Alexis Question: 

Hi there, this forum is fabulous. Thank you. I am so confused with dosing. How much is one gram of Biet in mL – milliliters. So confusing. I use a one mL syringe. One mL is a lot of cream. It is an eighty-twenty ratio and I will split the dose. Reading that your recommended starting dose is three milligrams, how much exactly is that in cream in terms of milliliters or MLs? That cannot be three MLs, that would be three syringes. Sorry to be daft. I have tried to find the answer on Google but nothing is making sense to me. Maybe that is why I need bioidentical hormones. Anyway, Help. Thank you, Alexis.

Short Answer: 

1 gram is equal to 1 mL.

A BHRT prescription can be written in either mg/gram or mg/mL. For example, when we call in prescriptions to a compounding pharmacy, let’s say the Biest prescription is 3 mg/gram with an 80/20 ratio. This is the same as 3 mg/mL with an 80/20 ratio. The instruction we give the patient is to apply 1/2 gram, twice per day. If the patient is using a Topi-Click device, 1/2 gram is equal to 2 clicks. We like to have the patient apply 1/2 gram because they have to apply much less cream to the skin. We always recommend women apply their Biest to the inner thigh. We don’t recommend applying Biest to the arms, forearms, wrists, abdomen, or vaginally. If the patient is having any vaginal dryness, then we will provide separate Estriol (E3) prescription that can be used vaginally. We don’t like to have patients apply Estradiol (E2) vaginally, especially if they still have a uterus.

PYHP 100 Full Transcript:

Download PYHP 100 Transcript

Dr. Maki: Hello, everyone. Thank you for joining us for another episode of the Progress Your Health Podcast. I am Dr. Maki.

Dr. Davidson: And I am Dr. Davidson.

Dr. Maki: So it is the middle of summer, enjoying some beautiful weather.

Dr. Davidson: Gorgeous.

Dr. Maki: It is a little hard to get into the podcast room and actually sit down and record some of these. You know, summer gets a little distracting. But nonetheless, we are here. Actually, some questions came in recently that were really good. Good in the fact that they are the ones that come up a lot and we figured that these would be good to talk about.

Dr. Davidson: It would be helpful to the listeners. Should we just go ahead and start reading the question?

Dr. Maki: Yeah, let us dive into this. What is the name of the first one?

Dr. Davidson: Yeah. We always change the names of the questions, you know, just to respect the privacy of our Progress Your Health community. So this one, we changed to Alexis.

Dr. Maki: Why is it Andrea and then you said, Alexis?

Dr. Davidson: I like the name, Alexis. But I like the name Andrea too, but I like Alexis.

Dr. Maki: Yeah. Okay. Alright. This person, we will call her Alexis.

Dr. Davidson: Alexis. So do you want me to read it?

Dr. Maki: Go ahead.

Dr. Davidson: So again, this is from Alexis. “Hi there, this forum is fabulous. Thank you.” Well, thank you right back. “I am so confused with dosing. How much is one gram of bias in ml- milliliters. So confusing. I use a one-ml syringe. One ml is a lot of cream.” She is right. “It is an eighty-twenty ratio and I will split the dose.” So this was actually from a reader from one of our blog posts. “Reading that your recommendation starting dose is three milligrams, how much exactly is that in cream in terms of milliliters or MLS? That cannot be three MLS, that would be three syringes. Sorry to be daft. I have tried to find the answer on Google but nothing is making sense to me. Maybe that is why I need vials.” Oh, so she is so cute, funny. Anyway, “Help. Thank you, Alexis.”

Dr. Maki: Yeah. We get a lot of questions like this about and dosing comes up all the time. There is this mystery about dosing because this is where the art and science kind of cross paths a little bit. There is certainly a science to it but the art comes in the dosing. That is the part that I think, you are the kind of the master of that. You know, all women have different lives, different physiologist, different genetics, different lifestyles. They cannot all have the same dose. We see a trend of these women asking us questions. We see that there is a very specific trend in their dosing they get from doctors across the country. It is usually always on the underdosing, or what we would consider pretty much on the underdosing side. Now, there are a lot of factors that go into a dose. She states three milligrams. If you and I had to pick the most common starting point, we would say for most women, at least mine is anyway. Mine would be three milligrams as a starting dose for most women.

Dr. Davidson: Exactly. So, Alexis, she wrote this in as an email, as a question. So she had read a blog post we had written and we had talked about three milligrams as kind of being sort of like an average dose that you would start with. As Dr. Maki said, everybody is different- age, goals, whatnot. Of course, I always tell patients too and we are starting out is sometimes less is best as we can always start off really low and work our way up as opposed to doing too much of a good thing and then you got to back yourself down. But we wanted to just clarify because we get a lot of questions like this and a lot of people, a lot of the readers, a lot of the question askers, they forget to put in their dose. I think that is probably like number one, that is important. But when you are looking at so many aspects of what is bias, what is a milliliter, what is a gram, what is the eighty-twenty ratio even mean? They sometimes forget what dose is on so we did go back to Alexis and ask her. Thank you for the information in the question, but what specifically dosing are you getting and it was 1.25 milligrams per ml.

Dr. Maki: Yeah, right. Which again, is a common, but she left that part out on the first email. That is what happens most of the time. They ask us about their dosing but they leave out the actual, what we would consider, you know, the dose or the concentration. The eighty-twenty is just the ratio of the two hormones that are in there, the estradiol and the estriol. Most of the time, eighty percent is the estriol and twenty percent is the estradiol. So you will see often the parentheses if you have a prescription. It will say a certain milligram number, in her case 1.25 mg slash ml- milligrams per milliliter, that is her dose. Then the ratio is the eighty-twenty. Some do fifty-fifty. We have done kind of almost every combination you can do.

Dr. Davidson: That is the cool thing with compounds as you can do ninety-ten, you can do anything you could conceivably think of to match that individual.

Dr. Maki: You could do straight estradiol, you could do straight estriol. You do fifty-fifty, you could do seventy-thirty. This is what people need to realize is that that is the beauty of bioidentical hormone replacement and compounding, in general. It is because those prescriptions are tailored by a doctor to a particular patient. Not the cookie-cutter approach where you have three options to solve your problems. Honestly, what happens most of the time if those options are not viable or effective. You are kind of left with no options left. That is why we answer these questions. That is why we started doing it in the first place because we noticed that this kind of information really is not online anywhere. Just like she said, she tried to Google it and she could not find it. Something is so simple to realize that, not to criticize her in any way, but to make this understandable in a way that to realize okay milligrams and grams are the same things.

Dr. Davidson: The milliliters actually to answer Alexis’ question. A milliliter is a gram.

Dr. Maki: Yeah, right. Sorry. So she is getting confused because when we call in a prescription to a pharmacy, we always do it in milligrams per gram. Now, that might be determined by the pharmacy, it might be determined by the pharmacist. It might be the dosing vehicle that they use, whether they are using a Topi-CLICK. In this case, she is using a syringe. That is the problem. Maybe that is the downside. There are so many different options that it does get really confusing, not only for practitioner pharmacy but also for the patient because every practitioner does it a little bit differently than the next.

Dr. Davidson: Yeah. As a patient, you know, it is different now. I remember my grandmother, she had a lot of prescriptions. She would show me all the prescriptions and she just had this color pill and this pill, and I take this one at this time and this one. I am like, “Well, what are they?” She did not know. The doctor prescribed them for her and she took them according to what the doctor told her. Which is fine, she trusted her doctor. But now, I think it is important for that patient… education to know. “Okay. What am I taking? What exactly am I taking? How am I taking it? What am I taking it for?”

Dr. Maki: Yeah. I do not know where I heard it. I was watching some kind of presentation. Maybe we were doing like CE lecture online or something and they are talking about how… Like, let us say, nineteen fifty. You got the Norman Rockwells, the style doctor, family doctor, where the doctor was the center of healthcare. So everything kind of revolves around the doctor. Now the patient is in the middle which probably the way it always should have been. The patient should be in the middle then all these other practitioners and allied health, and everything around the patient. But at the same time, those other people that are around the patient, unless there is not a lot of communication necessarily. So now the patient has to become their own advocate and try to figure some of these things out because there are not really great resources to be able to explain, whether you were talking conventional or functional medicine. You know, sometimes, it is challenging to get some of these simple answers. These simple detailed answers to get those answers.

Dr. Davidson: Yeah, exactly. Like with Alexis, she is going on Google trying to figure out, “Well, I am on an ml. Is it one ml, what is the grams.” Like you said, in some ways, yeah, we know this because we have been doing this for so many years. But I can understand when someone is looking at it. “Well, an ml, is that a gram?” and “Yep, Alexis, that is a gram.” So right now, she is on 1.25 milligrams per gram or 1 ml of her syringe is going to equal 1 gram. I hope this is not further confusing. To further educate, so her 1 ml syringe is equal to 1 gram
which that entire 1ml syringe is equal to 1.25 milligrams of bias.

Dr. Maki: Right off the bat, if her syringe is only 1 ml, that seems a little odd to me. It must be like almost like an insulin syringe. It must be a very skinny syringe.

Dr. Davidson: There are some 1 ml’s that are thicker than the insulin syringes but they are really small.

Dr. Maki: Yeah, right.

Dr. Davidson: Or the 3 MLS.

Dr. Maki: So that means that would be basically a one application. You will be going through a lot of syringes to be able to get through a month’s worth. So we do this. Let us say the most common these days is a Topi-CLICK. That is a little device, looks like a deodorant dispenser. A little click on the bottom, you turn it. What we always tell our patients, two clicks is equal to one-half gram. In this case, two clicks would be equivalent to one-half milliliter. Okay? Gram and milliliter are basically the same things. So when we write the prescription for a woman, we understand, more so because you figure this out a long time ago, that one gram is relatively a large amount of cream. So we increase the concentration. We always want them to apply their bias cream. We always want them to apply it twice a day. So she does one-half gram or one-half milliliter in the morning, and then one-half milliliter at night. So total for the day, she is using one gram total. But now she still gets to whatever the concentration is, in this case, 1.25 milligrams, we would probably never write a prescription for 1.25 milligrams. It is just too low.

Dr. Davidson: Actually, I used to do that a lot. I do that a lot, the 1.25 because half of that is 0.625, which is a very very small dose. But that is a really good starting dose in somebody that might be in perimenopause. There may be having some night sweats at night, there is some hormonal stuff going on with their periods, that doing a very low dose. Now granted, somebody that is in menopause that just got off Premarin or something super strong and not bioidentical. Yeah.1.25 milligrams a bias, would be like lotion. It would be nothing. It would do nothing. Like Dr. Maki had explained earlier, it depends on the individual.

Dr. Maki: Exactly. Like if they are in perimenopause, they are still having a period or maybe even a sporadic period. You give them too much bias, you give them too much estrogen and it is just going to make all of that worse. So you are right. In those particular cases, you would want to be very… Or if their menstrual history was fairly recent, you give them too much and their periods just going to come right back. Which is not a problem. It is not an emergency if their period comes back. We just want the bleeding either to not be there or we want it to be somewhat controllable, or at least somewhat predictable. The bias dosage, not the ratio. The ratio is kind of just a standard thing. You can pick any ratio you want. But this would also be, like in that woman that is in perimenopause, you would not want to give her anything stronger. You would want to give that woman a fifty-fifty ratio. You want to keep her at the eighty-twenty. So more estriol, less estradiol. Then you start out low, as you said, then you can gradually titrate that dose up over time as she has been able to tolerate that from whatever issues might come up,

Dr. Davidson: Alexis had mentioned in her question here that she was going to split the dose, which is a great thing to do. In our blogs, that is what we always talk about. The bias, the bioidentical hormones are awesome, they are amazing. But really the bias does not have a very long lifespan. So if you put it on in the morning, a lot of it is pretty much out of your system by the evening time. You are not going to have an effect of the estrogen or the bias by the evening time. So splitting it up is a great idea. But for Alexis, splitting that 1.25 milligrams per ml or 1.25 milligrams per gram in half, that would end up being .625 milligrams in the morning, .625 milligrams in the evening. That is still a very low dose, but that might be reasonable for her depending on like I said her age, her menstrual status, and her goals.

Dr. Maki: It is really a tough spot for a woman to be having hot flashes and then having a period at the same time. It puts the practitioner, and the patient too in a tough spot because you know that they need more estrogen but if you give more estrogen, it is going to make that bleeding a little more uncontrollable. So that is a challenge. When their period is done, they have not had one for six months or a year and they are having hot flashes, that is relatively an easy thing. Because now you can be a little bit more… I would not say aggressive, but you could increase that dose a little bit more. When there is still some bleeding going on, it kind of ties your hands a little bit.

Dr. Davidson: So just to clarify what Dr. Maki is saying about making the bleeding more excessive or whatnot, is estrogen loves to grow things., especially the uterine lining of your uterus. So if that lining is thick, then that can cause heavier periods, more frequent periods, chronic spotting. So that is one thing you have to be careful of in a menstruating female or even a woman with their uterus when your dosing estrogen, is that fine line. You want to give just enough to get the effects that we want. But at the same time you do not want that line to get too thick and then like Dr. Maki was saying was exacerbate the periods.

Dr. Maki: Yeah, right. Now we have talked about it on a couple episodes ago. We do rhythmic dosing. Rhythmic dosing is where you actually, a woman has her uterus, she is going to get her period back on purpose. With that dosing schedule, we are trying to specifically make their period return usually every 28 days. Now sometimes, a little earlier than that. But now you can control that and their dosing levels can go much higher which obviously has some benefits instead of having to stay in the in the lower dosing range.

Dr. Davidson: Now, some of you who are listening are probably chuckling a little bit, or maybe even a little horrified. Because there is not a lot of menopausal women that want to get their period back, but there are some that do. It depends on the goals. We can do rhythmic dosing or we are going to do static dosing. So yeah, just to confuse you more, there are so many different things you can do out there with the compounding and the bio-identical hormones. It is actually quite amazing.

Dr.Maki: Yeah. As you said, it really depends on the woman’s situation, what she is trying to accomplish. Most of the time, as we have said before too, that static dosing, same dose every day. That is what we are talking about, static dosing, eighty-twenty bias progesterone, all that stuff, progesterone at night. Hopefully, she did not mention anything about progesterone. So hopefully, she is taking progesterone as well. She should be taking, and we would recommend an oral form of bioidentical progesterone.
Again, as we said, to offset the growth of that uterine lining. The number one rule that we follow, we always have followed this rule, is you never give a woman on a post estrogen. A woman can take on post progesterone of almost pretty much any menstruating age, a woman can take progesterone. But as long as a woman still has her uterus, or even if she does not, we still do not give them on a post estrogen. As you said, estrogen likes to make things grow and it needs to have that balance to the progesterone. So there is that consistency over time.

Dr. Davidson: Exactly. So for Alexis, to summarize, I love the math questions just because I love math and I love numbers. So yeah, definitely, her eighty-twenty ratio, 1.25 milligrams of bias that actually equals, if you know, eighty percent estriol, 1.25 is one milligram. So a total of 1.25 milligrams per ml or gram, she is getting 1-milligram estriol with .25 milligrams of estradiol. As Dr. Maki said, eighty-twenty is probably one of the most common, although ratios out there for bias only because estradiol is so strong that it is nice to have that estriol which is more gentle, can kind of help buffer some of the negative side effects of estradiol. So they really work well together. But like we had mentioned, you can pretty much do any ratio you want to with a compounding pharmacy.

Dr. Maki: Yeah, and with a dose of 1.25 milligrams, you know, talk to your practitioner about that. But instead of trying to add more MLS or more cream, all of that needs to happen is the concentration that 1.25 milligrams just needs to go up. So maybe goes up to 3 or it goes up to whatever amount that is. But then, how much you apply, in our case, our default dose, our application is always half a gram, twice a day. Or on a Topi-CLICK, two clicks, twice a day. So that way they, as we stated earlier, they are not having to apply so much cream. But we can make the dosage or the concentration anything we want gram. That way, it does not get out of control, they do not have to be rubbing that cream for twenty minutes and it is able to absorb into the skin relatively easy. When a woman is up, ready for a refill of that prescription, now it can be adjusted relatively easily. Again, usually, a starting dose, as you said, you might start a woman at 1.25 milligrams. But she is not usually going to end there. It is going to be titrated up over time depending on how she responds. That is the beauty of the bioidentical hormones. You can change that number to whatever you want and it is very patient-centered. That is the best part.

Dr. Davidson: Yes. So if any of you have any questions about your dosage, or prescription, or conversion with the different dosing, because there are creams, there are capsules, there are strokies[?], there are transvaginal applications. There are so many different ways to do this that if you have any questions or you are unsure of, know that you are not alone because this stuff is confusing. When I first started out doing bioidentical hormone replacement in two thousand and four, I mean, yeah, the math was tough. Trying to figure out that math is tough and trying to explain it to somebody is even tougher. Because sometimes, we are not always doing it in a layman’s terms. But if any of you have any questions about dosing, or ratios, or milligrams, or grams or milliliters anything, definitely reach out.

Dr. Maki: Yeah, you can send us an email. We cannot answer all of them, we try to get to as many as we can. It is just impossible to answer all of them. But you can send us an email at [email protected]. We use that specifically for blog and podcast type things just so we can kind of track that and understand what is coming in. We appreciate it. We appreciate the feedback. We appreciate that you know, like in Alexis’ case that she finds it helpful, what we are talking about, right? That gives us in some ways the confirmation that we need to keep doing more of it because people are getting answers to these hard to find questions. Do you have anything else to add or we can bring this one to a wrap?

Dr. Davidson: We can wrap it up.

Dr. Maki: Okay. Until next time. I am Dr. Maki.

Dr. Davidson: And I am Dr. Davidson.

Dr. Maki: Take care. Bye-bye.