Bioidentical hormone replacement/restoration (BHRT) is a powerful tool to help people balance their hormones.  You can use BHRT for menopause, thyroid, adrenal fatigue, low testosterone, perimenopause to name a few. But every person is unique and may require a more personal approach to implementing BHRT.  Since writing these articles on BHRT, we have gotten lots of questions. Questions about symptoms of hormone imbalance to dosing questions. Questions on what kind of hormones they should take are the types of BHRT they are taking appropriate for their health goals.  We have also gotten a lot of questions from women on BHRT but they still feel awful and if there is another form of BHRT or if they should change the dose. I wanted to write this article on some of the questions we have received in hopes that it might shed light on how BHRT is an art form and is not a one-size-fits-all.  And how everyone can benefit from these questions.

Question – Rhonda:
I am 51 and had a hysterectomy @ 35. I started having hot flashes, weight gain and a complete loss of sex drive a few years ago. When I do have sex, I’m horribly dry, and it’s pretty painful. My dr just put me on Intrarosa 6.5 mg vaginal inserts and BIEST 50/50 1 mg each day. I will start both treatments tomorrow but wanted your advice on these, please.

Intrarosa is estradiol vaginal inserts meant for vaginal atrophy. I am not a fan of using estradiol vaginally.  There are three forms of estrogen that we make in our bodies: estrone, estradiol, and estriol. We do not need estrone, and the is more commonly made in young teen just starting their menstrual cycle, or it is made from adipose cells (fat cells).  Estradiol is the strongest form of estrogen. Estriol is the weakest or most gentle form of estrogen. Estriol is really good for vaginal dryness from menopause or lack of estrogen. Using estriol is great for vaginal dryness because it does not go into the bloodstream if you use a low dose.  

Estradiol is an awesome hormone, but she is very strong.  Using estradiol vaginally has a high risk of entering the bloodstream.  Rhonda is also taking a biest 50:50 ratio. Biest is a combination of estradiol and estriol.  A 50:50 ratio of a 1mg of biest means that there is .5mg of estradiol and .5mg of estriol. So the estradiol inserts (Intrarosa) may interfere with her total estradiol levels in her blood.  So I do like biest a lot and think Rhonda should take it. But instead of the Intrarosa, she could use a estriol only vaginal suppository or cream.

Question – Connie:
Hello – I have been using Biest 50/50 for ten years. I use 5 mg in the morning. I also use progesterone cream, 20 mg, at night. My doctor is now refusing to renew my meds. She thinks I have been on them too long. Is the product that I see on the internet, Biest, the same as the compounded product I was using? Also, I completely lost my libido and was on testosterone, but it did not help at all. I doubled the dose, but it still didn’t help. Any ideas about that? My doctor doesn’t know anything about BHRT.

I firmly believe you can take BHRT for as long as you live.  Now the conventional hormone therapy, I think you should not take longer than five years because of the levels of hormones and risk factors.  But there is a catch to taking BHRT for the rest of your life. You want to make sure your doctor keeping an eye on hormone blood levels in the body and making sure the dose is low but effective.  

If you are being treated with BHRT, make sure your doctor has experience and knows how to dose and monitor hormone levels. I understand that Connie’s doc might not want to renew her hormones if she/he does not normally work with BHRT.  That is why BHRT is a specialty should be treated by an expert in hormones. I encourage Connie to find a new doctor that specializes in hormones.

A doctor that loves treating people with BHRT. Because not only is BHRT safe, it can really help the quality of life, anti-aging, and longevity.  I wish wish wish that testosterone was the be all, end all for sex drive. But for us ladies, libido is all about the estrogen. Estrogen helps stimulation of the tissues and blood flow “down south.” The estrogen also helps the libido in the “brain” as there a lot of receptors in the brain for estrogen.  Testosterone is helpful for libido. But I always consider testosterone, like “the frosting on the cake.” You make the hormonal balance of estradiol, estriol, and progesterone. Then you add the “frosting” of the testosterone to add in as the end.

Question – Angie:
So I am on a combination of Bi-Est, Progesterone, and Testosterone. I’ve been applying it to my forearms and like mentioned above, have been getting excess hair on my arms. Would the inner thigh be better even though it’s a combination? Thanks!

Yes, yes, yes! Angie should apply her hormone cream to her inner thigh.  All hormones are made from a cholesterol backbone, meaning that they are fat soluble.  So applying your hormone cream to a “fatty” area of the body like the inner thigh will help the sustainability of the cream.  Because the skin of the inner arm is very thin and the hormone goes into the system very quickly. Then there will not be the longevity of the hormone dose as it would be to the inner thigh.  Applying hormone cream to the inner arm makes it easy to transfer hormones to other people, kids, and pets. As Angie mentions, she is growing hair on her arms. That is because testosterone will grow hair where you apply it.  Angie’s hormone cream has testosterone in it so it will grow hair on her forearms. Now quick note, if you apply testosterone to your head, it WILL NOT grow hair there (I know, not fair).

Question – Raquel:
Hi, I have a question, my doctor switched me to progesterone cream instead of pills of the side effects the bottle cream says to put 2 pumps in the inner upper arm 100 mg is it apply one in each arm or same arm?

This is a really common question.  Because how to apply hormone cream is not usually explained thoroughly, women end up either putting on too much or too-little cream.  Hormone cream usually comes in a bottle-pump or a topiclick.

The jars of hormone cream are outdated as they were messy, easy to get contaminated and everyone lost the little spoons that came with it.  Sometime women will mistake “two pumps to the inner arm” as putting two pumps to each arm, and that equals a double-dose. The two pumps would mean applying two pumps only once a day.  Ideally at night as progesterone can make you tired or relaxed.

Also, in reference to Angie’s question, Raquel still should apply the cream to the inner thigh. The upper inner arm is too close to the breast tissue.  If you apply cream to your inner arm as your morning routine and then rest your arms to your side, it will get on your breast tissue. Breast tissue is volatile, and I want hormone cream as far away from it as possible. So in answer to Raquel’s question, two pumps only to inner thigh.  Switch from one thigh to the other, each evening.

Question – Nickie
Hi, I was prescribed 200mg of Prometrium a couple of weeks ago to take on day 20-30 of my 32-day cycle. I ovulate around day 16. Day 20 was the night before our vacation, and after reading some potential side effects, I decided to wait until this next cycle to take them for the 10 days. They think I have PCOS, so I’m hoping it’ll make it easier to lose weight. My main concern is the potential side effects of the pills. Do you think using the cream is significantly better/less side effects than taking the 2 pills at night? I’ll also have a few drinks on the weekend and didn’t know how that would interact with the pills as well. I have about 2 weeks to decide which I want to do, so I’m looking for advice. Also – a history – I have many symptoms of low progesterone. Anxiety, thinning hair, inability to lose weight no matter what I do, and after having a miscarriage at 12 weeks last year, I had to take oral progesterone to stop the bleeding. Thank you!

Progesterone is great to take for PCOS.  PCOS stands for Polycystic Ovarian Syndrome.  The ovaries cream many many cysts, and there is frequently non-ovulation and low levels of progesterone.  Prometrium is a form of progesterone. Prometrium is bioidentical progesterone. But many people do not like the Prometrium because are several fillers and it has peanut oil in it.  

It is also instant release, meaning it goes right into your system.  Some women find taking a sustained release progesterone helps them sleep better through the night.  Also, Prometrium comes in two doses, 100mg and 200mg. These dosages might be too high for some women.  Weight gain is common in PCOS and low progesterone. Taking the progesterone may help Nickie with her weight loss goals.  

Nickie has been instructed to “cycle” the Prometrium by taking it on days 20-30 of her cycle. Progesterone is only made by the ovaries after ovulation.  Meaning it is only made mainly for half of a woman’s cycle. I do think the oral form of progesterone will be more helpful for Nickie’s goals. The cream does not have as much of an effect on the weight as the oral does.  Also, it will not interfere if you have alcohol intake.

Progesterone can make you relaxed, as well as alcohol. But most women will take their progesterone before bed, so having a glass of wine or a cocktail will not interfere with the progesterone.  Nickie has mentioned the unfortunate miscarriage at 12 weeks. Low progesterone is commonly associated with miscarriage. Now Nickie didn’t mention is her miscarriage was from low progesterone. But usually, as soon as a woman finds out she is pregnant, I test her progesterone.  

The placenta does not implant until about week 9 and then there are a lot of high levels of hormones made at that time. But prior to the implantation of the placenta, there can be low levels of progesterone. You cannot take “too much” progesterone in the first 9-12 weeks of pregnancy.  So taking progesterone can be helpful for the early part of pregnancy. As Nickie mentioned, she needed to take the progesterone to stop bleeding. Low progesterone can cause frequent periods, chronic spotting and bleeding. Progesterone orally can help stop bleeding, reduce heavy periods and chronic spotting.  I find the progesterone cream does not help bleeding as effectively as the oral form.

I want to give a great big thank you and shout out to Rhonda, Connie, Angie, Raquel, and Nickie.  Thank you for taking the time to write and send us your questions. We are all unique women, and BHRT should be based and prescribed based on us as individuals.  But with that said, many of us are experiencing similar symptoms. Thank you for sharing your personal questions and history so that it can help other women all over the world. If you have your own questions, feel free to send an email to [email protected].