Question: Hello. I am forty-five, perimenopausal diagnosed by blood work. I have my uterus and I am taking 200 milligrams of bioidentical progesterone each night orally by capsule. I do not take anything else for hormone balance other than evening primrose oil and some adrenal support. Neither of these is new to my regimen. What is new is the administration of the progesterone orally. Previously, I was using a progesterone cream, 40 milligrams per night. All nights of my cycle, no break. Doc suggested that I needed to be more cyclical with my administration and then I try oral progesterone instead. I am doing this. I go to sleep well but toss and turn a bit more than I used to, then wake up around four thirty-five and cannot sleep any longer. My body temperature seems to be all over the place. At some nights around that same time, I wake up hot, not really a hot flash per se but just hot, but the very next night, I can have on the same bedclothes, sheets, house temperature, et cetera, and will not get hot. She has me doing fourteen days, fourteen to twenty-eight, taking the oral progesterone. My trouble is the fourteen days I have to wait to take it, I have all the trouble sleeping and all the other symptoms while I am waiting for that fourteenth day to come so I can take my oral progesterone. My question, can I take it full-time during my cycle and never take a break or does that go against all medical wisdom and/or would be bad for my body not to have a break?

Short Answer: Based on a woman’s physiology, it does make sense to only take progesterone during the second half of the month. Typically, progesterone is produced from ovulation to the period and usually peaks around day 21 of the cycle. However, many women feel better when they take oral progesterone all month long. Oral progesterone helps reduce irritability, reduces anxiousness, and can improve sleep. Because of this, we most often prescribe progesterone to be taken all month long. Sustained Release Oral Progesterone is usually very well tolerated, but sometimes it can change a woman’s cycle. Based on how the cycle changes will determine if the dosage needs to be cycled or not. For example, we might prescribe 50 mg for the first half of the month and then increase to 100 mg during the 2nd half of the month. Then we have our patients stop the progesterone during menstruation.

PYHP 101 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: I am Dr. Davidson.

Dr. Maki: We have another question we are going to answer. This one is someone that is recently diagnosed perimenopause and progesterone. Again, this one is very appropriate. This progesterone conversation comes up all the time. Why don’t you go ahead? We will just dive right into it. Why don’t you go ahead and read the question?

Dr. Davidson: Sure. I will read the question. This is from Eileen, but we do change everybody’s names just for privacy. Again, we are calling her Eileen. Hello. I am forty-five, perimenopausal diagnosed by blood work. I have my uterus and I am taking 200 milligrams of bioidentical progesterone each night orally by capsule. I do not take anything else for hormone balance other than evening primrose oil and some adrenal support. Neither of these is new to my regimen. What is new is the administration of the progesterone orally. Previously, I was using a progesterone cream, 40 milligrams per night. All nights of my cycle, no break. Doc suggested that I needed to be more cyclical with my administration and then I try oral progesterone instead. I am doing this. I go to sleep well but toss and turn a bit more than I used to, then wake up around four thirty-five and cannot sleep any longer. My body temperature seems to be all over the place. At some nights around that same time, I wake up hot, not really a hot flash per se but just hot, but the very next night, I can have on the same bedclothes, sheets, house temperature, et cetera, and will not get hot. She has me doing fourteen days, fourteen to twenty-eight, taking the oral progesterone. My trouble is the fourteen days I have to wait to take it, I have all the trouble sleeping and all the other symptoms while I am waiting for that fourteenth day to come so I can take my oral progesterone. My question, can I take it full-time during my cycle and never take a break or does that go against all medical wisdom and/or would be bad for my body not to have a break?

Dr. Maki: Yeah. This is a really good question. Obviously, that is why we are answering it because this one does come up a lot. Now, we do like the idea of cycling hormones. We use cycle hormones all the time, rhythmic dosing, different types of things. Her symptom picture – she is not having a hot flash, she is just hot. Night sweats in this perimenopausal phase is a very common symptom. She is still having a cycle. She is not really a candidate for estrogen to take care of the hot flashes. What would you say about that?

Dr. Davidson: Really, with perimenopause, it is different than menopause when it comes to hot flashes and night sweats, where in menopause, those ovaries have ceased to work. They retired rightly so. They deserve it. That estrogen has dropped. That is going to cause an issue with their internal body core temperature, and they have the hot flashes and the night sweats, where in perimenopause, women are still making estrogen. It might dampen a touch but really, as in the case with Eileen, which is completely understandable, is in perimenopause, your progesterone plummets to the floor like there is nothing. That is why it is nice to replace that and that does help with the night sweats. Like Eileen says, in perimenopause, they are not really night sweats. Some people are more sweaty than other people but it is that hot. You wake up hot. It can be one day, I am hot, and the next day, I am not. A lot of times that does seem to be [inaudible] where you have that heat or that flush while you are sleeping about anywhere from seven to ten days before your next period, which is when that progesterone is supposed to come up. 

That is why it makes sense in her question. Her doc is having her take her progesterone from day fourteen to day twenty-nine, which is really when we are cycling females, that is when we make progesterone is the last half of the cycle. We do not necessarily make progesterone or much progesterone the first half of the cycle. In, I guess you can say, physiology respects or in theory, that is exactly how you should do it, but what we found over time is exactly what Eileen is running into is well, I feel good for those two weeks I am taking it, but what do I do about the two weeks I am not taking it when I do not feel good?

Dr. Maki: Yeah, right. We usually have women take it all month long, maybe not in every case, or we might actually depending on how the progesterone affects their bleeding. There are actual periods because progesterone is a beautiful hormone in the fact that it can make a woman start bleeding or it can make it stop bleeding depending on the situation. For example, in perimenopause, when a woman is in her mid to late 40’s, she can start having a lot of heavy bleeding. That is a perfect sign or a classic sign that that progesterone level is actually decreasing, but she still has lots of estrogen. As we talked about on other podcasts, she is pseudo-estrogen dominant but there is not enough progesterone to control the bleeding. If you give them some progesterone, now the bleeding is a little bit more under control. Now, if you give them too much progesterone like in this case, 200 milligrams, for some women, it could be too much. Now, that could create the same problem. It could create more bleeding. You really do not know how a woman is going to respond to a dose like 200 milligrams until they actually take it, and then depending on how their cycle changes over the next one to three cycles, that will determine whether or not you can stay at that dose or go down. You and I do not usually ever go any higher than 200 milligrams. That is about as high as we go.

Dr. Davidson: Yeah, that is pretty much on the top end there. Like Dr. Maki was saying, progesterone is great for keeping that lining of the uterus, the architecture, nice and solid, more compact, not so sloppy, so that it can help with heavy bleeding. On the flipside, progesterone, if you give it to soon, let us say we gave Eileen that 200 milligrams of oral progesterone on day six of her cycle, because usually if I am doing progesterone all month, I do have them take anywhere between three to five days off during their periods, just not having those hormones allows the lining to slough off and having just a few days off. You do not really have any major symptoms in that three to five-day period. 

Let us say we are going to have her start taking her progesterone on day six of her cycle. In some people, if you do too much progesterone, oral progesterone, is that can cause a bleed to come sooner than that twenty-eight days. That is where you get women saying, “My period is coming on day sixteen.” My period is coming on day sixteen or day nineteen or day fourteen. That is when you know starting that progesterone a little bit too early or maybe it is the dosage is causing their cycles to get too short. That is another reason in theory that a lot of docs say, “Do not start your progesterone until day fourteen, so at least it does not shorten that cycle, and you can still get a twenty-six to twenty-eight day cycle.”

Dr. Maki: Yeah, right. Now, some cases, again, just to complicate it even more, in some women like we talked about, depending on the dosing, how they tolerate to progesterone, we might do a lower dose than the first, let us say, day one to day eleven, which kind of contradicts what you just said a little bit about not taking it during their period.

Dr. Davidson: Like you said, a lower dose.

Dr. Maki: Yeah, a lower dose. You still have the full sloughing off of the uterus but enough progesterone there to give them, like in her case, some sleeping relief because that is one of those classic insomnia, classic perimenopausal symptoms, so you cannot take the progesterone. Most women do much better when they are able to take some dosing of the progesterone all month long like in her case. Can she take it the entire month or can she not? She would love to be able to take it the entire month, which is why we do it that way, or like I said, we might do let us say for example, 50 milligrams and 100 milligrams, or 75 and 150, or for some women, 100 and 200, depending on the woman and depending on the severity of their symptoms. Again, there are lots of possibilities there. It makes it really confusing for a woman to know how much is the right amount for her, but we usually determine that based on how their cycle changes once they have implemented. They feel good. They feel good. No news is good news. They are just doing just fine, but if they come back and report, “My cycle has changed in this way,” now, it helps us determine what needs to happen with that progesterone dose.

Dr. Davidson: Just to put that out there a little bit for Eileen, and this is very common because she represents pretty much all of our perimenopausal, and I will tell you I am forty-seven, even though I treated women for years with perimenopause and menopause and hormone imbalance, there is nothing like going through it yourself to really understand how that treatment works. Really, the sleep is probably the big issue and that may be why her doc suggested to do the oral progesterone because oral progesterone seems to have more in effect with the cortisol and the GABA at night and helps you stay asleep better because that is usually the typical thing is perimenopause is you can fall asleep but it is really difficult to stay asleep. That oral progesterone, we find, helps women stay asleep in that perimenopausal phase as opposed to the cream. It does not have quite as much an effect on ability to stay asleep. That may be why the doc suggested that.

Dr. Maki: Yeah, sure. We do some other things to assist the sleep. Progesterone does a pretty good job on the sleep side, but like you said, they still might be waking up a few times at night. We hear women say all the time, “I am hot, cold, hot, cold, hot, cold.” Covers are coming on and off because they go through this cyclical pattern over the course of the night. Now, like you said, it might not be every night. It might be that seven to ten day PMS window. There are some very good adrenal adaptogen herbs. We use glycine. We use PharmaGABA. We use a bunch of different things that granted there is not one supplement that works the best when it comes to sleep. It just has to be tailored, again, to the woman and a little trial and error to try this or try that or try a couple of different things. No one, at this stage of their life, is ever going to get great sleep. I think that is pretty rare. We are just hoping that could get them to at least good sleep. I ask a question at least on my intake form. I have them grade their sleep A to F. A, they sleep great. F, they sleep terribly. 

Most of the time, most women in perimenopause and into menopause, they would grade their sleep, which is their own subjective opinion, a D to an F most of the time. Some are maybe in the C- range. Very few of them are in the A and B… No, I do not think I have ever seen an A. Maybe a couple of Bs here and there. If they are in that D to an F range, we want to get them to a B range. That means at least what I would consider is they are able to fall asleep easy. A reasonable bedtime for most adults is going to be about ten o’clock. They sleep for three or four hours, preferably no restroom, and then they are able to just reposition, go back to bed, and sleep again for another three or four hours. At least that way, they can wake up to face their day with at least somewhat of a feeling of rejuvenation that they have actually had some decent sleep that night.

Dr. Davidson: Oh, yeah. There is nothing better than getting a good night’s sleep. It is almost like you know you are an adult when you want to make sure you get a good night’s sleep where when you are a teenager, it does not really matter. You might stay up until three in the morning, but definitely for perimenopausal women, sleep is important.

Dr. Maki: Yeah. Women these days are stretched thin. They are taking care of the kids. They are working full-time. They got so many things to do and and probably trying to exercise on top of that. We have talked about that before too. It is obvious how important sleeping is, but the frustration that I hear from women when they are not able to sleep, something that is so innate into human beings, and when you are not able to do it, the night seems like it lasts like an eternity when you are not able to sleep. The hours just go by so slow. Some people cover up their clocks so they do not see the clock, and there are people who see the clock because they are hoping they have more time so they can get more sleep before their alarm goes off or they have to get up for the day. For whatever reason, everybody gets their best sleep in that last hour to two hour window, or five o’clock, right before they have to get up and they finally actually sleep in. When they do wake up, they are exhausted because that cortisol circadian rhythm sort of thing is a little bit messed up. We will talk about that on another podcast, but progesterone certainly need relief all month long. This is a big problem.

Dr. Davidson: Maybe let us go ahead and throw another wrench into it and complicate it is, Eileen has her uterus so it kind of makes it easy to understand how you are going to cycle progesterone because hey, you get your period, you are back to day one, but what about women that do not have a uterus?

Dr. Maki: Yeah, right. Well, like we said earlier, taking it all month long, then it really does not matter much.

Dr. Davidson: In some respects, but then at the same time, with women that do not have a uterus, you automatic… Whenever a female does not have a uterus and they had a hysterectomy. It is usually because of heavy bleeding or irregular bleeding, and really the perimenopausal time, which is late 30’s to very, very early 50’s, I mean, perimenopause can last a long time, is that is when you see a lot of hysterectomies happen because of that drop in progesterone which causes the irregular bleeding, not heavy bleeding, chronic bleeding, painful periods. That is where you see that. Any time a woman has said, “Oh, yeah, I had a hysterectomy,” I will think, “Oh, they probably have low progesterone,” or as we will get into other podcasts is low thyroid, which low thyroid can impact that heavier bleeding for women that get a hysterectomy. Some women that have hysterectomies, we might cycle it a little bit too, but I find that just like with Eileen is women feel better when they pretty much take that progesterone all month long.

Dr. Maki: Yeah. Now, not to confuse things, again, the theme of all bioidentical hormones is there is not one way to do something. There is a lot of different ways and it really does depend on the patient’s situations, not the doctor’s opinion necessarily, which that comes up a lot. Doctors have their own style, their own way to do things, but it really depends on how, one, the patient’s situation and how they respond to help the practitioner determine what needs to be done. It is tailored to what the patient wants, which is symptom relief, to be able to sleep at night and maybe not be so hot, but sometimes, the response of the patient, it helps the doctor make those decisions. Rhythmic dosing which we have talked about before too, we can do that one both ways. We can do that one with capsules or with cream. It is designed to do it more with cream. We prefer capsules with the static dosing because it has that brain effect. It has the sleep effect. It kind of lowers anxiety. It reduces some of that irritability that women have. The cream does not necessarily do that as much. Rhythmic dosing would be more for menopausal women than is opposed to perimenopausal women. Now, I am curious. I have my answer in my brain but it says perimenopause diagnosed by blood work. How do you think that her doctor diagnosed her by blood work?

Dr. Davidson: If they did blood work, they probably did an FSH and an LH. Those are follicle-stimulating hormone and luteinizing hormone. Those reference ranges are so vast a lot of doctors do not really know what they are looking at. They are just looking to see are you in menopause or are you not. Maybe more of a progressive doctor might have done her blood work for progesterone anywhere between day fourteen and day twenty-eight because typically, in a perfect twenty-eight day cycle, the progesterone is highest on day twenty-one. When a perimenopausal woman is having a regular period, which is not always the case, but if they are having a regular period, then I usually try to get that progesterone tested somewhere around day twenty-day. It does not have to be perfect but around day twenty-one. If it is non-existent or it is low, then you can say, “Oh, yeah, you are in perimenopause.”

Dr. Maki: Yeah, right. Usually, when we have a woman going for hormone testing, we want them to go either on day twelve, depending on what dosing schedule she is using, or, like you said, day twenty-one because if you just do it randomly, now granted, you and I can look at a blood test and say, “Oh, they are probably at this part of their cycle or that part of their cycle,” if they are having a cycle. If they are not having a cycle, then those numbers do not really mean much of anything. A thirty-year-old woman going into the lab and you do not know what day she is being tested on, those hormone values are changing literally every day of the month practically. Every week, those hormone levels are different and estrogen is going to be high in the first fourteen days. Progesterone is going to be high in the second fourteen days. All the time, we do blood work on perimenopausal women, and their progesterone will be less than one. It will be like point five, point six, point seven. Now, once in a while, you will see one. Let us say forty-seven, forty-eight and her progesterone will be three, four, or five. She still have a fairly good endogenous production, meaning, that her body is still producing some progesterone.

Dr. Davidson: Which is great, but if you were going to say what is the optimal, regardless of age, if you are looking at somebody’s twenty-eight day cycle and they are day twenty-one, what would their progesterone be if it were the creme de la creme? That would easily be in the teens. Even like eleven, twelve, thirteen, fourteen kind of thing.

Dr. Maki: Yeah, sure. You can see that decline. Now granted, you and I have never done exactly that but we see women in these different periods of their life. Like you said, if they are twenty-five, their progesterone is going to be quite high on day twenty-one. Women in perimenopause, that number has already declined quite a bit where if you did it on a menopausal woman, if she is not taking progesterone, it will always be less than one. If she is taking it, then it will be… Usually, I see it with, and they are taking an oral progesterone like this, usually it is between two to eight. Is that the range you see the most where you see the progesterone level when they are taking progesterone?

Dr. Davidson: Again, it depends on if they are taking it orally or if they are taking it as a cream.

Dr. Maki: Yeah, orally.

Dr. Davidson: Orally, if I am dosing them and we are doing, again, to make it more confusing, a sustained release progesterone oral capsule, usually, you will see it in the morning. If you are doing a morning draw around nine or ten or eleven, it is usually around three to four. You do not really want it too much higher than that when you are doing a replacement just because progesterone is really relaxing. If your progesterone as a replacement as you are giving them as a dose, if it is higher during the day, sometimes that can just make people tired or lethargic.

Dr. Maki: Sure. Yeah. Some women absorb it really well so their numbers jump up there a little bit, but if that number is a little too high, that means they are probably still producing some of their own and the progesterone that they are taking as a prescription is bolstering that number. Day twelve, day twenty-one, those are landmark days to go to the lab. It does not matter in every case but depending on what we are looking for, we might specify go to day twelve, go on day twenty-one. It puts those numbers into better perspective. I was going to say it was probably an FSH level. For perimenopause, what is your FSH level range?

Dr. Davidson: If a woman is in perimenopause, the follicle-stimulating hormone, the FSH, if they are in the very early-early because with everything, perimenopause is a phase. It is not like I am in it or I am not in it. It is a phase. In the very early part of perimenopause, you might see it at fifteen to twenty-five. That is the early part. When they are in the throes of menopause, you see that like twenty-five to thirty-five. When you are going up higher than that, then that is usually the beginning of menopause.

Dr. Maki: You said the throes of perimenopause, say it again. The beginning is fifteen to twenty-five.

Dr. Davidson: Yeah, and usually anywhere between twenty-five to thirty-five, that is the main part of perimenopause. If you look at a reference range on LabCorp or Quest an FSH of twenty-five, it will say postmenopausal. That is not correct. I have women that come in and their FSH is at twenty-five and they are still having a period. They are not postmenopausal.

Dr. Maki: Yeah, the reference ranges. You develop your own reference range as you kind of just ignore whatever they say on there. When a woman goes into menopause, where is the typical starting point for menopause?

Dr. Davidson: Postmenopause – anything over a hundred on FSH. They are pretty much past menopause. They have not had a period for a year. They might have a hot flash here and there but nothing extreme. Their symptoms are probably minimizing. When you see someone’s FSH and they might be around sixty-five, that is when you are like, “Oh, yeah, they are probably having hot flashes during the day, multiple night sweats at night. Their [inaudible] ran away. They are gaining weight.” That is menopause and that is unfortunate because those reference ranges because that is what docs do is they just look at the reference range. If the reference range says this, they just follow that. The reference range is… You do not want to hang your hat on that. There comes in a lot of where you got to take into consideration that individual. I will have women that will tell me that their doctor tested their hormones and they had numb. They are on menopause. They have no estrogen and progesterone, and then I will ask them, “When did you get tested? Were you on your period?” They will say yes. I am going to say, “Well, of course your estrogen and progesterone would be low. You were on your period. They are always low day one to day five.

Dr. Maki: Yeah, timing. That is what we specify, usually day twelve or day twenty-one. Do not go to the lab on your period because those numbers are going to be… Those things are never really communicated to them. We communicate to our patients but…

Dr. Davidson: You do your best because it is like Murphy’s Law. I have so many women I will say, “Hey, can you go get your blood draw around here?” They will do and then they will call me and say, “You know what, I got my period on the way home from the blood draw. It was day twenty.” I am like, “That happens, Murphy’s Law.” Just like we always get our period when we go on vacation. It is just one of those Murphy’s Law. It does happen, but that is where you have to take into consideration not just the objective data from the blood work or whether you are doing saliva or urine, but that the patient is well in their goals, and their health history, and their family health history. There is a lot to take into consideration with that when you are putting it together, but that is the cool thing with the bioidentical hormone replacement in the compounds is you can do anything for that patient. It is not just a cookie-cutter. Everybody gets the same dose. That is where it can be so individualized.

Dr. Maki: Yeah. We say that all the time that it is very much tailored. Now granted, that causes sometimes some issues because everyone’s different. It is very difficult to scale that or to see lots and lots… The conventional medical system is just a revolving door of the same treatments. Everyone has a certain condition, they get a drug. Everybody that has that condition gets the same treatment style. We alluded to the fact that every woman we see, there is a lot of tendencies. There is a lot of similarities from one patient to the next, but each case is looked at as an individual, and their symptom picture their lifestyle, their genetics. All those things are taken into consideration that determine what they are going to be using, and then how they respond once they are on the hormones or on their particular prescriptions obviously will determine where they stay and how those doses change over time. 

They always change over time. It seems like a lot of women, they get on certain prescriptions whether it is conventional or not and they are just on the same thing forever. Maybe there is a business model behind that to some extent from a conventional perspective, but we are in the business of trying to optimize how people feel. We are not trying to achieve certain numbers on lab tests necessarily. We use the lab test to help guide decisions and keep people safe, but we are more concerned on the subjective. We want them to feel better. We want their symptoms to be resolved. We want their health to be optimized in the best way possible.

Dr. Maki: If you have any questions, you can send us an email at [email protected]. Again, [email protected]. Dr. Davidson, this was relatively quick. I think we threw in a couple things but the answer is that she can take her progesterone for the most part. She can take it all month long.

Dr. Davidson: Okay. Discuss it with your medical doctor. Disclosure, disclosure. Disclaimer, disclaimer. She could easily take it pretty much all month long or a patient that were like Eileen could take it all month long. They could do a different dose like Dr. Maki said one half of the cycle and a different dose later. She could do cream for half of the cycle and then capsules for another half of the cycle. We are confusing you again, aren’t we?

Dr. Maki: We do not want to go against what your doctor told you, but we prescribe progesterone for our patients all month long because, like you said, you need that relief. You need to be able to sleep. That is one of the main reasons why you give a woman progesterone in the first place is to be able to sleep. Hopefully, that shed some light on it. It does get a little convoluted and complicated, but at least for this question, which does come up a lot, hopefully we were able to answer that for you. Until next time, I am Dr. Maki.

Dr. Davidson: I am Dr. Davidson.

Dr. Maki: Take care. Bye-bye.