Lilly’s Question: 

Dear Dr. Davidson, I’m writing to say how illuminating your article on Estriol was for me. Especially your metaphorical descriptions of the actions of the 3 types of estrogens. I have a question, if I may. I am 49-years-old, I just entered menopause and started taking Botanical Phytoestrogens to help with the once a day hot flash. It helped for a month and then the flashes increased to several times a day. I then took Estriol, 5 milligrams and it helped. But since then that flashes have again increased and I’m using even more Estriol, 2 pumps morning and night. It’s made me feel very, very good, calm and a great sense of well being. My question is, is this too much Estriol to be using? What is the safe upper limit for Estriol in cream form? If I take progesterone and cream form as well, with this dull the good effects of the Estriol? Thank you for the possibility of asking these questions. Very best wishes, Lily.

Short Answer: 

Dosing for bioidentical hormones is dependent on the woman. It also depends on if she has her uterus or not. One of the rules of BHRT that we follow is that you never give a woman “unopposed” estrogen. This is especially true if she still has her uterus because estradiol and estriol will cause the uterine lining to grow. This is why progesterone is important because it helps to inhibit the growth of the uterine lining. For women that still have their uterus, we prefer to use bioidentical progesterone capsules, as opposed to progesterone cream.

PYHP 087 Full Transcript: 

Download PYHP 087 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: So, I’m just getting ready to start talking and my mic and my headphones practically fell off my head. How you doing this morning? 

Dr. Davidson: I’m doing great. Maybe you shouldn’t wear your Golden Knights hat. 

Dr. Maki: Yes, shoutout to everybody in Vegas. 

Dr. Davidson: We’d love The Golden Knights.

Dr. Maki: Yes, it’s really ironic. We live there for so long never had any professional sports. And right when they got that team, the season was going to start. And we left pretty much like, right as the season started and they had like one of the, I don’t know if anybody out there is a hockey fan or not I’m from Minnesota. So of course, I’ve liked hockey since I was a little kid. But they had like this crazy season that no one’s ever had before, for an expansion team. 

Dr. Davidson: It was definitely inspirational. 

Dr. Maki: And it’s funny too, well have granted it’s kind of started off in tragedy with that whole shooting they had there in October. But there are people there, we have patients there. And none of them really care for sports all that much now. Everybody is into the Golden Knights, which is kind of an interest, in which kind of a cool thing. It’s a very much created a very community-friendly environment. 

Dr. Davidson: And we wear our Golden Knights gear here in Washington like you’re wearing your hat right now. Which is why your headphones are slipping off but some people recognize it, it even appears in Washington, they recognize the team. 

Dr. Maki: Yes. Well, Seattle’s supposed to be, they already been awarded the team but now they’re going to be announcing the mascot here fairly soon or the logo or whatever. I’m not really sure what it’s going to be there’s rumors it was going to be the Kraken, and everyone thought was going to be the Sockeyes. Who knows? We’ll see. So we have another listener question to talk about. Why don’t you go ahead and read the question? 

Dr. Davidson: I think actually, this one was a reader. So this is one of the articles or blogs that we had written about Estriol and the different types of Estrogen. So this is a reader, this is a great shoutout to Lily. She wrote, “Dear Dr. Davidson, I’m writing to say how illuminating your article on Estriol was for me. Especially your metaphorical descriptions of the actions of the 3 types of estrogens.” Lily, you’re already my new favorite person. Illuminating metaphorical descriptions of, she’s awesome, anyway. So, Lily goes on to say “I have a question, if I may. I am 49-years-old, I just entered menopause and started taking Botanical Phytoestrogens to help with the once a day hot flash. It helped for a month and then the flashes increased to several times a day. I then took Estriol, 5 milligrams and it helped. But since then that flashes have again increased and I’m using even more Estriol, 2 pumps morning and night. It’s made me feel very, very good, calm and a great sense of well being. My question is, is this too much Estriol to be using? What is the safe upper limit for Estriol in cream form? If I take progesterone and cream form as well, with this dull the good effects of the Estriol? Thank you for the possibility of asking these questions. Very best wishes, Lily.

Dr. Maki: So, there’s a few things there. First off, she says she started off with Botanical Phytoestrogens. So that is herbs like black cohosh, red clover. 

Dr. Davidson: Dong Quai. 

Dr. Maki: Yes, those are herbs that have, they don’t have hormones in them. 

Dr. Davidson: Vitex too. That’s another real popular phyto es- well, that’s more for the progesterone.

Dr. Maki: Yes. that’s more on the progesterone side. But still, definitely, herbs that have somewhat of a, they don’t have hormones in them, right. They don’t provide the body with hormones, but they have a hormone-like effect. The phytoestrogens especially black cohosh it works by affecting the estrogen receptors so you get a similar response. Now granted, when a woman’s going from perimenopause into menopause, the severity of their symptoms will dictate just like in this case, whether those phytoestrogens will be effective or not. 

Dr. Davidson: Exactly. So you think, phytoestrogens are actually great to use in both lower hormones like from perimenopause to menopause. And it’s actually great to use also in people that have high estrogen. Because like you said as a phytoestrogen, what it’ll do is that black cohosh or as a phytoestrogen will kind of basically stimulate the receptor weakly like very weak stimulation of the estrogen receptor. So if you don’t have any estrogen in your system, and you have a weak stimulation of that receptor, you’re going to have a little estrogen activity in the body. Hence, with Lily, going into menopause, the phytoestrogens probably helped for a little bit. But let’s say you’re a younger female with you’re making too much estrogen so if you put that phytoestrogen, if they take phytoestrogens, it’ll actually block that receptor and dampen down the big reaction that they’re having from that estrogen dominance if that makes sense. 

Dr. Maki: Yes, right. So hormones in the body are produced by certain glands. They go into the bloodstream and then they attach to a receptor that is on basically all of our cells, our brain cells, our muscle cells, our liver cells, our kidney cells, every cell has receptors for these particular hormones. So when a woman’s in menopause or transitioning into menopause in her own hormone production. Progesterone and estrogen are declining, then taking a phytoestrogen in some respects makes some sense because now you’re still going to be stimulating those receptors in a way, but you’re not taking any hormone. But like this question says, or what she’s alluding to is which is what we see. You and I are naturopaths, we love our herbs but sometimes the herbs are just not enough to provide the relief that a woman needs. 

Dr. Davidson: Yes, so I like how she’s using basically, the therapeutic working at the very least intervention, at the very lowest therapeutic range. So, you never want to jump up to the top which would be harsher medications or surgery is you always want to start lower with lifestyle, or supplementation, or botanicals so she started at that lower intervention. Notice that it helped a little bit and then it didn’t. And that could be because really, truly if Lily’s 49 and she’s transitioning, she’s probably not necessarily 49, not exactly in menopause she’s between perimenopause just gently gliding into menopause, and the phytoestrogens to help spur a little bit and as her body is transitioning more into the full phase of menopause, she needed to go a little higher on that therapeutic intervention which is where the Estriol came in. And it looks like the Estriol seemed to work very well with her that she actually likes it. 

Dr. Maki: Yes Right. So, her actual real question is, is 5 milligrams of Estriol too much? And whether or not adding in some progesterone is going to kind of decrease the beneficial effects. This is where it gets tricky, right. One of our rules of hormone replacement. Number 1 rule is you never give a woman unopposed estrogen, ever. There’s not really a circumstance where that would really be, now sometimes you might do that if a woman’s having some vaginal dryness and we maybe prescribe an E3 or an Estriol cream. But most of those cases, usually there’s going to be some other symptoms involved and more than likely they’re going to have a progesterone prescription as well. 

Dr. Davidson: Exactly. So like you’re saying Estriol. Estriol is great for so many things, but specifically vaginal dryness, it works wonderfully for. But if you’re using a very low dose vaginally, it’s not going to go so much into the bloodstream and then create that effect of having too much estrogen without enough progesterone to balance it out. So like Dr. Maki said is if you’re going to do estrogen, any form of estrogen you truly want to investigate and possibly do some progesterone. Now, if you’re going from perimenopause to menopause, or even going into perimenopause the progesterone usually drops first and then the estrogen drops later. So we know with Lily, if she’s going into menopause and the Estriol is working well, we know that her progesterone levels are low and that it would be beneficial to add in some progesterone for her. And it looks like that she’s read probably a few of our articles about why you might need progesterone to balance out that estrogen that you’re taking but her question is, I think she’s worried that the progesterone would negate that positive benefit that she’s getting from the Estriol.

Dr. Maki: Yes, right. And I think that almost just the opposite that there needs to be, now granted, that brings up the other question about progesterone cream versus capsule, her being so close to her menstrual history and we talked about this on some previous episodes. At some point that estrogen dosing could become a problem, right. Because she needs the progesterone to balance and inhibit the growth of the uterine lining. It’s not going to negate anything. If anything, it’s going to create more balance because now you’re, both hormones are present. 

Dr. Davidson: And now like I said, Estriol is the most gentle weakest form of estrogen. There’s also Estrone E1 which is not a great estrogen. We, as adult females, we don’t make a whole lot of it, you do make a lot of Estrone if you have a lot of fat cells and also when you’re a young teenager, just kind of our young female just sort of going right into puberty and getting your first few periods, for a couple of years there you might make a little more Estrone but then as the body gets used to cycling, it doesn’t make as much Estrones. The whole goal is to not make too much Estrone but at the same time there’s Estradiol which is E2, that’s the strongest form of estrogen. Estradiol is very strong but Estradiol is an amazing hormone it’s great for your bones, it’s great for your cardiovascular system, it’s great for your brain, but she can be a little bit of a runaway train if you don’t rein in some of her negative effects. Where Estriol like I said, E3 is very gentle. So being that Lily is taking just Estriol, is much safer in some regards because I love Estradiol, I prescribe it all the time but you never want to prescribe Estradiol unless you’re doing some progesterone to offset that because of the strength of it. Like I said, she can be a little bit of a runaway train, so the progesterone kind of helps negate those unwanted side effects you might get from taking Estradiol. Now, on that flip side, I was saying that Estriol is very, very gentle, that you don’t have to be so adamant with the progesterone-like you would be if she were taking Estradiol. 

Dr. Maki: Yes, right. Then it’s more dose-dependent which is kind of what her question is. So the more of the Estriol that you’re taking the more than progesterone conversation needs to be had. But it’s not whether the progesterone is necessary or not, at some point the progesterone will be necessary. And whether it’s a cream or a capsule we’re not really big fans of Progesterone cream in the context of using it with Estrogen. That can be problematic at some point. 

Dr. Davidson: Now, for you know, we’re no disclaimer, disclaimer, we’re not giving out medical advice and all that. But just in our experience, I do feel like if she’s taking 5 milligrams of Estriol, that’s kind of that upper limit where I’d say 5 milligrams, you probably want to do some kind of progesterone just to balance that out. When someone’s doing 3 milligrams or less Estriol, you know E3, 3 milligrams or less, then I say, okay, we could kind of, let’s talk about whether you need some progesterone or not, it may not be necessary if you’re doing such a low dose like that but when you’re getting up to 5 milligrams, you think, okay, we probably want to put in some progesterone because estriol is very gentle. Progesterone cream may work well for Lily depending on if she starts to because the one thing with that unopposed estrogen is it can cause the lining of the uterus to get thick, and then you get a period back, you get sloppy spotting you don’t want to have an increased lining of your uterus, or your endometrial tissue so that’s actually kind of a risk factor. So, we’d probably want to come down to this, does she have a uterus? Does she not have a uterus? Is she? When was her last period? 

Dr. Maki: Right, that menstrual history as a woman is transitioning from her late 40s into her early 50s or from perimenopause into menopause. The proximity of that menstrual history makes a big difference. If it was just a few months ago, less than 6 months ago, and she starts right away on Estriol even at 5 milligrams that could cause her to start having either a full-blown period or to have unpredictable bleeding which is exactly what we don’t want. So, certainly, the progesterone is a good idea. Like I said, the cream versus capsule I think is the bigger conversation there and you cannot get progesterone capsules over the counter, right. Progesterone cream, in some ways, unfortunately, you can. I’m not really sure if I like that idea or not. I think they should be prescriptions because they’re still hormone. 

Dr. Davidson: It’s on the company. Who’s making it? How they’re making it? What’s in it? Where did it come from? 

Dr. Maki: They’re still hormones, they need to be respected and you need to be somewhat, you can’t just take a hormone-like that. Now, granted, progesterone, I think is a lot easier and a lot, I wouldn’t say safer necessarily, but you’re not going to necessarily have any bleeding problems, necessarily with the progesterone cream like you would with potentially with this estrogen cream. 

Dr. Davidson: So I would say in a case like this, let’s say somebody is taking some Estriol, and they’re liking it, it’s helping their symptoms, they’re you know, 5 milligrams. That’s where, and honestly, if you are working on hot flashes or menopause, you probably would and you’re doing Estriol only you probably wouldn’t go lower than 5 milligrams. I usually do 3 milligrams or less if we’re working on more like skin tonicity, vaginal dryness, but really for hot flashes, and that sense of well being 5 milligrams, probably is doing very well for her. That I would say for Lily that taking progesterone wouldn’t dull the effect at all. If anything it would probably complement it and she feels even better. She’d probably feel like she was sleeping better, her hair, skin, and nails were better, anxiety. Progesterone is very calming and relaxing it would probably even more so make her not feel wound up or stressed out. So that I think it would have a beautiful synergistic effect just in that regard. 

Dr. Maki: Yeah. Now you’re referring to capsule progesterone, right? As opposed to-.

Dr. Davidson: I would say either. 

Dr. Maki: Either, okay. 

Dr. Davidson: In this case. Like I said, anybody on an Estradiol or what we call bias that has Estriol and Estradiol together. Then I pretty much and they have a uterus we do progesterone capsules. But in this case, she could probably go either way. Talking to her practitioner or maybe her gynecologist. If she has a uterus doing a transvaginal ultrasound every so often, every year or so just to make sure that lining is not getting too thick if she’s doing the cream. The capsules usually prevent that but the cream, you can go either way with that thickening of the uterus. But just in regards to her question about feeling this calm, this sense of well being, the hot flashes, is doing progesterone in either form would like I said help. It wouldn’t dull the effect at all if anything would probably help enhance it. 

Dr. Maki: Yes. right. Certainly, progesterone capsules for sure work on that kind of mental-emotional plane. They help kind of tone down the anxiety, they help level out the mood. So, perimenopause were the classic symptoms of perimenopause, as women are irritable in everything. The way their husband breeze and the way he chews, the way he talks, and just a simple thing that he does and all sudden women are just in a fit of rage, and they don’t understand why. They think there’s something wrong with them. But those hormones are changing and their body is reacting in a way that they’re not really used to. Progesterone can really help to kind of level that playing field. 

Dr. Davidson: But it sounds like she’s feeling really great on that Estriol. Everybody’s different that’s why Bioidentical Hormone Replacement, or treatment or restoration, or whatever you want to call it. It’s important to treat the individual because there’s some people that Estradiol is too strong for them. You do their blood work, you do their urine test, you do their saliva test. Hey, you have no hormones, but you try to give them what you think would be a proper dose and it’s just way too much where they’re just too sensitive. And then there’s others where you’re, hey, you know, we’re on kind of a good amount of hormones and they don’t feel good unless the levels are even higher. Everybody is different. Of course, we’re looking at safety and precautions and longevity. But in terms of every female, males included, we’re all individuals, we’re all very unique that if this Estriol which is very gentle is helping Lilly, that’s wonderful. 

Dr. Maki: Yes sure, of course. Now, Estriol is FDA approved, it is by prescription.

Dr. Davidson: In this country, I mean, you can find it online. I think other countries because we’ve gotten emails and little comments saying hey, it’s available here down the street at my chemist and they live in, I’m not sure about other countries.

Dr. Maki: Germany or England or whatever, but in this country, Estriol is FDA approved. It is a legitimate prescription, but it is not in a commercial form. So you can’t get it from your most gynecologist or doctors that do hormone replacement but more from a conventional route, there are no prescriptions. We use it all the time for vaginal issues and when you go to the gynecologist complaining that you have some dryness or some pain or some discomfort or pain with intercourse, they don’t give women that option. Honestly, some of the conventional options are not very good. We always use E3 in that respect because it works very well and like you said before E3, Estriol is that weaker hormones you get all the benefit without as much of the risk that you would get with Estradiol. 

Dr. Davidson: Now, just for some of you out there listening, you might say, hey, I’m on Amazon right now and I see Estriol available for purchase and I’ve talked to different pharmacists, other colleagues about it. You know every company, you know, you don’t know where it’s coming from, you don’t know about the company, I’m sure we could go in and research. So, I’m not sure exactly how that’s being able to be bought on Amazon or over the counter or at whole foods, but I know that it is available. Just be careful if you do choose to go that route that it’s coming from a reputable company, and the sourcing is coming from a good source. 

Dr. Maki: Yes, right. What we’re talking about is by prescription. That’s the world we live in, that’s the world that we operate in. We are not commenting on things that are on Estriol, Progesterone, Estradiol, anything like that, that’s over the counter. That’s not what we’re pertaining to, and you cannot compare a prescription to those things that are over-the-counter, it is not the same thing. I don’t know really exactly how some of those things are able to be sold that way. That’s not for me to decide. But in the context of what we’re talking about, we’re talking about bioidentical hormone replacement therapy, that is by prescription, not what you can find on the internet. Because like you say, when it comes to supplementation, and this is the downside to supplementation. 

Yes, everybody has access to it and that’s great but at the same time, there’s not as much regulation on the supplementation side. Anybody can start a supplement company, like literally overnight. You have no idea what is in that supplement because no one is checking from a quality control, or an efficacy standpoint, or even clinical trials of that supplement that you’re buying off of Amazon, or getting it wherever. Now, we use a lot of supplementation with our patients but we use physician only companies that go through the quality control, the QA, the QC, all those things are met. So, that way you know where those raw materials are coming from, you know what the ingredients are, you can feel confident that there’s no heavy metals, there’s no toxins, all those things have been tested for. So, again, just because we’re talking about things that are available online, it’s not really the same conversation. 

Dr. Davidson: Exactly. So you can tell we’re definitely very passionate about what we’re trying to tell people to do. We want to advocate for people. So, like I said, if you do go that route of going to the health food store online. That’s your choice and you know a lot of our listeners and readers are very up to date on where things are coming from, and they’re savvy at what’s going on here, which is why we love to answer these questions. You go out on the street and you say, hey, you do you know what 5 milligrams Estriol is? They’ll just look at you cross-eyed, most people don’t know what this means. So it’s really cool to get these questions from you listeners and readers. And you know these numbers, you know what you’re talking about. So that’s why we love this podcast as we can really get into the nitty-gritty of hormone replacement. 

Dr. Maki: And we also know too, because we get these questions all the time from our own patients. Is that conventionally there just isn’t really a lot of answers that are given. Doctors just don’t seem to know, they don’t seem to want to know and patients are left to kind of fend for themselves to be able to get and find answers. That’s one thing I would say, in this kind of information society with having access to the Internet and all this information or fingertips. It just people go on Google and they look for answers all the time, and sometimes they just won’t stop until they find their answer, which I think is great. So, conventionally, sometimes there’s doors that are closed, you’re not getting the answers you want. So, that’s why we’re doing this podcast, and that’s why people find us for those exact reasons. So, I think we cover this one. The Estriol is great, Progesterone is a good idea. We would advocate the progesterone capsule versus the cream. Do you have anything else to add to that? 

Dr. Davidson: No, I think this was great and sorry if we kind of got off on a tangent, but hey, we love to talk on this podcast. 

Dr. Maki: Yes, so until next time, I’m Dr. Maki. 

Dr. Davidson: I’m Dr. Davidson.

Dr. Maki: Take care. Bye-bye.