Allison’s Question: I have opened a hormone wellness practice and came across your blog. You mentioned the application of estrogen cream to the face, neck, and chest to improve skin health. From what I found, it appears that .3% Estriol and .01% Estradiol is typically used. Do you recommend a once-daily application? Can this same dose be applied to the inner and outer labia for improvement of external skin appearance as well as the vaginal entrance to improve vaginal dryness, etcetera? Thank you in advance for any feedback you can provide.

Short Answer: We typically only use Estriol cream for the face and the vagina. For the face, we do recommend using estriol daily, usually as a nighttime moisturizer. As for vaginal use, we recommend daily use of estriol cream for the first 1 to 2 weeks depending on the severity of symptoms. After that, we suggest a frequency of 1 to 3 times per week. We don’t use estradiol for vaginal use. The dosage of estriol we typically use for both is is 4 mg/gram, but apply 1/2 gram with each application.

PYHP 102 Full Transcript: 

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

Dr. Davidson: And I am Dr. Davidson. 

Dr. Maki: So I got an email back this morning from the designer. The kind of the first draft of your book cover. It was in my inbox this morning. What do you think about that? 

Dr. Davidson: I think I am nervous as heck. 

Dr. Maki: It is good. There are two different versions. I like a couple of things about each one of them. I will show it to you a little bit later, but it just came in right before we sat down to do this. Got to change the color scheme a little bit but so far so good. 

Dr. Davidson: All right, and the book is on perimenopause. 

Dr. Maki: This is the middle of summer 2020 so hopefully this will be available on Amazon probably, I am hoping within the next month but there are some other things we want to do prior to that. Maybe by Labor Day, I am thinking and to be conservative and to give ourselves a little bit more time to make sure we have all the things that need to be working, working properly. But we will definitely keep everybody posted.

Dr. Maki: So today we are going to do a question that came in from a nurse practitioner. Why do not you go ahead and read the question? 

Dr. Davidson: Okay. So this question is from Allison. We change everybody’s names from anybody’s question just to protect their privacy. She is a practitioner. She says, “I have opened a hormone wellness practice and came across your blog. You mentioned the application of estrogen cream to the face, neck, and chest to improve skin health. From what I found, it appears that .3% Estriol and .01% Estradiol is typically used. Do you recommend a once-daily application? Can this same dose be applied to the inner and outer labia for improvement of external skin appearance as well as the vaginal entrance to improve vaginal dryness, etcetera? Thank you in advance for any feedback you can provide.”

Dr. Maki: Yes, so this is good, right? A professional has a hormone clinic somewhere in America and she is asking a question. We have talked about this in previous episodes about literally using estrogen as a kind of a nighttime moisturizer which may be on the surface, it seems maybe a little strange but we have been doing it for a long time. I know a lot of other doctors do that in women. When you say that, they get very excited because of course, the cosmetic industry over-the-counter is huge billions of dollars on an annual basis. But to be honest, nothing quite works as well as putting a little bit of Estriol in there.

Dr. Davidson: Estrogen is amazing for the skin. That is why when it starts to decline you see that elasticity change and then even people will say that the color of the skin changes. And really like females, I talked to a lot of patients and they are like, “I just want to put my whole body in it.” But we do use it for the face, and the neck, and a little bit of that upper chest. What is it called? The décolleté? 

Dr. Maki: The décolletage. 

Dr. Davidson: The décolletage. It does very well because it helps build collagen. Now, like Dr. Maki was saying is there are tons of over-the-counter serums, and moisturizers, and sunscreens. And trust me, I have a whole cabinet and probably a second cabinet full of all those things.

Dr. Maki: Unfortunately. 

Dr. Davidson: Hey, I like that stuff. I have my serums. I have my nighttime, morning time, you know it, and sunscreen which we will talk about in a different podcast about sunscreen. But anyway, you think those are not prescription based so when you think about getting a prescription, granted there are different prescriptions you can get from your dermatologist. I think estrogen just really is not talked about in terms of putting it on your skin and how amazing it can be. Now, just to back up with what Allison is asking here is about the types of estrogen in particular. So there are three different types of estrogen. There is Estrone which we do not use. There is Estradiol which is very strong which she mentions here. And then there is Estriol like Dr. Maki had talked about saying how great it is. And Estriol (E3) is very gentle. So when you are using, of course, any kind of hormone, if we are using it for skin purposes, we do not necessarily want it to go systemic into the body because then it can have its own little effects inside the body. We really just want to affect the skin. 

Dr. Maki: Yes, usually, kind of the rule of thumb is when you are trying to, let us say a woman is having lots of hot flashes, right, so you want to use a bias, we have talked about that before, as a systemic hormone replacement to take care of the hot flashes, the night sweats, insomnia, and then you use something locally for the face and or the vagina. And the little trick is is that those creams that can be used, we will get into the dosing whatever, but the cream that you can use for your face can also be and it is pretty much the same thing, can also be used for the vagina as well. Because in some ways, what it is doing in both different tissues is exactly the same, the benefit that the Estriol is providing to those tissues. 

Dr. Davidson: Yes, as you had mentioned, Dr. Maki said and a bias which is a combination of Estradiol (E2) and Estriol (E3) is normally used or what we normally use and also in a lot of functional medicine doctors offices as well, is used systemically to go into the bloodstream to help with other goals we might be trying to achieve for hormone imbalance or menopause which would be hot flashes, sleeping, getting memory recall, bones. But one thing that I had mentioned earlier here when we were talking about this is that Estradiol is very strong. So to be honest, I know a lot of pharmacists will talk about using Estradiol on the skin for the texture of the skin like on the face, even on the vaginal tissues which are mucous membranes, they are very thin as I find using the Estradiol a hedge away from because of its ability to go through the skin and into the bloodstream and into the body systemically. 

Dr. Maki: Yes, right. And of course, the vaginal tissue is very close to the uterus. We want to try to minimize especially if a woman, let us say she is in her late 40s, these things are starting to crop up. She is using the cream on the face. She is also having maybe some pain with intercourse or something like that that are just starting to crop up. You do not want that Estradiol to be in that close a proximity to the uterus because it could kind of throw off bleeding a little bit and then kind of increase the thickness of the endometrial lining. Just our preference, we prefer to use the Estriol instead of using a combination, or certainly, we would never use just straight Estradiol.

Dr. Davidson: And like what Alison is saying here that that combination that she has found with .01% of Estradiol, that is a very, very low amount. But I have found just over the years in practice when I have used Estradiol topically or other doctors have used Estradiol topically on a female for their skin or their skin integrity, when I have done the blood work it shows up in the bloodstream like I will see I know this is coming from that Estradiol that you are putting on vaginally or topically on the skin that is meant for the skin, not meant systemically. So then I get a little like, we do not really want it to go into the bloodstream. But Estradiol is an amazing hormone, I think it is the best hormone in the whole world. She is amazing for so many things in our system. But Estriol is kind of like an unsung hero when you are talking about the estrogens and what estrogen can do for you because Estriol is very gentle. It is very light. So that is why I do not necessarily, well, I guess with the Estriol because it is so light it does not permeate too much into the bloodstream so you can put it on topically without having to worry about it. Because I have women that have had certain health conditions that they cannot take bioidentical hormones or any hormones whatsoever. And here they are, postmenopausal and they cannot have intercourse because their tissues are too dry or painful or the atrophy. You got to find something to help and when the doctor gives them topical Estradiol or a Vagifem, I still find that it permeates into the bloodstream and you see those levels up. So that is why I use the Estriol because I do not find that it shows up as much when you are using it just for that topical basis. 

Dr. Maki: Yes, right. And most of the conventional products or almost all of them.

Dr. Davidson: Premarin [inaudible].

Dr. Maki: Well, for vaginal issues, they are all Estradiol based which tends to make them in our experience just way too strong for exactly everything that you just said. Estriol is still a prescription. E3 is still a prescription. You need a doctor to write it for you. But none of the commercial prescriptions have used Estriol. However, through compounding pharmacies, we can kind of make whatever we want which is again a benefit to the patient.

Dr. Davidson: Now, a quick side note on that because some of you listening are going to be like, “He is wrong.” because yes, you go on Amazon, you can find Estriol on there. If you live outside of the United States of America, you can probably find it, and there are places in the UK that I know that people can find it on their local pharmacist can sell it over-the-counter. I am not really sure about the laws and regulations outside of our country, but I do know that some of those products that are online, I do not know where they come from. I do not know what they are made from. I know they say they are made from this or that and that is fine if you trust that company or you know something about that manufacturer, but we typically use Estriol only as a prescription because we have prescribing rights and certain pharmacists –

Dr. Maki: There are exceptions. You are right. We did a podcast about Estriol and then someone sent us kind of a snarky email saying that “Well, I get it from my chemist in England.” —

Dr. Davidson: Denmark, or something.

Dr. Maki: — or something, whatever. Well, we do not live there so of course, we would not really be verse with that. We practice in North America. And so we apologize if there are some exceptions to that rule. But as far as American prescriptions go, Estriol is not in any of the commercial prescriptions. And I think that is really unfortunate for women because the Estradiol is stronger, provides in some ways more benefit because it is stronger. But at the same time because it is stronger and whatever context you are using it for can create more side effects which is the part that we are trying to minimize as much as possible. 

Dr. Davidson: Exactly. And like I was saying, Estriol is so gentle that it does not have that effect to go into the bloodstream but it really is nice for building collagen in the skin. It is great for that tonicity. It helps with wrinkles. The one thing with the Estriol is you can use lots of different doses, but I know Allison here is asking about, “Do you recommend a once-daily application? Do you put it on at night, in the morning?” And honestly, when we are working with patients, it kind of depends on that particular individual. Some people cannot even remember to floss their teeth before they go to bed at night, let alone put on one more layer of cream. Especially as ladies are listening, you have to put on your one serum in the morning. There is a layering effect that you do when you are doing your skin regime. So of course, adding one more thing to it sometimes throws people off. So really you can do the Estriol cream topically on the face morning or evening. You do not need to do it twice a day. I think that ends up just being a little bit of overkill. I think once a day. Some people I only have them do it a few times a week on their face and sometimes I will have them actually mix it with their moisturizer to kind of dilute it a little bit so we can get it spread all over the face, the neck, and the chest. I do think the Estriol is once a day. Now, we will talk a little bit here in a bit about the application vaginally, but I do think for the face, once a day. 

Dr. Maki: Yes, so from what she was asking, .3% which is basically the way that we would interpret that or the way that we would write that as a prescription. We will write 3 milligrams per gram. Now, the way that we like to do it and we talked about this again on the previous podcast, as we would like to make sure that when a woman whatever she is applying it for, whether it is on her face, whether it is vaginal, whether it is on her inner thigh, if you are using bias for hot flashes, we always want you to put it on your inner thigh. And then of course, if it is the face or the vaginal tissue, we make the concentration high enough so then she only has to apply half a gram or half a milliliter. We had that question just a couple of episodes ago, half a gram and a half a milliliter or 1ml and 1gram, in this context is the same thing as far as volume of cream. So by using half a gram or half a milliliter, you do not have to apply so much, you are able to get it rubbed into the skin easy enough. They are kind of rubbing it in for an excessive amount of time because there is less cream to apply.

Dr. Davidson: Yes. Now, on the flip side of that, we will talk about vaginally which is important, but on the skin, women are like, “Can I just put the whole thing on. I do not want to put a little half pea-sized thing on my face and I got to get it on my chest.” Some of us, I say, “Hey, there is a little residual on your hands. Before you wash them put them in the crooks of your elbows.” because we all know the tenacity and the crooks of the elbows can decline a bit as we are aging. Like Dr. Maki was saying, I still do agree with him that you want to do half a grammar or half an ml and now this is what you call it disclosure or not meant for medical advice, educational purposes only, whatever. I think 3 milligrams of Estriol might be a little bit too much. Usually, I find about 1 to 1 and a half milligrams for the skin of the face is plenty. It is still 3 milligrams, that does not necessarily go into the bloodstream but it is just when you are looking at the cost of all the fun stuff we use on our daily basis, we are kind of complicated and a little bit of high maintenance is, “Hey when you use a stronger dose, you are able to apply a half a gram, it can last longer.” So then the cost that you are paying for it is less because this stuff is not necessarily usually covered by insurance at least most, probably 99.9% of insurance companies would not cover it even though it is a prescription. If you can cut it, do a half a gram, the price is a little bit less, and then if you have a little bit less at the dosage where I feel like one and a half milligrams works just fine. There is a little bit of a nice price aspect to that too. 

Dr. Maki: Yes. So in this case, if the prescription was written for 3 milligrams per gram and you are applying half a gram as, let us say a nighttime moisturizer then basically you are getting 1 and a half milligrams as your nighttime application dose. If you are using the same thing vaginally, now, I do not know what dose you typically use but I usually do at least vaginally is 4 milligrams per gram and they apply half a gram, so they are getting 2 milligrams with each application if they are using it vaginally.

Dr. Davidson: So just jumping real quick to the vaginally, that really depends on the patient. So if someone is having a little vaginal dryness, maybe a little pain with intercourse, the tissues are not tearing those, there is no bleeding, no infection post intercourse from the atrophy. I might do a little bit of a lower dose even like 1 milligram if there is a female that had a hysterectomy and had not had a hormone replacement for years and years and years. And trust me, I have seen this before many times where they have not had intercourse in a few years and they meet somebody, fall in love and, “Hey we want to get it on.” and they cannot have penetration because of that atrophy for so many years, then I might use a little bit of a higher dose and use it a little bit more frequently.

Dr. Maki: Yes. I have to tell a story about a patient. She used to be a retired judge and she is a little spitfire and she knew this gentleman for years and years and years, her husband, unfortunately, passed away a few years before. She just thought kind of that chapter was closed and she is just going to move on. She met this gentleman and they end up getting married and she was having some really significant vaginal issues. Like you just said, they kind of tried and no penetration. It was not working. It was just uncomfortable, awkward, kind of ruined the mood and then we started working with each other, and lo and behold. We are having a point one day, she calls me up one day and she goes, “We did it.” She is all excited. You have to know her to understand. I am a man, she is a woman but she had no shame, she was just telling me everything and it was refreshing because she was just open about it. [inaudible] and we are just so excited. It took a few months but she went from not having any potential whatsoever by using a little bit of Estriol cream. It is not exactly perfect and I will say she is in her mid-70s so she is not like 40, 45, she is in her mid-70s and they are having a great time. And we have had a couple like that where women were, they could not wear pants, they can barely sit down there, they are having all this discomfort pain, burning, and then a little bit of Estriol. And we will talk about how to do it a little bit but really kind of transformative as far as their success with it. 

Dr. Davidson: It is really so nice to get those patients that are so grateful. It is so wonderful to hear. And might some of you might be thinking what is estrogen got to do with your vaginal tissues? Once our hormones drop, especially that estrogen, those little cells, and the vaginal cells turn into immature vaginal cells called parabasal cells and they will just stay that way. So estrogen actually feeds the parabasal cells to turn into mature vaginal cells which is why you have the resiliency, you have the lubrication, you have the nerve sensitivity. But when you have like a lot of women that might notice on their pap smear report that might be post-menopausal that will say significant pair of basal cells which is normal because they have the lack of estrogen from menopause. So when you add that little bit of Estriol to those vaginal cells, those parabasal cells, those baby vaginal cells grow up to mature cells. And that is why Dr. Maki was saying, with this patient, it took a couple of months but that is great because it took a little time for that cellular turnover to happen to create those adult vaginal cells. 

Dr. Maki: Yes. I even had a couple of women that have had bladder and uterine prolapse and they actually improved by using pretty much the same. Now, those might have been a little bit higher concentration as far as the hormone goes to really help kind of move that along as opposed to what you are talking about a few minutes ago like a starting dose, we started there and kind of worked our way up. One woman was contemplating surgery and she is doing all this research and this research, the procedures that they are using some kind of mash of some sort, those are not perfect and she was worried about it and this, that, whatever and I said, “Well, let us just try this in the interim you. Let us try it for a good six to nine months.” and it got to the point I do not know exactly how long it probably took. Honestly, probably took six months to a year at least if not a little bit over that where she did not ever even end up having to have the surgery. Now granted, that is not for every woman. You are not going to necessarily have that situation in every case but at least for the few that I have a low moderate or significant level of prolapse or I think both of those. There have been a few of them. They were probably in the low to moderate range probably not a high level of prolapse, they are actually able t improve their situation significantly. 

Dr. Davidson: Yes, Estriol can be great for the bladder. It is also really good for the urethra. So if some women in some cases are having a little bit of urinary incontinence, sometimes that Estriol actually helps because the urethra is like an elastic waistband. When the hormones drop the estrogen in particular, the urethra kind of expands a bit and it does not have the tenacity that it once had which is why once you hit 45, you do not really want to do any jumping jacks or sneezing or laughing. And sometimes in certain cases, if you just use a little Estriol vaginally which the urethra is right 12 o’clock when you are looking at the vaginal canal is it can help kind of tonify and help a little urinary incontinence. So that is a good point to bring out. I know we were talking a little bit more about what Allison was asking, but I totally forgot, we use that all the time for a little bit of urinary incontinence. 

Dr. Maki: Yes, and you know, I have had quite a few women and I am sure they will all tell you the same thing. They go to their gynecologist and nothing against her gynecologist, but they go to their gynecologist looking for solutions to these problems that are for women that are in there I would say their mid-40s to from there and beyond. From their mid-40s and beyond, there is not a lot of conventional options, and if there are some options, I do not consider them very safe options. Now, this hopefully will kind of open up the conversation a little bit, not real but just give you some ideas that there are some possibilities out there for this kind of uncomfortable situation that does not have to be complicated. These things just go into your nighttime, daily routine, and just a little bit of time. And things do change quite significantly.

Dr. Davidson: And one aspect, I guess to kind of differentiate. Using it on the face like I mentioned I say, I mix it with the moisturizer and you put it on your face, that way you can spread it all over and it works well that way and you can do it daily. But with the vaginal application, once you kind of get those cells hydrated and got that resiliency, you got that lubrication, you got that sensitivity is you do not have to use it every day. In fact, I usually start off having women use the Estriol vaginally and usually I say at night just because when you put it around the vaginal opening and then you waltz off for the day, sometimes that cream there can be a little uncomfortable. So I usually, “Hey put it on at night.| It is one big mucous membrane. It goes up into the vaginal canal and around the inner labia there. But I usually say start to take it for about five to seven nights and then after that, you might do it twice a week and then as those dishes get more hydrated, intercourses more pleasurable, then you might do it once a week. And some people do it once every other week, some people forget to use it until they get a little dryness back. When you are using it vaginally for the hydration for those parabasal cells to turn into mature vaginal cells for pain with intercourse, you do not necessarily have to use it every night. 

Dr. Maki: Yes, right. So I usually tell them to use it every night for the first week. Use it every night again for the second week if you have to. If it is a pretty severe case then they can go every other night and then eventually depending on the woman, depending on the severity of the situation, they are going to end up somewhere between one to three times a week. And if that still is not helpful at that point, that means we got to change things together. We got to change the concentration. So now they can get down to just that little bit on a weekly basis just to help maintain what they have already been achieving, would have already achieved from that loading phase. If there was any risk, and again, we are talking about the lining of the uterus, if they have their uterus, we are trying to minimize some of that but still give them the benefit of using the hormone.

Dr. Davidson: And some women will tell me, “Well. Oh, okay. I will put it on at night.” and you might do it like you said one to three times a night. And just on the side note — 

Dr. Maki: One to three times a week.

Dr. Davidson: I am sorry. One to three times a week. Just on a side note, if you have a male partner and, “Hey, I put on my Estriol and I am getting ready for bed.” and then spontaneously, “We had sex.” Do not worry, if it got on your male partner, they will be fine. 

Dr. Maki: Yes, that little bit of estrogen for him is not going to really cause a problem.

Dr. Davidson: Estriol in particular which is also why I hedge away from the Estradiol because it is strong, it can penetrate through tissues. But the Estriol, if you have a male partner and you put it on vaginally and then later that night, “Whoops. Here we go. That was fun.” Because the fellas get a little weird about, “I do not want to go anywhere near that estrogen.” but nothing would happen. 

Dr. Maki: Well, it is really unfair especially if men are taking testosterone and have viagra and women are not properly able to have intercourse is really unfair to the women because men are walking around with big erections all the time and they are ready to go. And a woman is just a little bit hesitant because it is painful, it hurts. So there are lots of options for men and there are really not that many for women. This kind of levels the playing field. So now there is a reciprocation on both sides, everyone is going to get their needs met and it is not going to be necessarily a one-sided conversation because women will not be so hesitant or reluctant because now they are in a similar situation and now they can come together in that intimate fashion that maybe they were able to do even maybe a few years before. But as time goes on, we have talked about this in many ways, her hormone levels are they are declining all the time, In that case, we definitely are restoring them to some level. Now, they are compatible again.

Dr. Davidson: You are right. That is actually a really good point to bring up. I have talked to a lot of female patients in they will say there are lots of other acts you can do other than penetration but at the same time, their male partner does not want to hurt them. They will even say they are reluctant because they do not want to hurt them so then it ends up you do not have that intimacy that they are looking for. Granted as I said, there are lots of other things that we can do, but I do think this sheds a really nice aspect on women especially once their hormones drop and you have that vaginal atrophy.

Dr. Maki: Yes, and this is one of those things that does not really get talked about a lot. And even from a climax or an orgasm perspective, this can even help with that and there are some other things we can talk about later that actually help with women achieving orgasm but usually, this is actually the first step to that process. So hopefully, this kind of pulling the curtains back a little bit giving women some ideas and some options to think about. Thank you very much to Allison for the good question and it is. It might seem a little weird but the same cream you put on your face as a nighttime moisturizer you can apply vaginally. Now, if the doctor or practitioner is going to write that prescription, you want to take the dosing into consideration so it can be used in both tissues. Now, it saves you from having to get two prescriptions. We do that for women all the time. 

Dr. Davidson: I know we are dragging this on, sorry, but I just wanted to say there are so many different types of creams that you can apply vaginally, on the skin, inner thigh, anywhere. There are different bases. There are hypoallergenic bases. There is a non-alcohol. So many different. Because I have had some patients that have very very sensitive skin so we have to get a particular very very hypoallergenic cream that works for them or someone else. You can slather on anything. Know that you have those options. 

Dr. Maki: So here we go. Now I am going to drag it on. Now you made me think of something else. You are right, some of the bases that they use can be a little irritating so sometimes it can actually burn more in the beginning. Just talk to your pharmacy and they can kind of work out some other bases that help minimize the irritation. Another thing I have noticed is that women use the cream vaginally for the first few times and they can get a yeast infection right away. That is somewhat normal just because of the Ph change and all the things that are going on down there. It is normal. We use boric acid suppositories. Yeast infection means it Is kind of irritated, itchy and there is going to be a white curdy discharge kind of like cottage cheese, that is how you know that it is a yeast infection.

Dr. Davidson: Oh, yes, trust me, us gals know about yeast infections. 

Dr. Maki: Well, there is in between BV or vaginal —

Dr. Davidson: Bacterial Vaginosis

Dr. Maki: Yes, bacterial vaginosis sometimes there can be some discrepancy there. There are some antifungal medications. We do not really ever use those because —

Dr. Davidon: They do not need to. 

Dr. Maki: — they are a little too strong, the boric acid seven days usually. Even the Monistat like over-the-counter stuff is usually pretty good. But if those do not work, then we usually go to a boric acid suppository and those are gentle enough to get rid of the yeast infection but not going to disrupt the flora too much like some of the prescription things. They are like an elephant gun to shoot the fly off the wall. They are just so strong and it is going to potentially set you up for reoccurring infections by using those things too much. 

Dr. Davidson: Yes, we do not want to scare you saying, “I do not want to use the Estriol.” because trust me, no lady wants a yeast infection. But if there were a little bit of some itching or uncomfortableness then the pharmacy can just change the base. There are so many different bases you can use for those creams. So know that there are lots of options. 

Dr. Maki: Yes, hopefully, this gives you some insight. And now you want to say anything else like —

Dr. Davidson: I could do on and on. No, this is great.

Dr. Maki: Okay, until next time. I am Dr. Maki. 

Dr. Davidson: I am Dr. Davidson. 

Dr. Maki: Take care. Bye-bye.