Linda’s Question: 

Hello, Dr. Maki. I hope you are well. I eat perfectly. I a small amount of organic food daily. No alcohol. No smoking. I bike forty miles a week. I am a 51-year-old postmenopausal woman at five foot eight.  I am now 25 pounds overweight at 154 pounds. I cannot lose one pound. My TSH was 1.6 free T4, 1.1 free T3, 2.6 reverse T3, eleven had very low sex hormones. Hence, probably the postmenopausal part, recently began one milligram of biest troche daily and 50 mg capsule of progesterone at bedtime. My worst symptoms are water retention, bloating, and weight loss resistance. I also have aching joints and muscles. This hormone protocol does not seem to be working. I was thinking of switching to an Estradiol Patch.

Short Answer: 

Most people trying to lose weight all use the same strategy. They eat less and exercise more. Over time, this approach does not work very well cause the body is forced to adapt to the significant drop in calories and increased exercise. This is especially true for women in perimenopause and menopause. For women to reach their weight loss goals, we encourage them to eat more and exercise less. Bioidentical Hormone Replacement Therapy (BHRT) can be helpful, but it is not as important as how much someone eats, how much they exercise, and how well they sleep.

PYHP 093 Full Transcript: 

Download PYHP 093 Transcript

Dr. Davidson: Hi everyone. This is Dr. Valorie Davidson. Thank you for joining us for another episode of the Progress Your Health Podcast. I am sitting here with my co-host and husband and partner in business. I do not know if that is a good thing or not but here we are with Dr. Maki.

Dr. Maki: Good morning everyone. How are you doing today?

Dr. Davidson: It is a very good thing to be married and to work with your husband and have our business together. I did not mean to say that inappropriately. It is a very good thing.

Dr. Maki: Yes well, it was not very nice to say. I like that.

Dr. Davidson: I am very sorry. Not only am I sitting here with Dr. Maki. We are also sitting here with our little Australian shepherd dog who is always our little shadow.

Dr. Maki: Oh, yes. He is always there.

Dr. Davidson: So if you hear a little click-click in the background. That is probably his paws on the wood floor or he is chewing on his little bony.

Dr. Maki: Yes, right. He is always underfoot all the time. So this one we are going to do a question. This one is from Linda. Why don’t you go ahead and read the question?

Dr. Davidson: Sure. Sure. Okay. So we are going to do a reader question. This is from a blog post that we wrote called “What is Biest?” and this is from Linda. “Hello, Dr. Maki. I hope you are well. I eat perfectly. I [inaudible] amount of organic food daily. No alcohol. No smoking. I bike forty miles a week. I am a fifty-one-year-old postmenopausal woman at five foot eight.  I am now twenty-five pounds overweight at a hundred and fifty-four pounds. I cannot lose one pound.” It looks like she also goes into her blood work here, which is great. “My TSH was 1.6 free T4, 1.1 free T3, 2.6 reverse T3, eleven had very low sex hormones. Hence, probably the postmenopausal part, recently began one milligram of biest troche daily and fifty-milligram capsule of progesterone at bedtime. My worst symptoms are water retention, bloating, and weight loss resistance. I also have aching joints and muscles. This hormone protocol does not seem to be working. I was thinking of switching to an Estradiol Patch.”

Dr. Maki: Well, I think there is a lot of things going on there. For one, she started one milligram of Biest as a troche. You and I are not really big fans of troche. Troches are kind of like a sublingual form of hormone delivery. You kind of put it under your tongue. You are supposed to let it dissolve. It does not take like twenty minutes for those things to dissolve.

Dr. Davidson: I mean, I have a few patients that maybe do not absorb as well transdermally with the skin because, with estrogen, you really do not want to take it orally. So troche is one way to technically bypass the digestion. So it is like this little sublingual, a little kind of squishy kind of looks almost a jello[?] but it is hard and you put it under your tongue or put it against your cheek. It does not taste great. It does take sometimes up to twenty minutes to dissolve. People get a little bit hurried and rushed and they want to drink their coffee or eat their breakfast and they end up chewing it up and swallowing or just swallow it. So then it ends up being more of a digestive way of getting the estrogen rather than a sublingual way. So there is a few little issues with that but for the most part, some people really do like their troches.

Dr. Maki: Sure. Yes, it is not something that like you say that we typically do. I think dosing wise for a troche is probably fine just because it is a troche. Transdermally, it is very low. If you are putting a cream on your skin in one milligram you might as well not even be taking it at that point. Now, her symptoms seem to be complaining of too many menopausal related symptoms. No hot flashes, no night sweats, at least she does not claim to have any insomnia which are kind of the classic three that most women are dealing with.

Dr. Davidson: I agree, but I wanted to kind of interject a little bit so that one milligram of Biest as you say might seems like nothing. It really depends on what the– I guess the ratio of that Estradiol to Estriol is. So when you say Biest, that is why she found our blog where we are talking about what Biest is. Biest is a bioidentical hormone replacement protocol where you combine Estradiol which is E2 with Estriol which is E3 where conventionally most doctors will do of course the old-school [inaudible] and nobody uses that anymore hopefully or they will do Estradiol which is very strong. So depending on how that one milligram is dosed out in terms of the ratio between the Estradiol and the Estriol can determine how strong it is.

Dr. Maki: Yes, right. So a typical one that we usually start with is an 80/20 ratio. So eighty percent Estriol, twenty percent Estradiol but when we get these questions from people, it seems like the more common ratio that we see are people asking questions is a 50/50 ratio. So it would be equal amounts, so be a half a milligram of Estriol and a half a milligram of Estradiol. Anytime that Estradiol when that amount goes up the side effects are in some ways more likely at that point.

Dr. Davidson: Yes, Estradiol is the strongest form of estrogen but it is beautiful– estrogen is just a beautiful hormone in general and has so much activity in the body. But Estradiol can have some negative symptoms if it is a little too high like, Dr. Maki said even if this was a 50/50 ratio of 0.5 milligrams Estriol, 0.5 milligrams Estradiol. It is still a little bit on the low side but I find some women are very sensitive to that Estradiol and they will have bloating and water retention. That is a classic sign of estrogen symptoms, not so much with Estriol because it is so much more gentle but Estradiol will definitely cause bloating, breast tenderness, ankle swelling, feeling like your pants are tight. So it could be a little bit that she is sensitive to that. And with that said just to jump to the end of her question is I really do not think she should switch to an Estradiol Patch. That is the strongest form of estrogen and a lot of women on Estradiol Patch is it does work incredibly for a night hot flashes, night sweats. Definitely an Estradiol Patch would work with that but typically, for the most part, anybody on Estradiol Patch will put on a few pounds.

Dr. Maki: Yes, is it not like kind of like birth control used to be like eight to twelve pounds something like that?

Dr. Davidson: Yes, birth control pills do not really do that anymore but of course, the old school ones do but the Estradiol Patch depending on the females frame usually you will see around four to six pounds. Trust me nobody wants to put on four to six pounds without actually earning it. So you do see that so I would say for Linda an Estradiol Patch would not help her with her weight loss resistance probably make her water retention and bloating a little bit worse and it sounds like from her, from what we are looking at with her question is she is really more concerned about weight.

Dr. Maki: Right. Well, she did send a kind of an addendum question to this one and said that the water retention had been there four years prior to the current. So the water retention has been going on even prior before she started the hormones. So is that related to the hormones? Which you are right Estradiol could certainly do that. She even said as she was in perimenopause is when some of those symptoms really started to appear. You are right as that Estradiol level increases or she switches to the Patch. So I am going to make those things potentially worse, the progesterone dose of fifty milligrams I think that that might be a little bit too low, but again if she is sensitive that goes up to seventy-five or a hundred to protect your uterus. Now that could exacerbate some of that water retention.

Dr. Davidson: So I would say if I was just looking at this, we do not know a whole lot of background here completely but with that thyroid that T3 level is a little bit on the low side. She does not have thyroid disease. She is not hypothyroid. She does not need thyroid medication. Her TSH is just fine. Her T4 is actually really great at 1.1, but the T3 level sometimes when you see it the free T3 level under 3.0 that can have a little a bit an effect on all moving parts in the body.

Dr. Maki: Yes, right. As we talked about metabolism how hot that metabolic fire is burning to allow or the burning the fat. We want to see that free T3 to be at least in the threes. If not in the mid threes if not closer to four and this is something that you and I both see all the time. We see a reasonable TSH one and a half or less. That is because of her activity. She said she bikes forty miles a week, but now she has a low normal free T3 where we want to see those numbers opposite of each other. We want to see a low normal TSH. We will see a high normal free T3. She says the first line of her questions is, “I eat a perfectly small amount of organic food daily,” that tells me right off the bat that she is more than likely under-eating. So she is maybe not over-exercising but she is exercising forty miles a week. You and I are not necessarily bikers as a form of exercise. I like to bike as a form of recreation would necessarily say that we do that on a regular basis as the [inaudible]. We are not logging our miles so to speak so I am not really sure, forty miles on a bike on a weekly basis. Running that would be a lot. That would be a tremendous amount of miles if you are running. Biking that seems — you and I talked about that before we started recording and you did not seem like that was too egregious.

Dr. Davidson: Doing forty miles in that one day for that week that could be possibly a lot but ten miles four times a week that actually sounds really fun. That sounds really fun. I would not say she is over-exercising which is because if you over-exercise that can drop your T3 level. Now, I am generalizing here but when you look at a thyroid panel like this. When you see a normal TSH, a normal free T4, and then a low free T3, my first thought is there is probably some caloric restriction going on. Now, I am forty-seven years old. I remember the 90s. It was, “Hey, let us drop our calories. Let us skip a couple of meals and to try to lose weight.” That was the whole thing back then was like if I under eat then I will lose weight and we all know from experience. Yes, you might lose a little weight, but then it comes right back with a few extra pounds. Now we know sure[?]` calories have an impact on our weight management and weight loss, but at the same time completely reducing them is going to have a negative impact. So we do not want to just focus on calories and it does not look like she is focusing on calories because she does not put in anything about how many calories I am eating, what are my macros and all that but it does look like she may be under eating and trying to lose some weight.

Dr. Maki: Yes, right and it does not make any logical sense like it is so counterintuitive to think that you have to eat more food in order to lose weight. You and I run into this all the time. I have these conversations with patients on a regular basis and they are all exercising. They have no problem doing the exercise piece. They all exercise diligently and consistently but they all — and I am generalizing here, but collectively there is a trend to under-eat on a chronic basis. RKCCP the Keto Carb Cycling Program, we put that together specifically to guard against the chronic under-eating. So going on a diet for weeks and weeks and months and months on end at a very specific amount of calories. She says a perfectly small amount of food. That means she is probably either measuring it, weighing it out. She eats the same thing on a regular basis, which is fine but when people tend to eat healthy, so to speak so fruits and vegetables, sources of protein that is very difficult to get to what your ideal even your maintenance level of calories is on a daily basis. It is very challenging to do that. Now, with this new popularity of intermittent fasting which is reducing the frequency of your meals. Now the likelihood for you getting to that right amount of calories, enough calories to be able to feel your activity, and to feel the weight loss process. It is that much more difficult to be able to get to that point.

Dr. Davidson: I am sure Linda does not exactly want to hear this and it does sound scary, trust me I am a female too. When someone tells you, “Hey, you have got to increase your calories. You have got to eat more food.” You think, “What?” that like, you said, it sounds counterintuitive but a lot of times when you are in — and I have women patients that will say I eat twelve hundred and fifty calories every day, every single day, and that technically is a very not a lot of calories. That is very very low but when you are eating the same amount of calories every single day, of course, your body is going to get adapted or habituated to it. So actually that is why we like to cycle a lot of those calories or cycle the macros so that the body does not get adapted or habituated to a static amount of food every day.

Dr. Maki: Yes, right. The body is not designed for a static amount of food and when it is a really low amount of food less than fifteen-hundred the magic number is twelve-hundred calories. Every woman thinks if they eat twelve-hundred calories are going to lose one to two pounds a week. Now that math makes some sense. It really does but not in a menopausal woman’s body. It just not make sense in a menopausal woman’s body because of the hormones are all different than the one they were when you were twenty-five. It just does not work anymore. So the strategy of how to get to that point. Now, we will be very gentle here, but she is a five-foot-eight, one hundred fifty-four pounds. She says that she is twenty-five pounds overweight. So in her mind, whatever the math is there that put her at somewhere between one hundred twenty-five and one hundred-thirty as her ideal. So I took her biometric data took her height, her weight, her age, her activity level and I put it into a caloric calculator that determines — there are all over the internet. You can find them everywhere. They are very simple, but they are based on some mathematical equations that give you an idea of what your maintenance level of calories are. Now I will tell you these mathematical formulas are [inaudible] and skewed. They are not perfect but I put hers in at a hundred fifty-four pounds. She needs two thousand and one hundred eleven calories as her maintenance level of calories every day. Now, I put it in at whatever a hundred minus a hundred and twenty-five pounds, which would be the lower anywhere she wants to be. Give or take and it went down to nineteen hundred and seven. Even though that is over a twenty-five-pound difference, maybe like a twenty-nine-pound difference it only went down two hundred calories. The average woman needs somewhere between two thousand to twenty-six hundred calories on a daily basis as maintenance level. Now, if you are at fifteen-hundred less on a perpetual basis, you are under-eating by anywhere from five hundred to a thousand calories. Your body is going to eventually compensate and then that is why we start to see those thyroid numbers start to be so low because your body is trying to slow down your metabolism, which means it is slowing down your metabolic rate. If your metabolic rate slows down, you are not going to burn any fat. It is impossible. You are turning off the fat loss process by under eating on a perpetual basis.

Dr. Davidson: Exactly and granted the scale is evil. One day, it says one thing the next day it says something totally different. If the scale is evil, so a lot of times when we are working with women and I will tell them, “Hey, let us not focus on the scale. So, “Hey, you are one hundred fifty-four pounds right now. As we are moving along just see where you feel comfortable at. It could be one forty-seven. It could be one forty-four, not one twenty-seven and a half.” So instead of focusing on the number let us focus on the health and let us focus on how you feel. Granted, I am sure Linda has some clothes she wants to fit into that she is not fitting into right now and she might be feeling heavy and not quite how she wants to feel in her body and that is okay as we are working on it we get to where she feels healthy and where she feels comfortable. Definitely when Dr. Maki said is that math equation sounds good in theory, but we have so many other moving parts metabolically in our body that that math equation is not going to necessarily work. I mean how many of you or friends that you know of have said I downloaded this app on my phone. I am putting in my macros and my calories and what I am eating and how much I am exercising and I am actually deficient in calories and I gained weight. I hear it all the time because it is not necessarily calories and calories out. I would say definitely Linda is having a struggle right now because that T3 is too low.

Dr. Maki: Yes, right. Yes. I think that that is in some ways kind of a symptom of her strategy and you are right. This is just a kind of repetitive. That is why we picked this one in the first place is because this is a situation. Now granted she is not morbidly obese at a hundred fifty-four pounds. I would imagine she probably looks fantastic. She wants to be under a hundred and thirty. Like I said, the calculator that I use said she should be between one hundred thirty-eight and one hundred forty-one. I mean she can get down to one hundred twenty-five. That is fine. That is her choice, but you have to pick the right strategy in order to get there. We can kind of beg to differ as far as where her ideal weight should be. It also calculates BMI at one hundred twenty-five and put her BMI at nineteen. I think that is a little bit too low. That is not– BMI in the low 20s, I think is appropriate. I think at the even at the one hundred fifty-four had her BMI like 23.3 which is reasonable, but the closer you get to what your ideal weight really is the BMI becomes not really that accurate. It is not really good gauge of anything. As long as your BMI is under thirty, then your risk for age-related diseases, like diabetes, heart disease, cancer all that stuff goes down. It is really hard to know exactly what someone’s number supposed to be. Like you said a minute ago maybe it is more about how your clothes fit or what your pant or dress size is because that is really ultimately what we are trying to exercise for and lose the weight for anyways is so we look and feel better on our clothes.

Dr. Davidson: Exactly. Yes, so I would say, there are like you said there is a lot to this question. Being postmenopausal, being menopausal that does — everybody knows that the metabolism goes down and then it is much easier to gain weight when you are fifty versus twenty-five. There is such a big difference between that. So I do like the idea that she is doing some bioidentical hormones and she is actually doing the bioidentical not any kind of crazy conventional ones that would not be necessarily safe for her and they are very low dose which it is always better to start off low and work your way up. I would say with the hormones being postmenopausal female, the progesterone maybe doing some blood work checking, her progesterone checking, her Estradiol levels may be switching that troche over to a cream and definitely probably splitting it up to twice a day because she says she does the troche daily. Probably once a day that Biest and the bioidentical hormones are a beautiful thing but they have a very very short lifespan. So any time I am doing any kind of estrogen or Bieist is I always do it twice a day because really if you put it on at ten o’clock at night by ten o’clock in the morning pretty much most of that estrogen is out of your system. But if you do it twice a day, you can keep that a little bit level. One thing we had talked about with Linda earlier before I am kind of looking at this question a bit is she might be a nice candidate for the rhythmic dosing which we had talked about in a previous episode.

Dr. Maki: Right, because her goal is weight loss. She is fifty-one. So she is fairly close to her menstrual history. It has not been ten years and for what she is trying to accomplish obviously she lives a very healthy good lifestyle. That is where the rhythmic dosing can be kind of a very good advantage because it raises up those hormone levels. Think of estrogen is when it is in balance, estrogen is a very slimming hormone. That is why when you are twenty-five you weigh less than you do when you are fifty-five because you have a lot of estrogen when you are twenty-five. We can raise those levels physiologically are two physiological levels, one is going to help buffer the stress of the exercise not saying that her exercise is stressful, but exercise is a stressor on the body. You couple that with a low-calorie diet. Now, you are magnifying the stress of the exercise. Now the female hormones can kind of buffer some of that. So now it is just not a cortisol party all the time.

Dr. Davidson: Yes, like we have talked about in other podcasts. The rhythmic dosing is essentially cycling the estrogen and the progesterone to physiological levels of that of like a twenty-eight-year-old female. That is a lot different than doing a static dose of  [inaudible] is you at this Biest at 1.0 milligrams. Maybe she goes up or she splits it up or changes up the ratio. Doing a static dose and having a little higher levels of Estradiol can cause puffiness and some weight gain. That is why an Estradiol Patch which you put on twice a week tends to be technically in some ways a static dose. That is why women tend to gain weight on that but when you are cycling the estrogen and the progesterone, you do not necessarily have that same effect.

Dr. Maki: Yes, right and now her symptoms water retention, bloating, weight loss resistance, certainly the water retention, the bloating they could get worse from what she is doing or changing those dose and even from the rhythmic dosing however cortisol as a stress hormone could cause those exact symptoms anyways. So in some ways, I think hers because our hormone dose she just started it. She had been on them very long. The doses are relatively pretty low. She is been having the water retention, the bloating for quite a while but four years, she says were that in some ways to me that seems like it is more of a symptom of cortisol dysfunction as opposed to it being related to her hormonal decline.

Dr. Davidson: Which could also impartly why her free T3 is low. I think it is probably a little bit low because of [inaudible] restriction or a little bit of under-eating but also high levels of just mental stress, whether it is life, family, job, whatnot. Mental stress can also raise up levels of cortisol, which will then lower your free T3 levels. So like you said addressing her cortisol will also help address that free T3 raising up. Changing up her dietary will probably also help address those metabolic hormones as well.

Dr. Maki: Yes, right. So if this one is complicated. This is what a lot of people that come to see us. A lot of questions we get is about this weight loss component and believe me you and I, do not really have all the answers because everyone is different, everyone—there is theories, there is philosophies, there is strategies, there is dietary approaches this that. Everyone has an opinion about some of those things but you have to kind of tweak and tailor them to work, to what is going to work for the individual. We are all the same in some respects. We are also vastly different. We have very different lives and sleep and stress and hormones and all those things in the food we are eating. In the food, we are not eating, all those things factor into what our weight management is going to be. That is a really tough thing to do but the things that jumped out to me, I think we kind of discussed. It is a big deal going for one milligram of Biest to rhythmic dosing. I will be honest that is a big adjustment but the ones that seem to thrive well on the rhythmic dosing their bodies were adapt to it well and it makes things like losing some weight and feeling a little more like yourself again. It makes some of those things a little bit more possible and more accomplishable. So do you have anything else to add or can we wrap this one up for now?

Dr. Davidson: Absolutely. No, this was a great question. I just want to say thank you for all of you for writing in your comments and your questions. We love that from all of our listeners and our readers and honestly, Linda you are doing great. I mean that like the weight thing, a lot of us has to do — we are females. We are concerned with our weight, but I would say even just looking at what she wrote here I am sure she is incredibly healthy that, “Hey, you want to fit a little bit better into our dresses, into our clothes,” but it does look like she really is on a good path, just couple little tweaks here and there like we all could do.

Dr. Maki: Yes, good lifestyle in general but trying to accomplish that goal that she wants. That is why I am always encouraging resistance training versus cardiovascular training because you are not — Now we are kind of getting back into it all over again, but it is not necessarily about trying to exercise those calories off. You are not going to be able to exercise the weight off. It does not work that way. The more you try to exercise that weight off the more difficult it becomes like she said she is been at this for four years so until next time. I am Dr. Maki.

Dr. Davidson: I am Dr. Davidson.

Dr. Maki: Take care. Bye-bye.