Lisa’s Question: 

I have recently started taking 50mg of progesterone and bi est cream 50.50 it’s been 3 weeks. Experiencing hot flash at night and seeing very little improvement in my sleep. Does it really matter where we apply the bi est cream, I was told inner highs, I feel I absorb it better in the inner arm, Also could the dosage be too low, I cannot tolerate more than 50mg of progesterone. These are compounded in pharmacy.

Short Answer: 

We recommend that our patients apply their cream to the inner thigh. In some situations, the back of the knee is fine, but most often the inner thigh is the best place. We do not recommend applying the cream to the upper arm or forearm, as this can skew blood testing results.

PYHP 075 Full Transcript:

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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 I’m not sure if you can tell or not, but we actually have some new podcasting equipment. We upgraded our microphones, we got this piece of podcasting equipment for all the tech geeks out there. It’s called a Road Caster Pro. It makes the whole process and the production of the actual podcast very, very simple and easy so far, it’s in pretty, I know you don’t really get too excited about any of that kind of stuff, but certainly, certainly I like all the gear and everything.

Dr. Davidson: Well, I liked all the options and I certainly like the color two little buttons on it. They’re real pretty.

Dr. Maki: Yeah, it looks very sophisticate looks almost like a mini version of a real radio studio. So hopefully this sounds, our voices sound good. And, I know our last one, the sound is okay. We still have a little bit of echo in the room. We’re in the middle of a Coronavirus quarantine. So we’ve kind of a stuck in the house a little bit. And we’ve been kind of planning this, kind of this new launch of our podcast, not really a lot is gonna change but really it was the upgrading the equipment and pretty exciting nonetheless.

Dr. Davidson: And the cool new microphones.

Dr. Maki: Yeah, yeah. Microphones are for those that are interested is the Road Pod mic, specifically designed for podcasting. Again, for those of you that are not into microphones, you probably don’t care. But these are considered dynamic microphones, so they, and they’re designed specifically for podcasting. And they’re meant to make your voice sound good without picking up all the extra sounds in the room. Our dog is at our feet and in the past he’s been chewing on a bone and sometimes that noise, it get picked up. You’re hearing a strange noise in the background but now this one is only supposed to pick up our voices and cut down some of the echo and, for example, in the summertime if the air conditioning comes on, our car drives by or something, the microphone isn’t gonna pick up all that extraneous noise, so.

Dr. Davidson: And we thought if we’re stuck in the house here for a few days that “Hey, let’s get some podcasts out and let’s reach out to people.”

Dr. Maki: Yeah, yeah. So a little bit of, kind of strange times with all this Coronavirus stuff going on. We’re not going to spend too much time talking about that. Pay attention to the right resources. Certainly, I think,  until we know more, I think a certain level of social isolation or as they call it, social distancing isn’t really a bad idea. And then just supporting immune function, be making sure that your sleep is good, all those things.

Dr. Davidson: Because we did do a podcast, probably I wanna say maybe the one before this one or a few before this one where we talked about the immune system, so that might be helpful and, working on strengthening and stimulating the immune system. So if you’re interested in that you can check out, I think it was maybe three podcasts prior to this one.

Dr. Maki: It was like 71 or 72. It was really before all this Coronavirus. It was, we really recorded that just because it was the cold and flu season. And we figured it was kind of, good timing, not because of the Coronavirus but just because the cold and flu season is kind of an annual thing. And then here we are, full-blown Coronavirus.

Dr. Davidson: And we do have a blog that we wrote as well on Covid-19. So that’s also on the website if you wanted to check that out. Now, granted it was published March 3rd. So a lots happened since then. But there is some more that immune system information on there if you’re interested in that.

Dr. Maki: Yeah, yeah, just things that we use with our patients that we’ve used, routinely over the years for these types of situation. Now granted, what we’re in the middle of right now is a little bit of extreme, but in what we can do to keep our immune systems functioning strong, none of the things that we recommend are cures for the Coronavirus, it doesn’t really work that way. I know that there’s some work on vaccination being kind of fast tracked through, already in clinical trials and you and I being in Washington, we’re kind of like Coronavirus ground zero, we’re like right in the middle of it, for the most part. We live up in Bellingham, which is north of Seattle by about 100 miles. It doesn’t seem like  there’s too much of a Coronavirus presence around here.

Dr. Davidson: Or a panic too much. I mean, people are distancing themselves, but they’re not going widespread panic. There’s still food on the shelves. I know my sister lives in Bellevue, and it’s a little bit more of a ghost town there which, Bellevue Washington is never a ghost town. So it’s kind of odd for them, but hey, we’ll all get through this, , we’ll all embrace each other and get to hang out at home and, and hang out with our families. And I was teasing Dr. Maki, I said, “Hey,  you know what, maybe we’ll look back on this and they’ll be a Coronaboom, what is it, baby boom.” So be a bunch of babies born nine months from now, hey, you never know. We always want to look on the bright side of things, because we definitely will get through this.

Dr. Maki: Yeah. So let’s, again, you and I are not immunologists or virologists. , we do some things that support immune function. So you can go back and listen to the other two podcasts that talk about that specifically. But let’s transition talk about the things that we still are getting questions on all the time with some of the other blogs and podcasts we put out and we get this constant, steady stream of questions. Because when it comes to hormone replacement, whether we’re talking thyroid adrenals, female hormones, male hormones, there’s not necessarily one way to do it. And that’s what makes it challenging. That’s what makes it complicated. You go to, if a patient goes to 10 different doctors, there’s gonna be 10 different opinions or 10 different prescriptions for that particular person’s situation. You and I have developed our own little style and our own, what would you say, our own approach to, people situations, and it’s proved to be fairly effective in most cases. So we’d like to continue with our previous format, and discuss a couple of… actually this one we’re gonna do her name is Lisa. So Dr. Davidson, why don’t you go ahead and read Lisa’s question.

Dr. Davidson: Sure, sure. So this is Lisa. And actually Lisa is a reader that she found us on a blog post that we had written about where to apply hormone cream. And it’s actually a really interesting question because we get, a lot of these questions really do seem like, honestly they’re valid for a lot of women taking hormones. , I’ve heard this question pretty much, , gosh 100 times over, over the course of our career, but this is from Lisa.

 “I have recently started taking 50 milligrams of progesterone and Bias cream 50-50 ratio. It’s been three weeks. I’m experiencing hot flashes at night and seeing very little improvement in my sleep. Does it really matter where we apply the Bias cream? I was told inner thighs and I feel that I absorb it better in my inner arms. Also, could the dosage be too low? Also, I cannot tolerate more than 50 milligrams of progesterone. And these come from a compounding pharmacy.”

Dr. Maki: Yeah, right. So these are fairly basic questions. Now granted, these should be ones that heard doctors answering, but like she said, it’s only been three weeks. So, first off, when, and this is another thing that we see quite often too when people tell us what they’re taking, the 50 milligrams of progesterone is fairly easy. She says that they’re coming from a compounding pharmacy, so we know that it’s not permethrin [?] we know that it’s more than likely bioidentical progesterone. But the Bias she says 50-50 ratio, the 50-50 ratio is, basically pertains to the concentration of the two forms of estrogen in that cream. It does not necessarily tell us how much that she’s actually taking. So, what we’ve noticed, especially when these kind of questions come in, and especially it’s been three weeks, her hot flashes are worse everything, it seems like it’s going the wrong direction she’s not improving. That would tell us without knowing what her dose is, that her dose is probably a little too low.

Dr: Davidson: Yeah, so definitely, let’s break this up a little bit. So she wants to know about the dosage. She’s not seeing any improvement in what she’s looking for which it sounds like sleeping and of course, if she’s having hot flashes at night, she’s certainly not sleeping. And she’s talking about progesterone not being able to tolerate it. And also,  where to apply the cream. So definitely, as Dr. Maki said, Lisa, your dose is way too low. And she may be applying it only once a day. So really with the bioidentical hormones, they’re awesome. I mean, they’re amazing. They look exactly like what our own hormones in our own body would be making being, hence bio-identical, but at the same time, they really don’t have a very long half-life. So if she’s applying her Bias cream in the morning, I guarantee you by midnight, one o’clock at night, it’s gone. So hence those nighttime hot flashes. And so definitely, I think the dosage would be low. What do you think?

Dr. Maki: Yeah, right. And this is one thing that we kind of coach our patients on, in the beginning, is that when you give a woman that is going through the perimenopause, or the menopausal transition and her symptoms start to show up. When she starts a hormone therapy, her symptoms could, initially get worse, which is exactly what they don’t want. Their hot flashes go up, their night sweats could either not improve or just kind of flare up a little bit. And that’s usually always an indication that dose needs to increase.

Dr. Davidson: And it has been three weeks. So by this time she’s giving it a good amount of time. It should have had some effectiveness, if the dose was proper, maybe like we’re saying it’s either too low or she’s not doing it twice a day because I really think that the hormone creams, not so much the progesterone, but the hormone Bias creams, they should be applied twice a day. So number one, Lisa should definitely be applying it at night and like I said, with the dosage. So when you say 50-50 ratio, it really doesn’t tell us a lot about what she’s taking. We know that she’s taking 50% of her doses, Estradiol and 50% of her doses Estriol. So for example, if she’s taking four milligrams of Bias 50-50 ratio, that’s two milligrams of Estradiol and two milligrams of Estriol. But she could be taking one milligram of 50-50 ratio Biased, which would be .5 of each Estradiol and Estriol. That’s really low, she could be taking 10 which is very, very high. So it really depends on what dose she’s on. So that would be the, probably the number one thing to raise that up. Because one thing with night time, as we are kind of talking about our immune system, is when we’re sleeping, our immune system rallies and raises up our body temperature, just a small, small amount. But in a female that’s going through menopause, that small raise in temperature will, will definitely stimulate or exacerbate hot flashes. So sometimes I actually have women take a little more hormone of their estrogen, Biased cream at night and a little less during the day, just to kind of account for that temperature rise in the middle of the night because nobody likes to wake up with their jammies soaked. I mean, I’ve heard stories of women, they sleep on towels. They have a spare set of jammies sitting right beside them so they can rip off their shirt and put on another one. I mean, definitely, if you’re having hot flashes at night, Lisa is not getting any sleep.

Dr. Maki: Yeah, right, right. She also mentions in there too, about applying it to the inner thigh or to the forearm. We usually recommend not applying it to the arm. Some women like to rub it into their wrists or the forearm or even the upper arm and we usually encourage women to keep it on the inner thighs. The absorption is still fine. It’s not necessarily absorbed to one, better one place or the other. But when you’re going for lab testing to check levels, if a woman is putting or even a man is putting their hormone cream on their forearms, it can skew the lab testing, make those levels look artificially elevated. If you think about it, when you go into the lab, they draw the blood from your what’s called your Antecubital fossa, which is basically your elbow. And no one really, , enjoys that process very much. But if you’re putting your hormone creams on your forearms and they draw blood, now those numbers are gonna be very inaccurate.

Dr. Davidson: And just a couple of points with that too, is you think this skin on your forearm, it’s really thin and there’s not a lot of fat there. But, most of us ladies have a nice fat pad on our thigh. So if you apply the hormones because all hormones are, basically have a cholesterol backbone, they’re fat-soluble. So I have always felt like if you apply it into an area that’s got a nice fat pad then it’s going to absorb into that fat pad and then it’s gonna pulse out over the next 12 hours as opposed to if I put it on the real thin skin of my forearm, it’s gonna go right into my system and it’s gonna go right out. So like I was saying earlier, the bioidentical hormones are beautiful, but their half-life is very short, that you wanna try to increase that longevity of it being in the system. So definitely, I love the inner thigh. And then also which all of you probably have thought of, in one idea, or another is if you’re applying your cream to your arm, and you wear a short-sleeved shirt, and you got a cat or a little dog or a little human being that you love to cuddle and hug on. Then you’re gonna just share that cream with other beings.

Dr. Maki: Yeah, right. Yeah. And that’s, may not be a big deal, for the amounts of hormones that women use. But if men are using testosterone, that can be a really big deal. But still, we don’t want to be leeching any of those hormones to any other creatures just because -one they’re small, whether it’s a human or a cat or a dog. And we wanna minimize that, we want to keep it for ourselves. We don’t want that to be, rubbing off on someone else. Like I said, not to mention the effect it can have on lab testing.

Dr. Davidson: Yeah, you’re right. Coming on a big man, with your hormone cream got on a big man, that wouldn’t be a big deal.  Men get all weirded out about “Oh my gosh! is that estrogen getting near me? What’s gonna happen? ” You’ll be just fine if you accidentally got that cream on you from your lady. But at the same time, you got a little animal there and they lick your arm. They’re gonna be more needy than they were to begin with.

Dr. Maki: Yeah, right, right. And now the other way though, for a man’s testosterone, if he’s using a transdermal cream and that rubs off on, again, the same the woman, the kids, the pets, that could be a big deal, because the dosage, the dosage amount that men use for testosterone is quite a bit larger. And it could have a little bit more, kind of far-reaching implications. But that doesn’t, we always coach everybody about that, that doesn’t happen very often, if ever, it’s a fairly rare occurrence just because we make a point to let everybody know about them.

Dr. Davidson: So and then just on a quick side note, talking about Lisa is her 50 milligrams of progesterone. So she doesn’t say and granted, they don’t need to go on to a whole diatribe about themselves, but she doesn’t say if she has a uterus or not, so I could see perhaps her practitioner might have been a little hesitant at giving her maybe a higher dose of the Biased because of her inability to take a higher dose of progesterone. So definitely like Dr. Maki said it came from a compounding pharmacy that 50 milligrams of progesterone is not Prometrium, which comes in 100 or 200-milligram tablets anyway, but the 50 milligrams that she’s taking is, bioidentical from the compound in pharmacy. But what progesterone does, I mean, progesterone does so many things. But one wonderful thing that progesterone does is it protects the breast tissue, and it also protects the uterine lining. Basically, the endometrial lining of the uterus, because if that endometrial lining thickens too much, which estrogen has a tendency to do that’s a side effect of all estrogens is if you have a uterus, it will grow things specifically the lining of your uterus, which then puts you at risk for a cancer, likelihood very, very low, but there’s still a higher risk than if you weren’t taking the estrogen. So one thing that you do to offset that, is you make sure that that female with the uterus has enough progesterone to offset that negative consequence of the thickening of the uterine lining, which is very easy. So you do a higher dose of progesterone-like a 100  and 125, a 150, 200 milligrams, to just to kind of compensate for that, so then you have no problems about her having any bleeding or thickening of the uterine lining, and then you can raise up that estrogen. So it might be that her doctor is just a little hesitant because of her inability to take more progesterone.

Dr. Maki: Yeah. Now this is something, that this issue right here comes up a lot. And then the next question would be well, what about creams versus capsules? This is what you just basically explain is exactly why we prefer capsules versus creams because progesterone creams do not have that same effect on inhibiting the uterine lining.

Dr. Davidson: Even though it goes right into your bloodstream and the creams really do raise up the levels. It just doesn’t have that effect on keeping the uterine lining thin. Now if you really wanted to keep the uterine lining thin, then you do you could do a progesterone trans vaginal suppository, but, vaginal suppositories messy and really irritating to the tissues anyways, so, doing an oral progesterone. So I’m thinking that, , maybe with Lisa if she could, maybe switch the progesterone to a sustained release or, try to work up her way to try to get to a100. If she had a uterus work that progesterone up to a 100 then she’d be able to raise up her Biased cream. So and then just like Dr. Maki was saying, I mean, I use creams with progesterone all the time for a certain, for other specific individuals. In this case, in Lisa, because she also can’t sleep is we got to get rid of the hot flashes, because I guarantee you even when she’s sleeping, she’s probably still having many hot flashes and she’s not even conscious and she’s not getting into that deep sleep. So it’s like she’s not getting any sleep all night long. And then so after you raise up that estrogen to help alleviate the hot flashes, doing progesterone as a capsule is awesome for sleeping, especially for helping you stay asleep through the night.

Dr. Maki: Yeah, right that first month when we deal with a new patient, that first month is really about that. It’s about getting rid of the hot flashes and improving the sleep quality. In some ways are kind of tied together, right? The sleep quality is diminished because they’re having all these night sweats. The covers are coming on and off and on and off and on and off. And they’re miserable, that bleeds into the next day, their energy is low, their moods low, they’re gaining weight like crazy. So, the first 30 days is to get rid of the hot flashes. So that means you might have to, and we’ll talk about this on some other episodes later about dosing and how to titrate and how to change things. But, that’s why the dose might actually need, after three weeks that dose should have probably have changed already. Because like you said, if she was gonna get an improvement, she would have already seen an improvement by now. It should happen relatively in that first week. She shouldn’t, right back or, give some feedback and say, “Oh my God, I finally slept, I’m actually feeling better, my hot flashes have been reduced by the three week period, should be reduced by at least 50% if not 75 to 80% in most cases.” Now, granted, there’s some stubborn ones sometimes, especially when their stress levels very high. Okay, they got a lot going on especially now with the coronavirus and all the adjustments to people’s lives, stress goes up, that’s going to make your hot flashes worse, and it’s gonna be harder to tame them down. So that’s where the practitioner has to be a little bit more, I wouldn’t say aggressive, but a little bit more, not as conservative on the dosing of the estrogen. And as you said too, that’s where the progesterone comes into play. So it’s definitely a delicate balance between the two of those and to find a dosage that is very specific to that particular patient.

Dr. Davidson: Perfect. Well, I think we’ve kind of broken up Lisa’s question. And hopefully, definitely want to give a shout out to Lisa and say, thank you for submitting your question because it will help so many other women because a lot of other women have the same concerns.

Dr. Maki: Yeah, right. So, just for future episodes. We’re going to probably, doing this kind of format, on an ongoing basis because it gives you and I something to discuss and talk about. You may see some similar questions or you might hear some repetition. But, a question like this answers lots of questions for lots of women. So if you have any feedback, certainly let us know. You can visit our website progressyourhealth.com, send us a message. Otherwise we will catch you on the next episode. I’m Dr. Maki.

Dr. Davidson: I’m Dr. Davidson Take care. Bye now.