Maria’s Question: 

Hello, I’ve been reading the articles on BHRT, and I have questions. Does the body or will the body develop tolerance to hormones? Whether progesterone, testosterone or estrogens, will I eventually have to increase my dose to get the same effect, progesterone for sleep, estrogen for hot flashes, testosterone for energy and libido… Thank you very much.

Short Answer: 

There are many factors that go into a BHRT dosage for a patient. This includes age, gender, lifestyle, stress level, and severity of symptoms. Typically, when we work with a patient, their BHRT dosage will increase over time. A patient does not necessarily develop a tolerance to bioidentical hormones; however, a lower starting dosage may not be effective to manage symptoms and a slight increase may be needed.

PYHP 083 Full Transcript: 

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Dr. Maki: Hello, everyone. Thank you for joining us for another episode of the progression podcast. I’m Dr. Maki.

Dr. Davidson: And I’m Dr. Davidson. 

Dr. Maki: So, we’re going to kind of dive right in. This is another question. This one comes from Maria. Again, looks like she found us on a blog post on how does bioidentical progesterone help. So, Dr. Davidson want to read the question from Maria.

Dr. Davidson: Sure, sure. So, I know we’ve been doing a lot of reader questions lately. Only because we’ve been getting a lot of questions in and I do think that they’re important, but know that we’re going to do a combination on what questions, topics, concerns.

Dr. Maki: Yes, yes. Like I said, we have a kind of a backlog. And these are very specific type questions. And we know, which is why we’re doing them that these kind of answers to these questions are next to impossible to find on the internet, you can’t just type in a question that we get and be able to find that answer. You have to look and look and look and then when it comes to hormone replacement in general, there’s a million different opinions, right? There’s not just one way to do a bioidentical hormone replacement therapy. 

You talk to 10 doctors. You’re going to have 10 different opinions, which makes it even more confusing for the patient. Because, well, their doctor does one thing, we say another, another doctor says something else. How does the average person make any sense of any of that, okay? But we have our approach. We have what works for our patients. And a way to when problems arise like on the last episode, when something comes up, knowing how to, which is also an issue that comes up quite a bit. Sometimes doctors do a dose or do a prescription or do a treatment plan, but then something comes up that is not favorable, and they don’t know how to fix it. That’s also why we’re kind of doing this podcast as well, because we end up seeing a lot of those people because they got it, they went to see somebody else, and they just didn’t get the results they wanted and they end up coming to see us. So go ahead. Why don’t you read Maria’s question?

Dr. Davidson: Okay, sure, sure. So, this is from Maria. This was actually an e-mail that she was reading some of our articles or blog posts it says, “Hello, I’ve been reading the articles on BHRT, and I have questions. Does the body or will the body develop tolerance to hormones? Whether progesterone, testosterone or estrogens, will I eventually have to increase my dose to get the same effect, progesterone for sleep, estrogen for hot flashes, testosterone for energy and libido… Thank you very much.” 

Dr. Maki: Yes, right, yes. I think that’s a good question. I mean, it’s kind of a broad question but one thing that I do tell women a lot when I speak with them, is I say, “Usually where you start on whatever hormone it is, we’re talking sex hormones, estrogen, progesterone, testosterone, whatever dosage you start at is usually not where you’re going to end up at.”

Dr. Davidson: Exactly. So, I wouldn’t say you’re not going to develop a tolerance just like with caffeine. You drink one cup of coffee really yummy. In a few months or years, you’re into two cups, you’re into three cups, to get the same effect. It’s not like that. You don’t build up a tolerance like that. But with time, like I always say, we’re not statues. We’re not static beings. We’re always changing, whether it’s with the seasons or with time, or with stress. We’re always changing. So, yes, doses do change often and they should change often. You don’t know how many patients have come to see me as a second opinion after being with another doctor, and they haven’t changed their dose for years, for years. And I say that’s because our bodies are always evolving and changing and we’re kind of looking at what end effect we’re trying to get from doing hormone replacement. 

Everybody also has a different goal when we’re doing bioidentical hormone replacement. So, to answer Maria straight up is, no, you’re not going to get a tolerance. Your skin adapt, if you’re putting on creams. You’re not going to get some kind of skin adaptation. You’re not going to need more. In some cases of conventional hormone treatment or conventional– when you’re doing very high strong doses, like injections or pellets which are bioidentical, is you can get an adaptation to that because when you give somebody a whole bunch of something they don’t need right away the receptors down regulate and then you don’t get the same effect the next time you do a pellet or an injection so I would say on that. But in terms of creams or capsules, and when you’re working with somebody monitoring their blood work and their symptoms, you’re not going to technically “become adapted”.

Dr. Maki: Yes, right, yes. Certainly, with pellets which it’s kind of died off a little bit. It’s not as popular as it used to be. But for a while there, probably what? Five years ago, maybe a little longer than that, pellet therapy was like this really hot thing, because you don’t have to take anything. You don’t have to rub on any creams. You don’t have to take any pills. You go through a little mini office procedure. It’s not as benign as they kind of claim it to be but you do a little incision on your upper rump area they insert some pellets and then those hormones degrade over time, it usually lasts about three to six months. And we don’t really care for that idea very much for exactly what you just said. 

That therapy for women was giving them testosterone, the same thing for men, giving them testosterone. And that’s exactly what happened, you get this huge amount of hormone, right off the bat. And as it slowly degrades that process of kind of flooding the body right away. Every cell in your body has a receptor for all these different hormones we’re referring to. And now that receptor, that’s the physiology term, the receptor basically. When there’s an abundance of a hormone present in the blood, the body’s response to that from being overstimulated is to get rid of those receptors. That’s the process of down regulation. And a lot of the women especially, both women and men, once they’ve gone through a round of pellets, they don’t necessarily feel very good after that. They feel really good for that first three months. And then after that three months they really kind of struggled to get back to where they were.

Dr. Davidson: So, there really is, in some ways, two answers to this question. So, just on the flip side, okay, you think of a female and she’s 48. In perimenopause, maybe drifting into menopause. And yes, we need to do some bioidentical hormones, maybe some progesterone, tiny bit of estrogen maybe, maybe no estrogen, just progesterone and some testosterone. That level of what she needs is a dose at 48 is going to be completely different from as she goes to actual menopause at 51 and a half. So, she’s not become adapted. It’s just the ovaries, rightly so have decided to work less, work less, work less and eventually retire, which they justly deserve having worked so long for so many years. 

But doing that replacement, so yes, you’re going to see a change in the dosage, but it’s not necessarily that the receptors are adapting to the dose or I need more because my body, like I said, with caffeine or other sort of substances that you need more to get that similar effect. It’s not like that as you’re transitioning from perimenopause to menopause to post-menopause, but just like Dr. Mackey was talking about. Say a fella, sure when a fellow is 28 years old versus 17 versus 58, their testosterone levels are going to be a little different. But the testosterone levels don’t necessarily go down to zero, which would horrify men. Like it would be with a female when our ovaries decide, “Hey, we’re not going to work anymore. Let’s go into menopause.” So, you do see men with their testosterone lowering over time, but still a 75-year-old fella that’s never taking testosterone therapy is still making some testosterone.

Dr. Maki: Yes, right. I’m so sorry, I didn’t mean to interrupt you there. I thought you were done with your thought. But the difference between men and women is that women stop producing the hormones, men do not stop producing the hormones. So, fundamentally there’s a big difference there. For women, the tolerance, like you said, it’s more about the need, right? Of having an appropriate dose of hormone that helps to ameliorate symptoms. And that, as we’ve talked about, on almost every podcast where we talk about hormone replacement, that dose is specific to the woman. Some can tolerate a lot, some need a lot, right? Because estrogen is what makes a woman a woman. So, it’s not about having too much, it’s about having enough. And that’s something that we do see a lot, is that women are prescribed doses that are always too low, always too low. And then they’re on that dose for sometimes months and years, when if their doctor would just give them a little bit more estrogen or a are a little bit more biased, they probably feel a lot better.

Dr. Davidson: Yes. Unfortunately, sometimes the bioidentical hormones get a little bit of a bad rap. Because they’ll come in and say, “Oh, yes, yes, yes. I took those hormones. I took the bioidentical hormones, and they didn’t do anything for me.” It really was because they’re very gentle. They don’t have a very long half-life. So, you have to make sure that you’re applying them at certain, daily, is that they just didn’t get enough.

Dr. Maki: Yes, right. At that point it comes down to a dosing issue. And that’s on the doctor to know how to dose it properly. You cannot use the same dose for every single woman. That is like BHRT number one. You can start somewhere relatively the same on each patient. But as we’ve said, you’re not going to end at the same dose because some can tolerate, as I said a lot, and some can tolerate very little. And most of them are going to fall in between somewhere. 

But every dose that a woman eventually gets to, after a few months or a few years, that dose is specific to her, not a population of millions and millions of women and they all get basically one or two or three doses. That’s ridiculous. That’s cookie-cutter trying to do something that is very specific on a mass scale. That’s why it just doesn’t work when you go see your gynecologist or a doctor that is using conventional hormones because there’s no options. There’s no choice that is customized to the patient. It has to be customized to the patient.

Dr. Davidson: And customize over time. So, like I said, a woman’s hormones at 48 is going to be completely different at 51 or a female that has, they have to have a hysterectomy and have their ovaries taken out. They’re going to go from hormones to no hormones. So, once someone has, let’s say those ovaries either have been removed or they have decided to retire. They’re in full post-menopause, they are not producing any hormones at all. A lot of women will say, “Well, they’re on their bioidentical hormones, and then, hey, it’s time to change them a little bit.” And they’ll say, “Well, why don’t we change them? My ovaries aren’t making any hormones. My ovarian function is gone. Why are you changing my hormones? Shouldn’t it be the same all the time?” And that’s where we come into, hey, we’re individuals, our adrenals affect our how we respond to hormones, our thyroid affects how we respond to hormones, stress, change in season can affect things.

Dr. Maki: Yes, right. Every time we go from winter to spring to summer. There’s always kind of an uptick. Now, we lived in Vegas for 15 years, when it starts to get May, June as the temperature starts to get to 100 degrees, women have an increase just because of the change in seasons, same thing going into winter or going into– in Vegas is kind of like two seasons. You’ve got basically summer and winter where everywhere else in the country they do have certainly four seasons, Vegas is kind of just two, you have four months of summer and the rest of it is kind of the same, which is nice. It’s pleasant. 

Dr. Davidson: It’s beautiful.

Dr. Maki: Yes, yes. But at the same time, you see, definitely these kinds of timings of where hot flashes and symptoms start to kind of rear their head. So, of course, their dose needs to be tweaked a little bit. And now, we’re not even talking about, what we’re talking about, basically, in this context and I’m just kind of throwing a wrinkle here. What we’re talking about, for the most part, is what they call static dosing, same dose every day. When a woman is menstruating, even when a man is creating testosterone, which they do up until when man’s in their 80s, they’re still producing testosterone. It’s not in a flat line. 

If you graphed out a level of hormone production for a female. And of course, we look at these hormone graphs all the time, kind of ebb and flow, right? You don’t have a consistent level of estrogen all the time. You don’t have a consistent level of progesterone all the time. You have a peak and you have a peak and a peak here and a peak there. When you go into menopause, basically those hormone levels flat line. Right? So, using static dosing is a good way to ameliorate symptoms, because all you’re doing is raising the baseline. Now you have a very relatively low baseline, the adrenals are supposed to kick in and make some hormone. So, all we’re trying to do is just increase that baseline to a point where their symptoms are taken care of. 

Now, another strategy that is completely different than static dosing is rhythmic dosing. Now the caveat to rhythmic dosing, is that if a woman still has her uterus, well, of course, we’re talking about women at the time, if a woman still has her uterus and she does rhythmic dosing with estrogen, she’s going to get her period back. In some ways that’s the point of rhythmic dosing. A lot of women that are in their 50s, mid-50s, or whatever, they don’t want to get their period back, so then automatically rhythmic dosing, they’re just not a candidate for so then they become, static dosing only. And that’s the majority, right? Probably 95%, 98% of women, they’re doing hormone replacement or doing some form of static dosing. 

Dr. Davidson: And just like rhythmic dosing sounds, you’re changing the hormones over basically a 28-day cycle, which is for females in a perfect world, we have a 28-day cycle, is you change the hormones throughout that 28-day period, that would mimic exactly what your ovaries had been producing when you were cycling. So that’s kind of the premise behind rhythmic dosing. Like Dr. Maki said is pretty much BHRT is static dosing. You take the same dose every day, you never change, you never change. And you don’t want to get a period, you don’t want to get a period with static dosing. That’s not a good idea. But on the flip side, is the rhythmic dosing for a lot of people is the gold standard of hormone replacement. I mean, you were literally mimicking exactly what the ovarian function was doing when those ovaries were, before menopause.

Dr. Maki: Yes. Now, even though you just said that it’s kind of the gold standard that is a little controversial from a dosing perspective.

Dr. Davidson: Truly.

Dr. Maki: Because you’re giving women that are in their 50s and beyond, you’re giving them relatively high doses of estrogen. And that’s where people get uncomfortable, practitioners get uncomfortable with that because they don’t really understand the rationale or why that would be a good idea. All we’re really doing even though the body, the female body goes through this senescence, basically, of the reproductive history. Why not increase that for a while if we can increase that because we have the ability to do that. For women, all the age-related disease that women experience happens basically over the age of 50. 

But if we can maintain those hormones for a little bit longer, now we are, essentially, we are reducing risk of diabetes, heart disease, dementia, osteoporosis, and not to mention all the symptoms that come along with menopause, those are going to be ameliorated as well. So, in some ways you and I both really liked the rhythmic dosing. It just some women are, they don’t want to have a period, which I totally understand. They’re just not a candidate for, so now all we’re trying to do is just make sure their symptoms are as manageable as possible.

Dr. Davidson: Oh, exactly. And still doing the static dosing. I have so many patients, probably the majority of my patients on static dosing, that’s what I originally started with, is it is great for anti-aging, it is great for longevity. It’s easy. But, hey, if you were really going to mimic mother nature, doing the rhythmic dosing is where it’s at. But, like you said, a lot of women they’re like, “I’ve had plenty of periods in my life. The last thing I want to do is keep having a period.” I totally get that. You have to change the dose every few days. So, you have to basically, track your cycle, which a lot of women are like, “I’m kind of done with that too. I don’t want to track my cycle on a calendar anymore.” And that’s okay, too. So, of course it depends on the person. And just like we had always talked about all dosings, all BHRT is dose-dependent on the individual, not on the masses.

Dr. Maki: Yes, right. And that’s where the rhythmic dosing I think does. There’s a couple of different stages where you start at the basic. You can increase it a little bit if needed. And then women kind of fall in line with what their body tells us, their body tells. Now, granted, we’re looking at lab work, and we’re monitoring some objective data along that path, but their body will tell us where their estrogen level needs to be. Because I know you always say estrogen is the best hormone in the world. That’s what makes a woman a woman. So, getting that estrogen level, not necessarily being worried about giving her too much but making sure that she has enough, that’s where she’s going to go from surviving really, in menopause. 

Just getting to a certain level of functionality to actually thriving in menopause because we’re just perpetuating that menstrual cycle for as long as she wants and now it’s amazing. I talk with patients on a regular basis and people are, in their 60s, 70s, even the 80s. And they’re living these amazing, very active lives, doing tons of things. When you and I were young, I was growing up in Minnesota, and I had– my grandmother was one of 13 children. So, I was around a lot of old people all the time. Auntie Fanny and Auntie Vivi and my grandma, Esther, and senior citizens were 55 years and older, and back then. At 65 they were considered to be old, okay? Now our patients at 65 they’re just getting started sort of, I mean, they’re running companies, they’re busy, they’re traveling, they’re doing things that when we were little people are using canes and walkers and in nursing homes at 65. So, even just in our lifetime, in one generation, it has been pushed back. The people’s level of quality of life has been pushed back, 10 to 15, almost 20 years in some cases which is remarkable.

Dr. Davidson: Oh, it’s awesome. It’s just awesome. So, yes, exactly. So, anything that can kind of help with that, and, with the longevity with the anti-aging, the BHRT as long as it’s, disclaimer, disclaimer, disclaimer, monitored and dosed, right, and all that jazz and you’re the right candidate. It can be absolutely amazing. But to answer Maria, I mean, thank you, Maria for your question is, no you’re not, your body is not going to get adapted to these hormones. But I do encourage you to have them tested, to talk with your practitioner about what’s working for you and what’s not. And if you need to tweak the doses, I love tweaking the doses, just a small little quarter of a milligram to a milligram change can make a huge difference in someone’s sleep because they always say, “Hey, I feel great, but–” But a lot of patients always say, “Well, I feel great, but I, I could feel better, why not?”

Dr. Maki: Yes, right. So, you just take an inventory of what symptoms are going on, what needs to be improved, what’s working well, what’s not, and then you kind of decide from there. So, evolving in a treatment plan for a patient over time really is about the goals that they’re trying to attain, or they’re trying to accomplish. Staying on the same dose forever, in some ways, kind of defeats the purpose. It doesn’t defeat the purpose. I mean, some women are just fine on their same dose consistently. That’s okay. But, there’s always, like you said, six months in the future, our bodies are different or situation is different. Our sleep is different. Our stress is different. Our diets are different, maybe not so much on the diet, people have a lot of tendencies about the diet, but it just means that there’s always room for improvement to some capacity. And for men, because men make testosterone on a regular basis, that’s why the rhythmic dosing is the only way that we do testosterone therapy for them at least most of the time. 

So, men get kind of lazy and they don’t follow the protocols so they default to static dosing. But for men, we found that the best way to get them the results they want is to do the rhythmic dosing. So, that wasn’t necessarily intended to be a rhythmic dosing tangent. But based on her question, her question is kind of broad. I do think that it needs to be kind of, thrown out there. As these two completely different philosophies about hormone replacement. You have static dosing versus rhythmic dosing. I think that it’s important for people to understand that there’s even an option. Yes, the rhythmic dosing, most doctors don’t know anything about rhythmic dosing. So, do you have anything else to add about that? I know like I said, I went on a lot about rhythmic dosing.

Dr. Davidson: No, when it comes to bioidentical hormones, we could talk for hours. I love them. They’re great. So, definitely thank you, Maria, for your question. Thank you for everybody listening, all you readers. We appreciate your support.

Dr. Maki: And so, nothing else to add until next time, I’m Dr. Maki.

Dr. Davidson: I’m Dr. Davidson.

Dr. Maki: Take care. Bye-bye.