Tammy’s Question: Hi. Recently, I read your article about estriol. I’m currently using a Biest Progesterone Vaginal Cream, but it’s compounded, and it’s expensive. I could use an estradiol patch and Prometrium and this therapy could be much more affordable. Would I expect a big change in that?
Short Answer: First off, we don’t recommend using Biest for vaginal use. We use Estriol only for vaginal use, especially if a woman still has a uterus to minimize any spotting or bleeding issues. Switching to an Estradiol Patch and Prometrium will not produce the same results, and could cause some unwanted side effects. Using Estriol is best for vaginal dryness and pain with intercourse.
For more information: read the article about the difference between Biest vs Estradiol.
PYHP 110 Full Transcript:
Dr. Maki: Hello, everyone. Thank you for joining us in another episode of the Progress Your Health Podcast. I’m Dr. Maki.
Dr. Davidson: And I’m Dr. Davidson.
Dr. Maki: So we’re back in the swing of things. We’re just going to dive right back in. Now, this time, we have a question from Tammy. This is relatively pretty short, but you and I have actually had a couple of recent experiences with the estradiol patch. Let’s just dive right in, and why don’t you go ahead and read the question.
Dr. Davidson: Like we’ve said in our other podcast, we want to say that we always change everybody’s names. We get lots of email questions from people, so we’re really trying to get to as many of them as we can. So we really love that you are sending in those questions, but know that we do change any personal information and all that jazz. Okay. So this one is from “Tammy”. Hi. Recently, I read your article about estriol. I’m currently using a Biest Progesterone Vaginal Cream, but it’s compounded, and it’s expensive. I could use an estradiol patch and prometrium and this therapy could be much more affordable. Would I expect a big change in that?
Dr. Maki: Yeah, right. So her question, she’s using right now a compounded by Biest Progesterone Vaginal Cream which based on our last episode and we are not sure about the Biest Vaginal part. We’ll segue back into that a little bit just as a refresher. So her question is, can she switch completely the types of prescriptions to the estradiol patch, also called the Vivelle patch?
Dr. Davidson: Or CombiPatch. There are a few different names. Now, they have the generic. So Vivelle was around, but now they have generic. So just estradiol patch.
Dr. Maki: They are all still basically estradiol. It comes in a couple of different which seems like – and this is what we’re going to talk about – which seems like a relatively low dose .025, .05, .075, and then, of course, Prometrium. Prometrium is commercially available progesterone, instant release progesterone. That’s something key that we’ll get to in a second. So tell me your thoughts, Dr. Davidson.
Dr. Davidson: Well, she’s using it as a vaginal cream and she’s using a Biest. We don’t know what the dose is because a Biest is a combination of estradiol which is very strong but it’s awesome but it’s strong, and then estriol which is one of the weaker estrogens but it’s really nice and gentle and good for so many things. So, it’s nice to have that combination of the estradiol and the estriol but we don’t know what the dose is. And same with the progesterone, that’s mixed in there with the cream to put up in the vaginal area. So we don’t know what the dose is on that either. But just to tell you from experience using vaginal creams, especially with Biest, it’s probably not a very high dose. So, she’s probably using an 80/20 ratio, 80% estradiol to 20% estradiol combination in that Biest. So, it’s probably not super high and when you put it on vaginally, it does go…
Dr. Maki: Probably 1 milligrams or something like that.
Dr. Davidson: Yeah. It could even be up to three, maybe even three and a half, 4 milligrams. Sometimes even five and that…
Dr. Maki: I’m sure it’s not anywhere close to that.
Dr. Davidson: I know, but I use so many different doses and usually not too low. Anyway, that Biest I would say in some ways is great, but it is not going to be anything near what an estradiol patch is. Estradiol patch is like a shotgun where this would be more like, I don’t know, like a dart. It’s like bringing in a huge tank and trying to hit a small mark. Estradiol, like Dr. Maki said, is when you look at the doses on the milligrams, you think “oh wait, the estradiol is like 0.25 or 0.05.” You’ll think that’s not a lot of estrogens compared to this Biest that looks like it’s 1 milligram or 3 milligrams, but it is like apples and oranges. Estradiol patch is always so much stronger.
Dr. Maki: Yeah. So we had recently a couple of cases as of late with the Vivelle patch and that’s the one that would appear to be really low dosing. You and I are just having a conversation about that because you’re trying to transition someone to BHRT, either a Biest or something. We’ll get to that in a second. I nailed you down like so what is the equivalent of the, let’s say, the .075 Vivelle patch, which is the strongest one they make, which again appears like it’s less than 1 milligram but now translating that to a Biest dose. I ask you and I kind of put you on the spot. What would you equivalent that to a Biest dose?
Dr. Davidson: Oh, I would go— so an 80/20 ratio of 80% estriol, 20% estradiol. I don’t even know if I would use an 80/20 because that estradiol patch is so strong, but if you’re due to the 80/20, gosh, I’d be closed up to like 8-10 milligrams.
Dr. Maki: Of the 80/20?
Dr. Davidson: Yeah. But honestly, whenever I’ve switched anybody from a Vivelle patch or an estradiol patch, I usually go higher on the estradiol component because you’ve got to match, in some ways, bridge that then I’ll actually start with a 50/50 ratio of 50% estradiol. So you have more estradiol in that Biest and 50% of the estriol. And then later, once the body gets used to it, then you bring it down. Same thing with birth control pills. I have had women walk into my office and they are almost 50 years old and they are still on birth control pills.
Dr. Maki: Yeah. Right. Which is we don’t agree with that at all, but sometimes that’s the only tool that their doctor wants to use to control their hormones and we just don’t like that idea at all.
Dr. Davidson: But that’s pretty strong too, so trying to bridge that over. That’s why sometimes bioidentical hormones or Biest get a little bit of a bad rap because people say “oh yeah, I tried. It didn’t work. I felt awful.” And that was only because they were probably underdosed.
Dr. Maki: Which is the trend that we see all the time, is that everybody that comes to us with these questions, the dosages that they are using are so minuscule that, of course, if they go from a commercial prescription like with the patch or something along those lines and they go to bioidentical hormones, you have to switch and increase at the same time, right? So you have to overcompensate. If you try to match up milligrams, which I know a lot of doctors try to do, they try to match up milligrams or at least sort of, then it’s like going backwards. That woman is going to always feel worse. Now, in this case, she’s going from Biest. She’s also on a Biest combo progesterone cream. I don’t love that idea either, right? We don’t necessarily care to do that, keeping them both in the same prescription. Yeah, it’s more convenient. It’s probably a little cheaper, but we would separate those. The progesterone, of course, gets turned into a capsule, and then the Biest would just be more of a systemic cream. Like I said, we always recommend applying it to your inner thigh or something like that.
Dr. Davidson: And not to get into all pricing and numbers and how much this costs and where this comes from and how much this cost, but I do think when you combine all three together, so the estriol, the estradiol, and progesterone. So basically a Biest and progesterone together. I think it cost a little bit more to actually put all three together. A lot of pharmacies already have that Biest separated out. And then if you do a capsule, it probably wouldn’t cost her much more, maybe even less using just a Biest cream and then a progesterone capsule. So I would say, if she’s looking at changing something in this regard, that would probably be a better way to do it just because some progesterone cream is not very strong when you’re working with a perimenopause or menopausal female that the capsules are a little bit stronger and you have a little bit more effect to prevent any kind of bleeding or endometrial hyperplasia in the uterus, and at the same time progesterone capsules seem to have a little better effect on sleeping and on mood and hair, skin, and nails. So with Tammy, I would look at that. I know she’s looking at trying to do that estradiol patch. She is not going to feel good on that estradiol patch. It’s going to be so much estrogen. And like I said, estradiol estrogen is the best hormone in the whole world. It’s amazing. She has so many effects on our system. But with too much, she can be a runaway train. You put an estradiol patch on someone that’s been on a Biest, I hate to say it, a lot of times they usually gain about 6 pounds because estradiol loves to grow things. So usually I see about 6 pounds. They feel a little extra stimulated, sometimes a little anxious, just kind of bluesy and anxious at the same time.
Dr. Maki: Bloated.
Dr. Davidson: Yeah. Almost like permanent PMS. It’s like I feel like a 14 year old with permanent PMS.
Dr. Maki: Yeah. Right. And not to mention the prometrium. The prometrium has plenty of its own issues as well. Some women do okay on it but the majority of women do not tolerate prometrium very well. So, like I said, one of our patients, we would never switch them from Biest and a progesterone capsule to the patch and to prometrium. We just wouldn’t do that because we know from experience that they just more than likely would not feel very good. Now, understand the financial aspect of that. Certainly, compound pharmacies, a lot of the insurance companies do not cover it. Maybe you need to find a new insurance company. I don’t know. To make that shift, the results are going to be very unpredictable, to say the least maybe. Who knows? Maybe she could tolerate it just fine. But there’s a reason why we don’t use those two things, the estradiol patch and prometrium, because women just typically across the board, very few women can actually respond well to that. They just don’t do as well as what we typically do, which is with the Biest, which is weaker in some respects. It’s not as strong or as powerful, but in some ways, that’s the benefit of it. It’s not as strong, so more women have more tolerance to it and they eventually feel better.
Dr. Davidson: Yeah. We don’t know a whole lot of logistics about Tammy like, is she 47? Is she 55? She’s using a vaginal cream. Some people like it more vaginally. It does help with atrophy. That what we’re working on is more atrophy, dryness, or we’re working on more the menopausal symptoms. So not knowing a lot of that logistics, but I would say just from her going on that really nice weak, gentle vaginal Biest progesterone cream to something so strong with the Prometrium and estradiol patch, it’s going to be a huge jump in hormones. Like a huge jump. And even the Prometrium. I have a few patients. I do have quite a few patients on Prometrium and they do great. And I have quite a lot that aren’t on it because they would never do well on Prometrium. But Prometrium only comes in two doses, 100 and 200, and it’s instant release and sometimes that might be too strong for somebody. Where when you’re doing the compounded, you could make anything. You could make a half a microgram change if you want to. Anything conceived, you can create. That’s why in some ways we love compounding pharmacies, because doing bioidentical hormone replacement is not one size fits all. It’s almost like an art or a dance where you have to create this treatment plan for this person but then you create a completely different plan for somebody else.
Dr. Maki: Yeah. When it comes to hormone therapy, I mean, maybe we’re preaching to the choir or certainly I’m preaching to you. Not intended, but you cannot address women that are dealing with this kind of hormonal issues in a revolving door fashion where every woman gets the same treatment. It just doesn’t work. There’s so many different nuances, and every woman’s life is different and every woman has different sensitivities. So, there has to be that level of individuality that is brought into that. And just using the patch and the Prometrium is easy and simple, but it just limits options if you run into problems. That’s why we don’t use it because more than likely this would cause some problems. At least 80% of our patients do not use it. There’s a small segment on both ends of the standard bell curve that is going to be able to tolerate that but those are few and far between. So yeah, I would expect some kind of a change. I can’t predict exactly like you can’t predict either exactly what she would experience, but as I said, it’s pretty…
Dr. Davidson: I would say she probably gained some weight. She probably gained about 6 pounds depending on the person’s body type. Usually, it ends up being about 6-12 depending on what size they are to begin with. And she probably feels bloated. She probably feels a little bit grumpy and moody and bluesy. Like I said, she’ll probably in some ways going to that higher dose depending on is she 47 or is she 57. Where are her hormone levels to begin with? But whenever somebody has too much estrogen and I would put her, she would jump into that estrogen dominant, and then with that extra Prometrium that’s a little bit strong, she would just feel like a moody 14-year-old. Nobody wants to feel like that.
Dr. Maki: Right. So this one was relatively pretty fast, kind of a quick answer. But again also, I think very importantly because what she was on just needs to be tweaked just a little bit and that would actually probably be worthwhile and maybe even raising that Biest dose. Estrogen, as you say, is the best hormone in the world. Estrogens what makes a woman a woman. The more of it she has, the better she feels.
Dr. Davidson: Except in the case of the estradiol patch.
Dr. Maki: Except in the case of the estradiol patch. Bioidenticals, yes to some extent, and we’ll talk more about rhythmic dosing versus static dosing later. That’s where that conversation really gets teased out a little bit. But the estradiol patch, even though it’s stronger, I just contradicted myself and saying more ration is always good, but that estradiol patch is just a little different. It’s just a little bit too strong.
Dr. Davidson: It would be maybe too much too fast. Does she really need that much? And I would say, we got financial concerns. Everybody’s got their budget. So for Tammy, I would talk to her practitioner a little bit and a lot of times even talking with the pharmacy. They give you discount if you fill three months at a time. So once you get the dose that fits for you and you know you’re going to be utilizing that for a while, you could get maybe more at once and then get a discount. You can change up some of. Sometimes those vaginal creams are a little bit more expensive than doing the topicals on just the inner thigh. So there are lots of options. You just need to coordinate and talk to the compounding pharmacy or the practitioner and just coordinate something.
Dr. Maki: Yeah. Right. So this is a really good one because we do get these kind of questions about commercial therapy and trying to replicate commercial therapy with bioidentical hormone therapy, and it just doesn’t work that well, which is why we again, not to beat a dead horse, but that’s why we don’t typically use them very often. So, if you have any more questions, as always, our email is firstname.lastname@example.org. Feel free to send us an email. It comes right to my inbox. I do screen them for the most part. Because we get so many, I do have to pick and choose. So sorry about that. We can’t get to every question, but we’re doing our best.
Dr. Davidson: We’re trying.
Dr. Maki: Yeah, we’re doing our best to try to keep up. But hopefully by answering Tammy’s question and everybody else’s question, there’s some overlap, so other people still get their question answered in some kind of roundabout way. And to be honest, if you send one email and you really want an answer, send it again. Not to make it complicated or anything like that, but like I said, the inbox is definitely filling up, which we appreciate because that means all of you are listening. We are giving you some information that is hard to find. We know that it’s hard to find, which is why we’re doing the podcast in the first place. Because you can search the internet long and hard, and to find these kinds of nuance answers is very difficult, which is where this idea came from in the first place to do a podcast just like this so you can find those answers. Let’s be honest, this day and age of the 21st century, information is everywhere and patients are very savvy, have done their research. They’re very educated when they go into the doctor’s office. And this is the way that we can help with that and everyone expands our knowledge-based so you can make the best-informed decisions for yourself and your family for that reason. So, we appreciate all your reaching out, and we’ll do our best to try to facilitate as much as we can. Dr. Davidson, do you have anything else to add about Tammy’s question?
Dr. Davidson: No, I just appreciate everybody that’s writing in.
Dr. Maki: Yeah. So one little plug, the book is coming out. Dr. Davidson wrote a book called “The Perimenopause Plan“. It’s not quite a formatted in design properly and we’re in the final stages of that. We will keep you up-to-date. Just excited about it. And as always, for now until next time, I’m Dr. Maki.
Dr. Davidson: And I’m Dr. Davidson.
Dr. Maki: Take care. Bye-bye.