This episode we respond to a reader question.  Jayme had sent us a question earlier in the year based on an article we wrote.  Now she has additional questions about taking progesterone as part of her BHRT. Jayme has had a hysterectomy and wasn't sure what dose of progesterone is best for her.  Or for that matter, if she should even be taking it.
Also, she has questions about her lab work and her estrogen dose.  We really like Jayme's question, because we get similar concerns often.  By answering Jayme's question, we hope to help other listeners understand a bit more about BHRT dosing, labs and progesterone with or without a hysterectomy.   
Just to throw it out there, this is not meant for medical advice and intended for educational purposes only…
Jayme's question: 
Dr. Maki, Thank you for answering me. Recently my doctor increased my biest to 4mg twice a day. I also stopped my progesterone to see if it was making any difference and I felt exactly the same, so I have not continued it. I had a complete hysterectomy, do you have thoughts on taking progesterone? I was taking compounded progesterone 200mg/day. Before my biest increase, I had my labs taken twice in one day: morning and late afternoon because I was feeling like they wore off. I was correct:
Jayme's Labs:
Total estrogen 112 morning and 60 evening
Estradiol 35.4 morning and  <5 in evening My estradiol has never gotten above 35.4. Any new insight would be so appreciated. Jamie We wanted first to address the progesterone.   If a woman has a uterus and is taking estrogen, she absolutely needs progesterone.  Estrogen thickens the endometrial lining. This can increase the risk of uterine cancer without sufficient progesterone.  But there is a theory in the medical community that if you do not have a uterus, then you do not need to take progesterone.  Whether a woman has a uterus or not, we never give unopposed estrogen. Progesterone helps to balance estrogen.  Estrogen is a beautiful hormone but can have side effects.  Some being weight gain, increasing breast density, moodiness, and even anxiety in some cases to name a few.  Progesterone is great at balancing these negative side effects of estrogen. Progesterone itself is very helpful for many symptoms.   It is great for helping a woman fall and stay asleep.  When the progesterone levels drop during perimenopause and menopause, can make staying asleep difficult.  Often women will complain of either waking up multiple times in the night or waking up for hours in the night.  Adding in a little progesterone at night can really do wonders for sleeping. Progesterone can also be great for mood and irritability as well.  When progesterone levels are low, women often remark that their patience has disappeared. Their tolerance levels have dramatically dropped. Progesterone can have a remark

In this episode, we respond to Karen.  Karen read an article of ours on BHRT and sent these concerns about her menopause and hormone dosages.  We love Karen's question because it shows how technical BHRT can be. As you will see from Karen's question, there are multiple aspects to consider when treating a woman with hormones.  

Karen’s Concerns: 

Her symptoms of weight gain, hot flashes, and night sweats 
The many avenues of dosing such as estradiol patches, hormones creams and the combination of taking progesterone, estrogen, and testosterone.
What ratio of estradiol to estriol she should be taking. And even if she should bypass the static hormone dosing and take a rhythmic dosing schedule.
Lab testing and what her levels may or may not be telling us.
If she can apply estriol vaginally
If estriol or some of these hormones are by prescription only
Not to mention, understandably she is concerned about the risks of estrogen without sufficient progesterone.

Karen's Question:
I am struggling to find the right dosage and combination of BHRT. I believe that I am sensitive to Progesterone. I am 53 and started menopause at age 50.

Hot flashes and weight gain are my two main symptoms (I was super thin my entire life, and now I'm 35 pounds overweight). I have 2-5 flashes a night not soaking, but they wake me (otherwise I would sleep fine) and always one at 4 or 5 am.

During the day I have several not unbearable but that is only while on BHRT (when I stopped taking everything it was brutal). I have been taking some form of BH for about 2 years now. I tried the patch Estradiol started at .5 and increased to .75mg.

My symptoms became tolerable, and the flashes were going away to the point that I only got the one early in the morning and maybe minor 1 or 2 during the day. But then I would take progesterone (pill) 100mg (and gradually tried to decrease).

As soon as I took the progesterone, the flashes would increase in intensity and frequency. I switched to cream currently taking a combined cream of 5mg estradiol/gm, 30 mg/gm of progesterone, 6 mg of testosterone/gm 1/4 gm applied once a day.

I still have difficulty losing weight, and flashes are still multiple times a night and throughout the day. (however, when I stop its 10 times worse). I'd like to switch to a biest and even cyclical dosing. I've read the Wiley protocol, but the dosing looks super high (at least to start).

In this episode, we answer a reader question.  This question is from Jen, responding to one of our articles. Jen's question is important because hormone treatment can often come as a prescription.  And it is important to understand our prescriptions and if they are actually going to be beneficial.

Jen's question relates to her current BHRT prescription that her doctor has recently put her on.  She has side effects from her medication. Plus she is not noticing the effectiveness that she was hoping.  

Question From Jenn:
Hi, I stopped cycle four yrs ago- for four weeks now – I'm taking E2/E3/T 1/1/4 (1/4 gr applied morning and 1/4 gr applied at night). If I am receiving 1/2 gram a day, I am receiving .50 mg E2 and .50 mg E3 & 2 mg of Testosterone.

I am getting dull headaches at the back side of head 4 to 5 hrs before the 12 hours app time, but breast tenderness which I hate. I have asked my doc to up to 1.5/1.5 per gram still applying the same quantity (1/2 gram daily)- and request Testosterone in a separate compound. Meaning I will receive .75mg of each E2/E3 a day and hold off on Testosterone to see if headaches are lack of E for sure.

After reading your responses, I wish I would have suggested a different ratio. Perhaps leave the E2 at 1mg/gr. Or drop to .50 and increase the E3 to 2.5 -3.0 mg. E3 might help w/breast tenderness? I take oral 1 mg prog at night. Your thoughts? Is 0.50mg/gr E2 which equates to receiving .25 mg of E2 a day too low, I want the benefits of E2 -hair skin happy, but don't want to feel fat and pregnant.
Thank you in advance for your response and your thoughts. Jenn

One thing we cannot stress enough is there is not a one-size-fits-all for BHRT dosing.  Everyone is unique, and there are many aspects to developing an individualized BHRT plan. In our patient population, everyone's BHRT is based on their personal and family history, health goals, symptoms, as well as lab data.  We then keep continuous follow up with them, because the body is not static.

People's BHRT doses will change over time, whether it is age, change in health goals, stressors, symptoms, etc.  It is important to keep close follow up with the patient to ensure their hormone doses are accurate and working well in their lives. We really like Jenn's message because her situation is common.  She is on BHRT, but it is not quite working for her and alleviate her symptoms.
Also, Jen is experiencing side effects from her prescription dosages. She is getting headaches and breast tenderness which is typical

When we started this podcast and writing articles, we were very naive about who would want to read this stuff. Honestly, I didn't think anyone would want to listen to a husband/wife couple-docs that only dealt with hormone balancing. Being an introvert, I am really pushing myself outside of my comfort zone with these articles and podcasts.
I cannot believe how many readers and responses we have gotten. I am absolutely amazed at how many responses we have gotten from people outside of the USA. I am truly flattered and amazed that people from all over the world are reading and listening to our content.
With that said, we have gotten lots of comments and questions from readers/listeners. It is hard to answer them one on one. So I wanted to write an article answering some questions that we have gotten. Some of these questions are from the states and others outside of USA.
Regardless of where we are from, we still experience hormone issues. I believe these questions might help others going through the same hormonal imbalances. And help us to know that our concerns are valid and we are not alone.
Question – Sherry
Hi, What is Estriol made from? I know that Estradiol is from equine urine, and I stopped taking it for that reason and also it caused my breasts to get really large and very tender. I want a natural menopause supplement that isn't animal derived. Does Estriol fit this description? Thank you, Sherry.
This is a great question. Many people are not sure of what BHRT and hormones are made from. Actual estradiol is not made from horse urine, or also known as equine estrogens. There are conventional hormone prescriptions that are made from horse urine.
These are commonly called Premarin and Prempro to name a couple. But estradiol is a bioidentical hormone. But as we talk about on this episode, estradiol is the strongest form of the bioidentical estrogens. Estradiol is an amazing hormone. It helps with bones, mental energy, hot flashes, sleep, libido, and vaginal atrophy to name a few. But like I mentioned, estradiol can be quite strong.
That is why Sherry is having the breast tenderness. For vaginal atrophy, we use estriol, which is the weakest, most gentle of the estrogens. It is great for vaginal dryness and atrophy without the side effects that estradiol can cause, such as breast tenderness and uterine thickening or spotting. So to answer Sherry’s question, both estradiol and estriol are bioidentical. But the estradiol may have been too strong for her, and that is why she had the breast tenderness.
Question – Rachelle
I have vaginal dryness, and I noticed a little bit of spotting today. I haven't had sex in over 3 yrs, but I do walk a lot. And I use cream from time to time. I also have a lot of burning off and on. The cream seems to help, but I don't want to use it too much.  That laser sounds worth it but too expensive for me. I was concerned about the spotting. I just had my pap smear done, and it came back good.
This questions came from an article that we wrote about vaginal dryness. The laser that Rachelle is referring to is a procedure that doctors are using to relieve vaginal dryness and incontinence. It works really well for both, and usually, only three treatments are necessary. But the drawback is that it can be costly, and insurance does not usually cover right now. We have seen many patients that have vaginal pa

 
Question: Hello, I am an almost 41 yr old female and I just read an article about cortisol levels (vampire, ghost, and zombie) that you wrote, and I'm curious to know more. I think that I'm like the vampire the most, but not exactly. I had a saliva test done recently and the results said that my levels were extremely low in the morning, then went to normal around noon but then by 4-5 they were dropping again. My doctor put me on progesterone because my estrogen to testosterone ratio was pretty severe (high estrogen/low testosterone). Although I take them at night because they make me extremely tired, I can't but feel the struggle even more in the morning now. Will DHEA help? Or anything? Thanks, Jaime
Jamie is referring to an article we wrote about cortisol levels, adrenal fatigue, and sleeping patterns.  Cortisol is a very important hormone. Without cortisol, we cannot live. But having your cortisol levels balanced plays an important part in daytime energy and sleeping patterns at night.  Cortisol is released from your adrenals glands in a diurnal curve . Meaning, cortisol is highest in the morning so you wake up bright eyed and bushy tailed , ready to start your day. Over the afternoon the cortisol will dip slightly.  Come evening it will drop dramatically so you are ready to go to sleep and stay asleep all night long.
In this episode, we talk about three dysfunctional cortisol curves that affect sleep and daytime energy. Having dysfunctional cortisol levels can create havoc on a person's quality of life.  We didn't want to poke light at these dysfunctional patterns as these are serious issues. But to help with learning and teaching we created three types of dysfunctional cortisol patterns relating to adrenal fatigue.
Three types of dysfunctional cortisol release patterns that affect and contribute to adrenal fatigue.  We call these types, The Vampire, Ghost A / Ghost B, and The Zombie.
Vampire: The Vampire has high cortisol in the evening and low cortisol in the morning.  That makes the Vampire feel really good at night. Inevitability because Vampires feel so good at night, they have a hard time falling asleep.  They will stay up late because they actually feel normal in the evening. But come morning, they have a hard time getting out of bed. These are the people that press snooze multiple times and usually takes them forever to get out of bed.  Even though they reluctantly crawl out of bed, they still complain about brain fog and feeling tired until at least midmorning.
Ghost: The Ghost is the person that falls asleep easily.  They always say, I have no problem falling asleep. My head hits the pillow and I am out.  But I always wake up a 2-4 hours later . That is because their cortisol is low in the evening.  But will raise up in the middle of the night, waking them up. You will find your Ghosts roaming the house in the middle of the night.  They might end up watching TV, eating, playing on their phones or even checking their email. Some get so fed up waking up in the middle of the night that they just get up and start their day.  Most Ghosts feel fairly well in the morning. But they disappear and Ghost everyone in the afternoon. Between 1230 and 330pm

We have have been getting a lot of questions regarding Bioidentical Hormone Replacement Therapy. We thought a good way to respond to these questions would be to answer them on the podcast. In this episode, we discuss a woman’s situation regarding her experience with testosterone pellets. Below is her exact email.
Listener Question: Nina 
Hello there, I have loved reading all your info with regards to BHRT, Hypothyroidism etc. There are two things I would love to get your opinion on. Firstly a quick background.. I am on BHRT and have had two rounds of Testosterone Pellets.
The first round, within 3 weeks of having it inserted I felt awful, couldn't sleep, cholesterol reading was high, cortisol readings were off the charts… and still only managed to get to my peak of 98 at 6 weeks( I believe the aim was to get to 150)… I swore I would never have it done again… however after 2 months and things had died down I decided to give it another go… this time my lovely doc increased the dosage to get me at my peak reading… this time around I was 10 times worse..my thyroid levels were bouncing around.. and had to increase my Synthroid from 75 mcg to 88 mcg and then to 100 mcg… couldn't sleep etc etc
Have just had my thyroid levels checked again, I was edging toward being Hyperthyroid… so I'm now back to 75mcg…I am due for my 3rd round of Pellets and I've decided this is not for me.
My GP just think this is all a coincidence when the Pellets are inserted.. my hormone doctor doesn't believe it either..
A friend s OBGYN said he dislikes the Pellets as he believes not enough study had been done on women, studies have come up that lipid and thyroid levels can go haywire…
I'm trying to get info and coming up against a brick wall.. nobody seems to believe me… do you have any thoughts on this… I would REALLY love to hear them.
Secondly.. I'm on Progesterone cream, have tried the tablets.. they were making me feel drowsy plus I was having some crazy dreams.. having said that after reading your article on uterine cancer and how it is better protected with oral progesterone, I'm willing to give it another try…
My Hormone doc says I'm pretty sensitive to medication (which I am)..
What do you think would be the best route for me to take with regard to drowsiness during the day.
Hope I'm making some sense…
Have bookmarked your page and will reread again and again… you seem to make so much sense.. I'm so glad I found you guys
Many thanks – Nina
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