is something that probably millions and millions of women are dealing with or, at least, hundreds of thousands. How many women that we talked within our practice are having this kind of digestive issues? That is why when you go to the drug store or the grocery store, there are two rows full of digestive relief products whether it is on the upper end or the lower end or everything in between. 

Dr. Davidson: They are probably two aisles, right?

Dr. Maki: Yes. Literally, two aisles of products that help people with this kind of problems, because they do come up. And they are very very common. 

But this one was interesting just because it is a little ironic. Usually, I would expect someone’s constipation to improve with the hormones. In this case, it actually got a little worse.

So Vitamin C can be used a lot of times to what they call bowel tolerance. If you take enough of it, it is going to cause some loose stool. And then, of course, the magnesium is something that we use quite often. And you cannot really take too much, but you have to make sure you take enough. Taking one or two capsules might not necessarily be enough. If you are looking for a milligram amount, what would you say, probably between four to eight hundred milligrams?

Dr. Davidson: Working with women, it is all over the board. Everybody has to have their personal dose. There are some women, 150 milligrams of magnesium citrate does the trick. Other women, 1,000 milligrams of magnesium does the trick. 

For me, personally, myself, I usually end up going anywhere between four hundred to eight hundred, of course, depending on how much water I drank and how much fibrous foods I have eaten and if I have gone for an exercise or walk. So everybody is kind of a little bit different.

And on a side note on that, of course, when we go traveling, as ladies, we will always say, “I am constipated.” You can never be constipated. But you go on vacation, and you get constipated, because that is really common. Then I would say, “Well, you increase up your magnesium a little bit more by another 150 or even 300 milligrams.

Dr. Maki: Yes. Right. Like you say, a capsule of magnesium is usually going to be anywhere between 50 to 200 milligrams, at the most. One hundred to one-fifty seems to be more average. So I usually just tell them to do it by the capsule. If you start with two and if it does not work, the next night, then take three. And if that does not work, then take four. And if that does not work, then take five. 

Usually, women, capsule-wise are going to be somewhere between two to four capsules which would put them between, what, 300 to 600 milligrams. But I like your range a little bit better. The four to eight hundred, it seems a little bit more appropriate.

Dr. Davidson: Yes. And the magnesium does not cause as much cramping as the Vitamin C. So a lot of women will say, “I cannot take that much Vitamin C, because it causes a lot of cramping.” Or, “I am up at two thirty in the morning with cramps.”

Same thing with the Cascara and the Senna, some women are really sensitive to that that it just causes too much cramping or aloe which I love to use, aloe root, with patients. But sometimes, for some of them, it is just too stimulating. Just like fiber, they take fiber, and they are just bloated. And then they do not go to the bathroom. 

So everybody just needs to kind of find what works for them, because everybody is so different. 

Dr. Maki: Yes. Right. Yes. I know the one aloe product that we use, there are two dosages. The higher dose, the four-fifty, is usually way too strong.

Dr. Davidson: That is the holy moly dose.

Dr. Maki: Yes. Yes. That one you–

Dr. Davidson: Let us go.

Dr. Maki: Excuse me [clears throat]. That is the one that you use for a really significant problem. You do not want to just give that to anybody, because they are going to have a real–

Dr. Davidson: But then in some women with really tenacious constipation, it is like a miracle. So everyone is so different. 

Dr. Maki: Yes. Yes. Yes. So you kind of tread lightly. You kind of experiment a little bit. Be a little cautious. Be a little conservative. But then eventually, you will find the amounts that actually work. And then it is relatively effortless. Then things are just moving. The conveyor belt is moving like it is supposed to. There is no straining. There is no pushing. It is not difficult in any way. It is more normal the way that it should be on a day-to-day basis. So do you have anything else to add? I think we covered this one pretty well. 

Dr. Davidson: No. But I think this is really great. Thank you, everybody, for reaching out and sending questions. We might not get to all of them, but we certainly do try. 

Dr. Maki: Yes. And if you are looking for some help, like I said, like you just said, we can answer all the questions. But we do like compliments. You can send us an email at [email protected].

If you want to keep it somewhat private, we will obviously, usually, in almost every case, change your name. We try not to use anything to identifying at all. Identifying, it is not really about that. It is just about using your situation to help as many people as possible, because if you are having that problem, more than likely, there are thousands and thousands of other people that are having pretty much exactly the same problem or, at least, some variation of that which is why we, like you said, we just take this kind of a question. We kind of take it for granted. But now, we turn this simple question into a podcast. And now, we leverage that. And now, lot of people can benefit from it. 

So until next time. I am Dr. Maki.

Dr. Davidson: And I am Dr. Davidson.

Dr. Maki: Take Care.