Anne’s Question: Since moving to the high desert, I have to use very large doses of Bio HRT or bioidentical hormone cream, and it is still not getting blood levels up to where my doctor would like. I tried switching to the patch and the level dropped to less than half. This is all giving me terrible symptoms and impacting my quality of life. I am worried the high doses are harming me somehow. Can I just rub some DMSO on the skin prior to applying the cream or will that help?
Short Answer: This is somewhat of a complicated question to answer because it is based on the type of BHRT a woman is using. We do have different blood level targets for women using static dosing vs women who are using rhythmic dosing. When prescribing BHRT for a patient, we have some very general blood levels that we are trying to reach, but the woman’s subjective response is a much better indicator for dosing. How she feels is much more important than her blood level of Estradiol. In regards to DMSO, we don’t typically use or recommend this for women, but we do add DMSO to testosterone cream for men because they have more body hair.
PYHP 108 Full Transcript:
Dr. Maki: Hello, everyone. Thanks 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: Of course, this is audio so nobody can see anything but you and I are getting ready and we were having a little problem with our boom mic stand. It was not sitting at the table. You are getting a little impatient with me and then you end up fixing it which was great. As we are just starting, our dog, Bob is at my feet right now and he is upside down, chewing on like a little bone.
Dr. Davidson: It is so cute. It is so cute.
Dr. Maki: I am trying to stay focused on doing the podcast and he is upside down with a little bone in his mouth. It is too cute. We are back into podcasting land. We have a ton of questions to get to. We are just going to do it. I think we kind of for a while we were kind of doing a few questions per episode. I think it is a little bit better, a little more focus by doing just one question per episode. It is also easier to figure out a title for it, that is more specific to what the question is about. This one is from Anne. So why not you go ahead and read the question.
Dr. Davidson: Now he just got up and you shake it around. All right. This question is from Anne. Of course like we always say, we change everybody’s names and any kind of pertinent information just for privacy protection. We kind of renamed her Anne. From Anne. Since moving to the high desert, I have to use very large doses of Bio HRT or bioidentical hormone cream, and it is still not getting blood levels up to where my doctor would like. I tried switching to the patch and the level dropped to less than half. This is all giving me terrible symptoms and impacting my quality of life. I am worried the high doses are harming me somehow. Can I just rub some DMSO on the skin prior to applying the cream or will that help?
Dr. Maki: Yeah. This comes up a lot, people are worried about absorption. DMSO is one of the rhythmic dosing protocols we use for men. We do add… The compounding pharmacy we use does add DMSO to the cream. They could add that to any cream if they wanted to. For those of you that do not know, DMSO is a liquid compound that helps to pull things. It is a sulfur-containing compound. It helps to pull things across the skin barrier which can be good and bad depending on what you have on your skin. If you are around a lot of toxins and things, a lot of chemicals, you do not want to be around DMSO in those chemicals, but in order to get things to go across the skin barrier and increase absorption, it can be very useful for something like that.
Dr. Davidson: Yeah. They have used it in some exercise or physical therapy as a sports massage. I think they even use it in horse racing with horses from a horse massage. So it is not toxic, but it is a compound. We have used DMSO often with men putting it, like Dr. Maki mentioned, in the testosterone just because men tend to have a little bit thicker skin than females. What I found…
Dr. Maki: And more hair.
Dr. Davidson: And more hair, but what I did find which was interesting, working in the high desert, were the men… Because we live in Washington now, but we have an office in California and Southern California and then we had worked in the high desert for ages. I did find that men did need the DMSO in their testosterone to absorb it to cross that skin membrane. We did that and then I did… Honestly, I do not have a whole lot of women having the compounding pharmacy put the DMSO in their hormone cream. I have a couple of women, but it is, out of everybody, I could probably count them on my hands. I would say for Anne or anybody thinking about this, you would not want to necessarily go buy some DMSO online or something, and then put that on and then put your cream on. You really would want to have the compounding pharmacy mix that together just because of the titration in the doses there.
Dr. Maki: Yeah. This kind of issue comes up a lot. She is saying very high doses, but she does not say what the very high doses are. With a question like this, she is using bioidentical cream, assuming Biest, you didn’t exactly say what that is, but we have to assume that it is a very high dose, but according to who? Right? According to her, according to her doctor. We talked, just a few episodes ago, about the Vivelle Patch. We are not big fans of the patch. If she was on the patch for a while, going back to bioidentical hormones, a transdermal cream, she is going to need a lot higher of a dose. The patch is not going to work that well.
Dr. Davidson: Well in her question, she says she added the patch. She just switched to the patch and the levels dropped being on the patch. The thing with them, I would say if we are just talking about the patch and testing, is for any kind… the Vivelle Patch and Estradiol Patch you put on twice a week. Let us say I put on a patch this morning and then I go get tested this afternoon. Of course, it is going to be very high, but let us say I put a patch on this morning and I wait a couple of days, maybe the day before I am supposed to put on my next patch, and then test then, it is going to be a lot lower because you have to change them twice a week. So there is going to be some variability throughout the week. The idea behind the patch is to release this level dose of estradiol, but I find all the time, as soon as you slap that patch on, the levels go up and as it wears off and goes down, it is time to change the new one, the levels are low. I would say it really might even come down to a testing issue, same with her cream. Is she testing right after she puts on the cream or twenty-four hours after she put on the cream?
Dr. Maki: Yeah, right. I mean certainly, we are trying to get a menopausal woman that is using transdermal cream to a certain level as well, but the symptoms tend to dictate more than the blood level. If you are trying to chase like you said, a lot of variables when it comes to lab testing. Lab testing is good whether you are doing saliva or blood or whatever. Which is also we do not know what kind of testing she is doing. If she is doing saliva…
Dr. Davidson: Urine.
Dr. Maki: Urine… It could be all over the place, and you are right at that point. It does come down to timing. When is she applying the patch? When is she having the test done?
Dr. Davidson: Or the cream, and then when is she having the test done?
Dr. Maki: Yeah, right. In some ways, this may be even a good question to even do because there is a bunch of information that we do not have. We are kind of speculating, but it caught my attention because this is a high desert. Vegas has a high desert. Utah has a high desert. Arizona is a part of that. It has a high desert. I think New Mexico. I think there are a lot of sections of the Southwest that are considered to be a high desert. What does that mean? For people that are not aware of it, that means really hot temperatures in the summer, very low humidity that can throw off a woman’s thermal regulatory centers, and make it kind of compound the hot flashes and night sweats that go along with menopause.
Dr. Davidson: Yeah. I think another reason why we like this question was it was talking about testing. For every doctor, this is like a craft. This is like art. It is a dance. Everybody is a little bit different. Doctors that prescribe bioidentical hormone replacement creams, therapies, whatnot. Everybody has a little bit different technique on how they do that, but I do think with testing, it is good to test. We always test hormones. A lot of doctors do not even test the hormones. They just go by the symptoms. Of course, the symptoms are super important, but pairing that with the blood testing or some kind of objective data, I do think is important. Most doctors, I would say… I just want to speculate here, but I would think that she is probably doing a blood test. If you think about the creams, the hormone creams especially the Biest which has the estradiol and the estriol in it, it is so amazing. They are so great. They are bioidentical. They are very gentle, but they do not have a very long half-life. Let us say Anne put on her hormone cream at night before she went to bed because a lot of times we have people put on their Biest cream, their hormone cream twice a day. She put it on at night and then she goes to the lab twelve hours later in the morning, but she does not apply her cream, then, of course, it is going to be low, but let’s say she got up in the morning, slept on her cream and then ran right down to the lab and they did not have to make her wait like they always do, to get a blood draw. She had her blood drawn thirty minutes after she applied her hormone cream, then yes, it would be falsely elevated. It is trying to find what levels you want to see, and when you want somebody to test after they have applied their cream.
Dr. Maki: Absolutely. Yeah. So the timing of when you apply your hormones to when you have your testing done, you want to create some sense of consistency there so you can see the changes before and after, but as you said too if it has been twenty-four hours since you put on your cream…
Dr. Davidson: Or even twelve!
Dr. Maki: Or even twelve. The numbers are going to be low. You are going to see an artificially… Now granted we are trying to increase… For a menstruating female, the hormone levels are kind of literally, they are cycling, they are oscillating over the month. Estrogen peaks on day twelve. Progesterone peaks on day twenty-one.
Dr. Davidson: For menstruating females.
Dr. Maki: For menstruating females. Then those peaks kind of just flatline. So the levels for a menopausal woman are just basically… The bar is really low and all we are trying to do in this context… What she is doing, static dosing is just raising that flat line. Let us say I met up, what would you say is common on a blood test, a really common estradiol level?
Dr. Davidson: Are you saying what you would like? What would we like to see?
Dr. Maki: No. Let us say hypothetically before a woman is on hormones.
Dr. Davidson: You mean as a menstruating female?
Dr. Maki: No. In menopause.
Dr. Davidson: A non-menstruating female, a menopausal female, she is probably fifty-one years of age or plus, give-or-take. Her ovaries have ceased to function. Of course, they are producing very low amounts of estrogen and progesterone. Technically, I do not like to do total estrogens when I am checking the blood work. I like to do the estradiol, but if in a menopausal female, ovaries are not working. They retired. They decided to leave the scene rightly. It would be less than thirty-two. It would be almost non-existent in the bloodstream.
Dr. Maki: Yeah. Right. That is why I wanted you to say it. Most labs can say less than thirty. Some labs will quantify those say sixteen. They will say nine. They will say five. Anything less than thirty is technically a menopausal number. The next question I have for you when you prescribe hormones for women, what blood level are you trying to get their hormones to once they are on a prescription?
Dr. Davidson: Now that is a little bit of that art and that dance. Every female is a little bit different. Some women just need a little bit of estrogen to kind of help them feel better, and some need a whole lot, but if what we like to do is we like to have the females put on their hormone cream in the morning, and then have their blood work done four to six hours later. That means every time we test their blood we can see we have a very consistent timing and when they have applied their dose to when they’ve had their blood drawn then over time we can see where their levels are at. Ideally, let us say she put on her hormone cream in the morning, went down, got her blood work done about five, five-and-a-half hours later, and like I said anywhere between four to six hours later. I like to see it right around eighty.
Dr. Maki: Yeah, right. Yeah. I was going to say about seventy-five would be a…
Dr. Davidson: Forty to eighty. Sometimes people are okay at forty-sixty, but eighty I would say more consistently.
Dr. Maki: I would have said seventy-five. We are very close in that range. Honestly, that is not very common. It is a little challenging to get it to even that high. Like she says here in the question. That her doctor was trying to get a certain blood level. We try to do that as well but as long… And she is having symptoms. Her blood level has dropped. She is having a lot of symptoms. That means there needs to be some kind of a dose adjustment of some sort, which is what I think she is getting at, but at the same time, she is worried about taking more hormones that is going to negatively affect her in some way. What are your thoughts about that? Granted we do not know how much she is taking. What is your thought about… Is it dangerous for her to take more?
Dr. Davidson: I would not say it is dangerous if she is not absorbing it. Let us say she is putting it on, then going to the lab to get her blood drawn four to six hours later, and it is still really low, then you raise the dose. She is not absorbing it. Then maybe consider talking to the pharmacy about not just DMSO. There are other different bases and hyper. I mean they can do anything. There are so many different bases to change the cream to. We always tell our patients to put that hormone cream on their inner thigh because for females it is very soft, usually, a fatty area there because hormones are all fat-solubles. We like to put it on something that has got a little fat there, but it is very soft skin. It can penetrate a lot easier than if somebody were putting it somewhere else.
Dr. Maki: Yeah, right. We have them do it, like you said earlier the half-life of estrogens are relatively pretty short. We always have them do it twice a day. She does not allude to the fact whether she is doing it twice a day or not. If she is doing the patch, she gets a nice bolus of hormone right away. Then like you said, you kind of tapers off, but with transdermal cream, we always want them to do it twice a day, especially if they are having lots of symptoms. It is almost essential what they put on in the morning. Let us say six, seven o’clock after their shower, ready for work or whatever it is. They put their cream on then. Then in the evening, as they are getting ready for bed, they are going to apply their cream again. Whatever they applied in the morning, gets them through the day. Whatever they applied in the evening, gets them through the night. Of course, we are always a little bit more prone to having… making sure that they are sleeping well because that is important. We might have them even apply more cream at night, so their sleep stays undisrupted because that is a really big issue in menopause. Women do not… I am probably preaching to the choir for the women that are menopause here. They all know that sleeping is kind of a precious commodity, but that is kind of the point. That is why consistently they need to be taking it twice a day. If they take it every twenty-four hours those blood levels are going to go up once they put it on as you said. Then by the time the next day comes around to reapply, their blood levels are going to be pretty much a bottom down. It is almost like this. You are starting over every twenty-four hours almost if you only do it once a day.
Dr. Davidson: Yeah. I think actually, that is exactly as I would say. If she was going to test, put it on at night and then sleep through the night. Get up in the morning. Get ready. Put on her cream and then maybe go in around lunchtime. Then have her blood drawn. Let us say it is still low. Those levels are low. Then that would warrant along with her symptoms, we got to raise the dose or maybe change the ratio, which could be a whole new topic itself.
Dr. Maki: Yeah. When it comes to dangerous levels of dosing, dangerous levels of hormones, I think she is kind of looking at it the wrong way now granted. We use two different philosophies when it comes to dosing hormones. We use static dosing which is what she is doing, which is what the majority of women do, and there is also rhythmic dosing. A lot of that comes into play. The dose comes into play when a woman still has her uterus. I am assuming that Anne probably still does, just assuming that she has her uterus. We do not know for sure. There is a certain point if you keep giving a woman estrogen, she is going to have some bleeding trouble, more than likely. They know that is also why we always recommend progesterone. The progesterone is there to inhibit any bleeding, so you do not have any unpredictability that way, but there is a certain threshold like you said just a few minutes ago. Every woman that threshold is a little different. What is a lot for one might not be a lot for another woman, that is why you can not speculate. I had another question that came in a few days ago and was wanting to know if 3 mg was the right amount for that particular woman. It is hard for me to say without having any background information. You do not know if 3 mg is enough, or maybe they need five. Maybe they need seven. Maybe they need ten. It is tough to say until you kind of gradually titrate a woman up. The symptoms will kind of tell you where their dose kind of needs to be.
Dr. Davidson: I agree. I would say for Anne or anybody else out there with similar questions, do not be worried about the level of the dosing. It is more about the symptoms and then also looking at the blood work, because if you are taking a certain dose, and then it is not showing up in your bloodstream, then you need to raise the dose. Now just to kind of really take a tangent out there. It could also be the pharmacy that she is using might be using a different filler that does not absorb as well as maybe the pharmacy she was using elsewhere. It would not even have to be about humidity and heat and location. It is really about you know the pharmacy she is using, but if she is using the same pharmacy because a lot of compounding pharmacies can send to different multiple states that she might have just moved and kept the same pharmacy, then that could just definitely be an environmental factor. There are a couple of really interesting kinds of thoughts about this.
Dr. Maki: Yeah. Sure. Yeah. She is trying to increase absorption, but she is not addressing what I think the issue is, not worrying so much about the blood levels. Sure, symptoms tell us the blood level is not high enough. The blood levels are important. The labs we do. Labs all the time. We always want to track those numbers to see where things are and where they are heading and potentially to avert any issues if they come up based on those blood levels. A lot of times, I just had one the other day. She came back. She just turned sixty. Her estradiol came back at four hundred and twenty-seven. Okay. All right. Something is off with that.
Dr. Davidson: A little high.
Dr. Maki: A little off. I think at that time, her dose was 5 mg per gram of Biest 80/20. There is no way that 5 mg of Biest is going to create four hundred and twenty-seven on an estradiol level. It is not possible. I mean you just see a number like that. You know that it is either an error or she applied her cream right before she went to the lab. Sometimes you look at the labs to see what time they did it. The time the labs were collected. Like you said earlier, based on when they applied their cream. Sometimes women will rub it on their forearms or rub it on their wrist, kind of like the rubbing in perfume. That is automatically going to skew those numbers. I just had to wait a week. She went back the following, whatever it was Tuesday, whatever, and their level came back at like fifty-eight, which is kind of like right in that. That kind of stuff does happen quite a bit. You have to kind of take those lab numbers with a grain of salt and then look at the patient and then say, okay. What is going on here? Then the dosing can be adjusted accordingly based on those two things: the objective data and the patient.
Dr. Davidson: Exactly.
Dr. Maki: Yeah. Do you have anything else to add about this one? As I said, we are missing some information, but it is, at least for you and me, it is kind of a nice one to speculate on because she is thinking of it in one way, that it is an absorption issue and I do not think it has anything to do with absorption because we have had a lot of women on cream and their absorption is usually pretty darn good across the board. Would you agree?
Dr. Davidson: Oh, yeah. Absolutely. I definitely would not have her go by DMSO and put that on with her cream just on her own. You got to talk to the pharmacy and maybe have them put that in there or change the base that they are using.
Dr. Maki: Yeah. More than likely it is a dosing issue. Do not be afraid. Do not be afraid to raise that dose, especially if you are having symptoms, because your body will tell you when it comes to hormones. Believe me. I am not a woman obviously, but you know the woman’s body will tell you when you’ve had enough estrogen or if you have in some ways if you have too much. It will tell you one way or the other and hot flashes. I am assuming she is probably having some hot flashes. That is a perfect indicator of not having enough estrogen. I know you always say that estrogen is the perfect hormone. It is the best hormone there is.
Dr. Davidson: It is amazing.
Dr. Maki: Yeah, right. That is what makes a women a women. The more of it they have, the better they feel. I think that even the tone of her email is a little bit more fear-based, where she is afraid of the estrogen as opposed to it being an empowering hormone in some respects. Anything else to add either about testing or dosing, anything like that?
Dr. Davidson: No, this was great. Thank you, Anne, for sending in your question. Thank you everybody for sending in your questions and listening.
Dr. Maki: Okay. Until next time. I am Dr. Maki.
Dr. Davidson: I am Dr. Davidson.
Dr. Maki: Take care. Bye-bye.