Dear. Dr. Maki, I read your article about progesterone cream versus oral format. I have used the cream with some satisfaction but not one hundred percent happy. My sleep has been my main complaint for the last six to eight months. I’m 44 years old, still menstruating with a lot of menopausal symptoms. Recently, I found a doctor in the Netherlands who did blood tests on me. She put me on oral progesterone and transdermal testosterone. The testosterone seems a little too high, one percent, but overall helped me a lot. Four weeks into my treatment, the oral progesterone, on the other hand, is driving me crazy! So, shortly after I take it, I feel a bit sleepy and then around two AM, full wide awake. Today, I took it during the day and I still can’t fall asleep in the evening. It seems like I’m converting it into cortisol, the progesterone. Any thoughts about what to do? Thanks very much.
The first question to ask is if the progesterone is sustained release or is it Prometrium. Sustained-release progesterone is often much more tolerated than Prometrium, which is instant-release. The next consideration of the progesterone is the dose. A typical dose for women in there mid ’40s is 100 mg. However, this could be too much for some. Reducing the dose down to 75 or even 50 mg might be helpful.
PYHP 089 Full Transcript:
Dr. Maki: Hello everyone. Thank you for joining us for another episode of the Progress Your Health Podcast. I’m Dr. Maki.
Dr. Davidson: And I’m Dr. Davidson.
Dr. Maki: How you doing this morning?
Dr. Davidson: I’m doing great! How are you doing on this beautiful, sunny, blue-sky day?
Dr. Maki: It is. It was actually raining like crazy overnight in Washington. It’s pretty common this time of year but woke up and looks like it’s going to be a really nice day today. So, be nice to be outside, which will probably go outside a little bit later but yeah time to get a podcast done. So, why don’t we kind of dive into that? We have a question from Laura.
Dr. Davidson: Yes, Laura. So Laura is a reader. So she had read one of our blog posts about progesterone cream versus the oral. So this is her question, “Dear. Dr. Maki, I read your article about progesterone cream versus oral format. I have used the cream with some satisfaction but not one hundred percent happy. My sleep has been my main complaint for the last six to eight months. I’m 44 years old, still menstruating with a lot of menopausal symptoms. Recently, I found a doctor in the Netherlands who did blood tests on me. She put me on oral progesterone and transdermal testosterone. The testosterone seems a little too high, one percent, but overall helped me a lot. Four weeks into my treatment, the oral progesterone, on the other hand, is driving me crazy! So, shortly after I take it, I feel a bit sleepy and then around two AM, full wide awake. Today, I took it during the day and I still can’t fall asleep in the evening. It seems like I’m converting it into cortisol, the progesterone. Any thoughts about what to do? Thanks very much.
Dr. Maki: Again, she sounds waking up at two o’clock. She sounds like she’s a ghost at least to a certain extent, right? So, we wrote, actually wrote an article. We did a podcast about the three different types of adrenal issues. The vampire, the ghost, and the zombie. That waking up in the middle of the night. What are your thoughts? What do you think about, the progesterone, and wake me up at two o’clock?
Dr. Davidson: And you’re going to go there we have to explain what the what are vampire, the ghost, and the zombie are. So that was an article that we wrote on adrenal fatigue on the cortisol levels that get secreted out throughout twenty-hour period.
Dr. Maki: Yeah, episode Sixty-Nine.
Dr. Davidson: Episode, sixty-nine and so with the ghost as you say, the ghost is the cortisol is bouncing up in the middle of the night. When ideally cortisol should be down in the evening so we sleep all night and then wake up in the morning with the cortisol high in the morning, so we’re bright-eyed bushy-tailed. But the ghost, the cortisol is coming up in the middle of the night which is why Laura’s asking is my progesterone converting into cortisol which is why she’s waking up full awake at two in the morning. We also have on that episode sixty-nine is the vampire,` where their cortisol doesn’t come up in the morning. Those are the people that can’t wake up in the morning, but their cortisol comes up in the evening so they stay up late at night. And then there’s the poor zombie, who has very little cortisol throughout the twenty hours period and they’re just literally a zombie twenty-four, seven.
Dr. Maki: Yeah, right. They could sleep all the time, they have no energy, they can exercise, they know they’re the zombies for sure, are struggling a little bit. You just to do some basic functions. I think some people might have some of those tendencies but it’s pretty rare to see an actual, zombie profile. The other two, the vampires and the ghosts, those are really common. Those are the ones we see most of the time.
Dr. Davidson: And I think with Laura, she’s definitely a ghost. She’s waking up in the middle of the night and said roaming the halls. She’s probably roaming her smart phone until she can get tired enough to fall back asleep. But definitely with Laura, she’s saying that she’s 44 years old, she’s still menstruating so she’s still getting her period but she’s having a lot of menopausal symptoms. So, she definitely sounds like a classic case of actually being, I don’t, you know potato-potato. But definitely, she’s more peri-menopause. I wouldn’t put her into menopause but she’s definitely that peri- that phase right before the ovaries definitely stop making the hormones.
Dr. Maki: Yeah, right. And she’s exhibiting one of those very classic symptoms. They get to their early to mid-forties and all sudden, they just at least what they relate to us, anyway, are to me is that they’re just having their bodies, just won’t cooperate anymore. All of a sudden they can’t sleep, they’re gaining weight, they’re, irritable all the time, these very classic peri-menopausal symptoms that show up kind of right around this time in a woman’s life.
Dr. Davidson: Exactly and I love that. We’re here, in the United States. So, it’s nice that having a podcast, having these blogs, having, the website that people from all over the world can reach out to us and so this is this is why we are really excited to do this question because she’s reaching out from, well, outside of our domain.
Dr. Maki: Yes, sure. Yeah. I know that we’ve had some other people reach out from other countries and that is pretty neat. It does make the world a smaller place that way. She’s in a completely different country, but we’re able to help and now we’re answering her question. Hopefully, we’ll give her some guidance and she’ll be able to make some better decisions moving forward.
Dr. Davidson: And that’s why we really liked Laura’s question is because she represents a lot of women like we had talked about. She is peri-menopause, she’s 44 years old, she’s still menstruating but she having a lot of symptoms and one of the main symptoms being in peri-menopause is waking up in the middle of the night. I love that her doctor in the Netherlands did some type of testing on her hormones because a lot of Doc’s don’t do testing on the hormones. In fact they kind of blow off anything that has to do hormonally. Because hormones aren’t necessarily, “disease.” So I love that they tested her hormones and then trying to find an individualized protocol for her, but that’s the fun part in doing Bio-identical Hormone Replacement, is it’s not like the first try always gets it, you’re always, sort of evolving or morphing or changing their prescription so it fits that particular individual.
Dr. Maki: Yeah, right and that’s the challenge both for the practitioner or practitioners. In this country and other countries and for the patient is because when you’re dealing with some of these hormonal issues, there’s not just one pill that’s going to solve the problem. That’s where it becomes a big challenge. Because and I think like you said doctors they don’t test the hormones because they’re not sure what to do with it. And really the only option they have for a woman that still menstruating is given them birth control pills or some other kind of a commercially available prescription but a lot of times it’s more complicated or it’s more convoluted than just giving them a pill and sing them on their way. That’s why women are continuing to look for answers and to find the relief that they want because it’s just not as simple as taking a pill on your own and your symptoms are all gone.
Dr. Davidson: Oh, exactly. I mean here in Laura’s case, one of her main complaints is that she’s not getting a good night’s sleep. She’s waking up after a few hours like our typical ghost. But the last thing she wants to do is get on some prescription medications for sleeping. Like, Ambien, or some of those really har, even just an over-the-counter Unisom or Benadryl ends up being habit-forming it’s not great for our memory long-term, that those are just band-aids that I love the fact that they’re looking into what is the cause which is the hormones.
Dr. Maki: Yeah, right. I mean sleeping, sleeping is a completely hormone-related phenomenon, right? It’s just something I don’t know if that’s the right term.
Dr. Davidson: Phenomenon. I like it.
Dr. Maki: Yeah, right. I mean it’s just a natural thing, right? As the sun sets the light the light disappears. Our other sleep-related hormones Melatonin, Serotonin, all these things go up and it’s this process that is innate within human beings at least a light-dark cycle that we have were not necessarily nocturnal unless you’re a vampire. But for something that so important to us as time goes on it becomes harder and harder to be able to get a good night’s rest. And with all of our patients that something and even on those podcasts we’ve talked about these sleep issues a lot because it’s the in some ways the foundational step like it has to be dealt with. Because if the sleep is left to be you know, if you’re not focusing on the sleep or you’re not improving the sleep then everything else still falls off that they still keep gaining weight, they’re still irritable, they’re still tired. It really just starts to detract from, their quality of life and if it’s left unabated for too long, now that can lead like to seriously lead to some age-related disease down the road. So even though it doesn’t thrill pre-menopause like you say all the time. It’s this limbo-land of hormones that doesn’t really get addressed for women. But if you don’t do anything about some of these things that are relatively, I wouldn’t say simple and minor, but they’re just a sign of dysfunction. They’re not full-blown disease yet. That’s where things get a little gray. No one roles really know how to deal with them collectively. Like you now, like you say insomnia there’s a pill for that. Okay, fine, but like you say, there are some side effects that you have to kind of weigh the cost-benefit is that worth it or not? Is that the direction that somebody wants to go. A lot of times it’s not and especially with the people that are asking these questions. They don’t feel comfortable doing those kinds of things.
Dr. Davidson: I agree. So I would definitely say for Laura her question is, she’s wondering if the progesterone, the oral capsule progesterone that she’s taking is converting into cortisol, and I really don’t think that’s the case. I do think that her cortisol is spiking in the middle of the night which is why she’s waking up at two in the morning wide awake. But I don’t think it’s necessarily a byproduct of that oral progesterone. If anything progesterone does help bring down cortisol levels. Now, like I always say everyone’s unique and different, and there are different experiences, and different environmental influences that can happen. But really, I would say probably more so is that she might be on instant release progesterone. Which is very common, even commercially it’s very common as a bioidentical instant release, so when you take it instantly goes into your system so sure you’re going to get a little sleepy and tired but because it’s so instant it comes out of your system fairly quickly when you’re doing it as an oral form. So it could be by two in the morning, four hours later five hours later. It’s just not in her system anymore and then her cortisol is bouncing back up.
Dr. Maki: Yeah right, sure. It could be related to, like I say they form of the progesterone or it could just be the fact that this is how her body is manifesting this transition. As we’ve talked about before about perimenopause as that progesterone is dropping. she says she still menstruating so we know that there’s this without even doing any blood work. We just know because where she is in her life and the fact that she’s still having a regular period that her estrogen level is still sufficient for her to still be menstruating. But we can assume that her progesterone levels are fairly deficient. Now, when you look at the different sex hormones, they are all they’re all categorized as steroids because they’re made from cholesterol. When you look at the cascade of all the different hormones. You have testosterone and estrogen on one side and then progesterone and cortisol on the other, testosterone and estrogen are very similar in molecular structure, cortisol, and progesterone are very similar in chemical structure. Testosterone and estrogen certainly convert back and forth. When you give a womb progesterone, it’s really intended really to give their adrenal glands a break because they have the stress and just the everyday living type of thing, but it like you say it’s meant to kind of, you know, it’s meant to buffer those adrenals as opposed to igniting the adrenals.
Dr. Davidson: Exactly. So I would say, going back to that progesterone as I do like the oral capsules for a female in her 40s because it just really helps with the mood and the irritability it helps with those heavier periods that she might be having every month because of the drop in progesterone. So I do think to maybe talking to her practitioner about switching it to a sustained release. Sustained release and I’ll tell women, don’t take the progesterone after dinner or when you’re brushing your teeth are getting ready for bed. Take it right before bed. Not before you going to watch TV. If I’m going to go to bed at ten o’clock and turn off the lights at ten o’clock take it at ten o’clock that way with that sustained release. It has the longevity to stay in your system all night, and then, by relaxing the adrenals keeping that cortisol down and then in the come morning time when that cortisol should be coming up, it’s six in the morning. It’s going to bounce back up. That’s what I would suggest for Laura.
Dr. Maki: Yeah, right. Yeah, that way, she’s getting the benefit of that sustained release for the entire night. Now granted there are some other supplementation things that can be done and honestly progesterone by itself in a situation like this isn’t always going to solve the problem. We usually have to focus on some lifestyle things and then as I mentioned the supplementation things that are nice adjuncts to the progesterone and now the night’s sleep waking up at two AM. if she wakes up at two AM but she’s able to just roll back over and reposition and go back to sleep, I think that’s reasonable. I don’t think she says in the question that she’s up to how long she’s awake for.
Dr. Davidson: She says she’s fully awake.
Dr. Maki: Yeah, yeah. So more than likely, she’s probably two in the morning and she’s staring at the ceiling, she’d probably awake for an hour or longer. But if she’s only awake for a short amount of time, that might be the best-case scenario. So she gets a nice chunk of sleep, she wakes up and then she gets another nice chunk of sleep, but the amount of time that she’s awake is very short. I think that the likelihood of her being able to sleep a full eight hours through, for anybody that we deal with I think is in a lot of cases sometimes unrealistic. But if they’re able to get a nice big chunk of sleep, wake up, and then another nice big chunk of sleep preferably with no restroom, need to go to the restroom, but she’s just like I said able to reposition that’s a success. I think that her sleep would be much improved if that was the case.
Dr. Davidson: You’re right. And you’re right about to know like I said when looking into that progesterone as a sustained release instead of instant. But you’re so right, granted this is not medical advice. It’s meant for education. Blah blah, a disclaimer. But looking at some other aspects like you would mention the supplementation. There are lots of really nice supplements. You can take to help bring down cortisol to stay down without being a sleeping pill. Looking at her adrenal glands like, Dr. Maki had mentioned is balancing stress. Is she exercising before she goes to bed, is her blood sugar balance, is her blood sugar dropping in the middle of the night, which is causing her cortisol to go up. So there are lots of kinds, it’s not like you said one size fits all or one pill fixes all it’s looking at the whole environment.
Dr. Maki: Yeah, right and there’s a couple of things like you said blood sugar is a key thing to make sure that your adrenals are in balance. So more protein being selective with your carbohydrates. You don’t have to, I don’t think for most women I think you have to eliminate them. I don’t think Keto necessarily is always the right answer because Keto diets I think tend to become low-calorie diets, which then puts more stress on the adrenals as well. So you mentioned exercise if you’re exercising like what a lot of people do in this country, they exercise after work, so they get done it five. They go to the gym. They’re doing a lot of aggressive cardiovascular work in the evening that’s going to make sleeping a little bit more challenging. So switching around your exercise routine, making sure you’re eating enough food, the right types of foods, as far as your macros go. Those all can be part of that landscape that’s going to foster some really good sleep during the night.
Dr. Davidson: And what’s also not to switch gears here. But what’s also very common in, Bioidentical Hormone Replacement for females, especially perimenopausal females is giving testosterone therapy and you can see that the doc gave her some testosterone. She thought it might have been a little too high for her. That’s an easy adjustment there, but that it helped her a lot. And when you think about testosterone, sure testosterone for males is a reproductive hormone, but for us females. As females testosterone is not a reproductive hormone it’s actually what I consider a little bit more of an adrenal hormone because we make DHEA from our adrenals, and then that will convert to testosterone. We make a little testosterone from ovaries in some other peripheral tissues but the DHEA conversion to testosterone from the adrenal glands is a good indicator that if the testosterone helped her, I would say definitely, it’s not just the reproductive hormones with the estrogen and progesterone that looking at those adrenal hormones.
Dr. Maki: Yeah, right. Yeah and starting off like right out the gate with testosterone. That’s just not something that you and I would typically do. But you’re right, I think it adds some credence that her adrenals if she felt better that way. Well, maybe we could do that in a little bit of a less aggressive fashion by using testosterone but still supporting the adrenals. So for example, you have this kind of diurnal curve to cortisol. So your cortisol supposed to come up in the morning as you mentioned, supposed to go down at night. So, if you do things to support cortisol in the morning, then automatically it’s going to start to come down at night. Plus there are some other things you can do to lower cortisol in the evening as well and now you’re able to sleep well. Like you said she did respond well to it, but who knows we don’t know what the amount was, we don’t know what her blood level is, and the fact that she’s still menstruating, maybe not really the best time for that might have been more appropriate, in a few years.
Dr. Davidson: Or as I said just finding that right dose that fits for her because if she does do well on it, it’s not causing her acne, it’s not causing her hair loss, it’s not causing her to feel testy, you know at testy and irritable then it might not be a bad idea. We’re always a little bit more conservative we think of testosterone like the frosting on the cake, you don’t want to add that little accolade, the little details, the fun details after you’ve established a base. But, like she said it did help her and then maybe dialing it back a little bit and just keep in and the Doc does test her blood it says does some blood testing so you can easily test testosterone on a blood test to make sure it’s not too high.
Dr. Maki: Right, right. So, I think that this one is I think we did an okay job on this one. Do you have anything else to add?
Dr. Davidson: No, no. I think we did a good job. I appreciate Laura for reaching out and taking the time to read our article and give a question that I think can help a lot of people, and reading or listening so you know and especially that it comes from people all over the world. I think that’s really cool.
Dr. Maki: Yeah, right, yeah. Well, thanks for your question Laura and until next time I’m Dr. Maki.
Dr. Davidson: And I’m Dr. Davidson.
Dr. Maki: Take care.