Mary’s Question: I am 58 years old and lost my thyroid to cancer eight years ago. I am finding it impossible to lose weight and have thinning hair near my hairline and no eyebrows. I started Bi-est cream, 50/50 ratio, 2.5 milligrams; progesterone, a 175 milligrams; and testosterone, 1 mg. About a year ago, it was lower doses and then went up to those as recently my doctor had me using it twice a day, the cream, and then the progesterone, one pill at night, because my levels have shown that my progesterone is 7, estradiol less than 5, – that means it is not even in the bloodstream – free testosterone is 1.2, total testosterone is 6 . I am so afraid I am going to gain weight more or more hair loss from some of the things I have read. Please give me your opinion. I also take Tirosint and Cytomel for my thyroid. Do I have to worry about any medication interactions? Please help. Mary.
Short Answer: Typically, bioidentical hormone replacement therapy (BHRT) is not going to cause consistent weight gain. When starting BHRT, there might be slight water retention, but should not lead to consistent weight gain over time. If weight gain continues once on BHRT, pay attention to insulin status and stress level. For more information on our approach, you can download our Keto Carb Cycling Program.
PYHP 105 Full Transcript:
Dr. Maki: Hello, everyone. Thank you for joining us for another episode of Progres Your Health Podcast. I am Dr. Maki.
Dr. Davidson: And I am Dr. Davidson.
Dr. Maki: So what are we going to do later today?
Dr. Davidson: I do not know. Hopefully, get to go, maybe, for a hike or a long walk.
Dr. Maki: Yeah. Weather is good. It is August in Western Washington. Beautiful. It does not get too hot here. You know, we still have some patience in the Southwest. When I am getting ready to talk to them I look at the weather app and I see those triple digits: hundred and five, hundred and nine, hundred and ten and I have to say, it makes me cringe a little bit.
Dr. Davidson: I remember living in the Southwest and, August, I could not wait for August to be over with, like, come on, let us get to September. Let us get to the middle of September. And now I am like, I just want August to last forever. Please go slow go slow. [laughs]
Dr. Maki: Yeah. It is amazing how much of a contrast in you and I in the summertime. So June, July, August– it seems like, in the Southwest, Labor Day is when everything starts to change. You can feel it. Like you wake up one of those mornings and it is like, “Oh, okay. Summer is just–
Dr. Davidson: It is still pretty warm, but at least you are on the tail end.
Dr. Maki: Yeah, but you can start to feel like it starts to, you know, you get rid of some of those hundred and ten degree days and it will be in the upper 90s, maybe a hundred, and then it starts to gradually trickle down. But I remember you and I used to go to California, we go to the mountains, we go to Utah to try to just get a reprieve from the heat. I remember one time, actually with your sister, we actually went camping in Utah. We were at this place, I think it was Fishlake National Forest or something, just north of this really popular area there called Duck Creek which is kind of by Zion National Park. We used to go to Zion all the time. But even the summer there, it is still blazing hot.
Dr. Davidson: It is still hot.
Dr. Maki: So we either go up to Duck Creek or we went to this one little campground literally at like nine thousand feet and it was like 65 degrees up there in July. It was beautiful. We were actually cold.
Dr. Davidson: I was going to say we were cold. [laughs]
Dr. Maki: And we came down. We came down after we were done with the weekend and we got down to St. George, Utah, or I think it was, maybe, Cedar City or something.
Dr. Davidson: Which I love St. George, Utah.
Dr. Maki: And it was like a hundred degrees. We went from like 65 degrees, come down the mountain, and it is like a hundred and two and it was like, “Oh my God.” That contrast is really hard to deal with, obviously, we don’t have that contrast here.
Dr. Davidson: It is going to be in the high 60s today which is beautiful.
Dr. Maki: Yeah. Bellingham does not really get much above, seventy, seventy-five. That is a pretty nice, kind of a hot day in Northern Western Washington. So stop droning on about the weather. But you know, it is a big deal, it changes all the time. I kind of sound like my dad. My dad always used to talk about the weather and this is well before they used to have the internet and everything. Weather and gas prices; that was the thing that he was always concerned about. Always complaining that gas was too high and he never liked it hot. His favorite kind of weather was fifty-two and drizzling all the time.
Dr. Davidson: Then he would have loved it here.
Dr. Maki: Yeah, he would have been fine– I am not sure why, he probably would have done pretty well in the Pacific Northwest. So this question is from Mary. Granted, we are changing the name of that. We just did a Mary a couple episodes ago.
Dr. Davidson: We are not very creative with the names. [laughs]
Dr. Maki: But again, it is just to, somewhat, try to protect identity; not that we really need to do that, but just for anonymity’s sake. So why don’t you go ahead and read the question from Mary?
Dr. Davidson: Okay, so this is for Mary: I am 58 years old and lost my thyroid to cancer eight years ago. I am finding it impossible to lose weight and have thinning hair near my hairline and no eyebrows. I started Bi-est cream, 50/50 ratio, two point five milligrams; progesterone, a hundred and seventy-five milligrams; and testosterone, one milliliter. About a year ago – sounds like about a year ago she had started that but – About a year ago, it was lower doses and then went up to those as recently my doctor had me using it twice a day, the cream, and then the progesterone, one pill at night, because my levels have shown that my progesterone is seven, estradiol less than five, – that means it is not even in the bloodstream – free testosterone one point two, total testosterone six. I am so afraid I am going to gain weight more or more hair loss from some of the things I have read. Please give me your opinion. I also take Tirosint and Cytomel for my thyroid. Do I have to worry about any medication interactions? Please help. Mary.
Dr. Maki: Yeah. So this is a good one. We have seen quite a few people with thyroid cancer over the years. Thyroid cancer patients, they have usually had their thyroid gland removed, sometimes half the gland removed but–
Dr. Davidson: Hopefully the entire gland all removed.
Dr. Maki: Yeah, right. If you got cancer, you might as well just– at that point, you might as well just take the whole thing out. So they automatically – because the gland is removed – they automatically go into a different category than everybody else that does have a thyroid gland and I think that gets missed sometimes as far as their management goes. So when you and I were discussing this case, she is focusing on her female hormones, and I am like, well, what is her Tirosint and Cytomel dose? She is losing her hair, she has got no eyebrows, clearly, she is undermedicated when it comes to her thyroid medication and which is really common for someone like this
Dr. Davidson: Possibly. She does not tell us her TSH, which is the thyroid-stimulating hormone, or any of the other thyroid function tests such as the free T4, the free T3. But I can tell that she is being treated from the standpoint of trying to replace her T4 and trying to replace her T3 because Tirosint is actually not a bad medication. It is much more hypoallergenic. It does not have the lactose in it such as Cytomel or your traditional levothyroxine because I do not want to have the lactose or any of those excipients in it. So the Tirosint really is not too bad and Cytomel itself is an instant released T3, which we could drone on and on and on about. But the point being that she is being prescribed a T4 and a T3 which in some ways is a good thing. When somebody is just on T4 monotherapy that really is not the best because you want to make sure that T4 is converting to T3. One side thing is – so I am going to go back to the TSH – is the TSH, thyroid-stimulating hormone, in someone that has had thyroid cancer, I always want to keep that suppressed. So there is a reference range of point four-five to four point five and in somebody that has had thyroid cancer and had their entire thyroid removed, is you want to keep that under that point four-five because when you keep that TSH suppressed any little cells that might have not been taken out from her thyroid are dormant. Where when that TSH goes up to two and a half, three, some of those cells start to get activated and then they want to grow and the last thing you want to do with somebody that has had a previous thyroid cancer is have their thyroid start to grow back.
Dr. Maki: Yeah, right. So you and I were just talking about this for another case that we actually have and you suggested that we test their thyroglobulin, not thyroglobulin antibody, when you are screening for Hashimoto’s there is anti-TPO or anti-thyroid peroxidase antibody and there is thyroglobulin antibody. That is for Hashimoto’s screening or monitoring or diagnosing Hashimoto’s but just regular thyroglobulin is what you are referring to.
Dr. Davidson: Yes. So thyroglobulin is another hormone that you test with somebody that does not have a thyroid for previous removal from thyroid cancer so it tells you if it is growing back. So you would do a TSH, a thyroid globulin, a free T4, and a free T3, definitely, to check with this. So like, Dr. Maki said is perhaps her Tirosint and Cytomel might be a little bit too low, so that is inhibiting the thyroid function. I will say from somebody that has had a hypothyroid and they have lost their eyebrows, it is in some ways very hard to grow them completely all back. They will grow back a little bit but it is very hard to get them to grow back. But the hair thinning, once you correct for the thyroid, the hair thinning from low thyroid definitely does grow back. So that was my first stand out in that was Dr. Maki’s first standout was it is probably about the thyroid because, really, the doses of hormones that she is on is not very high and certainly not high enough to cause weight gain or making it hard to lose weight because her testosterone is pretty low, one milliliter, that is not a lot of testosterone but now she is starting to use it twice a day so maybe the two milligrams for her, individually, might be a little bit too high and causing a little bit of thinning. But it is not so much that it would cause trouble with the weight loss. Sure, hormones are all steroids. You take too many steroids, you are going to have weight gain and I have had definitely women gain weight from hormones because they are too high but her doses, really, I would not say that they are high enough to really have an impact.
Dr. Maki: I mean, certainly like you said, okay, too much progesterone, too much testosterone, too much estrogen. Okay, yeah, they can contribute to a certain amount of, what I would call, residual weight gain. You might gain five to ten pounds or maybe even four to seven pounds, but you are not going to keep gaining weight over and over and over because those hormones are not fat-storing hormones. They are steroids, right, so you got to be careful with them, but they are not going to cause perpetual weight gain. So she is afraid of gaining weight by raising the dose, but when–
Dr. Davidson: It sounds like she is having a tough time also losing it.
Dr. Maki: Right, which is every menopausal woman, for that matter, every perimenopausal woman’s problem because when the hormones decline is what makes it so difficult. It is not a matter of having too much of them. Now, I will say as a flip side of that, when a woman’s estrogen dominance, so she is still menstruating, she is producing an excessive amount of estrogen, she has got fibroid, she has got endometriosis, she has got all these things, now, that can contribute to the weight gain and in that situation. But it is not exclusive just to the female hormones. There is usually something else going on either cortisol high stress or insulin that is driving the weight gain. It is not a direct result of the female hormones. And honestly, her estradiol level is less than five, with static dosing using Bi-est where do you try to like to get that Bi-est level to?
Dr. Davidson: It does depend on the person, if they have a uterus if they have fibroids, but really less than five is like nothing in the bloodstream, they cannot even find it in the bloodstream. Usually, I like to keep it between thirty and eighty. When you have it between thirty and eighty that is really a pretty good dose. I have a few women that we have closer to a hundred or a little bit over a hundred but their endometrial lining of their uterus is nice and thin, they feel really good on that level, everything looks good, there is no risk factors associated but on the typical, I would say just in my patient population since 2004 of dealing with hormones, is between probably thirty to forty, up to eighty with 60 kind of being that little magic number for most of them.
Dr. Maki: Yeah. I was going to say fifty, myself. You are right. You do not want that number to be too high, maybe an upper end would be, depending on the woman between if she has a uterus, this is all about if she has a uterus or not, is somewhere between, let us say, seventy-five and one twenty-five as a range. Because if you give her too much, if you give her too much Bi-est, eventually, she is either going to have really uncomfortable breast tenderness, that is usually the first sign that does not kind of go away or regress, or she is going to eventually start having some spotting or bleeding problems. Now, the thing you realize, too, when you are on hormones, bleeding and spotting is kind of par for the course, right? It may happen at some point. It is okay. It is not an emergency, you do not have to run to get a transvaginal ultrasound. If it continues over time, then it is a different story, either the progesterone dose needs to go up, the estrogen dose needs to go down, or something needs to adjust there but those kind of modifications are fairly easy to do, and the woman’s body kind of tells us what the dose is going to be eventually, right? You do not start on a dose and stay on the dose, we always titrate, usually, everything all the time but the woman’s symptom picture and kind of how her body responds will give us an idea of where that dose should be.
Dr. Davidson: And this is a question we get from so many women is when they are going to be put on bioidentical hormones or they are going to be put on hormone therapy, they are terrified of gaining weight. And I get it, it is hard to lose it and I am a perimenopausal female myself at this moment that hey, I do not want to do anything that is going to help contribute to weight gain. And so just to kind of let women know is, the bioidentical hormones, when you are using a Bi-est, when you are using sustained-release progesterone, when you are using a tiny tiny tiny tiny tiny little bit of testosterone, that is not going to make you gain weight. If anything, I find that it helps women lose weight.
Dr. Maki: Right. It might not help with the weight loss directly but as I said a few minutes ago, what is perimenopause and menopause? The female hormones are disappearing, some women have lots of stress in their late 40s to their early to mid 50s so you have this kind of uncontrolled environment where there is no balance between the sex hormones and the stress hormones and really that is why women go through all of these changes because it really comes down to kind of unabated stress response. They do not sleep, they are taking care of the kids, they are working full time, they are exercising too much, all the things that we talked about in this podcast basically manifest in them having this inability to lose weight, keep gaining weight, they cannot sleep. They have all these things going on. It is kind of a nightmare scenario that is because of the lack of hormones, the lack of female hormones, specifically estrogen and progesterone. I want women to think that estrogen, like you always say, I am biased, I think testosterone is the best hormone, but you think estrogen is and for a woman that is the best hormone, right? That is exactly that, that is what makes a woman a woman. In some ways, as long as it does not become a runaway freight train, the more of it she has the better she feels, right? The more of it she has the better she looks within reason, I mean, I am talking weight-wise because estrogen is relatively a slimming hormone that you know helps you keep certain enzymes. There is an enzyme literally called lipoprotein lipase that estrogen basically turns that enzyme off which basically tells our body to store fat and cortisol activates that enzyme. So the more cortisol you have, this lipoprotein lipase– that is why stress makes us gain weight because it activates this enzyme and it tells our body to– and if our insulin is high–
Dr. Davidson: Can you explain that again? You said that hormone – estrogen – turns it on or turns it off?
Dr. Maki: Turns it off.
Dr. Davidson: Turns it off, okay.
Dr. Maki: It turns off fat storage, but cortisol turns it.
Dr. Davidson: Got it, okay. So that lipase, our estrogen will turn off that lipase so they actually have a more estrogen will help reduce the storage of fat.
Dr. Maki: Yeah, right and that is also in the presence of insulin. Insulin is the gatekeeper when it comes to weight gain and fat storage. Now, we do not want to get into the debate. Neuroscience researchers say that weight gain and obesity is all in the brain and then all the low carb people say that it is all insulin. I think, obviously, it is a combination of both of those, it is not one or the other but they just argue back and forth. I heard a podcast on Joe Rogan thing they are just arguing, literally, back and forth, who is right, who is wrong and it was not about how to solve the problem, it was just arguing like a–
Dr. Davidson: Who is right and who is wrong. [laughs]
Dr. Maki: Yeah, right. Who is right, who is wrong as opposed to, “Okay. Well, what is the solution to the thing?” That is what we are all trying to figure out. Okay, we are all trying to figure out how in our complicated 21st-century environment that our genetics do not mesh well with how we live these days. That is why we have all these age-related diseases and it is all based on our lifestyle. All right, all the things that we deal with other patients, everything is related to our lifestyle. We do not sleep enough, we do not get enough relaxation, we do not eat right, we eat the wrong things, we are too stressed out, we are worried about the mortgage, we are worried about work, we are worried about all these things, and that manifests into, eventually, dysfunction, weight gain, disease, whatever you want to call it. So to say that hormones themselves, especially the female hormones, again, we have always say, when you are twenty-five, you have lots of hormone and lots of sex hormones for both males and females, that is when you are the healthiest in your life, right? If estrogen-progesterone actually cause women to gain weight by themselves, then every pregnant woman would literally blow up like a balloon, right? Because their estrogen-progesterone levels are just through the roof.
We do not even realize how high their hormone levels are when a woman is pregnant and to think that, and this is no criticism of Mary, by any means, but to think that a little bit of progesterone, testosterone, and Bi-est is going to cause that to happen, it just does not. Usually, those hormones are actually more beneficial in some respects. So in her case, we think that, not less is always more because there is a caveat to that, making sure that you have enough to make sure the dosing is right so that way her symptoms, whatever those symptoms might be, in this case, the hormones themselves are not going to help you directly lose weight. Although in some cases they can, we have seen that many times but it creates an environment for weight loss to actually happen. So some of those enzymes and receptors and different things get turned on and turned off and now weight loss is possible because you are not just swimming in cortisol all the time. That is really where those hormones kind of come into play and actually provide some benefit.
Dr. Davidson: Exactly. So like you said, when we first saw this question I am sure it made me think about a lot of women that I see, they are, they are concerned about taking hormones and gaining weight. So know that that is not the case. It is about balancing those hormones and then you are not going to gain weight on hormones. Sure, some conventional hormones, some of the patches, yeah, you are going to gain weight on that but when you are doing a Bi-est and doing it various ratios between 50/50 and 80/20, combining that with a little progesterone – or actually a lot of progesterone because I love progesterone, too, that is also my second favorite hormone – and then maybe a teeny tiny testosterone if needed, that is not going to cause you to gain weight. If anything, that is going to help a lot of those symptom pictures, help us achieve our goals, and then you feel better. When you feel better, you eat better. When you feel better and you are eating better, you might feel it and have more energy. You might be inclined to do a little bit more walking or a little bit more exercise. It all kind of comes together.
Dr. Maki: Yeah, right. Now, as we talked about earlier and we started off, the initial response was her thyroid dosing was probably not right or enough because she is still having some of those symptoms. Because she has had her thyroid gland removed, these types of patients always are on the highest dose. If we took a population of thyroid patients that were diagnosed hypothyroid either surgical, in this case surgical, or just diagnosed hypothyroid, they had initially had a TSH above four point five, that the ones that have had their thyroid gland removed are always, at least in our practice anyways because we know how to dose properly, proportionally higher than everybody else. And this particular case, I think that is exactly the same thing is happening. I think that she just really underdose in the thyroid and maybe for this situation, Tirosint and Cytomel might not be our first choice or first option. I know it is becoming very popular, this kind of combination. We like to do that a little bit differently and like you said, too, the TSH becomes almost irrelevant because she does have a gland anymore. The TSH comes from the brain. It comes from the pituitary that stimulates the thyroid gland, well, if there is no more thyroid gland there, we do not need to worry about the TSH. You cannot dose this kind of a patient based on the TSH alone. You have to look at some other data or some other numbers and the free T3 is something that should be– the more important hormone that should be tracked and followed and monitored.
Dr. Davidson: Exactly. So like you had talked about the adrenal glands with cortisol. We had talked about the– basically the sex hormones with the estrogen and progesterone, then we have got the testosterone which on a side note, I kind of consider more of an adrenal hormone for females, and then we are talking about the thyroid. It really is a collaborative process here on making sure all of that is balanced together in terms of getting the goals, especially for weight loss or preventing weight gain.
Dr. Maki: Yeah, right. Yeah, and that is really complicated. Like, seriously, that whole symphony of hormones, really, we are talking lots of different, very powerful, what we consider, metabolic hormones: insulin, cortisol thyroid; and then your secondary sex hormones: estrogen, progesterone testosterone. There is a lot going on there. But always, the hormones we cannot live without; insulin, cortisol, thyroid, those hormones dictate everything else in most cases. So when we are seeing things like this, those have to be addressed in some way. We always kind of talked about that cake foundation. The secondary hormones are there to kind of round everything out and maybe alleviate certain symptoms, but if you do not deal properly enough with those metabolic hormones then you are kind of walking uphill backwards.
Dr. Davidson: So in these types of cases, we would dial back; focus on those adrenals, the cortisol, the insulin which comes from the pancreas; and then focus on the thyroid. Then like Dr. Maki had said, is use the sex hormones, the secondary sex hormones like the estrogen and progesterone, as the frosting on the cake. We have got to build the foundation first, otherwise, they might feel good for a second but then ultimately they are not going to feel good and you are back to the drawing board.
Dr. Maki: Yeah, and even cases like this, and I am not saying exactly in Mary’s case but a case like this, even rhythmic dosing where the estrogen-progesterone doses actually go up quite a bit higher actually can help on that weight loss side and especially if there is changes to the hair. Getting the hair to change the way you want it to, especially in a menopausal woman, is very difficult, right? That is a really challenging problem. But again, that is because of lack of hormone. In this case, it could be female hormones, it could be thyroid hormone, we do not know her stress situation, it could be too much cortisol. So, again, part of a way to offset some of those perimenopausal and menopausal symptoms is making sure that there is a buffer in some respects, the female hormones. I do not know how many times I have heard it because I have asked the question on purpose but the women that are in their late 40s, early 50s that start on BHRT, the female hormones become their stress buffer.
Their stress tolerance goes down, they do not have the capacity they did even a few years ago because those hormones are gone. You give them some of those hormones and all of a sudden now they can start to handle their, sometimes, very chaotic lives. And at least they are able to hold their head above water, they are not drowning. Maybe they are moms or maybe it is the motherly instinct but women tend to give a lot of themselves to everybody else around them and then themselves kind of get sacrificed, right? So they take care of the husband which can sometimes just be a bigger kid, they take care of the kids, they take care of the work, they take care of all these things, and they kind of get sacrificed and that just raises stress and then all these things start to manifest off of that. So BHRT, in some ways, is a way to kind of help empower women, help them give back the tools that they need, in this case, hormones, to be able to kind of run the show, run their lives effectively, efficiently, and hopefully be happy at the same time.
Dr. Davidson: And not to overwhelm the listeners here, so not to overwhelm any of you, Dr. Maki is right. This is really complex, but the cool thing with BHRT is we have so many different options. I have a lot of patience, but I certainly– not everybody takes the same thing. It is so individualized because we have so many options to adjust for that individual. So, definitely with Mary there just needs to be a little bit more adjustment, maybe dial back, look at the picture a little bit differently, look at those adrenal glands – which is what we do with all the patients. So it is just finding that right balance for each individual.
Dr. Maki: Yeah, and I would suggest as just something very simple is just look at the free T3 level on your most recent lab tests. For her or for anyone else that has a thyroid problem, that has a reference range, depending on the lab, of two point three to four point four. Some labs it is two point zero to four point four or four point two. But two point three to four point four, we always want that number to be either high-end normal or in some cases even a little bit above the reference range because especially in a case like this where her thyroid gland is removed, we want that number to be as high as possible so she can actually function in the best way possible. If her free T3, in this particular case, if her free T3 is in the twos, that is part of the problem. That number needs to be in the threes, the low fours, or even the mid fours or above. And I know there is some discussion at some of these different endocrinology associations that they are contemplating increasing the reference range for people that have been on medications, specifically the free T3 level, because the medications kind of change all that.
Unfortunately, doctors, they use numbers a little bit to dogmatically that if your TSH is too low, they lower the dose, if your free T3 is too high, they lower your dose. They do not take the patient into consideration enough. The patient, when it comes to thyroid, the patient will always know when they are overmedicated, always before the doctor does. You do not need a lab test to tell if a patient is overmedicated because when it comes to thyroid, they will have some very classic symptoms: maybe an increase in heart rate, they will have some anxiety, they will have insomnia, they will have some very specific things that tend to show up that are related to that medication that if they do not have those but their numbers do not look right, it could be when they took their medication based on those blood tests. And I know there is some discussion out there, too, about medication timing on blood tests and that is a whole other discussion. I think we just did a podcast on that probably about three or four episodes ago because you cannot just go to the lab whenever you want or take it 24 hours before. There is a whole process there that we run our patients through so we can see the change of a baseline to improvement. And if you are not taking your medication properly the way that we recommend then you are getting skewed results and you might be either overdosed or underdose depending on how that plays out.
Dr. Davidson: Exactly. My goodness, with thyroid, I mean, and all the thyroid testing and we could get into reverse T3, we can get into Hashimoto’s there is so so much which we definitely will and we have not past podcast. But I would say just to kind of wrap this one up for Mary what would you say?
Dr. Maki: Like I said, I would just say go back to her practitioner and I would just have the thyroid kind of looked at a little bit more. She does not list her– the most important thing of this entire question is what is her Cytomel and what is her Tirosint dose and she left that part out.
Dr. Davidson: And that is because, just like a lot of females, they are wondering about the hormones. “Am I going to gain weight?” So, know that bioidentical hormones, when you are doing a Bi-est, I am going to say it again, with that progesterone, it is not going to make you gain weight. I mean, sure, if somebody was, maybe, thirty-eight and taking some of these bioidentical hormones when they do not need them because they have ovaries and they are functioning, yeah, that is going to make, you know– put too many hormones on top of hormones, that could potentially be a steroid effect and cause weight gain. But for a postmenopausal female, that is not going to be the cause of the weight gain. If anything, it is just like, you know. Wonderfully what Mary’s practitioner did was actually increase up her doses to kind of help buffer that
Dr. Maki: Yeah, right. I do like her prescriptions like those prescriptions are actually very good. I would agree with a lot of what she is doing but it comes down to dosing on all fronts. It comes down to the estrin dosing, the progesterone dosing, the testosterone dosing. I like to see her testosterones only at one milligram. That is great. So she is not getting a truckload of testosterone for no reason, but she does not put in the Tirosint or the Cytomel, and in this particular case, because of her history, the dosing of those two things are the most important things to kind of re-evaluate. Focus on those and then come back to the female hormones and then hopefully there is a different result over the course of another one to three months or something like that, so. Do you have anything else to add or is this one good for now?
Dr. Davidson: I think this one is really good.
Dr. Maki: Yeah. So again, if you have any questions yourself, you can shoot us an email at firstname.lastname@example.org. That is email@example.com. Like I say on every podcast, we cannot get to all questions, but we do like compliments, so that might help your chances of– we do kind of look at all of them and kind of decide, and the ones that either relate to cases we already have or ones that we think that we could have a good discussion about, like this one. I think this is a really good discussion. Please reach out and we will do what we can to help. Until next time, I am Dr. Maki.
Dr. Davidson: And I am Dr. Davidson.
Dr. Maki: Take care. Bye bye.