Angie’s Questions: 

Hi, I’m going to start Biest compounded at 80/20 ratio; 80% estriol, 20% estradiol, 2.5 milligrams once a day, and 100 milligrams compounded slow-release progesterone pill. My doctor and I decided on this amount because I read from a well-known hormone doctor that anything less will not help the heart, the brain, and the bones. Question. Will the cream travel through my body enough to help with those or should it be in a pill form, which I would rather not do since I’m already going to be taking a progesterone pill. I heard that the progesterone pill is a must if you have a uterus, I am in my late 50s and I started menopause later.

Short Answer: 

Biest is a very common form of Bioidentical Hormone Replacement Therapy (BHRT). This is often prescribed as a transdermal cream. Biest contains two different forms of estrogen, which is estradiol and estriol. A common starting ratio of Biest is 80/20, which means 80% of estriol and 20% estradiol. A typically starting Biest dose for us is usually 3 mg, but it depends on the severity of menopausal symptoms.

PYHP 076 Full Transcript: 

Download PYHP 076 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 we’re still stuck in quarantine coronavirus. 2020 is upon us still, I think we’re up here in Washington State. Everything’s closed except for banks and grocery stores, gas stations. Bars and restaurants are closed. Of course, hospitals are not, healthcare practices and medical clinics. But hopefully, this will resolve soon. Hopefully, by social distancing we’ll have some positive effects, and we’ll be able to get back to some normalcy fairly soon. In the meantime, we’re going to continue on with the podcast. It does seem a little weird, I’m talking about hormones when all this other stuff is going on but at the same time, we don’t want to focus on that too much. It is what it is. If we all do our part, I think it’ll kind of dissipate, and we’ll minimize some of the collateral damage as much as possible.

Dr. Davidson: Yes, I completely agree. Instead of panic, just try to hope for the best, everybody’s going to be okay. Let’s try to stay home and not infect anybody else. Like Dr. Maki said, we’re in Washington, which there is a lot more cases of deaths here so people are being extra proactive, which I think it’s wonderful that we’re all trying to support the community. I think when this is done, we’ll come together and try to help everybody else that have been impacted financially from this too because that could be very devastating.

Dr. Maki: Yes, completely. Let’s get back to hormones. The last one we talked about Lisa. So, again, some very typical questions. This one, we’re going to talk about Angie. In some ways, we’ve kind of paired these two together from last one to this one, just because it kind of reiterates some of the things that we talked about. Dr. Davidson, why don’t you go ahead and read Angie’s question.

 Dr. Davidson: Sure. This question is from Angie. Hi Angie. Angie’s actually a podcast listener. So I appreciate you listening to our podcast and putting out your question because your question is really important, and I love her specificity on this. This is really cool. Angie says, “Hi, I’m going to start Biest compounded at 8020 ratios; 80% estriol, 20% estradiol, 2.5 milligrams once a day, and 100 milligrams compounded slow-release progesterone pill. My doctor and I decided on this amount because I read from a well-known hormone doctor that anything less will not help the heart, the brain and the bones. Question. Will the cream travel through my body enough to help with those or should it be in a pill form, which I would rather not do since I’m already going to be taking a progesterone pill. I heard that the progesterone pill is a must if you have a uterus, I am in my late 50s and I started menopause later.”

Dr. Maki: So, again, similar to Lisa’s but she does provide some very useful information, the 8020 and this time she does give the– which is the ratio of the two hormones the estradiol, the estriol, but she also does give the milligram amount which in the last podcast, Lisa did not provide that milligram amount. So we’re kind of guessing a little bit, assuming a couple of things based on her symptom picture.

Dr. Davidson: Which was fun with Lisa because there’s so many– That’s the cool thing with the compounding hormones is, you can do anything and everything that you could imagine with a patient when you’re using a compounding pharmacy. You can use a quarter of a milligram, a microgram, you can make any changes you want. And so, that’s the cool thing. You can design a hormone dosing profile for a patient based on them individually, as opposed to, as we pretty much know in conventional medicine, it’s one dose fits all. What a 400-pound male dose for antibiotics would be the same if they gave it to me. I’m not 400 pounds. 

Dr. Maki: Yes, right. There’s no personalization, there’s no customization. There’s whatever dose the pharmacy has, or what the manufacturer makes, that’s what you get. That’s why this is– and I know you’ve said this before yourself. It’s just as much of a science as it is an art form to know what that particular patient needs based on their symptom picture. Sorry, there’s a little-

Dr. Davidson: A little maniac on the floor.

Dr. Maki: We actually had to redo this episode because we got some new equipment and we have a new setup. Of course, for those of you that have an Aussie out there, he’s always at our feet all the time. And now he’s chewing on a deer antler. It’s kind of banging up against the table a little bit. So if you hear any noise, we apologize.

Dr. Davidson: Sorry, but he’s our little partner in crime, our little Aussie dog.

Dr. Maki: He’s a maniac but he’s cute as they can get. Hopefully that doesn’t carry through. In the past, we do these episodes and he kind of get a little rambunctious and we would stop and rerecord. We’re like, “Ah, who cares? Let’s just let it roll. Just let it run with it.” I think people appreciate that everyone nowadays, not that they never love their dogs that much before, but I think nowadays people are very much open to animals and animals having a big part of our lives anyways.

Dr. Davidson: We love animals. I heard on animal planet, it’s going to be doing a 90-hour marathon of too cute, which is like the cutest show.

Dr. Maki: I’m sure you’re not the only one that likes it.

Dr. Davidson: When that starts I’ll be watching some.

Dr. Maki: So, back to Angie’s questions. She’s right on a bunch of things. The 80/20 is always a good place to start. When a woman’s never been on hormones before, 80/20 ratio is usually the most common or the most typically prescribed hormone ratio. Now the milligram amount, she’s on 2.5 milligrams, which I think is reasonable. I still think it’s kind of low. I usually start myself about three milligrams, maybe even up to five milligrams depending on the severity of their hot flashes.

Dr. Davidson: Yes, or their symptom. There are other symptoms as well. So I would say with Angie, 2.5 milligrams of an 8020 Biest equals 2 milligrams of estriol and 0.5 milligrams of estradiol, which like Dr. Maki said, isn’t a lot. The one thing that does jump out is she’s taking it once a day. So, really, I always say the bio-identical hormones are amazing. They’re awesome. They’re so fantastic. But at the same time, they just don’t have a very long half-life. If you put it on once a day, 16 hours later, I guarantee you there’s not a lot in your system, if any at all, which is why I always advocate to do it twice a day when you’re doing bias. Now, with Angie, she’s taking the progesterone pill once a day as an oral capsule, 100 milligrams, which 100 milligrams is the best dose. I mean, not the best dose but it’s most common doses. She takes that at night but I would say with that her Biest is it’s probably a little too low or she’d want to split up into morning and evening.

Dr. Maki: And even splitting it up. So she split it up two and a half milligrams, it’d be 1.25 in the morning, 1.25 in the evening, she’s barely getting enough hormone there to curtail her symptoms. But like you said, the half-life, it only lasts what you apply in the morning, gets you through the day, what you apply in the evening is going to get you through the night. If she’s only doing it once a day, those blood levels are rising and then dropping back to zero pretty much on a 24-hour basis. She’s almost starting over every time she reapplies her cream.

Dr. Davidson: So, one way if somebody is a little hesitant about increasing up their bio-identical estrogen is, like Dr. Maki said about blood levels, is test the blood levels. It’s really easy to go into the lab and have your blood drawn and then test the levels for the estradiol because that’s the easiest way to test. It’s to actually test a specific estradiol, not total estrogens, that’s not specific enough to give us an idea of how she is absorbing the hormone cream but to do an actual estradiol. And usually, what we would have Angie do is, “Hey, Doc. Start her on her hormones for three weeks up to maybe a couple of months, and then test the blood work.” So she puts on her cream in the morning, and then maybe, 4-6 hours later, do the blood draw so we can see how she is absorbing it and how it’s staying in her system. If she puts it on in the morning without applying her hormone cream, then we’ll know for sure it’ll be zero and it’d be a wasted blood draw. But you definitely always want to test somebody after they’ve had their hormone cream on for about four to six hours.

Dr. Maki: Yes, right. Typically, a menopausal level for an estradiol, we don’t do total estrogens, that’s not really necessary. We do an estradiol level for a menopausal woman that’s going to say less than 30. Some labs will actually give the number but it’s usually going to be less than 30. Our upper limit is trying to get that number somewhere between 75 to 125, but for some women, depending on what their dosage is, it might not even get to 50. But as long as their symptoms are under control, as long as their symptoms are improving, meaning their hot flashes have gone down, their night sweats have decreased, they’re sleeping better, then the blood level isn’t as necessarily as important. We still want to monitor and check it. We want to make sure that it doesn’t go up too high. We’re still always trying to increase it but it’s definitely a good thing to monitor and keep track of.

Dr. Davidson: Angie is also asking about taking her estrogen in a pill form versus a cream form. Now we always do like 99.9%, 99.5% do bias any kind of compounded estrogen as a cream, and that’s because when you take estrogen orally, the liver tends to eat it up, so you don’t really get the dosage as well. And also, that’s pretty much a pretty big burden on the liver to be taking oral estrogen, especially at higher doses. That’s not super healthy for the liver at the same time. So, definitely her doctors’ idea of saying, “Hey, let’s do this as a cream is fantastic.” It’s good that she’s doing a cream and doing a cream does go into the bloodstream. An unbiased cream is going to help the brain, the heart and the bones and the skin and the hair. It’s going to help everything. But her specific question was, is that going to be okay for the heart, the brain, and the bones? Absolutely as a cream it will be, but then here comes in terms of dosage. It might be a little too low that we might want to raise that up a little bit.

Dr. Maki: Right. Again, some similar things to our last episode with Lisa. But she’s right on about the benefits, getting through the bloodstream and besides just the menopausal symptoms, but having those age-related disease benefits on the brain, the bones, and the heart. There’s this connotation when it comes to female hormones that they’re dangerous, but this is the kind of the added benefit helps to maintain some of those things. You’re going to decrease the risk of heart disease, you’re going to decrease the risk of osteoporosis, you’re going to decrease the risk of dementia, because those hormones are helping too. One of the risk of those things go up for women when they go to into menopause. The hormones definitely play a role there, we can extend that a little bit. It’s going to certainly stave off some of those problems, hopefully indefinitely, but at least for a relatively long time, depending on the rest of the lifestyle, which usually in our experience, women that are doing these types of things or lifestyles are already very good to begin with. This just helps to kind of round things out for them.

Dr. Davidson: Exactly. I’d say for Angie that definitely the 100 milligrams compounded slow-release progesterone oral capsule is great. Taking that at night is going to be perfect for helping you stay asleep. Also, the dosage of the bias is good to use as a cream but the dosage might need to be increased or at least split up into morning and evening. 

Dr. Maki: Usually, what we’ve noticed over the years is that, where woman starts with her hormone dose isn’t where she’s going to end with our hormone dose. There’s little tweaks that happen. Again, like I said on the last episode, whether it’s stress, whether it’s the time of the year, what’s going on in her life, what happened six months ago, and fast forward six months in the future, her life is totally different in some respects. Some things are very much the same, but her body is different, the time of the year is different, her body does kind of acclimate a little bit to it and estrogen is what makes a woman a woman. So, usually, the more of it, it’s not about having too much necessarily, it’s making sure that the woman has enough. In menopause, when we’re doing static dosing like this, we’ll talk about rhythmic dosing on another episode. But when a woman is doing static dosing, meaning same dose every day, you really can’t give a woman too much. Her body is not getting anywhere close to what she did when she was menstruating. So all we’re trying to do is just raise that baseline up a little bit of those hormones so she’s at least functional, and all those menopausal symptoms are not driving her crazy.

Dr. Davidson: Exactly. And then testing the blood work to make sure because sometimes people can take too much, and then it’s a little high in their bloodstream, and then you just back it down a little bit. But like you said, don’t be too afraid of giving the estrogens as long as it’s the biased, especially an 8020 ratio of estradiol and estriol. So where that estradiol is pretty small in terms of the ratio, whereas a 5050, like we had talked about Lisa on another episode is, sometimes you can go a little bit too high when you’re doing a 5050 ratio. But just to kind of sum it up, I do agree with Dr. Maki, is don’t be hesitant but you can start off low and then work your way up. So maybe with Angie, they’re starting off at 2.5 milligrams once a day. They’ll go to maybe splitting it up to doing it twice a day, then raising it up a little bit more and then having that and maintaining from there. 

Dr. Maki: Yes, right. Now, the issue that does come up sometimes, like you said, when you do raise, that’s why her taking the progesterone is very good. Because if you raise that estrogen amount too quickly or too fast, then there can be some spotting or some bleeding issues. But her taking the bio-identical progesterone is very helpful, as we talked about already, that it helps to protect that uterine lining or inhibit the growth uterine lining. Because if you raise that dose high enough on the estrogen side, eventually it would make her bleed to some extent, which we don’t want because that bleeding is going to be unpredictable. That’s also where rhythmic dosing comes into play, which actually encourages a woman to have a period. Now, again, that’s complicated, and we’ll talk about that on another episode. But definitely two and a half milligrams is kind of on the bottom end, and more than likely, she probably feel a little bit better somewhere between, let’s say, 3 to 7 milligrams somewhere in that range. She’s going to find the amount that really eliminates most of her symptoms and she’s feeling really good. So, anything else to add about that Dr. Davidson?

Dr. Davidson: No. Thank you, Angie, for your question. And we’re going to do other questions as part of the format with our podcast. And just like our other episodes we’ve had, we might talk about specific topics and maybe not questions but they’ll all be related around hormones and hormonal health.

Dr. Maki: So, until next time, I’m Dr. Maki.

Dr. Davidson: And I’m Dr. Davidson. 

Dr. Maki: Take care. Bye-bye.