Thank you for writing your post weighing the differences between creams and oral capsules. What dosing would be typical for a premenopausal woman with PCOS and amenorrhea (1-2 menstrual cycles per year) who is seeking to regulate cycles?

We often prescribe between 50 mg and 200 mg of bioidentical, sustained-release progesterone for women with a variety of hormone-related symptoms. For PCOS, a good dose would be 75 mg of progesterone. It is common for many women with PCOS to have irregular cycles, so the progesterone can help to restore a consistent monthly cycle. Depending on the symptom profile, the dose may need to increase over time, but 75 mg is a good starting point.

Download PYHP 080 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 have another question. This one we’re going to talk about PCOS. But it’s a combination of PCOS and progesterone. This question is from Sarah. Dr. Davidson, why won’t you go ahead and read it? 

Dr. Davidson: Sure. Sure. So Sarah sent us an email about a blog post that we had written, talking about the difference between creams and oral capsules for bioidentical progesterone replacement. So Sarah’s asking or actually saying thank you. Thank you for writing your post weighing the differences between creams and oral capsules, that would be for the progesterone. What dosing would be typical for a pre-menopausal woman with PCOS and amenorrhea having one to two menstrual cycles per year who is seeking to regulate cycles?

Dr. Maki: Okay, so this is a fairly common situation that we deal with on a regular basis, both with the progesterone, the capsule versus cream comes up a lot. Prometrium versus progesterone comes up a lot. I know we’ve talked about Prometrium on the past. Prometrium always comes in a capsule. That’s what you get from a big box pharmacy. That post that you wrote or actually that was a blog post. That creams versus capsules is pertaining specifically to bioidentical progesterone. Which one’s better? Everyone has a different opinion. Most of the time, you and I prefer to use proges– bioidentical progesterone oral capsules.

Dr. Davidson: And well, not all the time but it kind of depends on what the situation is, you know. We use creams a lot as well but I tend to use more the capsules with women that are maybe more perimenopause or a little bit older wheres sometimes I’ll use the creams with younger women or maybe even teenagers trying to, you know, work on those– that hormone balancing. But what’s interesting here with the Sarah is she’s talking about PCOS, so Polycystic Ovarian Syndrome, with amenorrhea, meaning missing periods. So, in a perfect world, do you know– you know, a premenopausal female will have a period every 28 days. So once a month, you know we get a period, but with PCOS that can create a lack of ovulation and what she’s referring to here which is amenorrhea meaning no periods. So she might be having one period a year, it looks like maybe even two periods a year. 

Dr. Maki: Yeah, right with. And I know we did a post a while back. I know you’re an did some writing about the different types of PCOS. Right. We don’t think of PCOS as just being you have it or you don’t or I’d say black and white diagnosis and we believe that there’s a spectrum to it. And you kind of name some of those types. Classic, classic is just that it follows the, you know, the textbook diagnosis of PCOS. The common type, which is maybe has some of the characteristics of a full-blown diagnosis, but, you know, maybe not as many of them but it’s still the most prevalent form of PCOS. And then there’s the concealed type which is not necessarily exactly PCOS, but they have some of the tendencies of PCOS. You can go back and look at that. I’m not sure exactly right now, off the top my head what number– what episode that is but it’ll be in the show notes. 

Dr. Davidson: Yeah, exactly. So PCOS, Polycystic Ovarian Syndrome. So you think well the ovaries much at must have a bunch of cysts all over them but honestly, really, and PCOS, not all women have cysts on their ovaries but they do have a collection of an imbalance between their hormones, between the androgens which should be the DHEA, the testosterone and then their reproductive hormones, which should be that estrogen and that progesterone and then you’ll see manifestations that go to the adrenal hormones and also all really very highly likely also exacerbating the thyroid hormones or a thyroid condition. 

So, but looking, you know with them, with Sarah, it is common with PCOS to miss a period here and there. Like when someone says, “Hey I haven’t had a period for four months.”, and they’re not pregnant you, and they’re not menopausal, you start to think okay there’s some kind of hormone imbalance, possibly some form of PCOS cuz PCOS like Dr. Maki was talking about is really an umbrella, where we kind of characteristic, we have these different characteristics where we kind of grouped it into three different profiles which, like you said, we have another podcast and am also I think I have some blogs on that too. But one– in that– in those blogs and podcasts, we do refer to using progesterone with PCOS because one of– probably one of the hallmarks in all classic common and concealed PCOS is low progesterone.

Dr. Maki: Yeah, right, yeah. Now granted PCOS as a diagnosis, especially the classic or the common there and even in the concealed, they might have an increase to their androgen so the DHEA and testosterone have to be, you know, have to be evaluated. And I’m sure that has already been tested, because she’s, you know, she’s asking about progesterone in the use of with someone that has PCOS. So I’d imagine that she’s at least gone to that level. We don’t know what those numbers are. She didn’t tell us what her PCOS or what her DHEA or testosterone is. But I would assume that either one or both of those is elevated.

Dr. Davidson: Just to interject, if you’re hearing some kind of odd like whining and moaning sounds, our dog Bob is chewing on his elk. I think it’s his elk antler or his deer antler bone. And. This is our first Aussie or Australian shepherd. I don’t know if they all do this but he talks all the time but it’s not like barking. It’s like moaning and whining.

Dr. Maki: Yeah. Well he’s chewing on a deer antler so I don’t blame him. You know. It sounds like pretty much fun.

Dr. Davidson: So. If you hear some whining in the background, it’s the dog and he’s very, very happy. 

Dr. Maki: Yeah. Well, he’s like our little podcast sidekick. So every time we come into our little home studio that we have set up, he is immediately on the rug at our feet. He gets a little bit, you know, a little bit short attention span. The bone helps a little bit but then the bone kind of gets him all riled up. So, I don’t know if you heard that or not but he was kind of growling at the bone here just a second ago.

Dr. Davidson: So sorry to be distracting with that but yes, back to Sarah, the progesterone and it looks like she’s specifically, you know, asking a little bit between the creams and the capsules and definitely with the PCOS we pretty much most of the time use capsules for the PCOS to try to get that cycle regulated.

Dr. Maki: Yeah, right. And now, dosing wise for a woman that is menstruating, right, that’s where the dosing does differ a little bit because too much can shut the period off, the right amount, could you know, which is why she’s asking, the right amount could initiate, you know, or help get her period started cuz like you said, low progesterone is kind of a hallmark of PCOS. So when you don’t have the period there, you don’t have that landmark to kind of, you know, because the period– what happens with the period over time when someone implements progesterone, when a woman starts taking progesterone, the changes to the period help you dictate what the right doses, if that makes any sense. Like I said, progesterone is one of those things for a woman that can make a woman start bleeding or stop bleeding depending on the woman and depending on the dosage. So the fact that there’s no period there, now granted, if she starts getting a period enough, you know, few months after start taking it then we know we’re on the right track. But figuring that part out in the beginning might be a little bit challenging.

Dr. Davidson: Yes, so just you know not that we want to make it you know this answer super complicated but we’d look at, you know a typical hormone profile, so we look at some of her you know the estrogen, the progesterone. Excuse me, I would definitely look at her thyroid function, and specifically the androgen. So we look to see, “Hey is that testosterone high? Is the DHEA high?” And if it is, there is one– we want have work on ways to try to bring those androgens down and there’s medication to do that, there’s supplements to do that, there’s lifestyle to do that, there’s nutrition to do that. So we want to look at possibly bringing down those androgens, but by adding in progesterone, it would buffer the testosterone and the DHEA because in PCOS, the testosterone specifically is like the leader of the hormonal chain. You know it’s higher so it’s gonna be, you know the leader of the pack. It’s gonna, you know you’re gonna see more of those symptoms of the higher androgen levels, for sometimes just adding in that progesterone buffers those levels, and then you see that period and then you also sees also some of the other symptoms that you might be seeing possibly with Sarah, and you know, start to eliminate.

Dr. Maki: Yeah, right. Now if there is even some, you know, some sleeping issues, certainly that would be something to take into consideration cuz oral progesterone is gonna definitely help with sleep. If there is any mood-related issues, irritability, frustration, you know, things like that, that’s more on the mental-emotional plane, progesterone is also helpful with that. So it’s more than just getting the cycle to return. It’s some of those other things that can definitely show up in PCOS that progesterone is gonna help with which will also help determine the dosing. I mean, just as a number, I would say somewhere between 50 to 100 milligrams. We’d probably start at 50 and then maybe increase it to 100.

Dr. Davidson: Yeah. Usually what I find in patients that come to see me that have PCOS and they have higher levels of androgens and they’re only getting maybe a period once every four months or once every six months, is we usually start anywhere between 75 milligrams of progesterone oral capsule at night. It usually ends up being right around 100 seems to be the most common dose and that dose bring those periods back. You know, if you can buffer some of the androgens, and then like I said, you know we wanna, we don’t want just, you know, one catch you know one thing fits it all. It’s not just the progesterone. We might look at it more, you know, looking at like I said this other supplementation, lifestyle, nutrition, but definitely like you’re saying between 50 to 100 milligrams with a 100 probably being the most common.

Dr. Maki: Yeah and we use 100 milligrams for a lot of different things, especially for a woman that’s in perimenopause or actually in menopause. A 100 milligrams is gonna be the place to start. And then you put that in motion for a month or two or a few cycles, maybe two to three cycles to see what happens if she is still menstruating or not. If she’s not then it doesn’t matter then it’s more if she’s actually getting sleep relief, if her hot flashes are in control and if she has her uterus, if she’s not bleeding, right, because the story changes a little bit once they go from perimenopause into menopause, because the progesterone oral capsules are in some ways intended to inhibit the growth of the uterine lining. So we’re actually trying to stop the bleeding at that point, where in this case we’re trying to initiate, but the dosing might be exactly the same which is kind of odd.

Dr. Davidson: Exactly. Sometimes, when we just start off with that 100 milligrams, women will get their period immediately within, you know, 10 to 15 days. So like,” I started my period” and I’ll say, “Okay, that’s great, go ahead and stop the progesterone.”, cuz I usually have women stop the progesterone while they’re on their period because we want that entire uterine lining to slough off and not have any hormones around trying to inhibit that. So I have it played stop that progesterone you know for that five days so your period and then restart it. And if they get another period two weeks later, then we know for sure that, that progesterone at 100 milligrams is too high, and then you back it down. Now, at the same time, we’re treating people as individuals, but we also want to do the blood work. So I also tend to keep an eye on those hormones so I get a baseline where their hormones are at before we start with the treatment, and then after we’ve kind of got things moving, rocking and rolling, then we redo the blood works so we can compare it to see what’s changed. 

Dr. Maki: Yeah. Right. Yeah. Now, testing for a woman that’s menstruating, now, she doesn’t have her period right now with the hopes of getting it back. That be a fairly obvious success if it’s able to return. In this context, the day she goes to the lab, it doesn’t really matter. But normally with progesterone, you want someone to go in what– usually what, day 20, day 21?

Dr. Davidson: Yeah. if you’re cycling and, you know not everybody is a perfect 28-day cycler, usually, I say, “Hey anywhere between you know like day 18, 19 to day 25.”. That way we can catch that perfect spot when the progesterone is supposed to be the highest in your cycle. But like you said, if you’re not getting a regular period every month, then you don’t know where you are in your [inaudible] called “cycle”. So then I just say, “We’ll go ahead and just get your blood work done.”. I, we can usually figure it out. It’s pretty easy cuz we’re not just doing the progesterone and estrogen. We’re gonna do some stimulating hormones that are getting, like the follicle stiffening hormone, the luteinizing hormone will give us a little insight into if she is actually cycling or what we need to do to balance that out. 

Looking at the testosterone and the DHEA, some of the thyroid and the adrenal function so we would have a lot more to look at cuz it’s not always perfect and it’s Murphy’s Law. Like I’ll tell them, “Patient! Hey go get your blood work done, you know, ideally if you can get around day 21 that’d be fantastic.”. And they go into the lab, they leave the lab and all of a sudden they got their period. I’ll say that just happens all the time.” Don’t worry, I can figure it out.”. So you don’t have to be so hardcore about it because it’s really hard to plan for that. But ideally, if you could get it and what you would consider the luteal phase of your cycle, that would be great.

Dr. Maki: Yeah. Right. I know you told some other stories too like women that haven’t had a period for while they go on vacation and they get their period right when they go on vacation. Like when they least expect or least want it to happen, it shows up at the, you know, in an opportune time.

Dr. Davidson: Or like in menopause there’s a little quote that’s like once you hit 12 months of no period, then you’re quote, unquote “postmenopausal” and they’ll hit like 11 and a half months and get a period. Its yeah, there’s all sorts of Murphy’s Laws out there.

Dr. Maki: Yeah. So now let’s talk about a couple of the other things, cuz I know you mentioned thyroid. You said there’s some other you know certainly diet, insulin plays a role in PCOS. PCOS is in some ways an insulin-resistant type issue. So intermittent fasting, keto, carb cycling and that kind of stuff needs to be kind of looked at a little bit. If your having, anyone that is dealing with PCOS, if you’re having some food issues, you know that– that needs to be, you know part of this process because the medications, whether it’s Metformin, spironolactone, progesterone, those will do a good job but they won’t, you know, they won’t fix the entire issue– entire situation especially if you’re trying to regulate a cycle with the hopes of getting pregnant. PCOS is the number one reason for infertility. That brings me back to the thyroid and how we address thyroid, in a context like this, because the thyroid can kind of reinitiate that female cycle.

Dr. Davidson: Cuz typically with low thyroid, just low hypothyroid in general, it tends to cause cycles to be longer. So when someone’s having a 35-day cycle, a 33-day cycle, and maybe it’s a little heavier you can say, “Oh, you know, there might be something going on with that thyroid, and the thyroid is upstream from the female reproductive hormone.”. So, instead of chasing your tail and saying, “Okay I’ve got it.”, you know, work on this estrogen and progesterone, you do want to step back a little bit, work on that thyroid function because then it’s just gonna go downstream and help balance that estrogen and progesterone. So, while, you know, somebody that’s not having a period every month, maybe once a year, the progesterone would definitely be great, but like Dr. Maki said is, “Hey we look at that thyroid function, make sure that that’s well.”. And then also, like Dr. Maki had mentioned about the insulin, cuz insulin is you know one of the only fat-storing hormones and if somebody has PCOS, they’re typically gonna have more insulin, which is gonna make it harder for them to lose weight cuz I’ll say well you know I do everything I can, I exercise, I try to eat right but I still have a really hard time losing weight. So it is kind of like he was saying is coming back and looking at lifestyle, you know nutrition ways to reduce down your insulin burden.

Dr. Maki: Yeah. And one thing that I’ve seen with some of the PCOS patients that I’ve had over the years is that they all are extremely disciplined. They try so hard to change their bodies but in some ways, they tried too hard. They push themselves physically and mentally a little bit too much. And I think that in those, particularly sensitive individuals that by listening to what everybody says, eat less exercise more, go on a diet and exercise your butt off. For those ones that are sensitive, it actually makes their situation worse. So now you see the insulin rise, you see the DHEA, the testosterone, continuing to go up. They don’t actually get improvement, they actually get worse over time. So those need to be, you know, go to yoga, go do some meditation, go for a walk in nature, go you know, take some deep breathing. Don’t try to exercise the situation away cuz it, you know really won’t work. And all of that aggressive exercise is really going to exacerbate all of those as you just refer to what we talked about as those primary metabolic hormones, insulin, cortisol, thyroid. Those three hormones dictate all everything else downstream from that. Now granted, we’re not gonna turn this into an endocrinology class. But, you know, like you’re talking the secondary sex hormones, estrogen, progesterone, even the DHEA and the testosterone, those are downstream from those other primary metabolic hormones. And it, you know, it just creates more and more dysfunction. So, if you’re dealing with PCOS, if you’re having some of these issues, you know, certainly having a good, it’s not just about the estrogen, or excuse me, the testosterone, the DHEA, there are other things that need to be looked at. And now, a proper plan can be put into place. That, you know should be able to a– to achieve the result that you want, whatever that might be. Just getting your cycle back or pregnancy or losing weight, or, you know, whatever they, you know maybe all the above you know. That’s often the goal of many of our patients.

Dr. Davidson: But, just like you know, Sarah’s asking here is that definitely with a PCOS case, we would use the progesterone capsules. I would find that the cream probably wouldn’t have the effectiveness that we’re looking for. Even though a cream bypasses the digestion, it goes right into the bloodstream and then you know it goes up very, very quickly, it just doesn’t have the effect on those you know trying to regulate that cycle, as well as I found the capsules do. 

Dr. Maki: Right. So hopefully that wasn’t too complicated, you know for a simple dosing question, but we wanted to give a little context because PCOS is complicated, and there’s a lot going on there. There’s a lot of hormones that are affected, and it’s in every case we’ve already stated, every case of PCOS is not exactly the same. There’s, you know– there’s a, you know plenty of shades of gray when it comes to PCOS. So therefore how you approach each one, how you’d approach the concealed type as we talked about it versus the classic, a bit quite a different and how they get there, even though they have tendencies of the PCOS, the classic is pretty hard to miss, the concealed are the ones that’s why we call the concealed because they get missed all the time. You know, so hopefully, that was insightful. Hopefully, you know something was, you know are able to take away some tidbits from there, but no more– more likely the, you know progesterone capsules are the way to go. Somewhere between 75, 100, you know 125 maybe even up to 150. In some cases, we even go up to 200. Usually, there’s no reason to go really any higher than 200 but if you’re trying to get a period that might be too much for a situation like this.

Dr. Davidson: Exactly and thank you, Sarah, for your email and for also you know reading our blogs and thank you, everybody, for listening to our podcast.

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

Dr. Davidson: I’m Dr. Davidson.

Dr. Maki: Take care.