This episode we respond to a reader question.  Jayme had sent us a question earlier in the year based on an article we wrote.  Now she has additional questions about taking progesterone as part of her BHRT. Jayme has had a hysterectomy and wasn’t sure what dose of progesterone is best for her.  Or for that matter, if she should even be taking it.

Also, she has questions about her lab work and her estrogen dose.  We really like Jayme’s question, because we get similar concerns often.  By answering Jayme’s question, we hope to help other listeners understand a bit more about BHRT dosing, labs and progesterone with or without a hysterectomy.   

Just to throw it out there, this is not meant for medical advice and intended for educational purposes only…

Jayme’s question: 

Dr. Maki, Thank you for answering me. Recently my doctor increased my biest to 4mg twice a day. I also stopped my progesterone to see if it was making any difference and I felt exactly the same, so I have not continued it. I had a complete hysterectomy, do you have thoughts on taking progesterone? I was taking compounded progesterone 200mg/day. Before my biest increase, I had my labs taken twice in one day: morning and late afternoon because I was feeling like they wore off. I was correct:

Jayme’s Labs:
Total estrogen 112 morning and 60 evening
Estradiol 35.4 morning and  <5 in evening
My estradiol has never gotten above 35.4.

Any new insight would be so appreciated. Jamie

We wanted first to address the progesterone.   If a woman has a uterus and is taking estrogen, she absolutely needs progesterone.  Estrogen thickens the endometrial lining. This can increase the risk of uterine cancer without sufficient progesterone.  But there is a theory in the medical community that if you do not have a uterus, then you do not need to take progesterone.  Whether a woman has a uterus or not, we never give unopposed estrogen.

Progesterone helps to balance estrogen.  Estrogen is a beautiful hormone but can have side effects.  Some being weight gain, increasing breast density, moodiness, and even anxiety in some cases to name a few.  Progesterone is great at balancing these negative side effects of estrogen. Progesterone itself is very helpful for many symptoms.  

It is great for helping a woman fall and stay asleep.  When the progesterone levels drop during perimenopause and menopause, can make staying asleep difficult.  Often women will complain of either waking up multiple times in the night or waking up for hours in the night.  Adding in a little progesterone at night can really do wonders for sleeping. Progesterone can also be great for mood and irritability as well.  When progesterone levels are low, women often remark that their patience has disappeared. Their tolerance levels have dramatically dropped. Progesterone can have a remarkable impact on helping mood and reducing irritability.     

Back to Jayme.  She had a hysterectomy and does not have her uterus.  We still think that Jayme needs some form of progesterone.  Because she does not have a uterus, that gives us some versatility in dosing and form of progesterone.  To protect the uterus, you usually need an oral form and at least 100 mg taken at night.

Depending on Jayme’s symptoms we can use any dose and any form such as a capsule or cream.  I think it would be a good idea to reduce Jayme’s progesterone to 75-100 mg orally taken at night.  As mentioned above, this will help with her sleep and balance her estrogen. Moving forward her dose can be modified depending on her sleep.  
I would like to address Jayme’s concerns about her labs.  

Labs are very important, but you do not want to chase the lab numbers.  You also want to base doses on a person’s symptoms, personal and family history and their own health goals.  For lab testing, we are looking for absorbency.

For accuracy, apply your hormone cream 3-5 hours before your blood draw.  For example, say you have your blood tested without having applied your cream that morning.  This will show your levels non-medicated. Which in menopause will be zero. This doesn’t really tell us much about dosing and absorbance.  

I cannot stress how important it is to apply your hormone cream 3-5 hours before the blood draw. Also, to assess estrogen, always use the estradiol levels.  Total-estrogen in the blood is not accurate enough to determine absorbability and dosing. Jayme took her labs twice in one day, so that gives us some important information.  We are going to assume Jayme did put on her biest hormone cream 3-5 hours before her blood draw.

We need to base her dose on her symptoms, but her estradiol level is pretty low in the morning at 35.4.  Based on this, it may be helpful to raise her biest dosage. Bio-identical estradiol and estriol are a great way to treat menopause.  But they do not have a long lifespan. That is why it is important to apply your biest twice a day.

If you only took your biest in the morning, by bedtime or the middle of the night, it is pretty much nonexistent.  That could be why Jayme’s estradiol levels were so low in her evening blood test. More than likely, her dose may be low, to begin with.  By evening, it has worn off completely.

But we truly believe that less is best.’  If Jayme feels pretty good with this biest dose, then keeping it low may be a good idea.  But if she is having symptoms such as hot flashes, night sweats, vaginal atrophy, hair loss, mood swings, insomnia, brain fog, skin thinning and changes, then it might be helpful to adjust her biest dose.           

We really appreciate Jayme taking the time to share her concerns, labs levels, and BHRT doses.  There is not a one-size-fits-all dose for dosing BHRT. It really is a customized art and communication with the patient is key.  

As you can see with Jayme, she knows her dose, and she knows her labs.  We always find it essential to explain to a patient, what they are taking and why.  That is why it is important to address all of these questions and concerns when dosing BHRT.  Again, thank you Jayme, and we really think your concerns and questions can help others listening to this podcast. 

If you have any questions feel free to comment below or you can send an email to [email protected].