Progress Your Health Podcast

Heart Disease Doesn't Announce Itself | Here's How to Catch It | PYHP 198

Dr Valorie Davidson and Dr Robert Maki — Mon, 29 Dec 2025 08:00:49 +0000

Protecting your `heart health` is crucial, especially during `menopause`, when risks can increase. In this `women’s health` episode, Dr. Valorie Davidson and Dr. Robert Maki share essential `health tips` and insights into how `hormones` impact cardiovascular well-being. Learn about important lab tests and supplements to safeguard your heart. You’ll learn: ● Why heart disease in women is often a “silent” problem until it’s serious ● The difference between general “heart disease” and atherosclerosis ● Coronary calcium scores: what they are, what the numbers mean, and when to consider one ● Why total cholesterol alone is useless (and often scary for

Hormones After Hysterectomy: Is Rhythmic Dosing Still Possible? | PYHP 197

Dr Valorie Davidson and Dr Robert Maki — Mon, 22 Dec 2025 08:00:55 +0000

Can You Do Rhythmic Dosing After a Hysterectomy? Short answer: Yes, but there are some other factors to take into consideration to make sure someone is a good candidate. In this episode, Dr. Valorie and Dr. Maki explain how rhythmic dosing works without a uterus, why it can be an excellent option after total hysterectomy (with oophorectomy) or surgical menopause, and when a simpler static approach might be better. We cover candidates, myths (like “no uterus = no progesterone”), brain and bone benefits, and how to personalize dosing for real-life outcomes—sleep, mood, cognition, libido, and long-term bone strength. What you’ll

Osteoporosis at 52: Is It Reversible or Just About Staying Stable? | PYHP 196

Dr Valorie Davidson and Dr Robert Maki — Mon, 15 Dec 2025 08:00:47 +0000

Confused by your DEXA scan results? Not sure if your T-score is “normal,” “osteopenia,” or “osteoporosis”or what to actually do about it? In this episode, Dr. Valorie Davidson and Dr. Robert Maki walk through three real viewer examples to show You exactly how to interpret bone density scores in your 50s and beyond. You’ll learn: ● How to read your DEXA scan: T-score vs Z-score in plain English ● The cutoffs: ○ 0 to -0.9 → normal bone density ○ -1.0 to -2.4 → osteopenia ○ ≤ -2.5 → osteoporosis ● Why two women in their early 50s can have

The HRT Mistake Women Make Most | Static vs Rhythmic Dosing | PYHP 195

Dr Valorie Davidson and Dr Robert Maki — Mon, 08 Dec 2025 08:00:02 +0000

Many women confuse cycling static HRT with rhythmic dosing, but they’re not the same thing. In this episode, Dr. Valorie Davidson and Dr. Robert Maki from Progress Your Health break down the difference between the two, why it matters for your safety, and how to do hormone therapy the right way. In this video, you’ll learn: ● What “rhythmic dosing” actually means ● Why cycling your static HRT is not rhythmic dosing ● How improper dosing can impact mood, energy, and breast tenderness ● The risks of trying to adjust hormones on your own ● Why rhythmic dosing must follow

Perimenopause & Menopause Sleep Fix (Part 2): Night Sweats, Palpitations, Urination & Sleep Apnea | PYHP 194

Dr Valorie Davidson and Dr Robert Maki — Mon, 01 Dec 2025 08:00:09 +0000

In Part 2, we go symptom-by-symptom so you can sleep through the night again. Dr. Valorie and Dr. Maki cover night sweats, frequent urination, heart palpitations, muscle cramps, headaches, itchy skin, vivid dreams, and when to suspect sleep apnea (under-recognized in women). You’ll hear practical tactics—electrolytes, targeted magnesium types, phosphatidylserine timing, glycine, L-theanine, and smart melatonin use—plus when HRT helps and how to pair data (CGM, wearables) with your sleep plan. You’ll also discover practical, science-backed fixes like: Smart electrolyte balance & targeted magnesium types Phosphatidylserine timing for cortisol control Glycine, L-theanine, and optimal melatonin use

Perimenopause & Menopause Sleep Fix (Part 1): Estrogen, Progesterone, Cortisol & Blood Sugar | PYHP 193

Dr Valorie Davidson and Dr Robert Maki — Mon, 24 Nov 2025 08:00:47 +0000

Why midlife wrecks your sleep—and how to fix it naturally. In Part 1, Dr. Valorie and Dr. Maki unpack the hormone triad behind women’s insomnia: shifting estrogen/progesterone, cortisol dysregulation, and blood sugar/insulin resistance. You’ll learn the difference between trouble falling vs. staying asleep, how low progesterone affects GABA (hello 2–3 a.m. wake-ups), and the daily habits that reset your circadian rhythm. What you’ll learn ● The hormone triad driving midlife sleep loss ● “Vampire / Zombie / Ghoul” sleep patterns—what they mean ● Why blood sugar swings trigger nighttime cortisol spikes ● Morning fixes that help nights: protein breakfast, light

How to Strengthen Your Bones After Menopause | HRT, Diet, Supplements & DEXA Explained | PYHP 192

Dr Valorie Davidson and Dr Robert Maki — Mon, 17 Nov 2025 08:00:38 +0000

Are you worried about bone loss, osteopenia, or osteoporosis? In this episode, Dr. Valorie Davidson and Dr. Maki from Progress Your Health dive deep into what women can do—beyond medication—to protect and rebuild bone density through hormones, nutrition, supplements, and lifestyle. Learn how to: ● Understand your DEXA scan and what your T-score really means ● Support bone strength through weight-bearing exercise & muscle building ● Use HRT (estrogen, progesterone, testosterone) to slow post-menopausal bone loss ● Balance calcium, magnesium, vitamin D + K2, and collagen the right way ● Avoid common pitfalls with over-supplementation ● Discover why healthspan +

How to Read a DEXA Scan | T-Score, Z-Score & FRAX Explained | PYHP 191

Dr Valorie Davidson and Dr Robert Maki — Mon, 10 Nov 2025 08:00:25 +0000

Learn how to read a DEXA scan—step by step. In this live session, Dr. Valorie and Dr. Maki walk through real patient case studies and show you exactly how to interpret T-scores, Z-scores, and FRAX so you can understand osteopenia vs osteoporosis, track progress over time, and focus on what actually moves the needle for stronger bones. What you’ll learn ● T-Score vs Z-Score: What they measure and which one matters most for decisions ● FRAX (hip & major fracture risk): When it’s useful—and when it’s misleading ● Case studies over multiple years: How lifestyle, protein intake, weight-bearing exercise, and

Testosterone Rhythmic Dosing Explained: Dr. Maki’s Full Day-by-Day Schedule for Men | PYHP 190

Dr Valorie Davidson and Dr Robert Maki — Mon, 03 Nov 2025 08:00:35 +0000

In this episode, Dr. Robert Maki walks through his exact testosterone rhythmic dosing protocol—how he cycles doses daily across a 26 to 28-day month and seasonally (25% / 50% / 75%) to align with Dr. Valorie’s cycle. We cover why this “rhythm over static” approach is designed to preserve receptor sensitivity (avoiding the down-regulation common with large, infrequent injections), plus practical details like application sites, off-days, and lab targets. What you’ll learn: ● The men’s “rhythm”: monthly sync with partner + annual seasons (lowest winter → highest fall) ● Why off-days on 14 & 28 help up-regulate receptors ● The

Rhythmic Dosing Explained | Estradiol & Progesterone Daily Schedule for Perimenopause & Menopause | PYHP 189

Dr Valorie Davidson and Dr Robert Maki — Mon, 27 Oct 2025 08:00:51 +0000

In this episode, Dr. Valorie Davidson and Dr. Robert Maki break down exactly how Dr. Valorie runs her personal rhythmic dosing—including the day-by-day estradiol (E2) and progesterone (P4) schedule that recreates a 28-day ovarian cycle. If you’ve heard us talk about “In-Betweeners” (women transitioning from late perimenopause into early menopause) and wondered how rhythmic dosing actually works in real life, this walkthrough is for you. What you’ll learn ● The difference between static vs rhythmic HRT—and why some In-Betweeners thrive on a cyclical protocol ● How a day-12 estradiol surge (with a softer “landing” on day 13) can mimic physiology

Estrogen Drops & Migraines: Why Perimenopause Triggers Headaches | PYHP 188

Dr Valorie Davidson and Dr Robert Maki — Mon, 20 Oct 2025 08:00:27 +0000

Estrogen dips can trigger migraines—especially in perimenopause. Here’s how to spot it and what helps. Dr. Valerie Davidson and Dr. Robert Maki explain why sudden drops in estradiol can spark headaches/migraines in cycling women, perimenopause, and menopause, plus what to do if HRT dosing (patch vs BiEst vs rhythmic) is making things worse. They also cover DIM (diindolylmethane)—when it helps vs when it can exacerbate low-estrogen symptoms, and supportive options like magnesium glycinate, B-complex, Vitamin D, and blood sugar balance. What you’ll learn ● How luteal-phase and ovulation-time estrogen drops trigger migraines ● Why perimenopause creates spike-and-crash estradiol patterns (and

Hormone Creams & Wrinkles: The Truth About Estradiol vs Estriol | PYHP 187

Dr Valorie Davidson and Dr Robert Maki — Mon, 13 Oct 2025 08:00:05 +0000

Should you use estradiol cream on your face? Dr. Valerie Davidson and Dr. Robert Maki explain why estriol (E3) is a gentler, safer alternative for wrinkles, melasma, vaginal health, and hormone balance during perimenopause and menopause. They share the risks of estradiol absorption, why it can throw off your HRT program, and why estriol is often the better choice—for both skin care and vaginal tissues. You’ll also learn about systemic vs local hormone use, melasma risk, and the real-world challenge of getting access to estriol. If you have a question, please visit our website and click Ask the Doctor a

Women’s Hormone Blood Work Explained: Estradiol, FSH/LH, DHEA, Testosterone, ApoB & Insulin | PYHP 186

Dr Valorie Davidson and Dr Robert Maki — Mon, 06 Oct 2025 08:00:53 +0000

If you’ve ever wondered which blood tests actually matter for women’s hormones and longevity, this episode is your roadmap. Dr. Valorie Davidson and Dr. Robert Maki walk through real labs—from CBC/CMP to cholesterol, estradiol/FSH/LH, DHEA, testosterone, insulin, and apolipoprotein B (ApoB). You’ll learn how to spot insulin resistance (TG/HDL ratio), why ApoB beats total cholesterol for risk, how liver markers (AST/ALT/GGT) fit in, and how rhythmic dosing can mimic the natural ovarian cycle. We also cover hs-CRP vs ESR, vitamin D ranges, pregnenolone, and why individualized care wins over one-size-fits-all. What you’ll learn: ● How to read CBC/CMP for nutrition,

Spotting or Bleeding on HRT? How to Adjust Estrogen, Progesterone & Testosterone in Menopause | PYHP 185

Dr Valorie Davidson and Dr Robert Maki — Mon, 29 Sep 2025 08:00:58 +0000

Are you experiencing bleeding or spotting while on hormone replacement therapy (HRT)? In this episode, Dr. Valorie Davidson and Dr. Robert Maki from Progress Your Health dive deep into one of the most common — and frustrating — concerns women face on HRT: when and how to adjust estrogen, progesterone, or testosterone. Using a real-world patient example (shared with permission and anonymized), we break down: ● Why some women continue bleeding on HRT despite progesterone support ● The role of estradiol sensitivity and early heavy periods in predicting uterine response ● Static vs rhythmic dosing for estrogen — and how

Post Ablation HRT. Can you do Rhythmic Dosing? | PYHP 184

Dr Valorie Davidson and Dr Robert Maki — Mon, 22 Sep 2025 08:00:04 +0000

Can you use rhythmic-dosing HRT after a uterine (endometrial) ablation? In this episode, Dr. Valorie Davidson and Dr. Robert Maki explain why—and how to do it safely. Can you do rhythmic dosing HRT after a uterine (endometrial) ablation? Short answer: yes—and in this episode Dr. Valorie Davidson and Dr. Robert Maki explains why. We unpack how rhythmic dosing works post-ablation, what to expect if you don’t bleed, how estrogen and progesterone balance drives symptoms, and why individualized monitoring (including occasional ultrasounds) can give peace of mind. If you’ve worried that higher physiologic estradiol might “recreate old problems,” we cover how

Early Surgical Menopause Explained | What If You Have No Ovaries? | PYHP 183

Dr Valorie Davidson and Dr Robert Maki — Mon, 15 Sep 2025 08:00:22 +0000

Surgical menopause happens fast—especially if both ovaries are removed (oophorectomy). In this episode, Dr. Valorie Davidson and Dr. Robert Maki explain how surgical menopause differs from “natural” menopause, why symptoms can arrive abruptly, and how to think about HRT options (rhythmic vs static), bone density, brain health, and long-term prevention. If you’ve had your ovaries removed—or you’re facing that decision—this is for you. What you’ll learn: ● Surgical vs “natural” menopause: why timing and symptom intensity differ ● Oophorectomy, hysterectomy & endometriosis: when and why surgery happens ● Symptom timelines after ovary removal (often within weeks) and what that means

The “In-Between” Stage: Perimenopause vs Menopause Explained | HRT, Symptoms & Solutions | PYHP 182

Dr Valorie Davidson and Dr Robert Maki — Mon, 08 Sep 2025 08:00:25 +0000

Are you stuck in the in-between—not fully in perimenopause, but not quite in menopause either? In this episode, Dr. Valorie Davidson and Dr. Robert Maki from Progress Your Health dive deep into the gray area of women’s health that often gets overlooked. We cover: ✅ The most common in-betweener symptoms (hot flashes, brain fog, low libido, weight gain, hair & skin changes, sleep problems). ✅ Why the in-between phase is often the most challenging and overlooked in women’s health. ✅ How HRT (Hormone Replacement Therapy) and bioidentical hormones may help—and when to be cautious with estrogen. ✅ Lifestyle, supplementation, and

Why I Refuse to Let My Doctor Lower My Estradiol Levels | PYHP 181

Dr Valorie Davidson and Dr Robert Maki — Mon, 01 Sep 2025 08:00:26 +0000

In this episode, Dr. Valorie Davidson and Dr. Robert Maki from Progress Your Health respond to a powerful listener comment about estradiol levels and hormone replacement therapy (HRT). Many women feel dismissed when it comes to their hormone care—and this conversation gets right to the heart of it. We cover: ● Why some women feel terrible when their estradiol drops below 60—and why that number matters for hot flashes, sleep, energy, and exercise tolerance. ● The link between estrogen decline and rising cholesterol, cardiovascular risk, osteoporosis, dementia, and metabolic health. ● Static dosing vs. rhythmic dosing of estrogen—why it matters

Hormone Dosing Explained: Minimum vs Optimal for Bone & Brain Health | PYHP 180

Dr Valorie Davidson and Dr Robert Maki — Mon, 25 Aug 2025 08:00:52 +0000

Should You Aim for the Minimum or Optimal HRT Dose? Should women on hormone replacement therapy (HRT) use the minimum dose to manage symptoms—or aim for an optimal dose to support long-term bone, brain, and heart health? This is a common and important question. In this episode of the Progress Your Health Podcast, Dr. Valorie Davidson and Dr. Robert Maki break it down in a clear, practical way. Static vs. Rhythmic Hormone Dosing Not all hormone dosing approaches are the same. In this episode, we explain the key differences between static dosing and rhythmic (cyclical) dosing, and why this distinction

Can Vaginal Estradiol Make Fibroids Worse? | HRT Insights for Perimenopause & Menopause | PYPH 179

Dr Valorie Davidson and Dr Robert Maki — Mon, 18 Aug 2025 08:00:55 +0000

Exciting Announcement! We’re launching the Progress Your Hormones Community today—a space designed to empower women with expert guidance and support for navigating perimenopause and menopause. Get access to live office hours, hormone hot seats, lab interpretation, and more! If you have a question, please visit our website and click Ask the Doctor a question. Join the Progress Your Hormones Community Stay Connected Instagram: @drvalorie TikTok: @drvaloried Disclaimer: All content in this blog, including text, images, audio, video, or other formats, was created for informational purposes only. This video, website, and blog aim to promote consumer/public understanding and general knowledge of various health topics.

Biest Cream Dosing Explained: What’s Too Low, What’s Optimal & How to Adjust Safely | PYHP 178

Dr Valorie Davidson and Dr Robert Maki — Mon, 11 Aug 2025 08:00:35 +0000

Launching August 11: Join our new Progress Your Hormones Community! Get expert guidance, real support, and answers to your HRT questions—together, not alone. Get expert guidance, real support, and answers to your HRT questions—together, not alone. If you have a question, please visit our website and click Ask the Doctor a question. Join the Progress Your Hormones Community Stay Connected Instagram: @drvalorie TikTok: @drvaloried Disclaimer: All content in this blog, including text, images, audio, video, or other formats, was created for informational purposes only. This video, website, and blog aim to promote consumer/public understanding and general knowledge of various health topics. This content

Why Your Progesterone is Low (Even on HRT) | Timing, Testing & Uterine Protection | PYHP 177

Dr Valorie Davidson and Dr Robert Maki — Mon, 04 Aug 2025 08:00:29 +0000

Welcome to Episode 2 with our upgraded video setup! Dr. Valorie Davidson and Dr. Robert Maki from Progress Your Health answer a thoughtful listener’s question: Why are my progesterone labs always low even on 200mg oral HRT? If you’re taking progesterone and worried about low numbers or uterine protection, this episode is for you. We cover: ‘ ● ⏱️ Why timing your blood draw makes or breaks your lab results ● The difference between sustained-release vs. instant-release progesterone ● How genetic variants (like CYP enzymes) impact progesterone metabolism ● When to get a transvaginal ultrasound to

Why Am I Spotting After Starting HRT? | Bi-Est, Progesterone & Night Sweats Explained by Experts | PYHP 176

Dr Valorie Davidson and Dr Robert Maki — Mon, 28 Jul 2025 08:00:57 +0000

In this episode of the Progress Your Health Podcast, Dr. Valorie Davidson and Dr. Robert Maki answer a listener’s question about spotting and night sweats after starting hormone replacement therapy (HRT). Lisa, age 55, shares her experience using Bi-Est cream, oral progesterone, and testosterone—and why she’s now experiencing unexpected bleeding and sleep disruption. We break down: ● Why spotting can happen after starting HRT—even with low estradiol levels ● The difference between estradiol and estriol in Bi-Est cream ● How progesterone protects the uterine lining ● When to increase vs. decrease HRT doses ● The role of cortisol and adrenal

Saliva vs Blood Hormone Tests: Which Works Best for HRT? | Bi-Est & Progesterone Tips | PYHP 175

Dr Valorie Davidson and Dr Robert Maki — Mon, 21 Jul 2025 08:00:07 +0000

In this episode of the Progress Your Health Podcast, Dr. Valorie Davidson and Dr. Robert Maki dive into a question from Sabrina about the accuracy and usefulness of saliva versus blood testing for hormone replacement therapy (HRT). Is saliva testing more accurate for transdermal Bi-Est creams? Why does your estradiol look low in bloodwork but high in saliva? Does skipping your hormones before testing give a better result—or just confuse the picture? What’s a true 80/20 Bi-Est ratio, and how can you read your prescription dose properly? Why might oral progesterone make you anxious instead

Why You Still Feel Like Garbage in Perimenopause — Even on Hormones | HRT Not Working? | PYHP 174

Dr Valorie Davidson and Dr Robert Maki — Mon, 14 Jul 2025 08:00:12 +0000

In this episode of the Progress Your Health Podcast, Dr. Valorie Davidson and Dr. Robert Maki dive deep into a question from “Amber,” a 49-year-old woman struggling with extreme perimenopausal symptoms — despite being on progesterone, an estradiol patch, and thyroid medication. Topics Covered: ● Why HRT (Hormone Replacement Therapy) might not be working ● Common perimenopause symptoms: sleep issues, fatigue, brain fog, weight gain ● The pitfalls of cookie-cutter hormone prescriptions ● How cortisol, stress, and over-exercising sabotage your hormones ● When estrogen dominance, low progesterone, and thyroid dysfunction overlap ● Could progesterone be making things worse? ●

HRT Not Working? Why Rhythmic Dosing May Be Better for Menopause Brain Fog, Sleep & Symptoms | PYHP 173

Dr Valorie Davidson and Dr Robert Maki — Mon, 07 Jul 2025 08:00:46 +0000

Are your menopause symptoms still bothering you—even on HRT? In this episode, Dr. Valorie Davidson and Dr. Robert Maki of Progress Your Health answer a listener’s question about why her estradiol patch and progesterone aren’t helping enough—and explore how rhythmic hormone dosing (aka cyclical HRT) may work better for brain fog, poor sleep, joint pain, vaginal dryness, and more. Key Takeaways: ● Why your estradiol patch may not be working ● How rhythmic dosing mimics a natural menstrual cycle ● Why bloodwork is essential in hormone therapy ● Common symptoms that improve with cyclical dosing ● Why mainstream medicine

New! Safe Community for Women in Perimenopause & Menopause | Progress Your Health | PYHP 172

Dr Valorie Davidson and Dr Robert Maki — Mon, 30 Jun 2025 08:00:25 +0000

Are you navigating perimenopause or menopause and feeling confused, alone, or unsupported? You’re not the only one—and we’re doing something about it. In this episode, Dr. Valorie Davidson and Dr. Robert Maki share an exciting announcement: the launch of the Progress Your Hormones Community, a safe, expert-led online space for women 45+ to get real support, science-backed education, and connect with others going through the same hormonal transitions. ✨ Inside this episode: ✔ What makes this community different from other groups ✔ How the community will work (live events, symptom guides, expert Q&As) ✔ Who it’s for (and who it’s

Menopause Belly: What Causes It & How to Finally Lose It | Progress Your Health | PYHP 171

Dr Valorie Davidson and Dr Robert Maki — Mon, 23 Jun 2025 08:00:55 +0000

Are you gaining weight around your midsection during perimenopause or menopause—despite eating the same and trying everything? You’re not alone, and it’s not just about willpower: In this episode, Dr. Valorie and Dr. Maki dive deep into what’s really going on with that frustrating menopause belly. From insulin resistance to estrogen and cortisol changes, they break down the complex hormonal shifts that make weight gain in midlife feel inevitable—and nearly impossible to reverse. Here’s what we cover: ✔️ Why the “unearned weight gain” often starts in perimenopause ✔️ The truth about insulin resistance and menopausal metabolism ✔️ The role of

When Should You Test Hormone Levels for HRT? Timing Matters More Than You Think! | PYHP 170

Dr Valorie Davidson and Dr Robert Maki — Mon, 16 Jun 2025 15:00:00 +0000

In this episode of the Progress Your Health Podcast, Dr. Valorie and Dr. Maki tackle a common yet surprisingly confusing question: When is the best time to test your blood levels if you're using hormone replacement therapy (HRT)?

Lisa, a fellow Washingtonian, submitted a thoughtful Ask the Doctor question about testing estradiol and FSH levels when using a trochee or transdermal cream. Should it be 4 to 6 hours after application? Or 10 to 12? And what do the results actually mean?

We’ll break down:

The ideal timing for blood draws depending on delivery method (trochee, patch,
cream)
How estrogen and progesterone absorb differently
Why testing too soon — or too late — can skew your results
How to interpret estradiol and FSH together (and why context is everything)
Why the number isn’t the whole story — and how you feel matters most

Plus, Dr. Valorie shares insights from her own hormone journey, including rhythmic dosing tips and lab timing mishaps.

If you have a question, please visit our website and click Ask the Doctor a question.

Want more insights like this?

Be sure to subscribe to our newsletter for hormone Q&As, educational guides, and real-world strategies to help you feel like yourself again—especially during perimenopause and menopause.

Join the Progress Your Health Newsletter

Stay Connected

Instagram: @drvalorie
TikTok: @drvaloried
Join the Hormone Community: Click here to subscribe

Disclaimer: All content in this blog, including text, images, audio, video, or other formats, was created for informational purposes only. This video, website, and blog aim to promote consumer/public understanding and general knowledge of various health topics. This content is not a substitute for professional medical advice, diagnosis, or treatment. Please consult your healthcare provider with any questions or concerns you may have regarding your condition before undertaking a new healthcare regimen. Never disregard professional medical advice or delay seeking it because of something you have read on this website. If your healthcare provider is not interested in discussing your health concerns regarding this topic, then it is time to find a new doctor.

Are You Too Old for HRT? What to Do When Your Doctor Says Stop at 70+ | PYHP 169

Dr Valorie Davidson and Dr Robert Maki — Fri, 13 Jun 2025 22:00:00 +0000

Is there really an age limit for hormone replacement therapy (HRT)? What if you're in your 70s and still feel better on hormones—but your doctor says it's time to stop?

In this episode, we answer a great question from Mary, a 76-year-old woman who's been on HRT for over 20 years. She's dealing with weight gain, breast tenderness, and pressure from her gynecologist to quit hormones altogether. We break it down:

Why stopping HRT just because of age isn't always the answer
What to consider when switching from a trochee to a cream
Why estradiol levels matter more than total estrogen
The connection between insulin resistance, weight gain, and hormones
How to adjust HRT in your 70s to maintain quality of life without unnecessary risk

Whether you're well into postmenopause or just starting HRT, this is a must-listen if you're wondering how long is too long to stay on hormones.

If you have a question, please visit our website and click Ask the Doctor a question.

Want more insights like this?

Be sure to subscribe to our newsletter for hormone Q&As, educational guides, and real-world strategies to help you feel like yourself again—especially during perimenopause and menopause.

Join the Progress Your Health Newsletter

Stay Connected

Instagram: @drvalorie
TikTok: @drvaloried
Join the Hormone Community: Click here to subscribe

Can You Be Hypersensitive to Estrogen? | PYHP 168

Dr Valorie Davidson and Dr Robert Maki — Mon, 02 Jun 2025 19:00:00 +0000

In this episode, we’re answering a thoughtful (and very relatable) listener question from Kari,
who’s been struggling with unexpected body pain and inflammation after starting hormone
therapy. She wonders if she might be hypersensitive to estrogen—something most doctors
don’t talk about.

Dr. Valorie Davidson and Dr. Robert Maki unpack why this happens and what to do if you
suspect your body is reacting to estrogen differently than expected.

In this episode, we discuss:

Why some women experience increased pain, fluid retention, or inflammation on
estradiol—especially starting at higher doses too quickly.
The importance of starting low and increasing slowly, especially for sensitive
individuals
How Dr. Davidson’s personal experience with estrogen sensitivity helped shape her
approach
The role of the liver’s phase 1 and phase 2 detox pathways in clearing estrogen
metabolites
Why form, dose, and timing of hormone therapy (cream vs. patch, AM vs. PM) can
affect results
What to consider when adjusting your Biest ratio (80:20 vs. 90:10) or Rhythmic
Dosing HRT

✉️ Here’s Kari’s full question:
“I used Biest 80:20 for 3 years and suddenly stopped absorbing. I’m not sure why,
but I do know I didn’t always use it the same time every day. From the moment I
went on hormone therapy I’ve had body pain and thought I had fibromyalgia. When
my estrogen dropped due to the absorption issue I realized the body pain
completely went away. I then went on a patch because my doc said we should
change the method. Immediate body pain again and even worse. Terrible. I was on
0.025 and it was tolerable, but after raising it to 0.05 it got really bad. I think I may
ask to go on the compounded cream again—maybe change the site that I apply it
and be more consistent. I’m very frustrated because no one talks about a subset of
people that are very sensitive to estrogen. They only talk about it making joint pain
go away. Do you think I should use 90:10 instead? What would you recommend
that I do? I’m so sad and frustrated.”

If you have a question, please visit our website and click Ask the Doctor a question.

Want more insights like this?

Be sure to subscribe to our newsletter for hormone Q&As, educational guides, and real-world strategies to help you feel like yourself again—especially during perimenopause and menopause.

Join the Progress Your Health Newsletter

Stay Connected

Instagram: @drvalorie
TikTok: @drvaloried
Join the Hormone Community: Click here to subscribe

Can You Take HRT If You’ve Had Endometriosis? | PYHP 167

Dr Valorie Davidson and Dr Robert Maki — Wed, 21 May 2025 15:00:00 +0000

In this episode, Dr. Valorie Davidson and Dr. Robert Maki respond to a great listener question from April, who’s navigating hormone replacement therapy (HRT) while dealing with a history of endometriosis, polyps, and chronic cramps.

April’s experience is all too familiar: spotting, cramping, hormone experimentation, and the frustrating search for symptom relief. So, can women with endometriosis safely use HRT—especially estrogen?

The answer: Yes, but it has to be customized.

�� In this episode, we cover:

Why HRT is absolutely possible for women with endometriosis—but must be individually tailored
The difference between static vs. rhythmic dosing and why rhythmic HRT may be better tolerated for some women
Dr. Davidson’s personal story of having endometriosis, cysts, and polyps—and how she now uses rhythmic dosing herself without flaring
The important role of progesterone in managing endometriosis and minimizing estrogen reactivity
How to approach spotting, cramping, and cyst formation during HRT ● Why estrogen isn’t the enemy—but why it must be dosed thoughtfully

✉️ Here’s April’s full question:

“Hi—I am a 57-year-old woman in perimenopause. My question is: is it possible for women with endometriosis or adenomyosis to do HRT?

I started oral progesterone 2 years ago, got as high as 300 mg, but didn’t get much symptom resolution. Switched to a progesterone troche—50 mg morning and night. About 3 months ago, I added testosterone (0.25 mg once daily, 5 days/week) and

Biest 80/20 (1 ml daily, can go up to 2 ml).

Everything was good for a while, but now the cramping and spotting have returned. I’ve had heavy bleeding as long as I can remember. My main complaint is menstrual cramps throughout the month—not just during my period. I do not have fibroids, but I’ve had many cysts and polyps over the years and have had many ultrasounds and transvaginal ultrasounds because of this.”

If you have a question, please visit our website and click Ask the Doctor a question.

Want more insights like this?

Be sure to subscribe to our newsletter for hormone Q&As, educational guides, and real-world strategies to help you feel like yourself again—especially during perimenopause and menopause.

Join the Progress Your Health Newsletter

Stay Connected

Instagram: @drvalorie
TikTok: @drvaloried
Join the Hormone Community: Click here to subscribe

Does HRT Slow Down Aging? | PYHP 166

Dr Valorie Davidson and Dr Robert Maki — Tue, 20 May 2025 15:00:00 +0000

In this episode, Dr. Valorie Davidson and Dr. Robert Maki dive into a hot topic: Does Hormone
Replacement Therapy (HRT) actually slow down aging? While the short answer may surprise
you, the real conversation is about something even more valuable—your quality of life.

Here’s what we cover:

How HRT can support energy, strength, and resilience as we age

The role of hormones in brain function, memory, and mental clarity

Why estrogen and progesterone matter for muscle tone and bone density

❤️ The powerful connection between hormones and cardiovascular health

Why HRT isn’t about extending your lifespan—but enhancing how you feel through the
years

Obviously aging is inevitable—but suffering doesn’t have to be. This episode is all about helping
you feel more like you again, even as your hormones shift.

If you have a question, please visit our website and click Ask the Doctor a question.

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Natural Bone Health: Best Nutrients & Foods for Stronger Bones After 40 | PYHP 165

Dr Valorie Davidson and Dr Robert Maki — Mon, 19 May 2025 15:00:00 +0000

You’ve probably heard “drink your milk for strong bones,” but there’s much more to bone health
than just calcium—and definitely more than just dairy. In this episode, Dr. Valorie and Dr. Maki
breas down the key nutrients your body needs to build and maintain bone density as you age,
especially during perimenopause and menopause.

From calcium and magnesium to K2, boron, and collagen peptides, we’re covering the
supplements and whole food sources that truly make a difference for your bones. You’ll learn
which forms of calcium are best absorbed, why magnesium matters for your arteries, how
vitamin D and K2 work together, and the underappreciated power of prunes, chia seeds,
sardines, and seaweed.

What You’ll Learn:

Which forms of calcium are safest and most effective
The synergy between magnesium, vitamin D3, and vitamin K2
How to naturally support your osteoblasts (bone-building cells)
Best food sources of key bone nutrients
What to avoid if you’re prone to kidney stones or soft tissue calcification
The truth about collagen and bone strength

Whether you’re navigating menopause or just want to protect your bones for the long haul, this
episode offers actionable strategies backed by decades of clinical experience.

Don't miss this podcast to building stronger bones—naturally.

If you have a question, please visit our website and click Ask the Doctor a question.

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What is a DEXA Score? | Bone Density, T-Scores, and What You Can Do About It | PYHP 164

Dr Valorie Davidson and Dr Robert Maki — Fri, 09 May 2025 15:00:00 +0000

In this episode, Dr. Valorie Davidson and Dr. Robert Maki break down how to interpret your DEXA scan results—and why it matters, especially for women in perimenopause and menopause. We explain what your T-score and Z-score actually mean, how estrogen and menopause affect your bones, and what you can do to prevent or slow bone loss naturally.

Whether you’re already on HRT or just starting to explore options for protecting your bone health, this episode gives you clear, actionable insights to help you feel strong, confident, and informed.

In this episode, you’ll learn:

What a T-score means—and how to understand the risk ranges
What a Z-score tells you (and why it’s different from T-score)
How menopause and estrogen decline impact bone density
The role of HRT in maintaining or improving bone strength
How weight-bearing exercise helps preserve bone mass
Natural strategies to prevent bone loss (beyond calcium and vitamin D)
Real examples of patients’ DEXA scans and how their scores changed over time

Perfect for you if:

You’re in your 40s, 50s, or beyond and wondering what your bone scan means—or how to keep your bones strong during the hormonal transition.

If you have a question, please visit our website and click Ask the Doctor a question.

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Hormone Blood Tests Explained: What Your Labs Reveal About HRT & Menopause | PYHP 163

Dr Valorie Davidson and Dr Robert Maki — Thu, 08 May 2025 23:00:00 +0000

In this episode of The Progress Your Health Podcast, Dr. Valorie Davidson and Dr. Maki take you behind the scenes and share their own hormone blood test results. Learn how these labs help guide treatment decisions, track progress, and support hormone balance during perimenopause and menopause.

What You’ll Learn:

Key labs such as estradiol, testosterone, DHEA-sulfate, pregnenolone, LH, FSH
Additional panels like liver enzymes, cholesterol, and comprehensive metabolic profiles
How hormone replacement therapy (HRT) is monitored through regular blood work
Dr. Valorie’s personal experience with rhythmic HRT dosing during menopause
The difference between baseline and follow-up labs

If you have a question, please visit our website and click Ask the Doctor a question.

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HRT & Uterine Bleeding: What Every Woman Needs to Know About Hormone Therapy & Vaginal Estrogen | PYHP 162

Dr Valorie Davidson and Dr Robert Maki — Thu, 08 May 2025 15:00:00 +0000

In this episode, Dr. Maki and Dr. Davidson answer viewer comments from their YouTube channel, providing clarity and insight into hormone replacement therapy (HRT), uterine lining health, and vaginal estrogen options. They also touch on annual gynecological care and share a lighthearted moment with their furry companions.

Topics Covered:

How to identify uterine lining buildup while on static HRT.
Differences between static HRT (no bleeding) and rhythmic HRT (cyclical bleeding).
The importance of monitoring uterine lining thickness to prevent cancer risks.
The role of transvaginal ultrasounds in checking uterine lining, ovarian cysts, fibroids, and polyps.
Why current guidelines for Pap smears have changed, and what they do (and don’t) check.
Estriol vs. estradiol: why some doctors prefer estriol for vaginal atrophy and urinary incontinence.
How estriol can be a safer alternative for vaginal health and urinary stress incontinence.
A shout-out to comments about Vivian, the podcast’s beloved standard poodle, and Bob, the Aussie mix.

Episode Highlights:

Why it’s essential to prevent uterine lining thickening on static HRT.
The role of transvaginal ultrasounds in annual gynecological exams.
How estriol can be a safer alternative for vaginal and urinary health.
Viewer questions that sparked meaningful discussions.
A fun behind-the-scenes look at the podcast’s four-legged “producers.”
Listen now to gain a clearer understanding of HRT, uterine health, and vaginal estrogen
safety.

If you have a question, please visit our website and click Ask the Doctor a question.

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Menopause & Hair Loss: Why It Happens and How to Regrow Thicker, Healthier Hair | PYHP 161

Dr Valorie Davidson and Dr Robert Maki — Wed, 07 May 2025 23:00:00 +0000

In this episode of the Progress Your Health Podcast, we dive deep into why hormonal changes, stress, and nutrient deficiencies contribute to hair loss during menopause and the best ways to support regrowth naturally.

What you can do about it.

What You’ll Learn in This Episode:

The Hair Growth Cycle & How Menopause Disrupts It
The Role of Estrogen, Progesterone & Androgens in Hair Thinning
How Thyroid Function & Insulin Resistance Impact Hair Loss
Nutritional Deficiencies That Contribute to Hair Shedding
The Connection Between Stress, Cortisol, & Scalp Health
Best Supplements & Natural Remedies to Regrow Thicker Hair
Hormone Therapy (HRT) – Can It Help or Hurt Hair Growth?

Key Takeaways:

Estrogen & Progesterone Decline: Shortens the hair growth phase & weakens follicles
DHT & Androgen Sensitivity: Can cause miniaturization & pattern hair loss
Nutrient Deficiencies: Iron, Vitamin D, Zinc, & Omega-3s are crucial for healthy hair
Chronic Stress & Cortisol Spikes: Can push hair into the shedding phase
Scalp Health & Circulation: Poor blood flow reduces hair follicle nourishment

Solutions We Discuss:

DHT Blockers: Saw Palmetto, Pumpkin Seed Oil, Spironolactone
Best Hair Growth Nutrients: Ferritin (Iron), Vitamin D, Zinc, Biotin, Omega-3s
Stress Management Tips: Adaptogens, meditation, & lifestyle shifts
HRT & Hair Loss: Understanding the right type of hormone therapy for you

If you have a question, please visit our website and click Ask the Doctor a question.

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Can You Take Oral Progesterone with an IUD? | PYHP 160

Dr Valorie Davidson and Dr Robert Maki — Wed, 07 May 2025 15:00:00 +0000

One of our listeners: Can you take oral progesterone hormone replacement therapy (HRT) if you already have an IUD?

This topic doesn’t have much research or widespread discussion, but it’s a question we hear frequently. Tammy’s situation is common, and we’re here to provide clarity and guidance.

Topics Covered:

Why might someone take progesterone HRT while using an IUD?
Understanding estrogen dominance and its effects
The differences between an IUD and oral progesterone
Can too much estradiol cause uterine hyperplasia or bleeding?
Types of estrogen HRT and how they interact with progesterone
The benefits of adding progesterone HRT to your regimen

If you’ve ever wondered about balancing hormone therapy with an IUD, this episode will provide practical insights and actionable advice to help you make informed decisions about your health.

Tammy’s Question:

"Hello! I searched for "can i take progesterone with my IUD". I can't find much, but I found your interview. I am a 53yo female, 8 years into menopause. I started HRT Oct of 2024 (200mg progesterone, 1.0 transdermal estradiol). I felt human again! I started bleeding alot (!!) January 2nd 2024. It lasted for 2 months before I called my doctor. A vaginal US revealed thickening of the uterine lining, with some polyps. I had a D&C with biopsy and placement of IUD in April 2024. I stayed on the patch, my progesterone was reduced to 100mg. I lost my sleep, and I have PMS like symptoms since, just like the time before Menopause. My OB suggested to remove the IUD (it's only been 6 months!) and go back on 200mg. My worry is this: wouldn't i start bleeding again? will my lining react again, and it was a little over $2000 to get all that done. Could i not just take 200mg and keep the IUD? I am trying hard to research this topic. there is very little info out there. Thank you so much for reading this."

This episode is packed with valuable insights to help you navigate HRT options and better understand how they can complement your hormonal health, even with an IUD.

If you have a question, please visit our website and click Ask the Doctor a question.

Want more insights like this?

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Can I Take Progesterone Continuously in Perimenopause? | PYHP 159

Dr Valorie Davidson and Dr Robert Maki — Tue, 06 May 2025 23:00:00 +0000

In this episode of the Progress Your Health Podcast, we answer another insightful question from one of our favorite listeners, Victoria. She’s curious about the effects of taking bioidentical progesterone continuously throughout the cycle during perimenopause. Specifically, Victoria wonders if taking progesterone all month long would disrupt estrogen production during the first half of the cycle. Join us as we explore the hormonal shifts in perimenopause and how continuous progesterone use might affect estrogen levels.

Topics Covered in This Episode:

How hormones fluctuate throughout a woman’s menstrual cycle.
Do women in perimenopause still experience hormonal cycling?
Key hormonal changes that occur during perimenopause.
Does taking progesterone influence estrogen production?
The differences between premenopause, perimenopause, and menopause hormones.

Victoria’s Question

"Hi again! I submitted a question about a week ago, but I’ve been thinking about something I didn’t ask the first time. In short: if you give a perimenopausal woman progesterone during the first part of her cycle (e.g., starting a 100mg capsule on day 6), wouldn’t that dampen estrogen production in the first half of the cycle? Would this be counterproductive? Or is that dose low enough that estrogen production remains the same with or without the progesterone? Thanks so much!"

What You’ll Learn

This episode is perfect for women in perimenopause or anyone curious about hormone replacement therapy. You'll gain a better understanding of:

The delicate balance of estrogen and progesterone in the menstrual cycle.
How perimenopause changes hormone production.
Whether continuous progesterone use might be beneficial or disruptive during this transitional phase.

Have a Question for Us?

We’d love to hear from you! Visit our website and click on Ask the Doctor to submit your questions. Your question might be featured in a future episode!

Don’t Miss an Episode

Subscribe, rate, and review the Progress Your Health Podcast to stay up-to-date on the latest tips and insights for hormonal health.

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How to Stop Bleeding While on HRT? | PYHP 158

Dr Valorie Davidson and Dr Robert Maki — Tue, 06 May 2025 15:00:00 +0000

In this episode of the Progress Your Health Podcast, we dive into an important listener question from Amanda, a 57-year-old who is navigating uterine bleeding while on hormone replacement therapy (HRT). Amanda is using a transdermal estrogen cream and a separate progesterone cream but is experiencing bleeding every three weeks. She’s concerned about the safety of her uterus, the risks of endometrial hyperproliferation, and how to balance her hormones without reducing the benefits of estrogen.

We explore the root causes of uterine bleeding during menopause and share practical tips for balancing estrogen and progesterone to reduce bleeding, protect the uterus, and maximize the benefits of HRT. If you’re on HRT and struggling with similar issues, this episode is packed with insights tailored for you.

What You'll Learn in This Episode:

What hormones can trigger bleeding during menopause
How HRT supports muscles, reduces inflammation, and improves bladder control.
Understanding the 12-month rule for menopause diagnosis.
Comparing oral progesterone and transdermal creams: Which is best for you?
What is Biest, and how do you determine the right dosing and ratios?
Strategies to balance estrogen and progesterone to stop bleeding.
Rhythmic vs. static HRT approaches

Why This Episode is a Must-Listen

Whether you’re newly navigating menopause, adjusting to HRT, or dealing with side effects like uterine bleeding, this episode provides clear, actionable advice to help you make informed decisions about your hormonal health.

Amanda’s Question:

"Hello, thank you for your informative content. I’m using 80:20 biest 2x a day taking off Sunday plus 30 mg transdermal progesterone for the last 6 months and am doing pretty well. My numbers look good, no breast tenderness, muscles feel better, bladder stronger etc., however, I am having light bleeding for a few days every 3 weeks or so. I’m not yet menopausal but close as before hormones I did go 5 months without a period. I want to avoid any hyperplasia and am slightly concerned however I don’t think i can lower my dose of biest without negative side effects. Any advice would be helpful! I’m 57 years old. Thank you"

If you have a question, please visit our website and click Ask the Doctor a question.

Don’t forget to subscribe, rate, and review the podcast to stay updated on the latest episodes!

Want more insights like this?

Be sure to subscribe to our newsletter for hormone Q&As, educational guides, and real-world strategies to help you feel like yourself again—especially during perimenopause and menopause.

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Join the Hormone Community: Click here to subscribe

Disclaimer: All content in this blog, including text, images, audio, video, or other formats,
was created for informational purposes only. This video, website, and blog aim to
promote consumer/public understanding and general knowledge of various health
topics. This content is not a substitute for professional medical advice, diagnosis, or
treatment. Please consult your healthcare provider with any questions or concerns you
may have regarding your condition before undertaking a new healthcare regimen.
Never disregard professional medical advice or delay seeking it because of something
you have read on this website. If your healthcare provider is not interested in
discussing your health concerns regarding this topic, then it is time to find a new doctor.

What Causes Bleeding on HRT in Perimenopause? | PYHP 157

Dr Valorie Davidson and Dr Robert Maki — Mon, 05 May 2025 23:00:00 +0000

In this episode, we address a question from "Victoria" (name changed for privacy), who is experiencing prolonged bleeding while undergoing hormone replacement therapy (HRT). Victoria is in perimenopause and is taking compounded T4/T3 thyroid medication and progesterone. Despite normal test results, she often has bleeding that lasts up to 14 days, and her menstrual cycles are becoming shorter. These symptoms are quite common during perimenopause or when HRT is not properly balanced. Additionally, Victoria is dealing with joint pain and inflammation and wonders if these issues could be related to her hormones.

Topics Discussed:

The relationship between perimenopause and HRT
Causes of prolonged periods during perimenopause
Managing menopausal bleeding with HRT
Understanding estrogen dominance
Is estrogen therapy suitable for perimenopausal women who are still menstruating?
Optimal timing for progesterone HRT: continuous vs. cyclical use
The connection between hormones, inflammation, and joint pain

Victoria’s Question:

"Hi! Your podcast is awesome, thanks for making it available! I turned 50 four months ago. Still menstruating monthly - every 27-28 days (with one exception - see below). Generally feeling good - no hot flashes or night sweats that I can tell, sleeping 7-9 hours a night (might wake up once or twice on occasion but generally able to go back to sleep quickly). My brain is working fairly well and my mood is good. No vaginal dryness or libido issues so far. For reference, my mum had her very last period four months after she turned 54, and she has never ever had hot flashes (in case that's useful). For the last two years I have been taking 100mg bio-identical progesterone from day 14 (sometimes I might start it on day 12 or 13 of my cycle if I feel PMS-like symptoms). I have also been taking 1,5 grain compounded thyroid for the last two years. I can honestly say the progesterone and the thyroid medication saved me from a lot of suffering I had started to experience 6 months before I started taking them: I had just turned 48 and I started to gain weight, couldn't sleep, felt depressed and brain-fogged. After starting the progesterone capsule and the compounded thyroid medication I gradually returned to feeling normal again. Lately I have even managed to lose some of the weight I put on. My issues right now: My period, although still regular, is characterized by long bleeding. I can easily bleed for up to 14 days. Granted, the bleeding will lighten up after day 5 or 6 but it will continue for at least as many days, albeit light. And to cap it all, this month I finished bleeding on day 14 and started bleeding again on day 19 (this is the first time my cycle is that short for as long as I can remember). I do yearly vaginal ultrasound - all normal. My last one was in June this year. Questions: Could I manage the bleeding by starting the progesterone earlier in my cycle? If so, on which day? Or do I need to start adding a bit of biest into my regiment? My doctor suggested that I could introduce 2.5mg biest (80/20 ratio) from day 5 to day 25 of my cycle, but I am unclear on how this could solve the bleeding issues. Lastly, I am experiencing some joint pain and joint inflammation lately, and I keep reading that this could be a (peri)menopausal symptom. Could adding a bit of biest help the joint pain? Oh, my skin is also drying up and sometimes breaking out a bit, and I guess that's also related to the change of hormones. It's the bleeding and the joint paint though that I am mostly bothered about. I already have low iron levels as it is, and it's very hard to keep on top of them with the amount of blood I am losing each month. So your input on that matter is greatly appreciated! I eat a reasonable diet (low carb, nothing processed), fast for 16 hours and exercise reasonably (definitely not killing myself at the gym), so I think that's all helping. And I don't have much stress in my life, so THAT is super helpful, too :) Anyway, hope you have all the info needed. Look forward to answers. Thanks very much!"

Join us as we delve into these topics to provide insights and potential solutions for women experiencing similar challenges during perimenopause.

If you have a question, please visit our website and click Ask the Doctor a question.

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Is My Estrogen Dose High Enough? | PYHP 156

Dr Valorie Davidson and Dr Robert Maki — Mon, 05 May 2025 15:00:00 +0000

In this episode, we dive into the important topic of HRT (Hormone Replacement Therapy) dosing. Our discussion is inspired by a question from Leah, a 56-year-old listener who is healthy, fit, and navigating menopause. Leah has been experiencing significant anxiety and wonders if her current estrogen dose might be too low.

What You’ll Learn in This Episode

The difference between static vs. rhythmic HRT dosing and how they impact symptoms.
Various HRT applications, including estradiol patches, transdermal/transvaginal creams, and oral HRT options.
Key hormones involved in HRT: estradiol, estriol, testosterone, progesterone, and cortisol.
Why anxiety is a common and often overlooked symptom of menopause—and how HRT can help.

Let’s Read Leah’s Question:

"Hello there! After 6 months of deep diving I found your site! I feel like no one here in Vancouver has a full hold on how to treat me. Your information has been so invaluable, but now I’m worried I’m not being cared for properly.

I’m 56, fit, work out regularly at moderate intensity with muscle training, normal weight, healthy my entire life-no menopause issues till March.

I was a week away from a big gig and suddenly got this weird, crippling anxiety. It started with a massive hot flash upon waking one morning, then this feeling like I had just missed being in a car accident … like a fright- for no reason. It was bad enough the first week that I didn’t want to drive. It settled to about 30% and so was able to function. But it recurs at this level now and it’s been 8 months. Its the most uncomfortable feeling, and little things bring it on, like getting ready to go out and always first thing when I wake up.

I started with an obgyne who put me on .05 estradot patch with 100 mg progesterone. Hot flashes went away but nothing else. Went up to .075, no change. Also started on 2 mg testosterone ordered perivaginally.

Then I went to see a naturopath. Did a DUTCH. Test, my hormone levels looked as if I wasn’t taking anything! Also adrenals were fatigued and low cortisol.Basically everything really low but progesterone ok.

My naturopath put me on 50:50 bi-est 2.0 mg vaginally applied. Progesterone 40 mg transdermal and staying on the oral progesterone. No change after 3 weeks.

I feel like I need more hormones. My naturopath says she never gives more than 3 mg testosterone because it can raise cholesterol but all the research shows 5 mg starting dose?

I also asked her about vaginal application of biest and systemic concerns and she said because it was 50:50 the estriol would help regulate the estradiol.

After listening to all your podcasts and reading your case studies, I’m feeling like there’s so much contradicting info and I don’t want to apply it vaginally. I feel like my dose is too low, did I mention in addition to this weird anxiety, I’m also getting little hot flashes again?

I want to enjoy my life and feel like me again. This insane…

Would love to hear your thoughts and opinion?

Warmest Regards"

Whether you're new to HRT or looking for insights on optimizing your hormone therapy, this episode is packed with practical advice and actionable tips to help you feel your best during menopause.

If you have a question, please visit our website and click Ask the Doctor a question.

Want more insights like this?

Be sure to subscribe to our newsletter for hormone Q&As, educational guides, and real-world strategies to help you feel like yourself again—especially during perimenopause and menopause.

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Instagram: @drvalorie
TikTok: @drvaloried
Join the Hormone Community: Click here to subscribe

Disclaimer: All content in this blog, including text, images, audio, video, or other formats, was created for informational purposes only. This video, website, and blog aim to promote consumer/public understanding and general knowledge of various health topics. This content is not a substitute for professional medical advice, diagnosis, or treatment. Please consult your healthcare provider with any questions or concerns you may have regarding your condition before undertaking a new healthcare regimen. Never disregard professional medical advice or delay seeking it because of something you have read on this website. If your healthcare provider is not interested in discussing your health concerns regarding this topic, then it is time to find a new doctor.

HRT for Vaginal Dryness in Menopause | PYHP 155

Dr Valorie Davidson and Dr Robert Maki — Fri, 02 May 2025 23:00:00 +0000

In this episode, we discuss a listener’s question regarding her hormone replacement therapy, testosterone dosing, and vaginal dryness.

In this podcast, we discuss:

Vaginal dryness and menopause
Testosterone for women
Testosterone injections, pellets, and transdermal cream hormone therapy for women
Estrogen, estradiol, estriol, and biest hormone treatments
Hormone testing for menopause

Question:
"Hi! I am 52 currently on Cypionate 200mg/1ml 0.06 injection once a week, Progesterone 200mg orally, and Biest 50:50 1mg a day. I came off of pellets to this regime now. I was doing fine until the past 3 months. I all of a sudden got back my vaginal dryness pretty bad. My testosterone had gotten pretty high 334 from my normal 219 because the compounding pharmacy gave me Depo-Testosterone instead of my normal Cypionate. I know the depo is just brand name but it really through everything off. I have stopped the depo and have been on the Cypionate now for the past month. With that said I am still having vaginal dryness. Do you think it could have been due to being Testosterone dominate? Do you think I need to up my Biest Cream? I do use and have used the Estridol vagina cream for years and it's not helping. I tried one night doing one and half pumps of my Biest cream and the next day I had more discharge. Any help is greatly appreciated!"

If you have a question, please visit our website and click Ask the Doctor a question.

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Be sure to subscribe to our newsletter for hormone Q&As, educational guides, and real-world strategies to help you feel like yourself again—especially during perimenopause and menopause.

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Can Bi-Est Cream Cause Nausea? | PYHP 154

Dr Valorie Davidson and Dr Robert Maki — Fri, 02 May 2025 15:00:00 +0000

In this episode, we discuss a listener’s question about estrogen cream causing nausea. ‘Betty’ is a practitioner with a client that is having severe nausea as a reaction to her biest/estrogen cream. While her client has experienced much improvement with her hormone therapy, she is having a lot of issues with nausea and vomiting.

In this podcast, we discuss:

What types of hormone therapy can cause nausea
Why is HRT causing you to feel sick
Estrogen therapy for vaginal dryness
Blood work for menopause
Blood work for hormone levels
How HRT dosing is very individualized to each person

Let’s read Betty’s question:
"I have a patient with a history of hysterectomy who retains one ovary. She is currently on Biest cream 50/50, 1 mg daily. She is also on progesterone 100-200 mg orally HS. She initially did well: improved vaginal moisture, great sex and mood. Now she is experiencing debilitating N/V, which she did when taking synthetic estrogen from her gyn. Should I just have her maybe 0.5mg vaginally 3x/week? I have never had any patients experience this. BTW, she was not on progesterone when she was taking the synthetic estrogen so that's why we think it's the estrogen. Thanks."

If you have a question, please visit our website and click Ask the Doctor a question.

Want more insights like this?

Be sure to subscribe to our newsletter for hormone Q&As, educational guides, and real-world strategies to help you feel like yourself again—especially during perimenopause and menopause.

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Instagram: @drvalorie
TikTok: @drvaloried
Join the Hormone Community: Click here to subscribe

Disclaimer: All content in this blog, including text, images, audio, video, or other formats,
was created for informational purposes only. This video, website, and blog aim to
promote consumer/public understanding and general knowledge of various health
topics. This content is not a substitute for professional medical advice, diagnosis, or
treatment. Please consult your healthcare provider with any questions or concerns you
may have regarding your condition before undertaking a new healthcare regimen.
Never disregard professional medical advice or delay seeking it because of something
you have read on this website. If your healthcare provider is not interested in
discussing your health concerns regarding this topic, then it is time to find a new doctor.

What are Optimal hormone Levels in Menopause? | PYHP 153

Dr Valorie Davidson and Dr Robert Maki — Thu, 01 May 2025 23:00:00 +0000

In this episode, we discuss Connie’s question about her hormone levels in menopause. Hormone therapy should be tailored to the individual and not just blood work levels. We discuss how labwork can be important in determining hormone dosing. But it is only one part of working with hormone replacement. It is not wise to just depend on blood work to treat a client. It is taking in the whole picture, including their health history, family history, health goals and intention with hormone replacement. Blood work and lab values are an essential part of creating optimal hormone levels, but not the only consideration.

We discuss:

Optimal hormone levels in menopause
How to tailor hormone replacement to each individual
When and how to take estrogen and progesterone HRT
How important is lifestyle in aging well
Lifestyle changes for menopause
What is HRT static dosing
What is rhythmic hormone replacement therapy

Connie’s Question:

"Hi Dr. Maki and Dr. Davidson, Really appreciate your podcast and
listen to all of them. My age is 56 and I went on BHRT about 3 years ago, while not
quite in menopause. My plan was to be proactive before the levels tanked, but it did
create some issues with uterine buildup. That was addressed and all ok, but still trying
to find a perfect balance. I am in menopause now, based on blood levels and my goal is
to be at optimum levels of hormone replacement in order to protect bones, heart and
brain. My current compounded cream of Estradiol is 1 mg and Testosterone 0.5mg.
Progesterone compounded capsule is 225mg (a bit higher due to my lining build up in
the past). Last labs showed Estradiol at 51.2 and FSH at 70. Labs were run about
halfway after applying my hrt, which I apply at night. Wanting estradiol to be higher and
fsh lower and realizing blood work with creams is maybe hard to pinpoint accurately, but
do you think staying with these doses is optimal? Can the numbers get better with the
same static dosing or is this the best range I will get? Not really interested in having a
period what with the bleeding concern before, but does it make sense to not take
progesterone every night, maybe every other? Would that help or hinder things? Thank
you for any information!"

If you have a question, please visit our website and click Ask the Doctor a question.

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What is the Best Form of Progesterone for Uterus Protection? | PYHP 152

Dr Valorie Davidson and Dr Robert Maki — Thu, 01 May 2025 15:00:00 +0000

In this episode, we discuss progesterone capsules vs cream. We get many listener questions about what type of progesterone to use. Wondering should they take oral progesterone or topical cream progesterone when taking estrogen HRT. Not only is this important for symptom relief in menopause. It is also important as a healthy safety issue for women taking biest/estrogen/estradiol hormone therapy.

This discussion will address:

The difference between progesterone orally and cream.
Different types of progesterone, such as creams, gels, troches, capsules, tablets, and sublingual.
How does progesterone protect again uterine cancer when taking estrogen HRT?
Progesterone capsules help with sleep. What about cream?
Can progesterone cream protect the uterus when taking estradiol?
Can progesterone delay periods?
Can progesterone help with help with heavy periods?

If you have a question, please visit our website and click Ask the Doctor a question.

Want more insights like this?

Be sure to subscribe to our newsletter for hormone Q&As, educational guides, and real-world strategies to help you feel like yourself again—especially during perimenopause and menopause.

Join the Progress Your Health Newsletter

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Instagram: @drvalorie
TikTok: @drvaloried
Join the Hormone Community: Click here to subscribe

Can You Start Estrogen in Perimenopause | PYHP 151

Dr Valorie Davidson and Dr Robert Maki — Thu, 01 May 2025 01:00:00 +0000

Our listener, Jackie, wants to know if she can take estrogen even though she is in her late 30’s and has not started menopause. She wants something to help with weight loss, hair regrowth after pregnancy, improving mood, and help with libido.

In this episode, we talk about:

Risks from taking estrogen before menopause
When to start estrogen hormone replacement
The difference between estradiol and estriol
How to balance hormones in perimenopause
Using testosterone therapy for women and libido
DHEA and perimenopause
How estrogen might not be the right fit for someone in perimenopause.
What a women in perimenopause can do to help with hormone balancing.

Jackie’s Question:
"I am concerned that if I use estrogen cream, such as estriol, that I will gain weight and lose hair. I have seen conflicting accounts to whether this is true, and some say that it helps regrow hair and helps with weight loss. I have not started menopause yet, (I'm almost 40) and want something to help me stay youthful, lose weight and grow my hair which started thinning very badly and continues since pregnancy, help protect bone density, improve mood and memory, and get my libido back. Is estrogen cream a good fit for me? Thanks!"

If you have a question, please visit our website and click Ask the Doctor a question.

Want more insights like this?

Be sure to subscribe to our newsletter for hormone Q&As, educational guides, and real-world strategies to help you feel like yourself again—especially during perimenopause and menopause.

Join the Progress Your Health Newsletter

Stay Connected

Instagram: @drvalorie
TikTok: @drvaloried
Join the Hormone Community: Click here to subscribe

How To Lower Triglycerides | PYHP 150

Dr Valorie Davidson and Dr Robert Maki — Wed, 30 Apr 2025 21:00:00 +0000

In this episode, we discuss the best way to reduce triglycerides. Sasha, a podcast listener, asked us how to lower her triglycerides. We then go into depth about triglycerides, how to lower them, and why they could be high in the first place.

How to read a lipid panel
Supplements for lowering triglycerides
Lifestyle changes for lowering triglycerides
What do high triglycerides mean?
Building blocks for triglycerides
Improving metabolic health
Can menopause increase triglycerides?
High triglycerides and thyroid hormones

Sacha’s Question:
"I know this isn't a hormone question but was hoping you could give me some direction. I was wondering what is the best way to lower triglycerides? thank you for your help!"

If you have a question, please visit our website and click Ask the Doctor a question.

Disclaimer: All content in this blog, including text, images, audio, video, or other formats, was created for informational purposes only. This video, website, and blog aim to promote consumer/public understanding and general knowledge of various health topics. This content is not a substitute for professional medical advice, diagnosis, or treatment. Please consult your healthcare provider with any questions or concerns you
may have regarding your condition before undertaking a new healthcare regimen. Never disregard professional medical advice or delay seeking it because of something you have read on this website. If your healthcare provider is not interested in discussing your health concerns regarding this topic, then it is time to find a new doctor.

How To Lower Triglycerides | PYHP 150

Dr Valorie Davidson and Dr Robert Maki — Wed, 30 Apr 2025 21:00:00 +0000

How to read a lipid panel
Supplements for lowering triglycerides
Lifestyle changes for lowering triglycerides
What do high triglycerides mean?
Building blocks for triglycerides
Improving metabolic health
Can menopause increase triglycerides?
High triglycerides and thyroid hormones

Sacha’s Question:
“I know this isn’t a hormone question but was hoping you could give me some direction. I was wondering what is the best way to lower triglycerides? thank you for your help!”

If you have a question, please visit our website and click Ask the Doctor a question.

Disclaimer: All content in this blog, including text, images, audio, video, or other formats, was created for informational purposes only. This video, website, and blog aim to promote consumer/public understanding and general knowledge of various health topics. This content is not a substitute for professional medical advice, diagnosis, or treatment. Please consult your healthcare provider with any questions or concerns you
may have regarding your condition before undertaking a new healthcare regimen. Never disregard professional medical advice or delay seeking it because of something you have read on this website. If your healthcare provider is not interested in discussing your health concerns regarding this topic, then it is time to find a new doctor.

Fibroids and Estrogen Replacement Therapy | PYHP 149

Dr Valorie Davidson and Dr Robert Maki — Wed, 11 Sep 2024 06:09:20 +0000

In this episode, we discuss a podcast listener’s question. ‘Alesha’ is concerned that she should not take estrogen replacement therapy because she has fibroids. This is a common concern. The idea that estrogen can cause or propagate fibroids has left many menopausal women without support for their symptoms. Just because women have or have had a history of fibroids does not mean they are not a candidate for estrogen
therapy. In fact, women with fibroid can take estrogen hormone replacement therapy.

In this episode, we go into depth about taking estrogen with fibroids. And we break Alesha’s question into:

What are fibroids?
Fibroids and estrogen replacement therapy
Can I take estrogen if I have fibroids?
What is adenomyosis?
Estrogen’s role in fibroids
Difference between perimenopause and menopause
How menopause can affect prediabetes

Alesha’s Question:

“Is there any hope for someone with adenomyosis take estrogen? If so, when is the right time? I know adenomyosis is stimulated by estrogen. I even had 1 dr offer a hysterectomy so I could take estrogen without any issues ??!! I have a history of heavy periods have had many trans vag ultrasounds and biopsy’s over the years Uterus was enlarged, lining was wnl. Had a hysterscopy to remove some cysts they found 4 hrs ago. Last ultrasound showed probable adenomyosis.i am almost 57and I am in late perimenopause. Cycles have been erratic just went 6 months without a cycle then had a normal cycle…for years of perimenopause I had symptoms of high estrogen. Most of the time for the last year I had symptoms of low estrogen. Poor sleep waking up 4-5x night, dry skin, vaginal dryness, night sweats, brain fog, difficulty concentrating which makes my job very difficult. I have also developed mild sleep apnea(sleep lab) and after my last physical I am on the edge of pre diabetes. ( am normal weight, I walk daily and lift weights, eat high protein diet with lots of veggies and healthy fats.) I am currently taking a progesterone troche( 1/4 lozenge 50mg 2x day) and vaginal estrogen. I was taking an oral progesterone 300 mg thought it would help with sleep but didn’t. The progesterone has helped with GI issues, puffiness, bloating, cramping and anxiety.”

If you have a question, please visit our website and click Ask the Doctor a question.

Disclaimer: All content in this blog, including text, images, audio, video, or other formats, was created for informational purposes only. This video, website, and blog aim to promote consumer/public understanding and general knowledge of various health topics. This content is not a substitute for professional medical advice, diagnosis, or treatment. Please consult your healthcare provider with any questions or concerns you may have regarding your condition before undertaking a new healthcare regimen. Never disregard professional medical advice or delay seeking it because of something you have read on this website. If your healthcare provider is not interested in discussing your health concerns regarding this topic, then it is time to find a new doctor.

Premature Ovarian Insufficiency or Menopause | PYHP 148

Dr Valorie Davidson and Dr Robert Maki — Mon, 09 Sep 2024 07:30:52 +0000

In this episode, we talk about POI (primary/premature ovarian insufficiency) and early
menopause. Samantha sent in a question about whether she is in menopause or has
POI at the age of 36.
We break Samantha’s question into:
– What is POI (Premature/Primary ovarian insufficiency)?
– Taking estradiol during perimenopause
– Difference between perimenopause and menopause
– What is an FSH?
– Insulin resistance and perimenopause
Samantha’s Question:
I am 36 and have been slowly noticing perimenopause/low estrogen symptoms for the
past year and a half. I went to an online provider and started HRT and have
experienced so much relief! From mental symptoms to night sweats to dryness
(everywhere) I have started to feel so much better being on estradiol and progesterone
for 3 months. I have been working with a functional nutritionist on my diet, walking daily,
etc.
i had gestational diabetes for all 3 pregnancies and also got my tubes removed last
year. After I came off the birth control all of my symptoms started! I recently saw my
normal OBGYN so I could get my HRT through insurance and he agreed- but made it
clear this isn’t menopause, could be POI, but seemed skeptical. I got bloodwork done
and my FSH has risen in the past few months from a 3.7 to an 8. But it’s still considered
normal. All of my thyroid and other bloodwork also comes back normal. Is POI a
possible diagnosis? I feel crazy!!
If you have a question, please visit our website and click Ask the Doctor a question.

Disclaimer: All content in this blog, including text, images, audio, video, or other formats,
was created for informational purposes only. This video, website, and blog aim to
promote consumer/public understanding and general knowledge of various health
topics. This content is not a substitute for professional medical advice, diagnosis, or
treatment. Please consult your healthcare provider with any questions or concerns you
may have regarding your condition before undertaking a new healthcare regimen.

Never disregard professional medical advice or delay seeking it because of something
you have read on this website. If your healthcare provider is not interested in
discussing your health concerns regarding this topic, then it is time to find a new doctor.

Signs Perimenopause is ending | PYHP 147

Dr Valorie Davidson and Dr Robert Maki — Fri, 06 Sep 2024 07:01:07 +0000

Can you be in both in perimenopause and menopause? Can you be menopausal and
perimenopausal at the same time? The difference between perimenopause and
menopause is not a line in the sand. It is not like crossing through the Peace Arch from
Blaine Washington to the country of Canada. And at times, there is nothing peaceful
about perimenopause or menopause.
There is a gray area where you are just moving out of perimenopause and into
menopause, where you are not quite in perimenopause but are not completely in
menopause. We delve deeper into the place that is between perimenopause and
menopause:
– What is the difference between perimenopause and menopause?
– Can you be both in perimenopause and menopause?
– The difference between perimenopause and menopause
– What it feels like to go from perimenopause to menopause
– Can you take estrogen or biest when you are going from perimenopause to
menopause?
– Is bleeding in menopause considered perimenopause?
– Top symptoms of perimenopause
– Top symptoms of menopause
– Are you a candidate for estrogen replacement in perimenopause?
If you have a question, please visit our website and click Ask the Doctor a question.
Disclaimer: All content in this blog, including text, images, audio, video, or other formats,
was created for informational purposes only. This video, website, and blog aim to
promote consumer/public understanding and general knowledge of various health
topics. This content is not a substitute for professional medical advice, diagnosis, or
treatment. Please consult your healthcare provider with any questions or concerns you
may have regarding your condition before undertaking a new healthcare regimen.
Never disregard professional medical advice or delay seeking it because of something
you have read on this website. If your healthcare provider is not interested in
discussing your health concerns regarding this topic, then it is time to find a new doctor.

Estriol Cream for Face Wrinkles | PYHP 146

Dr Valorie Davidson and Dr Robert Maki — Wed, 04 Sep 2024 07:30:17 +0000

In this episode, we discuss a listener’s question about how to apply estriol to your face. ‘Connie’ is confused about whether she can use her Biest cream on her face. And she wanted to know the difference between estriol and Biest when it comes to treating menopausal symptoms.

We analyze Connie’s question into:

Applying estriol to the face
What is biest?
What is estriol?
What is the difference between estriol and biest?
Applying estriol vaginally
It is not a good idea to apply biest to vaginal tissues if you have a uterus

Connie’s Question:

“HI there, I loved your article on estriol for the face. I was prescribed an 80-20 bi-est cream for HRT. My question is, how is that different from a 0.3 estriol cream for the face like the kind My Alloy makes? Could I just use more of my Biest cream on my face? Would that be stronger than the My alloy 0.3 estriol cream? Lastly, the .3 estriol cream is not supposed to affect your overall hormone levels, but the Bi-est cream is supposed to affect your hormones and relieve symptoms of menopause. Why does one estriol work differently than the other? Thank you so much for any guidance you may be able to offer. It’s so hard figuring all of this out!”

If you have a question, please visit our website and click Ask the Doctor a question.

Where To Apply Biest Cream | PYHP 145

Dr Valorie Davidson and Dr Robert Maki — Mon, 02 Sep 2024 07:37:26 +0000

In this episode we talk about where to apply hormone creams. Sadie, our listener wants to know if she needs to rotate the application sites of her hormone cream.

In this episode we discuss:

Where to apply biest cream
What to apply testosterone cream for females
Places you should not apply your testosterone cream
Best absorption sites for hormone creams

Sadie’s Question:
“I have been using hormones for a little over a year. I swear by them!! I have not rotated sites at all. I use testosterone/DHEA cream behind both of my knees and E3/E2 on both of my inner thighs every morning. I take a progesterone capsule at bedtime. My doctor and everything I read says to rotate sites. I found an article by Dr. Collins and now I found your article about not having to rotate sites, so I am going to keep doing what I have been. I put the cream on both of the backs of my legs and thighs. My question is should I alternate one back of knee and then the other and the same with the inner thighs or does it matter?

If you have a question, please visit our website and click Ask the Doctor a question.

Estriol vs Estradiol for Atrophy and UTI | PYHP 144

Dr Valorie Davidson and Dr Robert Maki — Fri, 30 Aug 2024 11:21:37 +0000

In this episode, we discuss a listener’s question. ‘Hannah’ has been dealing with vaginal
atrophy, frequent UTIs, low libido, and reduced elasticity in her skin. She has been to
her doctor for treatment that has not helped.
We breakdown Hannah’s question into:
– Can vaginal atrophy be reversed?
– Menopause and libido
– Vaginal microbiome
– Menopause and UTI
– Estriol vs conventional treatment for vaginal atrophy
– Genitourinary syndrome of menopause

Hannah’s Question:
Hi Dr. Maki and Dr. Davidson. I am told to keep using my Premarin cream. I was initially
on estradiol 0.01% and changed to Premarin. I do not want to take Prempro. I have
used it for years with no improvement of my atrophic vaginitis and dysuria. I continue to
get UTIs. And, as an OR nurse, I cannot drink water in the operating room, it is a risk to
sterility. So I become water deficient, and I get urgency and I cannot leave the OR in the
middle of case. Sometimes a case can go 5 hours or more. Further, I am a 52 year
woman and post menopause. I became menopausal in 2015. The skin on my face and
neck are sagging — making wrinkles more pronounced. My vulva has become looser
and sagging. I cannot perform sexually because I cannot get aroused using clitoral
stimulation because it is so dry there. Lube does not help. I am very frustrated by this,
as is my husband. I get anxious as well because my mind is constantly worried about
my atrophy and vulvitis. Going to a specialist— they are very conservative in treatment.
My husband doesn’t understand. He continues to ask and I say my vagina is broken.
Can you please help me
If you have a question, please visit our website and click Ask the Doctor a question.

may have regarding your condition before undertaking a new healthcare regimen.
Never disregard professional medical advice or delay seeking it because of something
you have read on this website. If your healthcare provider is not interested in
discussing your health concerns regarding this topic, then it is time to find a new doctor.

Perimenopause and Thyroid | PYHP 143

Dr Valorie Davidson and Dr Robert Maki — Thu, 27 Jun 2024 14:29:14 +0000

In this episode, we return to a listener’s question regarding thyroid dosing in
perimenopause. In our previous episode, we answered Tracy’s question about taking
estrogen in perimenopause. Tracy also asked us an additional question about her
thyroid doses. Tracy does not have a thyroid gland and has been noticing her dose is
continually increasing as she progresses from perimenopause into menopause. Does
the hormonal changes in perimenopause and menopause cause increasing thyroid
hormone dose?

Tracy’s 2nd question:
HI- I do not have a thyroid and take compounded T4/T3 daily. I have also noticed that I
am also needing to take more thyroid hormone than I have previously to keep lab
values in optimal ranges and to keep hypothyroid symptoms at bay. It seems that the
farther I get into perimenopause the supplemental thyroid hormone Im requiring is
increasing as my sex hormones are naturally decreasing. Are naturally decreasing sex
hormones and thyroid hormone optimization in the body related? Do you see this in
your perimenopausal and menopausal patients? Needing to supplement thyroid
hormone to continue to achieve optimal results and acceptable symptoms? thanks!

In this episode, we discuss:
● What is Compounded Thyroid Medication?
● What are the types of thyroid medication?
● Having no thyroid
● Do hormonal changes in perimenopause and menopause require increasing
thyroid hormone dose?
● Thyroid testing
● Converting from instant-release thyroid to compounded T4T3 sustained-release
thyroid medication.
If you have a question, please visit our website and click Ask the Doctor a question.

Biest and Perimenopause | PYHP 142

Dr Valorie Davidson and Dr Robert Maki — Thu, 27 Jun 2024 10:42:13 +0000

In this episode, we discuss a listener’s question regarding perimenopause and estrogen
hormone replacement. Tracy is concerned because she is still having a period but also
has symptoms of low estrogen. She is not sure if she is a candidate for estrogen
therapy since she is still cycling.

Tracy’s Question:
Hi- you’ve discussed in past podcasts that you shouldn’t supplement with estrogen
hormone replacement therapy if you are still cycling. I will be 50 in a few months and
still cycling, albeit irregularly. My cycles will be 10 days long, 33 days long, 15 days long
etc. I am taking bioidentical testosterone and progesterone. I am suffering from dry
crepey skin,brittle hair, achy joints, really intense brain fog- so much so that I might
forget to attend an appointment or random names while in conversation, etc. I am also
struggling with some insomnia (waking at 4 am) and restless sleep even though I am
taking progesterone (up to 200 mg per day depending on where I am in my cycle). I am
concerned that my brain is not getting enough estrogen? What is your solution if you
aren’t supplementing with estrogen even though it might be fairly low in lab values or at
least the symptoms seem to show that? How do you help your patients find relief in the
interim? Thank you!

This episode, we will talk about:
● Estrogen therapy while still having a period.
● Perimenopause transition into menopause.
● Hormone levels in perimenopause and menopause.
● What is FSH and how does that determine menopause?
● What is Biest?
● Can you take Biest in Perimenopause?
If you have a question, please visit our website and click Ask the Doctor a question.

Menopause and Anxiety | PYHP 141

Dr Valorie Davidson and Dr Robert Maki — Thu, 27 Jun 2024 10:34:56 +0000

In this episode we discuss Jenell’s question she submitted on our website (Ask the Dr).
Jennell has been having terrible anxiety since entering menopause and it is really
affecting her quality of life.

Jenell’s Question:
Since starting menopause, I’ve had debilitating anxiety, especially bad in the morning.
By evening, It practically goes away. I’m 54 and have been on BHRT 50/50 Bi-est and
175 mg progesterone for 3 months. My hot flashes reduced but the anxiety remained.
Now hot flashes are returning and the anxiety is increasing even more. It was
determined to put me on Bi-est 50/50 0.8 mg/ml of estrogen cream and 175 mg
progesterone SR. I know I need estrogen to keep up serotonin levels. I tried this new
delivery method (est cream and prog pills) for 2 days and felt drugged but with even
more very high anxiety, if that’s possible. I’d like to get back to work of some kind, but I
can’t seem to get this anxiety under control, although I’m told progesterone will do that. I
hope you have some ideas. It’s been three years and my life has radically changed
because of this anxiety.

We breakdown Jenell’s question into:
● Why does menopause cause anxiety?
● Hormone replacement dosing for menopausal symptoms.
● How adrenals can affect anxiety.
● How to reduce morning fatigue caused by oral progesterone.
If you have a question, please visit our website and click Ask the Doctor a question.

Can Menopause Cause Heart Palpitations? | PYHP 140

Dr Valorie Davidson and Dr Robert Maki — Thu, 27 Jun 2024 10:15:35 +0000

In this episode, we discuss a listener’s question. Amanda is 50 years old and starting to
have menopausal hot flashes and weight gain. However, she is most concerned about
the heart palpitations she is having. Amanda has had a cardiovascular workout and
does not have heart disease. Most people might not be aware, but feeling abnormal
heart rhythms without heart disease or feeling like your heart is doing flip-flops in your
chest can be a symptom of menopause.

Amanda’s Question:
Hello, I am 5o y/o and had HYS sparing ovaries at age 40. Been on oral micro
progesterone and love it. However over last few years the flashes started and
supplements helped for a while, and had about a 7 ibs increase over the last 18 months
slowly and my small frame felt it. Then our of the blue 3 months ago I started having pvc
palpitations (with no chest pain, dizziness etc,,,, just annoying and not a comfortable
sensation. I am super fit and eat very clean.
My Functional GYN started me on BiEst 80/20 about 3 weeks ago. I do 4 pumps in the
am on my thighs (not sure if I should be rotating thighs) my throughout the day
palpitations felt a little better within the first week then came back BUT seems a few
when I wake up, I do the cream and then they go away and now they start again about
1pm and throughout the rest of day into evening….occasionally they wait until evening
5-6pm to start again.
I have kept a record. I have my follow up in June, but don’t want to wait to try and see of
two times a day is better for me? two questions….am I metabolizing through it? Should I
split 2 pumps in am and the other 2 in the evening when the palps start again? Will that
backslide any progress I have made? Should I rotate thighs every day? Thank you

In this episode we break Amanda’s question into:
● What are heart palpitations?
● How does estrogen affect the heart?
● Why does menopause cause heart palpitations?
● How to dose hormone therapy to help heart palpitations?
If you have a question, please visit our website and click Ask the Doctor a question.

Does Progesterone Help You Sleep in Perimenopause? | PYHP 139

Dr Valorie Davidson and Dr Robert Maki — Thu, 27 Jun 2024 09:46:09 +0000

In this episode, we discuss a listener’s question about perimenopause. ‘Maggie’ is in
her 40’s and experiencing severe insomnia with anxiety. She has tried supplements and
different doses of progesterone with minimal results. She is having so many ups and
downs with her insomnia, anxiety, and hormones. She is wondering how long this is
going to last and whether will it ever end.

Let’s read Maggie’s question:
Help, I am about to turn 44 and entered peri menopause 1.5 years ago. I suffered,
almost overnight it seemed, from severe anxiety/panic attacks which led to severe
insomnia. My integrative doc started me on 100mg bioidentical oral progesterone and
then it had to get increased to 200mg because my anxiety was so severe and that’s
what I’ve been on for about a year now.
It has been a roller coaster of ups and downs, nothing consistent but it generally helped
the anxiety. Recently though I’ve been experiencing pretty severe insomnia where I
can’t even fall asleep! I get maybe 0-2 hours a night. I haven’t changed anything in my
routine or diet and nothing stressful has happened in my life.
I take things to help like magnesium, glycine, melatonin, ashwagandha, gaba, drink
calming teas and more as advised by my doctor to help with sleep and anxiety. I also
have a strict routine of daily exercise, getting sunshine, not sleeping in past 7, and not
watching tv or on my phone late at night, eating hormone balancing foods and even
taking Epsom salt baths to help relax my body before bed.
Like I said it’s been a roller coaster but two months ago I started sleeping like I was 20
years old again getting 8-9 hours of sleep for the first time since entering perimenopause
however it just stopped few weeks ago and now I can’t sleep at all! My eyes seem wide awake
though my body is exhausted and.
I have Xanax and Trazedone as a last resort as prescribed by my regular MD but I really
hate using them for lots of reasons. Will this phase pass quickly, just another ride on this
crazy hormone roller coaster or will I not be sleeping for awhile? Is it other hormones
now off that need addressing? I don’t see my doctor until June and it’s April. I know how
much sleep is crucial for balancing hormones so I feel like my body is working against
me and everything I’ve been doing to balance those hormones. I’m a stay at home mom
of four and would love even a few hours at this point! Any advise would be greatly
appreciated. Thank you!
There are so many relevant points pertaining to perimenopause in Maggie’s question.
And Maggie is not alone. Insomnia and anxiety are hallmarks of perimenopause.

In this episode, we talk about:
● Perimenopause symptoms.
● Perimenopause and insomnia.
● Perimenopause and anxiety.
● Supplements for perimenopausal insomnia and anxiety.
● Stress and perimenopause.
If you have a question, please visit our website and click Ask the Doctor a question.

How to Treat Premature Ovarian Failure? | PYHP 138

Dr Valorie Davidson and Dr Robert Maki — Fri, 14 Jun 2024 18:09:00 +0000

In this episode, we talk about Mary’s hormone concerns after ovarian failure. She is only
34, and in the last 7 years since her ovarian failure has tried many hormone
replacement options, all without the success she was looking for.

Let’s Read Mary’s Question:
When I was 27 years old I was diagnosed with iatrogenic primary ovarian insufficiency
due to chemotherapy treatments for a gestational trophoblastic disease (molar
pregnancy). I am now 34 years old, and I am currently struggling most notably, with
fatigue, low libido, dry skin/eyes/hair, low mood, annxiety, and brain fog. I began HRT
about 3 years ago, but I was not consistent.
In the beginning I tried estradiol 1mg and medroxyprogesterone 2.5mg with no symptom
relief or rise in serum levels. For 9 months I faithfully took esterified
estrogens/methyltestosterone 1.25/2.5mg and 100 mg of micronized progesterone at
nighttime. My estradiol levels only rose to 16.9pg/mL (estrogens, total 56pg/mL), and
free testosterone only rose to 0.2pg/mL (testosterone, total undetectable). The T
actually decreased.
My doctor was baffled by how stunningly this application failed. 3 months ago I began
estradiol patches (0.1mg/twice week), testosterone 1% gel (12.5mg/1.25gm) pump (1/2
pump/day), micronized progesterone (100 mg/bedtime), and Intrarosa (vaginal DHEA)
at nighttime. I do not have any current bloodwork for this new regimen. I have noticed a
decrease in my symptoms, but I am no where near where I would like to be regarding
symptom relief.
Is it possible to increase my estrogen dosing? I’ve read POI dosing will often be
signicantly higher. Fertility isn’t my primary concern (we have been blessed with two
children), but I’ve heard mixed opinions that cyclic HRT for someone my age may have
benefits outside of fertility such as the lining of the uterus becoming unresponsive to
estrogen and the ability of cyclic HRT may stimulating the uterus to reestablish this
responsiveness.
I’ve never had a DEXA scan, nor discussed bone health with my provider, who is a
university physician. I am also traveling to MN this summer to see a reproductive
endocrinologist with the Mayo Clinic in hopes of finding further solutions. Thank you for
your time.
In this episode, we break Mary’s question into:
● What is ovarian failure?
● How hormone replacement is helpful for sleep, mood, libido, energy, and brain
fog.
● Consider the long-term consequences of low to no hormones in women.
● Estrogen and bone density.
● Cyclic/rhythmic HRT vs static hormone dosing.
If you have a question, please visit our website and click Ask the Doctor a question.

Is Biest Better Than Estradiol Patch? | PYHP 137

Dr Valorie Davidson and Dr Robert Maki — Fri, 14 Jun 2024 17:52:38 +0000

In this episode, we answer a listener’s question about her HRT dosing. ‘Donna’ is 63
years old and has been on some type of hormone replacement therapy for the last 13
years. Hormone therapy is not ‘one size fits all.’ There are so many types of menopause
hormone therapies that each treatment needs to be tailored to the individual. And
overtime hormone treatments will change due to age, specific health goals, symptoms,
and life changes. Even stress can create a need to adjust hormone doses.
Let’s Read Donna’s Question:
Good morning, I am 63 & postmenopausal (menopaused @ 35).
I was from age 50 to 58 on a combo bio identical hormones Biest (?) & progesterone
200mg. A few years ago the doses were dropped to Prometrium 100mg & Biest 0.3mg
(1.5 mg divided by 4 days). My doctor isn’t interested in bioidentical hormones so I
instructed myself. Now at 63, I am “reasonably” well but some vaginal atrophy/dryness,
still some moodiness & bad sleep. I tried stopping & got really “weird” emotionally. I tried
Estriol cream but it’s messy + Prometrium 100mg. Going back on the torches +
Prometrium? I was going to try patches but your podcast made me reconsider. Any
advises please. With kind regards
We take Donna’s question and discuss:
– What is vaginal atrophy or also known as genitourinary syndrome of menopause
(GSM)?
– Different types of hormone replacement: troches, patches, creams, and others.
– Prometrium vs progesterone.
– Not all doctors have a knowledge base of hormone replacement.
– What is biest?
– What is estriol?
– How hormone replacement can help mood.
– How to help treat vaginal dryness due to menopause.
If you have a question, please visit our website and click Ask the Doctor a question.

Is Biest Better Than Estradiol Patch? | PYHP 137

Dr Valorie Davidson and Dr Robert Maki — Fri, 14 Jun 2024 17:52:38 +0000

Menopause and Heart Disease Risk | PYHP 136

Dr Valorie Davidson and Dr Robert Maki — Fri, 03 May 2024 10:08:15 +0000

In this episode, we discuss a question from Janice, a podcast listener’s question
regarding the benefits of estrogen therapy for heart health. There is much evidence to
show that estrogen has cardiovascular protective benefits. We wanted to discuss how
estrogen benefits heart health and can help reduce the risk of cardiovascular disease.
Janice’s Question:
Are Biest 50:50 sublingual tablet safe? My Dr. prescribed 2.5 mg tablets but told me
To take ½ tablet in AM and ½ tablet in PM. I’m worried about blood clots, cancer etc.
In this episode, we dive into:
● Estrogen and its positive effects on cholesterol.
● Differences between men and women in terms of cardiovascular risks.
● Women have less risk of cardiovascular disease because of estrogen levels in
the body.
● How does estrogen can help reduce the risk of heart disease?
● What is cholesterol?
● HRT and Cholesterol
● Break down the components of cholesterol and what they mean.
● How does estrogen help manage blood pressure?
● Types of estrogen hormone replacement can be used for menopause to help
● How weight gain occurs in menopause to increase risks for cardiovascular
disease.
If you have a question, please visit our website and click Ask the Doctor a question.

Estrogen and Bone Density | PYHP 135

Dr Valorie Davidson and Dr Robert Maki — Thu, 02 May 2024 16:26:13 +0000

In this episode, we talk about the benefits of estrogen on bones. A listener’s question
(Alison) inspired this episode. Alison asked if taking vaginal biest has the same heart
and bone effects that other estrogens and estrogen therapies have.
So, we wanted to expand on estrogen’s role in helping keep bones strong and healthy.
In this episode, we expand Alison’s question into:
● What is bone formation and resorption?
● How does estrogen help with bone formation?
● How does estrogen help discourage bone degeneration?
● What lifestyle factors contribute to promoting healthy bones?
● What lifestyle factors contribute to bone degradation?
● Hormone replacement (HRT) and bone density.
● The lowest dose of estrogen for osteoporosis.
● What supplements can help with bone health?
If you have a question, please visit our website and click Ask the Doctor a question.

Does Estradiol Cause Weight Gain in Perimenopause? | PYHP 134

Dr Valorie Davidson and Dr Robert Maki — Thu, 04 Apr 2024 01:30:10 +0000

In this episode, we talk about hormone treatments for perimenopause and menopause.
There is a vast distinction between perimenopause and menopause when it comes to
treatment options. We often see women who are being treated for menopause when
they are genuinely not in menopause.
Meet Linda:
Linda is a listener who sent us a question on our website about her hormone
replacement treatment. Linda is in her 40’s and has her period regularly. She was given
an estradiol patch and gained 20 pounds.
Linda is in perimenopause, yet being treated for menopause. This will cause weight
gain and other symptoms, which we discuss in depth in this podcast.
Let’s Read Linda’s Question:
Hello, I am 44 still cycling. I am currently on estradiol patch 0.05 and progesterone and
testosterone cream. Since I switched from Biest cream to the patch, I have put on 20lbs.
Help.
In this episode, we break Linda’s question into:
● Differences between perimenopause and menopause
● Does a woman in perimenopause need to take estrogen?
● Weight gain and hormone replacement
● What is estrogen dominance vs progesterone insufficiency?
● What symptoms will occur is estrogen levels are too high?
● What hormones should a woman take in menopause vs perimenopause?
● Does hormone replacement cause weight gain or weight loss?
If you have a question, please visit our website and click Ask the Doctor a question.

When to Apply Biest Cream | PYHP 133

Dr Valorie Davidson and Dr Robert Maki — Thu, 04 Apr 2024 01:26:51 +0000

Recently, Catherine posted a question on our website about Biest cream, and we knew
this could interest our listeners.
Biest is a combination of estriol and estradiol, one of the most common forms of
estrogen therapy used in bio-identical hormone replacement. There are many doses,
ratios, options, and methods of using Biest, so we thought this would be an episode
dedicated to Biest and everything Biest.
This episode of the Progress Your Health Podcast is for all the Catherines out there with
questions about Biest hormone replacement cream.
Catherine’s Question:
Hello! Should I apply Biest only in the morning OR morning and night? My dose is 2
clicks. I’m asking because I’m wondering if Biest can be energizing. Thanks so much.
In this episode, we address:
● What is Biest?
○ Biest is a combination of estriol and estradiol used for hormone
replacement.
● Can Biest give you energy?
● Should you take Biest morning and evening?
● How to dose Biest.
● Other hormones involved in hormone replacement, such as progesterone and
testosterone.
If you have a question, please visit our website and click Ask the Doctor a question.

Perimenopause and Sex | PYHP 132

Dr Valorie Davidson and Dr Robert Maki — Wed, 20 Mar 2024 23:58:16 +0000

Welcome to the Progress Your Health Podcast!
This is a podcast that helps you learn about balancing hormones, especially during
perimenopause and menopause. We love hearing from our listeners. If you have a
question, please visit our website and click Ask the Doctor a question.
Let’s read Brigitte’s question!
I have been listening and learning more. Your September 26, 2023 episode on
symptoms of Perimenopause felt extremely validating!!!!!
Almost everything you mentioned I am experiencing. I was first prescribed by my GYN
the Estridiol patch and what you described was spot on and I am glad to confirm that it
didn’t seem right as I still am getting my period regularly! I would be interested in your
thoughts on the BiEST and perimenopause.
I also really related to the “no thought of sex” whatsoever and not initiating, rejecting
and feeling guilty. It can be sometimes over 6 months between. I thought I might be just
losing interest because I can only think of maybe a couple of times in the last 10-15
years that I might have had a true orgasm. For a while now it seems it can be
pleasurable leading in, but feels like it’s taking forever and then starts to feels intolerable
(not pain) but more irritating – numb like – as though the nerves have been
overstimulated or irritated (not pain – more like hitting your “funny bone”) where it
doesn’t feel good anymore and its quite disappointing. I found a different episode about
the estrogen patch and it was mentioned that the Estriol cream applied vaginally – could
help with this.
I also wonder about other things I have been experiencing, a lot of hair breakage or
shedding and nail breakage and a huge change in my skin, and the muffin top!!!!
Hoping and looking forward to a follow up episode on symptoms of perimenopause and
hope to get insight on Estrogen bioidentical compounded cream!
Thank you so much! This has helping me fill in the blanks and clear up confusion after
my appointments!
In this episode, we broke down her question into:
– Using an estradiol patch in perimenopause
– Low libido in perimenopause
– Why is sex not as pleasurable in perimenopause?
– What is estriol, and can it be used on vaginal tissues for lubrication and sex
drive?
– What is Biest, and can it be used in perimenopause?
– Perimenopausal weight gain, aka ‘muffin-top’
– Perimenopausal effects on hair and nails
Because Brigitte’s questions are so common in perimenopause, we
also went on to talk about:
– The vaginal microbiome
– Changes in the vaginal vault and how that can increase susceptibility to
infections.
– Hormonal changes in perimenopause and menopause can make you more
vulnerable to bacterial vaginosis, yeast, and urinary tract infections.
I hope Brigitte’s questions and concerns may have helped others who might be
experiencing symptoms of perimenopause. We appreciate all of our listeners and those
who take the time to write us reviews and reach out with questions.
If you have a question, please visit our website and click Ask the Doctor a question.

Is Perimenopause the Same as Early Menopause? | PYHP 131

Dr Valorie Davidson and Dr Robert Maki — Wed, 20 Mar 2024 23:48:03 +0000

In this episode, we talk about the difference between perimenopause and menopause.
Both Dr. Maki and I (Dr. Davidson) have worked with women in perimenopause and
menopause since 2004 and sometimes get a bit myopic and technical when it comes to
explaining the differences.
The other day, a patient of Dr Maki’s asked the question, ‘Is perimenopause actually
early menopause’? This is such an excellent, straightforward question. The question
made us both pause. The answer is no; perimenopause is not early menopause. But
you can imagine that many others may be asking this question, too.
In this episode, we breakdown this question into:
– What is early menopause, and is there such a thing?
– When does perimenopause really start?
– Can you have a period in perimenopause?
– Can you have a period in menopause?
– If you don’t have a uterus (hysterectomy) but have your ovaries, are you in
perimenopause or menopause or neither?
We love your questions. If you are having any questions about hormones,
perimenopause, and/or menopause, trust me, others have the same exact question.
When going through perimenopause, menopause, or any hormonal imbalance, you are
not alone. Your questions can help other listeners find answers to their concerns as well
as realize that their symptoms of perimenopause and menopause are valid.
If you have a question, please visit our website and click Ask the Doctor a question.

Does Perimenopause Cause Irritability and Weight Gain? | PYHP 130

Dr Valorie Davidson and Dr Robert Maki — Sun, 10 Mar 2024 07:21:22 +0000

We recently got a great question from a listener and want to share it with you.
This question is about a perimenopausal 51-year-old female. She is still menstruating and having confusion about her hormone testing and the hormone therapy that she is currently taking.
She is experiencing some breast tenderness and irritability related to her cycle. She is taking some supplementation and wondering if that is right for her and her hormonal concerns. And while she is nowhere near overweight, she feels that her body is carrying a little extra in the middle, despite exercise and healthy eating.
Here is her question:
‘I am 51 and have had very regular periods, and still do. I do have heavier flow on day 2 and then a few days of light flow. It has been this way since my late 30s. I am 120lbs with a BMI of 19.4. I recently had saliva testing done because I felt I was very irritable during the luteal phase day 20 – 28(ish) sometimes my cycle is as short as 24 days, but more often 28. I noticed the tender breasts and irritability starting closer to day 15 or 17 more recently.
The saliva test results are Estradiol 1.1, Estriol <0.9, Estrone 2.6 L, Progesterone 50L, Ratio Pg/E2 (Saliva LCMS) 45, Testosterone 36 H, DHEAS 1.2, Cortisol 3.4. My naturopath started me on Black Cohash and I started Prometrium 100mg 3 days ago. It feels fairly normal getting up, but sleeping in about an hour longer in the morning but I may feel a bit sluggish later in the day. I generally have good energy and sleep well. In my late 20s and early 30s I did have chin and jawline acne that cleared up with Tretinoin. I still use tretinoin for preventative. I don't have abnormal hair growth, I have had only one breast cyst. I do exercise a lot, but it's a balance of weights, cardio and yoga. I also eat well, I think enough. I do have mid section weight gain. My normal weight is 115, I don't care about the number, just the middle bloating and flab - it's not terrible, but would like things to fit better! My question is about the high testosterone. What would be the next questions to ask or what tests to figure out how to balance this. Could the high testosterone be the source of the irritability and also you mentioned a guide to calories in the show notes for episode 59 but I can't find these. Thank you! I just started listening and have passed this on to others’. In this episode, we break our listener’s question into: ● Weight gain or change in body fat distribution in perimenopause. ● Lab testing for perimenopause and what it means. ● Supplements thoughts for perimenopause. ● What estriol, estradiol, progesterone, and testosterone are. And what they mean in perimenopause. ● Other hormones affected in perimenopause, such as DHEA and cortisol. ● Can testosterone cause irritability in perimenopause? If you have a question, please visit our website and Ask the Doctor a question. Thank you for listening.

Can Progesterone Help with Sleep? | PYHP 129

Dr Valorie Davidson and Dr Robert Maki — Sun, 10 Mar 2024 07:13:19 +0000

in this episode, we answered a listener’s question. We love questions from listeners. If you have a question, please visit our website and click Ask the Doctor a question.
Here is the listener’s question:
I have been perimenopause for at least 4 years now
I am 47 and after completing a Dutch test with a holistic chiropractor she told me to ask
my doctor about Prometrium. I was scared to take it and then 6 months ago my sleep got really bad and three months ago I got very ill with gi issues and gallbladder issues. I had to have gallbladder surgey and developed full blown insomnia. I was sleeping 0 to 3 hours.
Two weeks ago I got two very contradicting solutions for my low progesterone. The functional medicine/ gyno prescribed Promterium at 400mg and told me to go down to 200 mg if too sedating.
A few days before that I saw an integrative doctor. She told me to take 25mg of sr bioidentical progesterone and bump it up by 25mg every week. I was also put on ashwagnhda 700mg at night and 100 mg of L-theanine at night to help lower cortisol and for stress and anxiety. I also take 200mg of magnesium glycinate at night.
I am working with a sleep coach for my insomnia/anxiety. I have calmed down significantly and do not care or panick if I dont sleep
The 25mg dose did nothing. I tried 200mg of Prometrium and it upset my stomach. I felt dizzy until like 3 and then was wide awake and then maybe fell asleep around 5am for 3 hours.
After reading everything on here. I asked gyno to prescribe compounded sr bioidentical in 100mg. She still insisted I take 200mg. The integrative doc thinks it is dangerous to try various doses. I tried 100mg sr and it did not help me sleep. I tried 150mg for 3 nights and it helped me sleep some. I now increased to 200mg two nights ago and my sleep is still horrible but am sleeping a some.
The integrative doc told me it is dangerous to do what I am doing with the doses and told me to stay on 75mg until I see her (that is in a month).

The gyno/functional medicine doctor told me to take 200-400mg and will follow up here in a month.
I am 110 pounds and the integrative doctor told me that 200 mg is way too high for me. She said progesterone will not be a quick fix for my insomnia. I don’t expect it to be but I keep on reading how sedating it is.
How long do you need to be on a dose until you know if it is the right dose and what are the side effects of too a high of a dose? The bioidentical compounded dose does not hurt my stomach like the Prometrium. I feel slightly dizzy at night but not at all sedated. I am very confuse with advice but I would like to follow the gyno/functional medicine doctor.
This listener had a few issues happening here. As that is the case with everyone. There is no clear ‘one size fits all’ when balancing hormones.
In this episode, we broke down her question into:
● How progesterone relates to perimenopause.
● Forms of progesterone such as orals, creams, troches, and gels.
● Dosing of progesterone. There are multiple potencies and dosing of
progesterone.
● The difference between Prometrium and micronized progesterone.
● Appropriate doses and forms of progesterone for a perimenopausal female.
● How sleep is affected in perimenopause.
● Consider gastrointestinal, liver, and gallbladder implications in perimenopause.
● Weight gain in perimenopause.
● Side effects and safety of progesterone therapy.
● How long does it take for progesterone therapy to work?
Again, if you liked this episode, or have your own hormone concerns, please reach out and Ask The Doctor a question.

Vaginitis vs Yeast Infection | PYHP 128

Dr Valorie Davidson and Dr Robert Maki — Fri, 06 Oct 2023 11:14:45 +0000

The dreaded, uncomfortable, annoying, burning, itchy, achy, irritating vaginal infection.

Ladies, we have all been there. And for those unicorns that have never had a vaginal infection such as yeast or bacterial vaginosis, well, you are certainly one of the lucky ones. While a yeast infection or BV is not life-threatening, not fatal, and maybe not an emergency, that does not mean it’s not urgent.

Especially vaginal infections that are chronic or keep returning can be incredibly annoying, painful, and frustrating. It is very accurate that once you have a yeast infection or vaginal infection like BV, it can come back over and over. I have had many patients come to see me because no one could help them with their vaginal issues. Not only is it embarrassing and uncomfortable, but often, doctors will blow off vaginal issues.

Perhaps it was not expressed enough as an issue. As I know it can be challenging to talk about issues ‘downstairs’ to a stranger, doctor, or no doctor. Geez, most women have told me that their mothers and grandmothers would not go near the subject of anything to do with ‘the vagina.’ So can you imagine telling a doctor you have never met that you are in pain, super itchy, tender, uncomfortable, and not-normal discharge is discharging, a lot… takes a lot of courage to say.

As I said, a vaginal infection is not fatal. It might feel like your vagina is on fire, but you will live. Uncomfortably live to say the least. I think it is essential to talk about having a vaginal infection. If you had a sinus infection, no one would bat an eye. If you have an ear infection, that is easy to talk about. It should be the same with vaginal infections.

Bacterial vaginosis (BV) and yeast (candida) infections have nothing to do with hygiene and are not contagious. They can happen for many reasons, just like an ear infection or sinus infection.

So that leads me to a great question from a reader about her issues with vaginal infections. She says she had 6 yeast infections in six months and more months of grief with no relief. I really feel for this woman because that is not how to live life. After all the treatments she has used and put on/in her poor vagina, she is terrified to put anything else near it. I don’t blame her. But what a predicament to be in. I am sure she is not even contemplating being intimate, let alone sexual, when her poor privates are on fire. I’m sure she is constantly worried that darn infection lurks around the corner at every turn.

Here is our reader’s question, which I will answer (we always change the name for privacy).

Melissa’s Question:

I am 52. Have Sjogrens and Hashimotos. I have Atrophic Vaginitis. A year ago I started Vagifem for 3 weeks. Yeast infection after. Then I was put on Premarin Cream then yeast again. But I continued with the Premarin. I did this for 6 months and treated 6 yeast infections during this time. Finally I stopped all medications and took a vaginal moisturizer. I did well with this for three months. Then I got another yeast infection or so I thought. This has been a battle for another 2 months. The dr did swabs and everything negative for yeast BV STI. I feel swollen in the vag and when I urinate I feel pain afterward and sitting feels like my vag is hurting. No cystocele or rectocele. I have also reacted to lubes with glycerine or glycol. Now the Dr wants me to start Intrarosa and I am paranoid to start incase I get yeast. Does anyone have any advise as I am at my witts end!

I will answer Melissa’s questions plus:

What are GSM and Vaginal Atrophy?
What is Vagifem?
What vaginal Premarin?
What is a vaginal moisturizer?
What are yeast and BV?
What is Interrosa?
What is Sjogren’s syndrome
What is Hashimotos?
How about Estriol for GSM?

What are GSM and Vaginal Atrophy?

GSM stands for genitourinary syndrome of menopause. It is a new term that replaces vaginal atrophy. But GSM and vaginal atrophy can be used interchangeably. When a woman enters menopause, her ovaries stop producing estrogen and progesterone. The vaginal cells and tissues respond and maturate to estrogen. So when the estrogen levels drop, you will see changes in the vaginal tissues and cells. Immature vaginal cells are called parabasal cells.

Parabasal cells are like baby vaginal cells. You feed them estrogen, and they will grow into mature vaginal cells. When the estrogen levels drop in menopause, you will see changes in the vaginal tissues. It can cause vaginal dryness, pain with intercourse, and even bleeding from the fragile, thin tissues of the vaginal vault. Also, because there is less lubrication and more fragile tissues, it can alter the biome of the vaginal canal. The vaginal canal/vault has a symbiotic relationship with bacteria, yeast, organisms, and flora. When the vaginal tissues and cells change during menopause, this can disrupt the flora balance increasing the risk of vaginal infections. Also, when this flora is disrupted, it can cause an increase in urinary tract infections (UTIs).

Disrupting the beneficial bacteria can allow e.coli to travel up the urethra to cause a UTI.

Also, estrogen can help tone the urethra (the tube from your bladder to the outside world). When the estrogen levels drop in menopause, the urethra can become more lax, allowing easier access for the e.coli to cause a UTI. And it can cause urinary leakage, also called urinary stress incontinence. You know, jumping jacks, coughing, sneezing, laughing, exercising, anything you are putting a little strain on the bladder can cause a little leakage. I like the new term GSM, even if it is a mouthful to say, genitourinary syndrome of menopause. It explains that more can happen to the vaginal vault and urinary tract than just vaginal dryness.

What is Vagifem?

Vagifem is a estradiol vaginal insert. It is used for GSM/vaginal atrophy. There are three estrogens that we make in our bodies, estrone (E1), estradiol (E2), and estriol (E3).

Estradiol is the most potent form of estrogen. It is a beautiful hormone and helpful in many areas, from brain health to bone density. But estradiol can be too strong in some cases. Ideally, estradiol applied vaginally should only stay localized to the vaginal tissues to help with GSM.

But I have found that my patients taking Vagifem, had elevated levels of estradiol in their blood when they were not taking any systemic hormone replacement. That may be unsafe for women who should not be on estrogen therapy. This is why I do not prescribe vagifem. Estradiol, in many cases, can to too strong for the vaginal vault and can cause yeast infections. That is why women will get a yeast or bacterial infection very shortly after using estradiol vaginally.

What is Premarin Cream?

First off, I do not prescribe Premarin in any form. Not just for the ethical (or really unethical) sourcing of it (google it, you will be horrified). But also because it is not bio-identical. I only use bio-identical estrogen (estriol and estradiol) for hormone replacement. Premarin is not estradiol but is even stronger. Premarin cream can (like estradiol vaginally) can disrupt the flora of the vaginal vault making it easy to get a yeast or bacterial infection.

What is a Vaginal Moisturizer?

There are vaginal moisturizers and lubricants and each are different from each other. A vaginal moisturizer increases the water in the vaginal cell. They often have hyaluronic acid in them to increase the water content in the cell. A vaginal lubricant sits on the surface of the tissues to relieve friction. A lubricant would be used during intercourse and a moisturizer would be used regularly to help the tissues retain more moisture. Both are helpful with GSM but sometimes the benefit is minimal depending on the severity.

What is a Yeast Infection and What is BV?

Most of us have heard of BV and a vaginal yeast infection. One of course is an overgrowth of bacteria and the other is yeast. Bacterial vaginosis is a overgrowth of garderella species. Garderella is a bacteria that is non-pathogenic in our vaginal canals. But when it grows like crazy, it can cause BV.

Garderella will propagate when the pH of the vaginal canal becomes more alkaline. The vaginal vault likes to be in a more acid state. That is why the beneficial bacteria of the vaginal canal have names like lactobacillus acidophilus. That is why probiotics that have Lactobacillus reuters and Lactobacillus rhamnosus are really popular for women. They help to keep the vaginal vault more acidic to help prevent BV.

A yeast infection is an overgrowth of candida. Candida albican is the main fungus that causes a yeast infection. Yeast infections can happen in the mouth (called thrush), and I have even seen yeast under the creases of the breasts, in the ear, anally as yeast can grow anywhere that is moist.

The symptoms of yeast and BV are similar but also quite different. BV:

Itchy, burning, feels like your vaginal area is on
Always worse after intercourse and often better after your period. But can come back with a vengeance about mid cycle (for those premenopausal women).
There is no constant discharge. But the discharge is very watery and clear. And will periodically all of a sudden discharge a watery discharge that you will notice and want to run to the bathroom bc it does feel like, ‘did I just pee myself?’.
Like I said above, BV is not about hygiene. It happens because the pH is thrown But it does have an amine odor. That is a nice way of saying it smells fishy. But like I said, it has nothing to do with hygiene and all about the pH of the vaginal vault.
What causes BV? Wel the pH of the vaginal canal becomes more alkaline. That can happen from antibiotics, dietary, vaginal lubricants, GSM, and for no reason whatsoever, BV can happen. Even intercourse can cause BV. Seminal fluid is very alkaline, so intercourse can change the pH of the vaginal vault causing BV.
Pain with urination (and it is not a UTI).
The vaginal tissues looks really red. If it is really bad, the tissues will look swollen and inflamed and bright red.
If the infection is really advanced the vaginal tissues can look like there are little cuts on it. And even sometimes the tissue can bleed and you will see light red blood on the toilet paper.

Yeast Infection:

Itchy, burning, did I say itchy, very very itchy. It’s like a mosquito bite on steroids. And of course you can’t itch in public. Not proper behavior young lady! Which makes it incredibly annoying and you can’t stop thinking about it while you put on a happy face and go about your normal business like you are not ready to scratch your vulva off.
It always seems like your vaginal area and underwear are moist and damp and
The discharge is more creamy colored, pretty thick and no Some people will say it smells ‘yeasty’, but really it is not a noticeable odor like BV.
The vaginal tissues look almost grayish and white with a tinge of the pink. People will describe the tissue as looking,’dull.’
There can be ‘satellite lesions’. Meaning you can see little red dots around the vulva on the thighs and bum.
Yeast infections can happen from antibiotics, medications, GSM, food allergies/sensitivities, sitting too long in a bathing suit or out of nowhere for no

What is Interrosa?

Interrosa is a vaginal insert that is made of DHEA. DHEA is an amazing hormone. It is a hormone that is mainly made from the adrenals glands and systemically is more of a masculine hormone, but can help with energy, drive, immune system and much more. I give lots of women DHEA supplements. Now us ladies should take lower doses of

DHEA systemically/orally. But it has so many benefits. Interrosa is a vaginal insert of DHEA. There are studies that show that vaginal DHEA can be helpful for dryness. I have also seen literature that shows that vaginal DHEA can help with libido. Honesty, at this time, I have not found that vaginal DHEA helps with libido, but I am open to it.

What is Sjogren’s syndrome?

Sjogrens could be its own series of blogs and podcasts. But I do want to touch on this as Sjogren’s can make GSM/vaginal atrophy symptoms so much worse. It is a connective tissue autoimmune syndrome that causes dryness. You will see dryness in the eyes, skin, and pretty much any mucous membrane. Vaginal tissues are a mucous membrane that can be affected in Sjogrens. Making the vaignal tissues more dry, increasing the risk of disrupting the vaginal flora and pH, this increasing the chance for vaginal infections.

What is Hashimoto’s?

I deal with Hashimoto’s all the time. It is more common than you think. Hashimoto’s is an autoimmune syndrome where the immune system makes antibodies to attack the thyroid. Eventually this will cause the thyroid hormones to drop becoming hypothyroid. The main Hashimoto’s antibodies are thyroid peroxidase antibody (TPO), and thyroid peroxidase antibodies (TGab). If one or both of these are elevated then you have Hashimoto’s.

How about Estriol for GSM?

As you read above, estriol is one of the three estrogen we make. Estriol is a very gentle form of estrogen. I love using estriol for GSM and vaginal atrophy. By helping correct the GSM it will help prevent and lower the risk for UTIs and vaginal infections. Estriol vaginally will not enter the bloodstream like vaginal estradiol can. Because it is gentle estriol is much more likely to cause any yeast infections or change the pH making one more susceptible to BV. Estriol can come in suppositories, cream, vaignal inserts. But it typically comes from a compounding pharmacy. Meaning they can make any filler, binder, dose and vehicle for administration we want. We do have many readers and listeners from outside the U.S. that tell us that estriol is available without prescription where they live. But working with patients in the U.S. I usually will prescribe it from a compounding pharmacy.

Thoughts on Melissa’s question:

Melissa started with the vagifem (estradiol vaginal insert). And quickly after that she noticed the yeast infections starting. The estradiol was too potent for her vaginal vault, which triggered a yeast infection. This also goes for the Premarin cream that she tried. It was way too strong for her vaginal vault and disrupted the flora and pH causing these frequent infections. Also Melissa mentions that she was tested for STIs. STI stands for sexually transmitted infections. It is the new replacement term for STD, sexually transmitted disease. Which is a much better name, because they are not diseases but infections. Kathy was negative for STIs and also for BV and yeast. I do know the STI testing is accurate. But swabs and testing for yeast and BV are not always accurate. I believe Kathy’s vaginal vault is in complete dysbiosis. Her flora was off, so the beneficial bacteria was so low it could not compete with more pathogenic bacteria. And the pH of her vaginal canal was disrupted causing a perfect environment for bacterial vaginosis to flourish.

It sounds like the vaginal moisturizer was helpful for several months. Which is encouraging. The increase in the water content of the cell helped to balance the flora of the vaginal vault temporarily. But because of the advanced GSM the moisturizer was not enough to keep the infections at bay.

I think something that would be safe and gentle for Melissa is to take a woman’s vaginal probiotic. A probiotic that has Lactobacillus reuteri and Lactobacillus rhamnosus.

Taking it orally would be great for Kathy. But also using an old-school method of poking little holes in the probiotic capsule and inserting it vaginally to try and repopulate with beneficial bacteria and changing the pH to a more acidic environment.

I really feel like Melissa was dealing with more chronic BV. I know I don’t have all the information but from her description it sounds like chronic BV. She says it is burning and she feels pain with urination (no UTI). BV is pretty notorious for being chronic with the symptoms waxing and waning. With this in mind, I would consider trying to work on her pH. Another great way of doing this is to use boric acid vaginal capsules. This is also a ‘old-school’ method of making the vaginal vault more acidic. I know people get concerned about the ‘acid’ part. But boric acid is a very gentle, healthy treatment for the vaginal canal. I also use boric acid vaginal capsule for UTIs, they work great, for prevention and treatment (but that would be another topic).

Honestly, I do not think the interrosa is going to be helpful or Kathy. I still think she is going to be still suffering from the GSM symptoms and the chronic infections (BV is my thought). Melissa mentions that she has Sjogren’s and Hashimoto’s. Both of these can considerably contribute to GSM/vaginal atrophy. Sjogren’s can cause dry mucous membranes. Hence, Melissa’s GSM, altered vaginal biome/flora. And Melissa says she has Hashimotos. Which means she is most likely hypothyroid and on thyroid medication. Hypothyroid can also cause dry tissues, from constipation to dry hair, skin and nail and even contribute to dry vaginal/mucous membranes.

My additional thoughts for Melissa would be to implement estriol vaginally. I know she might be apprehensive at this point of letting anything near her vagina. But estriol vaginally could help to feed the vaginal cells to create more resiliency, hydration and rebalance the pH for the proper flora to propagate. It is not the infections that we want to eradicate. The goal is to change the environment so that the infections cannot flourish.

If you have any questions, feel free to reach out and send us a message on, Ask The Doctor

All content found in this blog, including: text, images, audio, video or other formats were created for informational purposes only. The purpose of this website and blog is to promote consumer/public understanding and general knowledge of various health topics. This content is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Please consult your healthcare provider with any questions or concerns you may have regarding your condition and before undertaking a new health care regimen. Never disregard professional medical advice or delay in seeking it because of something you have read on this website. If your healthcare provider is not interested in discussing your health concern regarding this topic then it is time to find a new doctor.

Can Progesterone Cause Anxiety? | PYHP 127

Dr Valorie Davidson and Dr Robert Maki — Wed, 04 Oct 2023 12:13:24 +0000

Can Progesterone Cause Anxiety?

Often we get reader/listener questions about their own experience with hormones. We love that readers of our blogs and listeners of the podcast (TheProgressYourHealth Podcast) reach out for more information. If they have concerns and questions, that means many, many other people have the same concerns. A lot of questions we get are hard to get answers online.

Honestly, hormones and hormone replacement is an art that should be designed around the patient. Every person taking hormone replacement has different reasons for doing so. Those hormone goals can range from weight loss, mood improvement, insomnia, bone density, energy to sex drive just to name a few. Those of you that are regular listeners/readers, I’m sure, have heard this from me a thousand times over. And I will continue on that soap box, so bear with me.

Hormone replacement is not a cookie-cutter approach where one size fits all. It needs to be tailored to the individual. This article is about a recent podcast that we did on a reader question. I feel this is an interesting question because it is about hormone replacement therapy, but there are so many nuances to tease apart. When talking about hormones, everyone is focused on the estrogen and progesterone dosing and not considering the other hormones involved that could be part of the issue.

Here is the question (we always change the names of readers and listeners to protect privacy).

From ‘Kathy’

Hi Dr. Davidson.

My question to you, is what do you suggest if a woman is on Biest and can’t take the Prometrium because it has the opposite effect and gives her anxiety?

Yes, she has a uterus, yes she is on Biest, but what if cream is her only option? Thanks in advance – Kathy

There is a lot to tease apart here, but let’s explain a little more thoroughly about the hormone regime she is on.

What is Biest?

Biest is an estrogen combination of estriol and estradiol. There are three main estrogens in a female’s body. Those are Estrone (E1), Estradiol (E2) and Estriol E3). Estrone is not commonly used, and it is mainly seen in younger women going through puberty or is made by adipose tissue. Adipose tissue is ‘fat’ tissue, and yes, your fat is like its own endocrine gland, secreting other hormones and estrone (lepton, adiponectin to name a few popular ones).

Biest is part of bio-identical hormone replacement, meaning the estriol and estradiol are made from plants to look exactly like what our own bodies make. So if it looks just like what our bodies make, then it will have a better response and fewer side effects.

Kathy is taking a Biest cream for her estrogen replacement, which is commonly used as a cream. She applies her biest cream topically, also called transdermally. You can apply your hormone cream to the inner thigh or back of the knee. Because all hormones are fat-soluble, and the inner thigh, as we all know, has an excellent fatty pad there, making it a great site. Applying hormones to thin tissue like the inner arms, can cause quick absorption and then it is eliminated from the system quickly. Plus, inner arms means you could share it when you hug or touch or carry pets or other humans. Some research shows that the neck and face are excellent places for transdermal absorption. But if you love giving kisses to your pets, little ones or family, you could end up sharing your hormones.

Progesterone for Uterus Protection:

As Kathy mentioned in her question, she could not tolerate the Prometrium (an oral form of progseterone), and she has a uterus. The reason she mentions this is because it is essential to take progesterone anytime you are taking estradiol/estrogen therapy and you have a uterus. Estrogen loves to grow things, especially the uterine lining. If Kathy did not take progesterone and only took biest (estriol/estradiol), it would be a matter of time before her uterine lining started to increase. This can cause spotting, abnormal uterine bleeding, a period, and an increased risk for uterine cancer.

Oral Progesterone or Cream for Uterine Protection:

If you have a uterus and are taking estrogen therapy for hormone replacement it is important to take an oral form of progesterone. The oral form protects the lining much better compared to the cream. I do not think it is appropriate to take progesterone cream when taking estrogen therapy because of the risk of thickening the uterine lining. I do not prescribe less than 100mg of oral progesterone when a woman is taking a form of estrogen therapy and has a uterus. Some women may need a higher dose of progesterone, such as 125-200 mg, or even a little higher. But it really should be oral

progesterone. It was asked of me if a progesterone troche could be a replacement for oral progesterone. A troche is a sublingual tablet/gel tablet that you put under your tongue or the side of the cheek of your mouth. It is meant to be sublingually absorbed. Meaning a troche would not be an oral form of progesterone. I have found that the troches are absorbed sublingually, but there is an oral component of it as some of it will be swallowed. But even still, I do not think a troche could protect the uterus as well as a oral form.

What if a Woman with a Uterus just cannot take oral progesterone?

There are a few options here.

One, would be she just could not take biest. At least in my practice, I would not feel comfortable prescribing any estrogen/estradiol therapy without oral progesterone to protect the uterus.

Two, find out if it is the oral progesterone causing the issue. I have run into this issue in the past with patients. And all the time, we find a way to take oral progesterone or find out if it is something other than the progesterone causing the anxiety. I will get into this more later in this article.

Three, let’s do bio-identical hormone replacement as rhythmic dosing instead of static dosing. The biest that Kathy is taking is considered a ‘static dose.’ Meaning she applies/takes the same dose daily, and it doesn’t change. Rhythmic dosing for estrogen and progesterone is taking the hormones in a cyclic dosing so that it mimics that ovarian natural hormonal rhythm.

You take both the estradiol and progesterone as a cream, but the doses change throughout a 28-day cycle. It basically mimics the natural hormonal changes you would see in a 28-29-year-old female. In this case, the rhythmic dosing would create a monthly period. So the estradiol would thicken the uterine lining, but it would be sloughed off every month, just like a period. So there is never a long-term accumulation of the lining in the uterus. In static dosing, there should never be any spotting, bleeding, or a period.

Thoughts About Kathy’s Issue with Progesterone and Anxiety:

I have run into this issue where a woman takes oral progesterone and has anxiety. There are a few issues that could be the culprit.

It could be the Prometrium that she is taking. Prometrium is considered bio-identical progesterone. But it could be the fillers, binders, or excipients in it that she is reacting to. If she were sensitive to a filler, it can cause any side effect you could imagine from

digestive distress to rashes to yes, even anxiety. Prometriums are made with peanut oil. Anyone sensitive to peanuts, ever thought they were sensitive to peanuts, thought they reacted to peanuts, or dread to think, allergic to peanuts, do NOT take Prometrium.

Instead, take a compounded progesterone made in a compounding pharmacy, where they can make sure to use fillers that you are not sensitive to.

Prometrium is an instant-release formula, and that is what Kathy is taking. Meaning that as soon as she swallows it, it goes right into her bloodstream. It could be the instant release it could be stimulating to her. Ideally, progesterone is supposed to lower cortisol and stimulate GABA. But the quick, fast, instant release could be causing a rebound of her sympathetic nervous system, causing cortisol levels to jump up and anxiety.

It’s All About Timing:

Ideally, oral progesterone is supposed to be taken in the evening. The evening could mean a lot of things. Personally, I am a baby, and go to bed at 8:30 and try to be asleep by 9:15 (beauty, sleep, ya all!). But other patients I have are night owls and stay up until 2 am. The last time I stayed up to 2 am was in college, and a few times (okay, every weekend), I went to dance clubs; yes, we are talking techno and 90’s dancing. Meaning that taking your progesterone at 8 pm is much different than taking it at 2 am. So, if a woman is complaining about anxiety after taking the progesterone, I have them taking it at a different time. Take it at 7 pm and go to bed at 10. It could be taking it so close to bedtime is just not enough time to let the body get into a parasympathetic state.

Prometrium and progesteorne:

Yes, Prometrium is a commercially available form of bio-identical progesterone. But there are so many differences, as I mentioned above. Progesterone compounded can come as a sustained release instead of the instant release Prometrium. Sustained release is slowly absorbed and rises gently as you sleep and then drops before you wake up. I have found switching to a sustained release progesterone can help immensely with anxiety as well as sleep and the mood the next day. So honestly, my first suggestion for Kathy is to switch to a sustained-release compounded progesterone. That way the fillers she might be sensitive to are eliminated and it doesn’t instantly rise in her system after she takes it.

Dosing?

The dose of the prometrium could possibly be causing the anxiety Kathy is experiencing. Prometrium comes in 100mg and 200mg. It could be the 200mg is too high for her or the 100mg is too low for her. Unfortunately, you can only do 100mg or 200mg with prometrium. If she were able to do the compounded we could do any dose we wanted. Perhaps a 125mg or a 150mg she could have a better outcome.

It could be the Biest:

The bio-identical hormones, inparticular the biest (estriol/estradiol) do not have a long lifespan in the body. Usually it lasts about 12 hours in the system. If Kathy were taking her biest cream once a day, that could be the issue.

If she were taking it in the morning by the time the evening comes around the biest would be out of her system. Which that can cause hot flashes. I have a lot of woman that hot flashes will cause anxiety and panic attack. I have even had quite a few women mistake a hot flashe for anxiety. I would make sure that Kathy was taking her biest twice a day (am and pm) and also taht the dose was enough for her. Checking this with her symptoms and blood work would give us good insight into if her biest dose needed to be adjusted.

It could be her Adrenals:

Remember when I said that the progesterone could be causing a cortisol rise? Ideally, progesterone is very relaxing. It stimulates GABA and is suppose to balance cortisol levels and helps with sleep.

But progesterone can convert to 17-OH-progesterone. And 17-OH-progesterone can convert to cortisol. It would be a good idea to test Kathy’s 17-OH-progesterone and cortisol levels to see if this is the case. Not everyone converts progesterone to

17-OH-progesterone. Some very little and others there is very high conversion. That is because there is and enzyme called, 21-hydroxylase enzyme that some people can be deficient in. I won’t continue to bore you with all of the science, but it would be a good idea to check her 17-OH-progesterone and cortisol levels.

This could be another reason to switch Kathy to a sustained release. Again, another theory, and something I have noticed in practice perhaps is when taking a instant release such as Prometrium, that huge bolus of progesterone entering the system could trigger a immediate fast conversion to 17-OH-progesterone. The body is very smart. It sees a bunch of progesterone and is not quite sure what to do with it, then just converts to 17-OH-progesterone which then converts to cortisol causing anxiety.

I want to send appreciation to all of our readers and listeners for sending in their questions. If you have questions about your hormones, trust me, there are many others that have the same concern. It is great that we can all help each other and also know that we are not alone in our hormonal health.

If you have any questions, feel free to reach out and send us a message on, Ask The Dr.

All content found in this blog, including text, images, audio, video, or other formats, was created for informational purposes only. The purpose of this website and blog is to promote consumer/public understanding and general knowledge of various health topics. This content is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Please consult your healthcare provider with any questions or concerns you may have regarding your condition and before undertaking a new health care regimen. Never disregard professional medical advice or delay in seeking it because of something you have read on this website. If your healthcare provider is not interested in discussing your health concern regarding this topic then it is time to find a new doctor.

Other Related Episodes:

Episode 118: When Should A Woman Take Progesterone?

Episode 113: Can Progesterone Cause Dizziness?

Episode 111: Does Progesterone Help With Perimenopause?

Can Progesterone Cause Anxiety? | PYHP 127

Dr Valorie Davidson and Dr Robert Maki — Wed, 04 Oct 2023 12:13:24 +0000

Can Progesterone Cause Anxiety?

Here is the question (we always change the names of readers and listeners to protect privacy).

From ‘Kathy’

Hi Dr. Davidson.

My question to you, is what do you suggest if a woman is on Biest and can’t take the Prometrium because it has the opposite effect and gives her anxiety?

Yes, she has a uterus, yes she is on Biest, but what if cream is her only option? Thanks in advance – Kathy

There is a lot to tease apart here, but let’s explain a little more thoroughly about the hormone regime she is on.

What is Biest?

Progesterone for Uterus Protection:

Oral Progesterone or Cream for Uterine Protection:

What if a Woman with a Uterus just cannot take oral progesterone?

There are a few options here.

One, would be she just could not take biest. At least in my practice, I would not feel comfortable prescribing any estrogen/estradiol therapy without oral progesterone to protect the uterus.

Thoughts About Kathy’s Issue with Progesterone and Anxiety:

I have run into this issue where a woman takes oral progesterone and has anxiety. There are a few issues that could be the culprit.

Instead, take a compounded progesterone made in a compounding pharmacy, where they can make sure to use fillers that you are not sensitive to.

It’s All About Timing:

Prometrium and progesteorne:

Dosing?

It could be the Biest:

It could be her Adrenals:

Remember when I said that the progesterone could be causing a cortisol rise? Ideally, progesterone is very relaxing. It stimulates GABA and is suppose to balance cortisol levels and helps with sleep.

If you have any questions, feel free to reach out and send us a message on, Ask The Dr.

Other Related Episodes:

Episode 118: When Should A Woman Take Progesterone?

Episode 113: Can Progesterone Cause Dizziness?

Episode 111: Does Progesterone Help With Perimenopause?

When Is It Too Late To Start HRT? | PYHP 126

Dr Valorie Davidson and Dr Robert Maki — Fri, 29 Sep 2023 12:11:32 +0000

When is it too Late to Start HRT?

Recently we received a great question/comment from a listener of our podcast (The Progress Your Health Podcast). I’ll call her ‘Jenny’ (because I never reveal any personal information for the sake of privacy). Jenny was wondering if she is too far into menopause to be able to take bio-identical hormone replacement therapy.

She has been post-menopausal for the last ten years, using an estradiol vaginal insert for her GSU/vaginal atrophy. Her pharmacist thought that changing her prescription and implementing bio-identical hormone replacement could help with her bones, cholesterol, and heart protection. This is an excellent question, as many other women have these same thoughts.

Am I too old to take/start bio-identical hormone therapy?
Are hormones going to help my cholesterol?
Is hormone therapy going to help reduce the risk of cardiovascular disease?
Can hormone replacement help with bone density?

Below is the question from our podcast listener:

I am a healthy and uber fit 60 yr woman who has been menopausal for ten years. My chief complaint is GSM. I have been on 10mcg Vagifem for this entire time, 3-6/week. Well-controlled. My cholesterol is 7! LDL 3.5 / HDL 3.28

I saw a pharmacist who is a BHRT specialist, and she recommends:

.25mg BiEst, 100mg progesterone and +- testosterone depending on levels. She thinks this will balance my hormones better, possibly improve my lipid profile, and protect my heart and bones. Am I too late in the game for BHRT? Do you agree with her suggestions?

What is GSM?

GSM stands for genitourinary syndrome of menopause. It is a new term that replaces vaginal atrophy. GSM and vaginal atrophy can be used interchangeably. Vaginal atrophy occurs when the estrogen levels drop causing changes in the vaginal tissues. Estrogen really primes the vaginal cells and will maturate them from parabasal cells into mature vaginal cells. When the estrogen drops in menopause, the tissues can become dry, with less lubrication and the tissues can become more fragile. This is where you will find pain or even bleeding (from the tissues tearing) with intercourse.

I like the term GSM, genitourinary syndrome of menopause because when the estrogen drops it can cause so much more than just dry, fragile vaginal tissues. It can cause the flora of the vaginal vault to change. This increases the risk of vaginal infections such as yeast/candida and bacterial vaginosis. It can also cause more increased risk for urinary tract infections. As well as urinary stress incontinence. The urethra (the tube that connects the bladder to the outside world, aka the toilet), can become more lax when the estrogen levels drop in menopause.

This can cause urinary leakage with coughing, jumping, laughing, exercising, sneezing, doing crunches, jogging, walking, you get the drift. GSU/vaginal atrophy can be so mild that women do not even notice any changes. And other women can have such severe symptoms that they cannot even go for a walk without the tissues chaffing and causing pain.

Jenny had been using an estradiol vaginal insert (vagifem) to help with her GSM/vaginal atrophy symptoms and was getting excellent results. Ideally when using an estrogen vaginal application, the estrogen is not supposed to enter the bloodstream and just provide local symptoms relief. In my personal experiences with patients, I have found increased estradiol levels, when only using an estradiol insert.

So while in theory, the estradiol is only supposed to stay localized to the vaginal vault, it could be matriculating into the bloodstream. This is why I usually only use estriol vaginally for GSM. Estriol will not enter the bloodstream and will stay localized to the vaginal tissues. Estriol will also not have an effect on the uterus and cause thickened endometrial lining as you would see in estradiol.

Jenny’s pharmacist recommended adding in bio-identical hormone replacement (BHRT). This is where the questions we get sometimes don’t have enough information. Did Jenny’s pharmacist want to replace her estradiol vaginal insert? Or did she want to add the biest/progesterone/testosterone in addition to the vaginal application of estradiol?

These are two very different scenarios. The biest/progesterone/testosterone BHRT would be a systemic dosing, meaning the goal is to get it into the bloodstream. Biest (which is a combination of estriol and estradiol) would most likely be a transdermal cream/application. As well as the testosterone would be transdermal. Oral dosing of estrogen and testosterone is not well tolerated and puts a burden on the liver and has minimal absorption.

Progesterone can be dosed as a transdermal cream or oral. If a woman has a uterus and is taking any estradiol systemically, she should be taking the progesterone orally. Estradiol can thicken the uterine lining when taken without progesterone. Oral progesterone protects the uterine lining better than the cream form. My point being here, taking the biest/progesterone/testosterone systemically may not be enough to help Jenny’s GSM/vaginal atrophy. The vaginal tissues respond much better to a localized application for GSM.

I have many women taking their progesterone orally and their biest and testosterone transdermally in addition to a local application of estriol to the vaginal tissues. This is where you get the best of both worlds, a solution to the GSM symptoms plus the benefits of system BHRT. Those benefits range from better sleep, improved libido, ceasing hot flashes and night sweats, improved mood and hair/skin to name a few. So I do not think Jenny should replace her vaginal application with the BHRT. But should consider switching to estriol for the GSM.

Is Jenny too old to start BHRT?

The dose that Jenny’s pharmacist recommended was a very low dose of biest. The progesterone at 100mg is a very common dose. I am thinking her pharmacist wanted to start low on the biest and work their way up. It has been ten years since Jenny’s own body was producing hormones. When introducing the hormones after such a length of time can cause side effects. While the .25mg biest is very small, it is a wise choice to start low and slowly increase as needed.

It is much easier to start small and work up, then to overshoot the mark. Like I mentioned, 100mg of progesterone is a common dose. I do not go under 100mg of progesterone if a woman has a uterus to help prevent the lining from thickening when taking estrogen.

So to answer the question, Jenny is not too late to the table for BHRT. But I do think the longer a woman has not had hormones in their body, start small.

Cholesterol and the Hormone Connection:

Jenny mentions her cholesterol is high. Every country has different units for labs and lab values. A total cholesterol level for Jenny should be less than 5 (The U.S. has different units less than 200). Her total cholesterol is high at 7, which she is perplexed by because she is very healthy and a good exerciser.

There could be some familial genetic component at play here. I have lots of female patients who have higher cholesterol than you would expect given their lifestyle and dietary habits. But sometimes that darn genetics can have an influence. Also, the total cholesterol is misleading. What is more important is the breakdown of the cholesterol. Cholesterol is broken down into LDL (low density lipoprotein), VLDL (very low density lipoprotein), Triglycerides and HDL (high density lipoprotein).

The LDL and VLDL are considered the “bad cholesterol”. And the HDL is the beneficial cholesterol, the higher the better. Jenny’s HDLs are good, so having a high HDL can make the total look falsely elevated. I have some female patients whose HDLs are close to 100 (U.S. values), which is astonishing. But it will make their overall total cholesterol look high.

Also like I mentioned, the triglycerides are important to consider here. There is an equation you can do to see if you have insulin resistance. Insulin resistance is a marker for diabetes. You take your triglyceride and divided them by the HDL number. And if it is less than 1.5 you do not have insulin resistance. There are other factors to look at such as blood sugars and fasting insulin levels.

But it is a neat quick equation anyone can do if they have their cholesterol values. For example if someone had a triglyceride level of 130 and their HDL level was 50. 130 divided by 50 equals 2.6. That is looking like a risky factor for insulin resistance should be investigated. But lets say someone’s triglycerides are 100 and HDL is 75. 100 divided by 75 equals 1.333. That looks pretty good.

It is true that hormones, especially estrogen can help keep cholesterol levels down. This is why once a woman hits menopause you will see the cholesterol start to rise. So, yes, Jenny’s pharmacist is right that the hormones could in theory help her cholesterol levels. But as I mentioned above the biest dose is quite small at .25mg that you might not see much of a decrease in the total cholesterol for Jenny.

Other factors that are more important than cholesterol:

There are other factors that are more important that your LDL and total cholesterol. It might be of benefit to run some other testing for Jenny. Really to give her a piece of mind. She is very fit and obviously takes great care of herself, but seems to have more than likely familiar high cholesterol.

Running a LPa (lipoprotein A), Apo-b(Apolipoprotein B), NMR lipoprofile would give us a better insight into if Jenny’s higher cholesterol were really a risk factor for a cardiovascular event.

LPa (lipoprotein A): This is a test that you really only need to do once. It is more of a genetic marker that high cholesterol is going to cause a cardiovascular risk. If it is high then you have a risk factor for cardiovascular disease.

Apo-b (Apolipoprotein b): This helps differentiate if a high LDL level is dangerous. If the Apo-b is high then it is necessary to aggressively work on reducing the LDL cholesterol NMR (nuclear magnetic resonance): this is a lipid subfractionation test. This really breaks down the cholesterol profile to tell you if your cholesterol levels could be a risk.

Bone Density:

Jenny mentioned that the BHRT could help her bones. This is true, hormones are very helpful for bone density. That is why when women enter menopause they should get a baseline screening for bone density called a DEXA scan. Because you will see bone density decrease over time with post-menopausal women when the hormone levels are non-existent.

But like I mentioned before the biest dose is pretty small that it might not have an impact on Jenny’s bones. Now one of the best ways to preserve and build bone density is weight bearing exercise. Anything that allows your body weight on the ground. This would be walking, hiking, lifting weights, running. Runners always have good bone density (maybe not great joints long term:/). I would say, the fact that Jenny says she is uber fit must mean she exercises. That right there is helping her bones much more than a low dose hormone protocol.

Hormones: Take or Not to Take?

With the speed of innovation in social media and the internet, there is so much information on hormone replacement, healthy hormone strategies, menopause bellies, supplements, powders, gummies… There is almost too much information out there, making it hard to weed through to see what is beneficial and what is just not. Coming from a doctor that has worked with thousands of women with hormones since 2004, I will tell you, BHRT can have an amazing impact on your life and quality of life.

But it needs to be tailored to you. Because you are not one size fits all. Your hormone goals, lifestyle, genetics, even your personal environment, will have an impact on what your BHRT doses or the type of BHRT would be best for you. I have had women change their jobs, end marriages, get married/partnered, move, become empty nesters, and it changes what BHRT doses and types of hormones they are taking. We are always changing, growing, becoming stronger versions of ourselves. That means our supplements, BHRT and lifestyle change with our growing selves.

If you have any questions, that means many, many other women have the same concerns too. Feel free to reach out and send us a message on, Ask The Dr.

Other Related Episodes:

Episode 025: Who is a Candidate for BHRT?

Episode 085: Can You Take BHRT During Perimenopause?

Episode 105: Can BHRT Cause Weight Gain?

What Are Five of the Most Common Symptoms of Perimenopause? | PYHP 125

Dr Valorie Davidson and Dr Robert Maki — Tue, 26 Sep 2023 12:55:27 +0000

Perimenopause is the time in a woman’s life prior to entering menopause. Most people are familiar with menopause, which is when the ovaries stop producing hormones and women stop their periods. There are many options to deal with menopause (which is an entirely different podcast and blog). But perimenopause is a completely different animal compared to menopause. Perimenopause is usually between the ages of 40-50. I have seen some women enter perimenopause in their late 30s and well as in their early 50’s. But on average, perimenopause usually hits between the 40 -50. It can last for years. Which is unfortunate because the symptoms can really affect the quality of life. Many women have come to see me and tell me how their hormones are ruining their life. They have been to their general practitioners, gynecologists, PCP only to be told there is nothing wrong. These women end up feeling disregarded and frustrated because they are not finding answers or help. This is because perimenopause is not often discussed. Like I mentioned, everyone is familiar with menopause. But women in perimenopause are dismissed because many do not realize what perimenopause is. When I talk to these women and explain to them, yes it is your hormones causing your unwanted symptoms. They are stunned to find out there is a name for what they are experiencing. It’s called perimenopause.

So let’s get to it! Learn about the top five most common symptoms of perimenopause.

(I tried to put these in order of the most common. But honestly, these five symptoms are all equally common)

Fatigue:

Women in perimenopause are often repeating over and over how tired they are. They are tired of complaining about how tired they are. I’ve had many patients remark on their family members (mainly kids, because they can be so honest), tell them they are repeating over and over how tired they feel.

But it is a different kind of tiredness. It’s more of a mental fatigue. I will ask my perimenopausal patients, ‘if I were to make you take a 3 mile hike with me right now, could you do it’? Which they reply, they could. How can you hike 3 miles and say you’re tired? It is because it is more of a mental fatigue. Yes, they could do the work/activity physically, but mentally they are just not into it.

Loss of Libido:

Speaking of just ‘not into it’. Perimenopausal women often say their libido has not only left the building, it left the stratosphere. There are no physical issues going on here like you would see in menopause. In menopause when the estrogen has dropped dramatically, that can cause vaginal dryness, vaginal atrophy and pain with intercourse. In perimenopause, the estrogen has not declined that dramatically, so the libido issue is more of a mental one. Sex is just not on the brain. Perimenopausal women will say they are not interested or even thinking about sex. A hot-human can strut across your path, and it was like you didn’t even notice them.

Weight Gain:

Weight gain is a common complaint of both perimenopause and menopause. Women in their 40’s will often comment that it felt like they gained 15 pounds overnight. And the sad fact is that this weight gain was not due to any changes in their diet or lifestyle.

Trouble Staying Asleep:

This is a very common issue in perimenopausal women. They have no trouble falling asleep. Your head hits the pillow and you are out in minutes, seconds even. But 3-4 hours later, you are up like it’s morning. And it can take hours to fall back to sleep. And of course by the time you do fall back to sleep, you need to wake up shortly. By morning, you are so tired.

Period changes:

As mentioned earlier, in perimenopause the estrogen has not dropped that much (as you see in menopause). But the progesterone has dived in perimenopause. This can cause period changes. It can cause days and days of spotting. It can cause heavier periods, which then can cause low iron (anemia). And/or it can cause two periods in one month, or changes in cycle length. Which of course makes it hard to predict when you next period will start, so make sure to keep some of those menstrual products around (everywhere…car(s), purse(s), pockets, even your grocery bags).

Other:

I have to say, there are more than just 5 symptoms of perimenopause. So I wanted to include some of the other changes that women might not attribute to their hormones when in perimenopause.

Hair changes: The change in hormones in perimenopause can cause your hair to get more curly (in my case, frizzy). It also makes your hair more vulnerable to damage (no more cheap drugstore shampoo/conditioner, here comes super expensive salon products). It can make your hair thinner and increase the shedding phase of hair.

Skin changes:

Why are we breaking out on your 40’s? The change in hormones, mainly the drop in progesterone levels can cause the androgens (testosterone and DHEA) to become the leaders of the hormonal pack. So it can cause more acne, pimples, and even cystic acne prior to your period.

Short term memory, Forgetful:

No, it’s not dementia. In perimenopause we can become forgetful, absentminded, and seriously feel a little ‘out to lunch.’ Post it notes, lists, alarms on your phone become the norm (they are great helper tools to be honest). Even people, mainly family, because they have no manners (my own perimenopause head rearing) will remark, ‘you just asked that question!’ Short term memory can fly out the window. Not the long term memory. You can easily remember the dress you wore to a wedding 15 years ago (and what size it was, sigh). It is the short term memory that just won’t stick.

Mood Changes:

I don’t like to blame mood on hormones. There are so many factors in our lives that can drop a mood or change our moods. So I don’t like hearing others remark, ‘oh you’re in a mood, are you pms-ing, getting your period?” But between you and me, hormone changes in perimenopause can make us more irritable. In perimenopause when the progesterone drops and the estrogen and androgens are left in charge. Plus cortisol is not balanced, that can really cause irritability, or patience is short. Sure, not sleeping well and being tired can make you crabby, but the drop in progesterone can also wreck a mood.

I really could go on and on about the symptoms of perimenopause. Of course that doesn’t mean that perimenopause is really that horrible. I wanted to just show you that the reason you might be feeling the way you are, is because of your hormones. In fact, perimenopause is a great time of life. Trust me, I would not want to be 20 again (using plastic cutlery with only campbells soup in my cupboard). I really like my life right now at 49. But these symptoms can be helped and your hormones can be balanced.

If this resonated with you or you feel like you are in perimenopause, we have other blogs and podcasts about balancing your hormones.

Have questions? All questions are welcome. Just click on the link: Ask the Dr

All content found in this blog, including: text, images, audio, video or other formats were created for educational purposes only. The purpose of this website and blog is to promote consumer/public understanding and general knowledge of various health topics. This content is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Please consult your healthcare provider with any questions or concerns you may have regarding your condition and before undertaking a new health care regimen. Never disregard professional medical advice or delay in seeking it because of something you have read on this website. If your healthcare provider is not interested in discussing your health concern regarding this topic then it is time to find a new doctor.

Other Related Episodes:

Episode 116 How Do I Stop Weight Gain During Perimenopause?

Episode 098 What Diet Is Best For Perimenopause?

Episode 057 Perimenopause vs Menopause

What Are Five of the Most Common Symptoms of Perimenopause? | PYHP 125

Dr Valorie Davidson and Dr Robert Maki — Tue, 26 Sep 2023 12:55:27 +0000

So let’s get to it! Learn about the top five most common symptoms of perimenopause.

(I tried to put these in order of the most common. But honestly, these five symptoms are all equally common)

Fatigue:

Loss of Libido:

Weight Gain:

Trouble Staying Asleep:

Period changes:

Other:

I have to say, there are more than just 5 symptoms of perimenopause. So I wanted to include some of the other changes that women might not attribute to their hormones when in perimenopause.

Skin changes:

Short term memory, Forgetful:

Mood Changes:

If this resonated with you or you feel like you are in perimenopause, we have other blogs and podcasts about balancing your hormones.

Have questions? All questions are welcome. Just click on the link: Ask the Dr

Other Related Episodes:

Episode 116 How Do I Stop Weight Gain During Perimenopause?

Episode 098 What Diet Is Best For Perimenopause?

Episode 057 Perimenopause vs Menopause

Can Estriol Cream Be Used For Vaginal Atrophy | PYHP 124

Dr Valorie Davidson and Dr Robert Maki — Wed, 23 Aug 2023 21:52:52 +0000

Some things are just plain hard to talk about. Especially, when it comes to issues, “down south.” And after going through menopause there are some changes that need to be discussed. It’s hard to talk about vaginal dryness, vaginal irritation. It’s hard to talk about urinary leakage, incontinence. Trying to bring up a conversation with your doc about painful intercourse or tender vaginal tissues can be difficult. It’s easy to talk about cholesterol, family genetics, and cutting back on sugar to improve glucose. It’s not so easy to ask your doc if there is something to help with painful sex.

That is why this article and accompanying podcast talks all about how estriol can be helpful for the vagina and urinary tract after menopause.

The body makes three different types of estrogen, Estrone (E1), estradiol (E2) and Estriol (E3). Estrone is made by adipose (fat) tissues and is also prevalent in young teen women just starting their periods and in puberty. Estradiol is the strongest form of estrogen. It is helpful for the brain, heart and bone. Estriol is made more often during pregnancy and it is the most gentle of estrogens. And estriol is great for vaginal tissues and the urethra.

Applied topically to the vaginal tissues, estriol can very much help with atrophy. Menopausal vaginal atrophy is where the cells of the vagina stay immature. These immature cells are called parabasal cells. When supplied with estrogen, the parabasal cells will develop into mature vaginal cells. In the case of menopause, the estrogen levels have dropped. Meaning that there is a high amount of parabasal cells. Causing vaginal dryness, and the tissues can regress and become smaller causing painful intercourse. Vaginal atrophy can also change the vaginal microbiome making a woman more susceptible to vaginal infections such as bacterial vaginosis and yeast/candida.

The drop in estrogen during or post menopause can also increase the risk of urinary tract infections. The lack of lubrication and atrophy can change the microflora of the vaginal canal (vaginal microbiome). This can be less protective against organisms (specifically E.coli) that can cause a urinary tract infection (UTI).

The urethra (that is the tube that connects your bladder to the outside world) can become lax when in menopause because of the drop in estrogen. I liken it to an elastic waistband. When the estrogen drops in menopause the urethra becomes loose, or loses that elasticity. Not only does this make it also easier for the bacteria (E.Coli) to crawl up the urethra to cause a bladder infection or UTI, it also can cause urinary leakage and/or urinary frequency. Urinary leakage, also called stress incontinence can be helped with topical estriol application. By applying estriol vaginally it has direct access to the opening of the urethra to help with tonification.

Using estriol topically to the vaginal canal and tissues can be very helpful with vaginal atrophy, urinary leakage and reduces the risk of urinary tract infection. In application, it is really only needed 1-3 times a week. It is best to apply at night, as it is less messy and has an easier absorption while you are lying and sleeping.

In past articles and podcasts, we have always talked about how important it is to take progesterone anytime a woman is taking estrogen and she has her uterus. This is super important in the case of taking estradiol (again the strongest of the estrogens). That is because estrogen can cause a thickening of the endometrial/uterine lining. And that is a risk for uterine cancer. Estriol does not have quite the same effect on the uterine lining that estradiol does.

Although, it is upon the discretion of your practitioner that is recommending the estriol, often many women can forgo the progesterone. As long as they are not taking estradiol or they do not have a uterus (hysterectomy). In the United States estriol is a prescription that can be made at a compounding pharmacy. It is not normally found at your big-box pharmacies. Although it can be found online, please just be wary about buying without consulting a practitioner that is familiar with the product and the treatment using estriol. We have listeners of our podcast and readers of our blogs all over the world. And in some countries estriol can be found without a prescription at a local pharmacy. But in these cases it would be wise to consult with the attending chemist/pharmacist before using estriol.

Commonly we get the questions about how long a woman can use estriol for vaginal atrophy and urinary stress incontinence. As mentioned, estriol is very safe and gentle and can be used long term. We have many patients in their 70’s that use estriol vaginally. But we do advise guidance from a practitioner experienced in the treatment of estriol.

Other Related Episodes:

Episode 050 What is Estriol Made From?

Episode 036 What is the Difference Between Estriol and Estradiol?

Episode 109 Does Estradiol Work for Vaginal Dryness?

Can Estriol Cream Be Used For Vaginal Atrophy | PYHP 124

Dr Valorie Davidson and Dr Robert Maki — Fri, 18 Aug 2023 10:57:35 +0000

That is why this article and accompanying podcast talks all about how estriol can be helpful for the vagina and urinary tract after menopause.

Does Estrogen Cause Weight Gain? | PYHP 123

Dr Valorie Davidson and Dr Robert Maki — Thu, 01 Dec 2022 21:36:02 +0000

Download the diagram above, click here.

Tracy’s Question:

Episode 052 – What Biest Ratio is Best for Menopause?

This is such helpful information. I have often wondered who 80:20 is good for and who 50:50 is good for.

One thing I’m still confused by is the estrogen weight gain component. You said that estrogen (as well as menopause in general) could be the cause of her weight gain. I can relate. I was very thin my whole life, now 53 and about 30 lbs overweight. But you also said she might benefit from getting her estrogen balanced, and she was not using enough.

If too low a dose made her gain weight, won’t an increased dose cause more weight gain? I have heard other podcasts and read articles that in menopause, we gain weight because our estrogen falls. Estrogen seems to be blamed for weight gain, whether it’s high or low. Can you help clarify? There’s something I’m not understanding. Thank you! Tracy

Short Answer:

Often estrogen has been the scapegoat for weight gain. I’m sure you have heard too much causes weight gain. Too little can pack on the pounds. It can be pretty confusing. So which is it? Is too much estrogen causing my pants to become uncomfortably tight? Or is it too little estrogen that has given me the gut I never had?

Well, it’s not that simple. Estrogen levels do have a hand in weight gain and weight loss. But it is not the only variable. It really is the combination of the balance of estrogen with other hormones in your body. To name a few main players, progesterone, insulin, and cortisol, as well as enzymes, lipoprotein lipase (LPL), and hormone-sensitive lipase (HSL). Okay, I know that sounds vague and doesn’t answer the question. Let’s back up a bit and look at what women are saying about estrogen.

As soon as menopause hits, women complain that they are instantly 15-30 lbs heavier. Not because of diet or lifestyle. It’s like menopause adds an unwanted 15-30 lbs overnight. Then some women are on hormone replacement therapy, taking estrogen, and are horrified because the HRT caused them to gain 10 lbs in a month. So what is it? Did the lack of estrogen in menopause cause that 20 lb weight gain? Or did that hormone replacement estrogen create rolls that were never there? Well, actually, both are true. Before you throw out your jeans in favor of high-waisted yoga pants, let’s learn about the other players in weight gain.

Progesterone will buffer estrogen. Estrogen does like to grow things’. That is why in puberty, you grow breasts and hips. Progesterone helps to balance some of the growth’ that estrogen can cause. That is why in perimenopause, when the progesterone drops and the estrogen is running the show, the weight gain begins. That is also why when a woman starts estrogen therapy for menopause but not enough progesterone, there is weight gain.

Cortisol and insulin are one of the biggest players in weight gain. In fact, insulin is the only hormone that will cause fat storage. Insulin is secreted from the pancreas in response to a rise in blood sugar. If you drink apple juice, your blood sugar (glucose) will rise. And in response, the pancreas will release insulin to unlock the cell door to allow glucose to enter. If you do not burn that glucose, then it is stored as fat. I know this is a simple description; otherwise, we could be here for a while.

Elevated levels of cortisol will cause the body to release glucose from muscle stores. In the wild’, a vicious predator will lunge at me, causing a tremendous release of cortisol and adrenaline. That release of cortisol and adrenaline will cause my muscles to release glycogen (stored sugar), and then I can either put up my dukes or run like the wind. Hence the familiar term, fight or flight.’

Our society has a different kind of wild’ to it. There is no life-threatening creatures to tear me limb from limb. But there certainly are stressors that seem as looming as a bloodthirsty Orc. Too many commitments, family drama, work emails, bills, the news, politics, health ails you get the idea. All these stressors can cause a rise in cortisol. Hence, a rise in insulin and thereafter, another inch to your gut.

You might be asking, I thought we were talking about estrogen’? What does cortisol and insulin have to do with the estrogen causing weight gain?

Lipo Protein Lipase (LPL) is an enzyme that causes fat storage. Estrogen will turn off the enzyme LPL. That means estrogen can inhibit LPL hence, causes no fat storage. Cortisol will turn on the enzyme LPL. Meaning cortisol will cause fat storage by way of LPL. In menopause, the estrogen levels drop, decline, and are nonexistent. Then LPL is more easily turned on because there is no estrogen to inhibit it. And there is plenty of cortisol to turn it on.

Hormone Sensitive Lipase (HSL) is also an enzyme that can turn on fat burning. For weight loss, we want to turn on HSL. Insulin is directly released to HSL. Insulin will turn off HSL causing a decrease in fat burning. A lack of insulin will turn on HSL promoting fat burning.

So ideally, you want to have estrogen to turn off LPL and hold back the effects of cortisol. You also want enough progesterone to balance the estrogen. And holding back the cortisol by way of enough estrogen will inhibit insulin (unless needed for digestion) from keeping HSL turned on for fat-burning.

If you have questions regarding your hormones, feel free to Contact Us.

Other Related Episodes:

Episode 117 Can Ovarian Failure Be Treated?

Episode 116 How Do I Stop Weight Gain During Perimenopause?

Episode 086 What Biest Dosage is Best for Menopause?

The post Does Estrogen Cause Weight Gain? | PYHP 123 appeared first on .

What Hormone Tests Should I Get? | PYHP 122

Dr Valorie Davidson and Dr Robert Maki — Tue, 22 Nov 2022 00:42:27 +0000

‘Doc, I really don’t feel like myself. I think it’s my hormones. Could it be my hormones? Can you test my hormones?’

How many times have I heard new clients tell me this story? They go to see their GP, Gyno, or Internist, asking to have their hormones tested. Only to be told that there is no testing for hormones. Or that it’s not necessary to test hormones. Only to leave feeling dismissed, with no answers to why they do not feel well.

While I understand that your GP, Gynocologist, and Primary Care Physician are not the jack of all trades,’ there are many tests for hormones. There are blood tests, urinary testing, and even saliva testing. The more difficult part of hormone testing is the interpretation. The basic lab values assigned by the labs are very vast, and without experience and training, it can be quite difficult to determine if there is a hormone imbalance.

If you are feeling like you have a hormone imbalance or having symptoms concerning your hormones, below is a list of common hormones to be tested and why. Because blood lab testing is so popular, I am going to stick to blood testing. Later we will have more labs and interpretations for urine and saliva.

To start, blood testing is just a look at one moment in time with respect to your hormone levels. In a menstruating woman, her hormone levels are changing every day. But in a menopausal woman where the ovarian function has ceased, her hormone levels are going to be pretty level day to day. So in a female that is still having her period, I like to try and aim for getting the blood drawn around day 12 and/or day 21. In a 28-day cycle, the estrogen will surge around day 12, and the progesterone will surge on day 21. This can give us better insight into her levels of progesterone and estrogen. In a menopausal woman that has not had a period or has sporadic periods with common menopausal symptoms, I will have her draw her blood any time of the month.

FSH and LH:

FSH stands for follicle-stimulating hormone, and LH stands for luteinizing hormone. These are not actually hormones. They are stimulating hormones.’ Meaning both the FSH and LH are released from the pituitary gland (in your brain) in response to estrogen and progesterone production. The FSH and LH work in what is called a negative feedback loop.’ Meaning if the levels of estrogen and progesterone are high, then the FSH and LH are low. In turn, if the estrogen and progesterone levels are low, then the FSH and LH are high. It is like when you want your husband to take out the garbage. If he doesn’t, you might raise your voice until he does. It is the same with all stimulating hormones. If the ovarian production of hormones is low, as in menopause or perimenopause, the FSH and LH levels will look high.

Estradiol and Progesterone:

Always test estradiol to get specific results for estrogen levels. Estradiol is much more specific for estrogen levels than simple total estrogens. Ideally, in a menstruating woman having the blood test around day 21 will give you insight if that woman is ovulating. It will so give you insight if there is progesterone deficiency or estrogen dominance. Just a little background. In a perfect 28-day cycle, the period is from about days 1-4, and the estradiol and progesterone are low. After the shedding of the uterus (period), the estradiol starts to climb, peaking at day 12. The rise in estradiol will cause ovulation on about day 14. Where the egg leaves the ovary to travel down the fallopian tube is a spot called the corpus luteum. The corpus luteum will start to secrete progesterone. This is why I like to test progesterone post-day 14 (around day 21). If there is no progesterone post-day 14 then that means there was no ovulation. If the progesterone is low, then there could have been ovulation, but the secretion of progesterone is low. This is very common in perimenopause (ages 40-50yo). Now, if post day 14, the estradiol is quite high, then that woman is experiencing estrogen dominance. Estrogen dominance and progesterone insufficiency have a lot of symptoms and are very treatable, but that is another blog/podcast.

Testosterone and DHEA:

I consider testosterone to be more of an adrenal hormone for females. Testosterone is a reproductive hormone for men but for women, it is not. Women make DHEA from the adrenals, and it will convert to testosterone. We do make a little testosterone from the ovaries, but the majority is from the conversion of DHEA to testosterone. Both DHEA and testosterone are considered androgens. Meaning they can cause more androgen symptoms such as acne, hair loss, and irritability. But I feel testosterone and DHEA are super important to the balance of hormones in a woman’s life. But if the estrogen and/or progesterone are dropping/declining, then the testosterone and DHEA can become the leader of the pack. They are unbuffered by estrogen and progesterone, thus causing androgen symptoms. Testosterone is usually pretty stable throughout the cycle (it can increase during ovulation). But you can blood test for testosterone pretty much any time of the cycle. DHEA should be tested as DHEA-Sulfate. DHEA-Sulfate is a metabolite of DHEA. But it is much more specific as a marker for DHEA than a total DHEA.

Cortisol:

Cortisol in a blood test is not very accurate. Ideally, the more accurate form of cortisol testing is saliva testing. In fact, multiple saliva samples in a 24-hour period give very specific results. As cortisol is released from the adrenal glands in a diurnal curve. Meaning it is highest in the morning, drops slowly in after, and is the lowest at night so that you can get a good night’s sleep. But for convenience sake, I will do a serum/blood cortisol level. It does give you some insight as to where the cortisol levels are at. Especially if the saliva test is too costly for a client or too time-consuming to be collecting samples of saliva in a day.

Insulin:

Insulin is often not tested. I love to have a fasting-insulin blood test. It is so common in hormonal imbalance, such as perimenopause or menopause, to have weight gain. As soon as a woman hits perimenopause, it is like they gain 10-15 lbs overnight. This can be due to insulin. Insulin a fat-storing hormone. If there are higher normal levels of insulin, that makes it really easy to gain weight and difficult to lose.

Thyroid Testing:

Just because the thyroid has such an impact on the female hormones, I always do thyroid function blood testing. TSH (thyroid stimulating hormone) is another stimulating hormone from the pituitary gland. It monitors overall thyroid levels in the body. Never base a simple TSH on the function of the thyroid. Always get a FreeT4 and a FreeT3. The thyroid mainly makes T4, which will then travel in the body, and the peripheral tissues will convert T4 to free T3. Free T3 is the active hormone of the thyroid. So it is important to know that the T4 is converting to T3 for thyroid function.

If you have never had your thyroid tested before, make sure to test for Hashimoto’s antibodies. The main Hashimotos antibodies are thyroid-peroxidase antibodies (TPO) and antithyroglobulin antibodies (TGab). Hashimotos and Hashimoto’s antibodies are a whole lengthy podcast, but be sure to check at least once in your lifetime to see if you have Hashimotos.

As I mentioned at the beginning, many docs will not test your hormones. If you are having trouble getting your hormones tested, go to progressyourhealth.com/labs. We have comprehensive hormone panels and individual ala-cart tests. If you are reading this, then it is enough to assume you are ready to take control of your hormonal health. We are here to help and guide you on that process.

For a list of some of the panels we offer, click here.

If you have questions, feel free to contact us.

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Is Surgical Menopause Worse Than Natural Menopause? | PYHP 121

Dr Valorie Davidson and Dr Robert Maki — Thu, 10 Nov 2022 20:05:42 +0000

Michelle’s Question: Hi, thank you so much for sharing your knowledge with us!

In March 2022 at 42 years old, I had a total hysterectomy with bilateral salpingo-oophorectomy because of stage 4 endometriosis, grapefruit-sized fibroids, ovarian cysts, and my left ovary adhered to my colon.

I was immediately put on an estradiol patch. I was recovering and doing well until the beginning of June. Then I started having hot flashes, 24/7 anxiety, insomnia, and not feeling well every day.

Since March, my dosage has gone from .25, .5, .75, and 1 mg. But I saw no improvement in my symptoms and have said this was the worse summer of my life.

I am debilitated by it. After much research, I decided to try bio-identical creams that have estriol, estradiol, progesterone, pregnenolone, and DHEA.

Even though I no longer have a uterus, I know that my body is used to having these hormones and am hoping they help me get through this surgical menopause and be able to function again. Is this a combo hormone protocol you’ve ever done for your patients?

If so, should I apply estriol and estradiol in the morning, and progesterone, pregnenolone, and DHEA at night?

Short Answer:

Surgical menopause is much different from what you could call your typical menopause. Honestly, there is nothing typical about menopause. Some women breeze through menopause and others have symptoms so severe it can seriously affect their quality of life, not to mention the people around them. And I (Dr. Davidson) can say this honestly, being just shy of 50 and feeling the effects of menopause. But being that I am a hormone doctor, I have some advantages to easing my transition. This is why we do what we do, here at Progress Your Health Inc. We know that hormone imbalance can alter how you feel. From your energy to your sleep, to your libido (or lack of) and more. Hormones can even affect your actual overall health.

Menopause is when the ovaries naturally start to decline and then cease producing hormones. Those hormones in particular are estrogen (estradiol) and progesterone. Menopause is a natural part of life. Those ovaries have worked well for a long time and are ready to retire, naturally so. Making that transition is where we come in. Helping with lifestyle, supplementation, and even medication to help the process.

Now surgical menopause is an entirely different story. In natural menopause, the ovaries start to decline and eventually cease hormone production. In surgical menopause, the ovaries are surgically removed. In an instant, you go from making hormones (estrogen and progesterone), to making absolutely none. This is a huge change. In a flash, a woman goes from producing hormones to an abrupt stop.

In most cases, the removal of the ovaries is necessary. Perhaps there is endometriosis where the ovaries have adhered to the abdominal wall, uterus, and/or colon. Or there are so many complicated cysts causing a tremendous amount of pain. There can be many reasons for an oophorectomy (removal of the ovaries). At this point, there is usually a hysterectomy (removal of the uterus) as well. As the uterus could have fibroids, polyps, and thickened lining. But in any case, removing the ovaries will put a cycling woman (having her period and usually in her 40s) into instant menopause.

After surgical menopause (depending on the reason for the removal of the ovaries), it is usually necessary to implement hormones. That being said, the abrupt decline of hormones can cause a woman to feel absolutely awful. From horrible hot flashes to not getting any sleep due to night sweats. There is weight gain seemingly overnight, hair loss, loss of libido, and vaginal dryness. Brain fog to the point of word recall being horribly embarrassing.

The thing with surgical menopause is dosing. In surgical menopause, you need to make sure to get the right dose for the individual to get a positive effect. Most docs end up starting too low when using bio-identical hormones (which unfortunately can give BHRT a bad name). BHRT can be amazing. But if not dosed well, it seems like, well, nothing. Many times, women are given an estrogen patch after surgical menopause. An estrogen patch is made up of estradiol. Which usually can actually be too strong. Being that it causes an instant 8-15 lbs of weight gain overnight and symptoms of estrogen dominance (which is a whole other podcast/blog post).

What we use for surgical menopause is Biest. Biest is a combination of estradiol and estriol. The estriol has a more gentle effect and helps buffer some of the strength (or side effects) of estradiol. But in the case of Biest, as mentioned before, it is about dosing. The difference between a conventional estradiol patch and Biest is like apples and oranges. The dosing is so different. So many women get underdosed with Biest. There are many ways to dose BHRT. It is so individualized that in our practice rarely are patients on the same dose. Everyone has their own individual doses based on their goals, health history, family history, and lifestyle. In some cases, we will do rhythmic dosing. Which is cycling hormone doses based on a natural 28-day cycle. As I mentioned, everyone is so unique that their BHRT dose is unique as they are.

Another unfortunate factor in surgical menopause is doctors’ neglect to implement progesterone. There is a conventional philosophy that if there is no uterus, there is no need for progesterone. But we firmly (very firmly) believe that progesterone is necessary for more than just a uterus. Progesterone has so many positive benefits. Such as helpful for irritability/mood and for breast protection for hair and skin (again, the benefits of progesterone is another podcast/blog).

As I said, surgical menopause is different from natural menopause. But it can be addressed in a way that can be incredibly helpful. If you have any questions, please contact us.

Other Related Episodes:

Episode 117 – Can Ovarian Failure Be Treated?

Episode 108 – What Should Esradiol Level be on BHRT?

Episode 1

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Is Armour Thyroid Better Than Levothyroxine? | PYHP 120

Dr Valorie Davidson and Dr Robert Maki — Thu, 22 Sep 2022 18:37:34 +0000

Laura’s Questions: I am on 25 mcg of Levothyroxine for 6 yrs with hypo symptoms, every one! My endocrinologist just took a panel, and the results are the following:

TSH 2.36 uUI/mL Reference Range = 0.45 to 4.5 uUI/mL
Free T4 1.1 ng/dL Reference Range = 0.82 to 1.77 ng/dL
Free T3 2.9 pg/mL Reference Range = 2.0 to 4.4 pg/mL

Should we up my dose of Levothyroxine to 50 or should I just switch to Synthroid or Armour? Thanks!

Short Answer: We typically don’t recommend or prescribe Levothyroxine or Synthroid for our patients. Both of these medications only contain the T4 hormone. This is referred to as T4 Monotherapy. These medications do a good job of lowering the TSH level but do not always help the patient feel better. We like to prescribe thyroid medication that contains both the T4 and T3 hormones. In our experience, our patients tend to feel much better on a combination medication, rather than on a T4-only medication.

In our opinion, we feel that sustained-release compounded thyroid medication is the best option most of the time. This type of thyroid medication gives the doctor many dosing options, which is certainly good for the patient and their overall symptom profile. Because this medication is compounded, the T4 and T3 hormones can be changed independently of the other hormone. With a commercial prescription, there are only so many dosing options, and both hormones are affected when raising or lowering the dosage. Also, the sustained-released nature of the medication helps to reduce any unwanted side effects that are common with commercial instant-release thyroid medications.

Related Podcast Episode:

PYHP Episode 038 – Do You Have a Low Free T3 Level?

Check out Dr. Davidson’s new book – The Perimenopause Plan

Buy the book on Amazon.

If you have questions about your thyroid or any other hormone related issue, feel free to contact us.

The post Is Armour Thyroid Better Than Levothyroxine? | PYHP 120 appeared first on .

Why Am I Getting Acne In My 40s? | PYHP 119

Dr Valorie Davidson and Dr Robert Maki — Fri, 16 Sep 2022 18:05:51 +0000

Patient Question: Why am I getting acne in my 40s?

Short Answer: Women’s hormones are always changing. From puberty to middle age, to when the ovaries cease producing hormones in menopause. When we hit our 40s, our progesterone starts to decline. And our estrogen levels drop slightly as well. But the androgens, which are testosterone and DHEA do not decline. That means that there is less progesterone and estrogen to buffer the effects of the androgens.

Testosterone and DHEA are great, useful hormones for a female’s body. They help with muscle mass, motivation, ambition, libido, bone density, and stress management to name a few. But in our 40s when estrogen and progesterone start to decline that makes the androgens the ‘leaders of the hormonal pack.’

There is no buffer against the negative side effects of androgens. One being, acne. Women in their 40s are usually still getting a period and cycling. So that means that the breakouts and acne are worse anywhere from 7-14 days before their period. That is because women really only make progesterone in the last half of their cycle. Those days being days 14-28. Because of the decline of progesterone, acne can be quite prominent before a period.

But because the estrogen may have declined a bit in our 40s, we are still apt to have breakouts all month long. Because acne in the 40s is from the unopposed androgens, the acne is mostly on the chin and jawline. Although the neck and back are also common in a lot of women in their 40s. And the breakouts are more cystic in nature. They are deep and hard to “pop” (which we all know we should never ever do, and yes, I can’t help it either). And cystic acne lasts for weeks. So when one cystic pimple is starting to heal, aggravatingly three more show up. It is very frustrating.

In addition too unbalanced androgens, stress, and cortisol levels can exacerbate acne. Women in their 40s are busy. There are family commitments, work, home life, and trying to stay fit is certainly not as easy as it was in our 20 and 30s. Plus the drop in progesterone and estrogen lets the androgens (testosterone and DHEA) make us feel more easily ‘testy.’ The stress and unbalanced hormones cause cortisol levels to rise. Which unfortunately also makes the breakouts worse.

We really like to use Acnutrol and Inflammatone to help with breakouts.

Below are some other episodes where we discuss other issues related to Perimenopause.

PYHP 116 – How Do I Stop Weight Gain During Perimenopause?

PYHP 115 – Why Do Breasts Grow During Perimenopause?

PYHP 111 – Does Progesterone Help With Perimenopause?

Also, if you are in your 40’s, check out my new book: The Perimenopause Plan.

Buy the book on Amazon.

If you have more questions about your hormones, feel free to contact us.

The post Why Am I Getting Acne In My 40s? | PYHP 119 appeared first on .

When Should A Woman Take Progesterone? | PYHP 118

Dr Valorie Davidson and Dr Robert Maki — Tue, 30 Aug 2022 23:26:52 +0000

Listener’s Question: Hello, recently my Nurse Practitioner recommended that I should start taking progesterone because she mentioned that I was estrogen dominant. I don’t have any real symptoms, so just want to make sure if I even need to take the progesterone. Thanks.

Short Answer: If you don’t have any direct symptoms, then progesterone would not be necessary. We prescribe progesterone to women of all ages, but usually, they have a symptom profile that justifies the prescription. It is not likely for a woman to be truly estrogen dominant without any noticeable symptoms (fibroids, endometriosis, heavy bleeding, etc).

If a cycling woman does her blood work around day 12 of her cycle. The estradiol will be higher, and the progesterone level will typically be less than one (<1.0). It could appear to be too much estrogen compared to progesterone, but this is normal. A woman’s body does not produce any progesterone until ovulation, which typically occurs about day 14 of the cycle. This is why it is important to know what day of the cycle the lab work was done in order to interpret the estradiol and progesterone levels.

Once a woman enters the 40s, her body begins to change; however, we don’t prescribe progesterone simply based on a blood test. The patient’s symptom profile is a better indicator of whether or not to prescribe progesterone. Some of the common symptoms we look for are heavy periods, irritability, anxiousness, and poor sleep quality.

Generally, for a woman dealing with classic perimenopausal symptoms, we will prescribe 100 mg of bioidentical, sustained-release progesterone capsule taken at night 60 minutes before bed. This is a good starting point but may need to be adjusted based on the woman’s response. We do get a lot of questions asking about progesterone cream, but in our experience, it does not seem to be as effective at resolving perimenopausal and menopausal symptoms as oral progesterone.

For more information about progesterone, below are links to previous episodes.

PYHP 101 – Can I Take Progesterone All Month?

PYHP 111 – Does Progesterone Help With Perimenopause?

PYHP 113 – Can Progesterone Cause Dizziness?

If you have more questions about progesterone or other female hormone issues, feel free to contact us. We are here to help.

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Can Ovarian Failure Be Treated? | PYHP 117

Dr Valorie Davidson and Dr Robert Maki — Wed, 17 Aug 2022 19:48:25 +0000

Sarah’s Question:

Hi I was diagnosed with ovarian failure at the age of 36. Its been 4 years now, I have been to a few different clinics, trying to figure out what works best for myself. Right now I am using estrogen patches, which do seem to work well, and Prometrium. My main problem that I still face is lack of sleep. The estrogen patches help my mood and sleep some but I have tried a few different progesterone creams and pills, and have not found any improvement in sleep from it. I am wondering what is the brand name of the slow release progesterone you described. Thanks

Short Answer:

We almost always use bioidentical sustained-release progesterone from a compounding pharmacy. A typical dose we like to start with for sleep is 100 mg. The commercial form of progesterone available at big box pharmacies is Prometrium, which is an instant release. However, in a situation like Sarah’s being diagnosed with Ovarian Failure at 36, we would consider prescribing Rhythmic Dosing to restore her hormones to physiologic levels. This type of dosing protocol is intended to initiate a period in a menopausal woman that still has a uterus. If Sarah still has a uterus, she would also resume menstruating on a monthly basis. Estrogen is what makes a woman a woman. In many cases, the more estrogen a woman has, the better she will feel. The better she will sleep. For more information, below is another episode we did explaining the rationale and how Rhythmic Dosing works.

Episode 91: How to Cycle Bioidentical Hormones?

One of the best pharmacies we work with for Rhythmic Dosing is Harbor Compounding Pharmacy, located in Costa Mesa, CA. They are PCAB Certified and are currently licensed in 32 states.

Feel free to contact us if you have more questions regarding Ovarian Failure or Rhythmic Dosing.

The post Can Ovarian Failure Be Treated? | PYHP 117 appeared first on .

How Do I Stop Weight Gain During Perimenopause? | PYHP 116

Dr Valorie Davidson and Dr Robert Maki — Fri, 05 Aug 2022 23:02:06 +0000

Megan’s Question:

This was great information. I have been 130lbs until I turned 48. Now up to 157. Weight gain all in my stomach, legs, arms, boobs and butt. I have still been working out intensely with weights and cardio and no weight loss . After listening to this is sounds like I should do less intense workouts and eat more. No period for 7 months now. I am soooo frustrated and want to loss this weight.

Short Answer:

Many of the women we work with are desperate to stop the weight gain during perimenopause. As a strategy to lose weight, most women in perimenopause try to “eat less and exercise more.” This translates to going on a calorie restricted diet and engage in cardio-based exercise 4 to 6 days per week. This strategy works when your 25, but does not work after the age of 40. The simple mantra we discuss in the podcast is to “eat more and exercise less” in order to lose the desired weight. Also, instead of cardio-based exercise, we encourage women to start strength training as their fitness foundation and to eat more protein on a daily basis.

Instead of trying to lose weight, the paradigm shift should be to build muscle instead. Exercising as a mode of “burning calories” in order to lose weight does not work well for women in their 40’s or beyond. Also, stress needs to be reduced and sleep quality needs to be improved before exercise is a priority.

The decline of progesterone and lots of stress make women more responsive to cortisol, which contributes to the unwanted weight gain in perimenopause. So going on a diet and exercising a bunch only adds to the stress. This can make losing weight almost impossible.

Check out Dr. Davidson’s book: The Perimenopause Plan

Book on Amazon

Why Do Breasts Grow During Perimenopause? | PYHP 115

Dr Valorie Davidson and Dr Robert Maki — Mon, 22 Nov 2021 20:34:16 +0000

Question: I am forty-six years old and a 34A. Now, I’m a 34BC. My breasts hurt at least two weeks out of the month. Swollen, heavy, painful, have to take ibuprofen. It’s annoying as hell and it’s changed how I view my body. Not to mention, my midsection has changed too. I never wanted large breasts. I know BC cup is not large, but it is to me. And now I need to wear two sports bras to run. And I like to run all the time. And I feel like I did when I was nursing. This totally stinks. Does it get better?

Short Answer: During a woman’s 40’s, there are many hormonal changes that are happening, which lead to a wide variety of symptoms. Progesterone is declining, and estrogen is still being produced and stress levels can be all over the place. These changes can lead to many unwanted symptoms. Breast tenderness and an increase in cup size is generally related to too little progesterone and proportionally too much estrogen. There is not necessarily an increased amount of estrogen production, but really just a lack of progesterone that leads to many of the symptoms of Perimenopause.

PYHP 115 Full Transcript;

Download PYHP 115 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’re back, we’re back in the saddle do another podcast.

Dr. Davidson: We sure are.

Dr. Maki: It’s been a little while. We haven’t posted any for a little while. We apologize for that. But we’ve been very busy. We got a new puppy.

Dr. Davidson: We did get a new puppy, a poodle puppy.

Dr. Maki: Alright. So we’ve talked about Bob, our little co-pilot. He is having a little bit of a crisis. He’s kind of having a crisis with the new puppy. About one minute, it was really funny, we brought her into her first grooming sessions placed here in town called Bailey’s and she looked like a little bit of a shaggy mess. And then they just really didn’t do much because this is her first one. She’s only like four weeks old and she came back from the groomer with a nice blowout. She got her hair done. And Bob was all interested and her name is Vivi, Vivian, one of my relatives. Bob’s named after my dad, and Vivi, our new poodle is named after another relative. She was technically my great aunt, but more like my grandmother. So it’s Bob and Vivi. She came back from that groomer, a grooming session. And Bob was, he was very… he changed his tune about Vivi very quickly.

Dr. Davidson: Yeah. He went from being annoyed, “When is she going to go back home?”, to he can’t be separated from her. So it’s really sweet. And I think it’s summertime we’re enjoying the weather, playing with the new puppy, with the dog, and spending time outside. And we went and saw your family reunion in Wisconsin. So it’s been a little bit busy.

Dr. Maki: Oh. Yeah, yeah. And we’ve been, not to mention still…

Dr. Davidson: Good busy. Fun busy.

Dr. Maki: Yeah. Yeah. A good busy. Yeah. Now I know we had some other podcast, we mentioned that we’re in the process of trying to publish this book about perimenopause, it’s called the Perimenopause Plan. From this posting of this episode, it should be like days away from being published. We’re just working on a couple of the website details and there are a lot more things that went into it. Then we realized, that we didn’t understand necessarily we’re doing it all ourselves. For the most part of works, it’s kind of, for the most part, self-publishing it, we didn’t realize how many pieces, how many steps there are to that, or maybe a little naive. And as with everything right, I think this is one thing when you’re in business, you realize that things always take longer than you anticipate them in the beginning.

Dr. Davidson: So anytime you buy a book off of Amazon’s, kudos to all of them because it did take a while. But hey, you know what, it’s always a learning process. So I’m excited. So the book will be out on Amazon. We’ll also have it on our website too. And because it’s about perimenopause, we wanted to answer a question from a, looks like a reader from one of our blog posts about perimenopause.

Dr. Maki: Yeah,. And that the title of the… if you want to look it up. The title of this particular blog post which I actually remember when you wrote it, and the title is, ‘Why Is Perimenopause So Horrible?’ Which I think is just a, a not laughing necessarily why that perimenopause is horrible. But we understand that fundamentally because we talk to women all the time, that they say the same thing. Why is perimenopause so horrible? Even though at the time, maybe a little bit more now, but when we started helping women in their 40s, that’s really what perimenopause is women in their 40s. They didn’t really know what to call it. They just like, “Oh my God, my body is not cooperating anymore and I have all these things going on,” and no one can help them. So that’s why we started, without even realizing it, we were kind of seeing more and more of those. Because I remember we’ve said before, like, when you first got into practice all menopause. So, women, they’re basically in their 50s and now it shifted down a decade or two. Now it’s women between their mid-30s and even to their mid-60s. It’s encompassing the PMS, the perimenopause, and the menopausal postmenopausal, but really lately, it’s been a lot of tremendously, a lot of those perimenopausal women.

Dr. Davidson: And that’s kind of why we wanted to talk about it. And also why we put out that book about perimenopause. We’re going to do another one about menopause, probably on thyroid and a few different other conditions that we love to treat. But there is a definitive distinction between being in perimenopause and being in menopause, so they aren’t all lumped in one beat. And that was probably what kind of spurred a lot of this impetus is, I had so many women coming into me after starting practice dealing with menopause and women would come in saying they want to deal with their menopause. And I’m like, “You know, you’re 44 years old still having a period. You’re not in menopause.”

Dr. Maki: Yeah, right. Yeah. They just had to, you know, probably from their other doctors, their doctors would tell them, they’re in menopause. We’ve heard so many different things of what the other practitioners tell them. That practitioner didn’t even have a word, perimenopause. They are kind of misinterpreting some of the lab work and not understanding the symptoms in there. And really, at the end of the day, the treatment option is where everything falls off. Whether you have a name for it or not, or a diagnosis or not, it’s really what happens on the treatment side and how you’re going to deal with some of those issues. So this is from MW, she didn’t leave her actual name or anything, which we…

Dr. Davidson: That’s okay. We always change them anyway.

Dr. Maki: Which we certainly understand, but why don’t you go ahead and… why don’t you go ahead and read the question.

Dr. Davidson: Okay. So this question is… So this is about a blog post like, Dr. Maki had said on, that I had written called, ‘Why Is Perimenopause So Horrible?’ So this is a response to that blog post and she’s writing, “I see nothing on here about breast size increase, swelling, and pain. I’m forty-six years old and a 34A.” Which was really cute because I had to explain to Dr. Maki, what A, B, and C sizes mean in bras [laughs]

Dr. Maki: You did not.

Dr. Davidson: [crosstalk] you don’t understand what that means as much as I do [laughs].

Dr. Maki: Okay, I’m not a woman. I said that. You didn’t have to explain it to me. I said you would know that better than I would. Okay. I’m not a complete idiot.

Dr. Davidson: [laughs] Hey. You know when you’re thirteen years old when you get your first bra, we learn all about A, B, C, and hopefully would love to have a D. But then okay, I’m going to go back on. So, “I am forty-six years old and a 34A. Now, I’m a 34BC. My breasts hurt at least two weeks out of the month. Swollen, heavy, painful, have to take ibuprofen. It’s annoying as hell and it’s changed how I view my body. Not to mention, my midsection has changed too. I never wanted large breasts. I know BC cup is not large, but it is to me. And now I need to wear two sports bras to run. And I like to run all the time. And I feel like I did when I was nursing. This totally stinks. Does it get better?”

Dr. Maki: Yeah, right. This was a comment on, Why Is Perimenopausal Horrible? Because these are the types of questions and concerns that we get on a regular basis. Alright, there’s kind of a lot going on there, but we’re kind of just dive into her discomfort two weeks of the month.

Dr. Davidson: And truly, when I wrote that blog post, I mean I could write for days on perimenopause which I kind of did when the book comes out and you read it, but I didn’t put a lot in there about the breast increase. And it is important because a lot of women do get swollen breasts. And like she said, she’s forty-six years old, she’s always been a 34A. So this change to go up plus a cup and almost 2 cup sizes. That’s a lot. And a lot of it is inflammation and water weight, which can be really uncomfortable. And when they’re saying two weeks out of the month, so usually now we’re going to kind of play around with this a little bit, is that two weeks is probably two weeks before her period.

Dr. Maki: Yeah, right. So without her actually specifying, so if we broke down her cycle into a 28, 30-day cycle, right? So, there’s the first fourteen days or the first thirteen days, and then there’s the second fourteen days. So more than likely, if we asked her a few more clarifying questions from ovulation. If she still ovulating, which she might be, at forty-six, may or may not be. It’s the second half of her cycle, which is predominantly, usually, from ovulation to her period is what’s called the luteal phase.

Dr. Davidson: So, usually in that last two weeks, when you’re in your 40s and that’s that perimenopause. So menopause is the hormones have ceased to really dropped that estrogen and progesterone are almost non-existent. Wherein perimenopause, you see a lot of different patterns that can happen most typically, which is probably happening with M here, is that that progesterone is too low for the amount of estrogen she’s making for the last half of the cycle. So then that would exacerbate “PMS symptoms”, one in particular, is the breast size.

Dr. Maki: Yeah, right. And perimenopause like what is- like if someone nailed you down and was asking you for a definition of perimenopause, let’s just start there. I know we’ve talked about this before but we haven’t done any podcasting. We got a book coming out. So what would be your kind of off-the-wall, off-the-cuff kind of definition of perimenopause?

Dr. Davidson: It would be definitely an imbalance between estrogen and progesterone production.

Dr. Maki: So, what do you mean by an imbalance? What does that mean?

Dr. Davidson: So, like you would mention. So the estrogen, estrogen is an awesome hormone and it’s being secreted by your ovaries and when you’re on your period, all your hormones are low, so estrogen and progesterone, I would say, your estrogen and progesterone are low. So that’s what causes the lining of the uterus to shed, but then that estrogen will start to come up and peak on day twelve and then you ovulate, then you make progesterone. Usually, from about day fourteen to day twenty-eight, if we’re looking at a perfect 28-day cycle. So what you end up seeing–

Dr. Maki: Which is a chapter in the book, by the way.

Dr. Davidson: Yes. And not everybody’s perfectly 28-days and that’s okay. But if you’re looking at a perfect 28-day cycle, estrogen surges on day twelve, we have progesterone start to come up on day fourteen, and then the height of progesterone would be right about day twenty-one. And then if there’s no fertilization or pregnancy, then the hormones come down. And then back to day twenty-eight. Day 1, you get a period. So between that day fourteen and day twenty-eight, the last two weeks, as M is talking about here, is that production of progesterone is not sufficient. But in perimenopause, we’re still making estrogen. We might make a little less, we might make a little bit more, we might make exactly what we need to make. But it’s really about, what is that progesterone doing? And so, you think, if you have a good amount of estrogen which like I said, estrogens one of the best hormones in the world, is if you have a good amount of estrogen, but you don’t have that balancing effect on the progesterone. It is going to put you in estrogen dominant or what would be considered or progesterone insufficient balance. So that’s why you see a lot of–

Dr. Maki: So you said two things there. So it really is more progesterone deficiency or insufficiency, but it presents like estrogen dominance.

Dr. Davidson: Exactly. So, you think you’ve got- just like you think salt and pepper if you had to have that balance when you put it on your food. If you have too much salt, it’s too salty. If you have too little pepper, sometimes it tastes too salty because you don’t have the pepper to balance out the salt. It’s kind of like it–

Dr. Maki: Or like even what like was salad oil and vinegar, you have that balance between those two guys [crosstalk]. Okay

Dr. Davidson: If you have a lack of one, the other one presents itself more acutely; even though the level is probably fine. It’s just the other balancing factor to it.

Dr. Maki: So we could base, just based on what you described there which I knew that, but I was just kind of setting you up just so you could actually articulate it. But really then, we could say, if she is having these symptoms that didn’t show up before we could assume that she’s probably not ovulating anymore. Because ovulation is what creates progesterone production. She’s not ovulating, she’s not creating progesterone, and now she has these symptoms she’s never had before.

Dr. Davidson: Exactly. So there’s probably a part of that. Now I know, I don’t want to you know, I feel like I like, want to jump in the deep end right away, but I understand trying to explain this to everybody. So also to when you hit that perimenopausal phase, and, “Hey, we fought this imbalance a little bit with the hormones.” Sometimes our bodies become a little bit more sensitive to other things that in our environment, or what we ingest, or what we’re around, or stress because you’re–

Dr. Maki: How much we’re running on a weekly basis?

Dr. Davidson: I like to run. And honestly, I wear two sports bras too because I don’t like bounce.

Dr. Maki: Yeah, right. No. I know you’ve always- what is your cup size?

Dr. Davidson: I’m about what she is now. That, you know about a 34-36 BC.

Dr. Maki: BC, okay. I thought you were like a C.

Dr. Davidson: No. I’m more like a BC. I would love to be a big C, maybe a D.

Dr. Maki: Oh. Whoa. That might be fun. Okay. so you see that; even though I- that’s how much I don’t know. Like, I don’t know.

Dr. Davidson: Like I thought [laughs].

Dr. Maki: I thought you were a C and you’re saying like a BC so, I didn’t understand.

Dr. Davidson: I will tell you all, the ladies listening to me now if you go to a shop at one store versus another store and you buy this bra, that bra, this bra, sometimes they’re different.

Dr. Maki: And which makes no sense.

Dr. Davidson: I know.

Dr. Maki: How can they not be the same?

Dr. Davidson: Just like jean sizes, a perfect 7, a perfect 3, a perfect 9, a perfect 12. I mean, it’s all you know, anyway, we won’t go into sizes. But what I was mentioning is things that you’re exposing themselves, whether it’s stress or food and I do think when you go into perimenopause, you know, we’re in their 40s things change. But she could be ultra-sensitive to caffeine now that she wasn’t ten years ago because caffeine will create fibrocystic density in the breast tissue and some people are more sensitive to it than others and it can cause sore breasts.

Dr. Maki: And now she says–

Dr. Davidson: Chocolate can do that too.

Dr. Maki: She says, she’s not happy because of the running. She says, in parentheses, in her question that she runs all the time. The reason why I kind of picked on that part is that that type of stress on a regular basis, running, exercise in general of any sort, is another stressor for the body. In some ways, that is actually putting more pressure on her adrenals, which is further dropping her progesterone production. Because her body is increasing cortisol production because of the running. The proverbial runner’s high is really nothing more than an increase in cortisol. A lot of women, the only time they feel good is either when they’re running or right after they’re running, depending on how many miles per week. And she also mentions in there, the midsection that she’s never had before. That is basically cortisol redistributed body fat deposition. With a big mouthful right there. Women normally put weight on the hips and thighs. They are not prone to put weight around the midsection unless there is maybe an overproduction of cortisol for some reason. So again, we have a short little section on this in the book as well, because this is something that we see over and over and over. We’re speculating here, we don’t really know much about her life other than she likes to run a lot. But if does she have kids, is she working full-time. How many miles a week is she actually running? How well does she sleep? What is her overall stress burden on a weekly basis? All those things matter. And it’s going to translate the more stress she has, a lack of sleep, a busy family life, a demanding job, plus excessive running, and I think excessive- In a seven-day week, what would you consider to be excessive running in this context?

Dr. Davidson: Everybody’s different. That’s really hard to put a point down to. I have some patients that love to run 5 miles a day and my jaw drops because I can maybe do 3 and then feel pretty good after that, and maybe not every day. Some people want to run every day. As you said, it really depends on the symptoms. If they’re getting good sleep. They’re getting good nutrition. They’re not skipping meals or not super stressed and they’re running every day and they still feel pretty good and they don’t have any of these issues, then maybe that’s alright for them.

Dr. Maki: Yeah, right. You’re right. That is a little bit of an unfair question. I think somewhere between 3 to 4 days a week at the maximum, I think is reasonable

Dr. Davidson: Because I think humans, especially in our country, do need to be more active. Granted there are only 24 hours in the day. So I get it when you can’t fit in but I love that she’s trying to be active.

Dr. Maki: Okay. Yeah. Certainly, we can’t discourage especially in the country nowadays. You can’t discourage anybody from exercising, maybe like you said most people probably could be a bit more active but there’s also a limit there. There is a point where a good thing becomes maybe not so much of a good thing. And this is something that we see quite often where there’s running all the time means she’s probably doing it 5 to 7 days- 5 to 6 days a week.

Dr. Davidson: Well, you mentioned, so just to try to clarify a little bit, that the running, doing a little bit too much or you might be pushing it too much is going to raise the cortisol.

Dr. Maki: Yes.

Dr. Davidson: And then you also said, a little bit other things that raise the cortisol.

Dr. Maki: Yes. Stress, just stress in general, lack of sleep, family job, all the demands.

Dr. Davidson: Skipping meals

Dr. Maki: And that’s the other one too. And maybe a way to balance out the running is there has to be a commensurate increase in caloric intake. So, that way recovery can happen on a regular basis. So if you’re gonna be an athlete, if you’re going to run all the time or exercise all the time, the calories have to be adequate enough, and believe me, this is another thing we’re going to do a whole podcast and probably a series of podcast on how common it is for women to be under eating as a way to achieve their weight loss goals. And there’s a lot of them are under-eating anywhere from five hundred to a thousand calories, if not more on a daily basis, that puts a tremendous amount of pressure and stress on the adrenals and it manifests as female hormone-related problems.

Dr. Davidson: On a separate topic, I do notice that nowadays, hey, it’s 2021 that finally, you’re seeing a lot more things in the media, from other doctors, from experts, what not saying we need to eat. So because I remember, in the 90s eat less and exercise more. That was how to, or maybe just skip eating and that was how you were supposed to lose weight and that doesn’t work long term. So I do love now in this day and age, you do see people advocating like, “Hey, we got to eat.” Like, I had a patient that’s pregnant and she’s asking me, “How many calories can I take? Or can I reduce my calories so I don’t gain weight?” I’m like, “You’re pregnant.” Please!

Dr. Maki: Yeah, right. You’re eating for two, you need more calories.

Dr. Davidson: You’re so focused on that whole, caloric intake and reducing, that I love that you’re saying like, hey, if you’re going to exercise which I’m sure M’s loves it. You got to eat.

Dr. Maki: Yeah, and it’s really counterintuitive to think that in order to lose weight to get your body to change the way you want, you actually need more food as opposed to less food. Now it makes perfect sense and I can see logically why if you just exercise more and eat less that is going to make it work, okay. But that is only the very kind of superficial logic that turns a very complex system like the human body with all the hormones and all these sensory inputs into basically a math equation. The math equation on paper works, but it does not work in the real world. And especially after the age of forty, for both men and women that math equation works when you’re twenty-five. Eat a little bit less, and drink a little more coffee. Maybe have a couple of cigarettes every once in a while and then exercise a bunch in your body will just do whatever you want. Because that’s what women tell us both all the time. But when you’re in your mid-40s and beyond, it doesn’t work that way. So your whole strategy needs to be different in order to get your body to cooperate the way you want it to. And I can certainly see why she would never correlate the running to contributing to her symptoms. She would never understand that. And even her gynecologist would never even understand that.

Dr. Davidson: As you said about that cortisol is when your hormones you know, “hey”, they always say, “Well I’m getting older,” and doctors will say that, “Oh well, you’re getting older is your metabolism going to slow down so it is what it is just deal with it.”

Dr. Maki: That’s ridiculous.

Dr. Davidson: I totally agree, but you think about those female hormones, especially that progesterone does have an effect to buffer some of those adrenal stressors like the cortisol, which is why when you’re twenty-five years old, you can drink milkshakes and stay thin or exercise and eat a little less and lose 5 pounds overnight, but you can’t do that when you’re forty-five years old because you don’t- the female hormones have readjusted themselves in a way that can’t buffer that stress anymore.

Dr. Maki: Yeah, right. I mean that’s really at the end of the day, a woman is actually- so in a case like this, right, we’re talking progesterone or a lack thereof – you said progesterone insufficiency.

Dr. Davidson: And then there’s some cortisol manifestation happening. That’s probably a little higher than it might have even been when she was in her 30s.

Dr. Maki: Yeah right. So and maybe there’s not necessary more cortisol. There’s just like you said, there’s less of a buffer between the female hormones and that may be just our own way to explain it, may not be actually physiologically true or just kind of talking in layman’s terms here, but it sure seems that way. That once the female hormones disappear and they flat line, which is what menopause happens, there are no more peaks and valleys that are just basically a flat blade baseline. That’s when all these things seem to be magnified. Woman’s up until her 40s, everything’s going well and all said now her stress goes up everything else. Now, the female hormones start declining and her body starts not cooperating anymore. All right, and they’re completely kind of dumbfounded as to what’s going on. So this is the reason why I picked this one out, just because I thought it’s broad enough, but it’s also something we see very repetitively. Even though she’s talking specifically about her breast size, there are so many nuances to that as to- In a very “holistic” sort of way. Checking with her sleep, see what her stress level is. How many miles a week is she running? What is your caloric intake? A little bit of bioidentical progesterone could be very helpful. Maybe even a little dim or something like that to tone down some of the estrogen maybe. That might not be appropriate, but it certainly could be in a case like this. It’s not just, let’s take a pill or let’s go on birth control and be done with it. Right? And it doesn’t work.

Dr. Davidson: The last thing a 46-year-old woman wants to be on is birth control pills–

Dr. Maki: Or should be on, is birth control.

Dr. Davidson: I agree. So but I will have to say like I said perimenopause, and that’s why we wanted to talk about this, I didn’t write too much about the breast tenderness in the blog and I’m glad that M called me out for it. But I did want to say perimenopause is different from menopause because yeah, she’s noticing a change in breast size because of the hormonal imbalance that’s- and I wouldn’t call it an imbalance it’s natural, it happens in your 40s, but there is an imbalance between the estrogen and progesterone. But once you hit menopause and those ovaries have decided, “We’re in full retirement, we’re not working anymore. We’re not making any estrogen, any progesterone”, you actually see a lot of women lose about a cup, a half a cup to a full cup size from the breast tissue because estrogen is what can pretty much grow that breast tissue. That’s why when you, as you know, go through puberty, you start to grow breasts. So when you see those hormones ceased to be produced from the ovaries you will see a reduction. And then when we do some hormone replacement if that’s warranted for them and that’s okay for their personal history. You do see it grow back. They get it, but it doesn’t grow back bigger than it was before because that would be too good to be true.

Dr. Maki: Yeah, right. but you’re right. The breast is a very- as we as women, all know, as practitioners understand. The breast tissue is a very hormone-sensitive tissue. So, of course, it’s going to respond. Usually in a good way, at least when we’re in charge of something, but in a case like this, it kind of goes a little bit racked[?]. Because Is that, like I said, that, teeter-totter, the balance between the extra estrogen progesterone. It’s not necessary that the estrogen is necessarily too high, it’s just too high in relationship to the lack of progesterone, at least, in this case, it could be different in other cases, [crosstalk] at least in this case,

Dr. Davidson: Possibly. And we’re in some ways speculating but we’ve seen this so many times over, but we do a lot of lab work to correlate or I don’t even know where the correlate or justify or whatnot to put that symptomatic picture of a 46-year-old female that likes to run who has breast tenderness for two weeks out of the month. We do, do blood work to make sure that that coincides together. So like you said, we’d probably do some labs with M, maybe some bioidentical progesterone if warranted or that works out or maybe you would start a little bit lower on balancing those hormones with lifestyle, with other supplementation, like herbs or vitamins or minerals. That’s the cool thing about all of this, there’s so much stuff we can do.

Dr. Maki: Yeah, but that’s also the confusing part is because there’s not really one way to do it, right? Even with functional medicine, natural medicine, integrative medicine, whatever. That’s part of the problem is not one size- now, that’s the best part. It’s not a one-size-fits-all because we’re not- like we don’t practice cookie-cutter medicine. We shouldn’t be practicing cookie-cutter medicine or everybody gets the same treatment. So from a conventional standpoint, that’s why women are reaching out to us and doctors like us because they just keep getting told “no, or there’s no treatment or there’s nothing you can do,” or the options they are given antidepressants, anti-anxiety, medication, and birth control, it’s not helpful. It doesn’t work, it doesn’t help, but that’s the only options that are offered to them, and that’s why we have a bunch of comments on the website that we, are still pending. One thing about that, if you are going to write in a question on the website, either through the email help@progressionhealth.com or if you post a comment right on the website because we do like to, got into a- I didn’t realize this at first but realizing it right now if you put your name on there and then we publish the comment and could be a little bit of a privacy issue. So you might want to use either initial like in this case or a fake name or something. So that way, it’s just, if we do publish your comment on the website, so other people can read what we wrote or at least referring. We might not be able to write on every single one, but at least point you to the episode, that answers your question now, no one gets to see your name. That’s, to be honest, part of the reason why we haven’t published some of the comments because their names, on there and I don’t want other people to see their names when they’re asking some of these things. I mean she’s talking about her cup size and it hurts and I mean that’s kind of a female-specific issue. Not everybody needs to see that or know who actually wrote it. So something to think about if you decide you want to- we love the comments, we love the questions, we love to be able to facilitate in that way, but we certainly want to keep a certain level of anonymity for everybody. So we’re not hearing it all out there for the world to read.

Dr. Davidson: Exactly, which is why M’s mentioning this, and when I read that, I was like, “Oh, yeah,” gosh, there’s so many symptoms and perimenopause I didn’t put that in that blog. Maybe I need to readjust the blog or something. But if she’s having these symptoms, just like we said before, lots of other people are having the same symptoms. So it’s nice to- I don’t know what the word is, but just when someone feels that validation, that you’re not alone, or that there are options, or that we can learn from each other. So we do really appreciate the comments.

Dr. Maki: One little other side note about breast tenderness in general, because we talked about the breast does, of course, have a lot of estrogen-progesterone receptors. It also has ironically a lot of iodine receptors. And iodine, we should do a whole other episode about iodine. I know we’ve done some of those in the past, a couple of things to think about, evening primrose oil, number one, that can be a nice anti-inflammatory to help kind of reduce some of the tenderness, but iodine specifically for breast tenderness can be very helpful. However, a little caveat to that, there’s a lot of supplements on the market that had these huge mega doses of iodine. We’re talking six, twelve, twenty-five, fifty milligrams of iodine. Be very careful with those types of doses because in most cases, if you have a normal functioning thyroid, and you take those big mega doses, you’re going to create some thyroid suppression and that might contradict what you’re trying to accomplish.

Dr. Davidson: Because yes, we have noticed when you do high doses of iodine it can suppress the thyroid. If you do even kind of like lower doses of iodine, it can make the thyroid go up. I mean everybody is a little different. So whenever we use something that might have another effect downstream on another organ or maybe have another possible side effect, then we test for it. Hey, you know what? You test for iodine and it’s through the roof. It’s not something you want to take.

Dr. Maki: We’ve seen it many times. You take iodine and these mega doses. There are a few products out there that have these really high doses. Those, we usually use for hyperthyroid situations. That is a very small percentage of all the thyroid problems. Most people are having hypothyroid problems in the last thing you want to do. If you take iodine is too much your TSH increases as opposed to and hyperthyroid, your TSH goes down. So the RDA for iodine is 150 micrograms, in a situation like this, you don’t need a lot to actually have an impact on something like this.

Dr. Davidson: And we about… The caffeine intake that she might be extra sensitive to caffeine that she might just want to cut that out and all other sources of caffeine.

Dr. Maki: Which can also be a little challenging to do. People love their coffee or love their chocolate, and stuff but… Yeah.

Dr. Davidson: Something to think about.

Dr. Maki: Yeah, that’s why I thought this was a good one to discuss because even though it’s very much about her breast size and it’s painful, there’s a few other things in there that allow us to elaborate and really paint a picture of what’s really going on there, even though we know very little about M, so hopefully, that was helpful. Do you have anything else to add about that one?

Dr. Davidson: No, no, I yeah, hopefully, that was helpful in the context of perimenopause. As you said, we could go on and on and on and no lab testing, screenings, ultrasounds all that, [crosstalk] we are talking about.

Dr. Maki: We have a lot more episodes. We can’t do it all in one episode. So you might be hearing a lot over the next to several episodes about perimenopause. But we’re going to try to keep it broad enough so other people can listen and delve into some of the thyroid stuff in some of the adrenal stuff, even into some of the menopausal stuff because it’s all related. A lot of those women that are in perimenopause are going to be soon enough into menopause, so we’ll try to keep it relevant but yet, cover enough basis, so everyone find some value. So I mentioned it just a minute ago, help@progressionhealth.com, you can send us an email. You may or may not get a response but we, please send them in. We do run through them, pick and choose what emails, what questions are going to be read. And we appreciate you taking the time to do that. We try to facilitate as many as we can. It is a little challenging to get a lot of them. And the book, it’s called the perimenopause plan. It will be published from the posting of this episode. Probably, it’s either already been published, that would be nice, or it’s going to be published within a few days of this episode’s airing. So pay attention to that. If you’re not on our email, go to our website. There’s a little video course you can sign up for and then we’ll give you updates on different things like that. So until next time, I’m Dr. Maki.

Dr. Davidson: And I’m Dr. Davidson.

Dr. Maki: Take care. Bye-bye.

Dr. Davidson: Bye.

The post Why Do Breasts Grow During Perimenopause? | PYHP 115 appeared first on .

Which is Worse, Perimenopause or Menopause? | PYHP 114

Dr Valorie Davidson and Dr Robert Maki — Tue, 05 Oct 2021 23:59:15 +0000

Patient Question: A patient in her later 40’s, who is having a tough time with perimenopausal symptoms, recently asked me which is worse, perimenopause or menopause?

Short Answer: After dealing with many patients over the years, it is clear that both Perimenopause and Menopause are difficult and the symptoms can have a significant impact on a women’s quality of life. However, there are better treatment options for menopause then for perimenopause.

PYHP 114 Full Transcript:

Download PYHP 114 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 this morning, we’re just going to kind of sort of a question, but this was not actually one that someone answered on the website or wrote to us. This is actually from a patient that I recently saw. She’s 46, which is kind of a- I’m sure you would agree, it’s kind of like a very common age for our new patients. She’s kind of miserable at the moment, has a lot going on, and just does not feel very good. And she actually asked me the question because she hears horror stories about menopause, but she’s feeling pretty rotten right now. So she asked the question, “Which is worse, perimenopause or menopause?” So I thought that was a very nice way for us to do an episode around that.

Dr. Davidson: Exactly, because we see this all the time, you know, a lot of menopausal females, perimenopause. And sometimes, we kind of overlook a little bit of the differences between the two and how people feel because, you know, everyone’s different.

Dr. Maki: Yeah. Now, honestly, this is the reason why we’re doing the podcast in the first place, because when it comes to some of these female hormone issues in general whether it’s PMS, PCOS, perimenopause, menopause, the conventional treatments and approaches are just not very good. Women are kind of left to their own devices. They’re not really given a lot of options. We’ve kind of figured that out over the years, right? There’s this big gap in the problems that women are experiencing. Before, it used to be just, “Well, that’s just aging and you just have to deal with it.” I don’t think that’s really acceptable, really, in the 21st century.

Dr. Davidson: I think some people still hear that, you know, “It’s okay. That’s just getting older.”

Dr. Maki: Well, yeah. That’s easy for the practitioner to say when they’re not the ones dealing with it, right? But a busy woman that’s got kids and a job and a family and is running the household — all those things, I mean, she can’t afford to have her body not cooperate the way she wants it to. And, you know, perimenopause, there are a lot of similarities, but it’s a little different for every woman. And again, when it comes to them getting some kind of relief, the options are pretty limited.

Dr. Davidson: And, perimenopause can span from your late ’30s to your early ’50s, and then you got menopause from your early ’50s beyond. In some people, it lasts for a short amount of time and in other women, it lasts for years. So that’s a long time for somebody to have to not feel well or just feel like they just have to put up with it.

Dr. Maki: Yeah, right. I mean, you figure from the beginning of that. Let’s say 40, right? Let’s just say 40 is the beginning and then 50, 51, you start menopause, there’s a decade already right there. Plus, you know, menopause into postmenopause, you’re looking at probably another 5 plus years there. That is anywhere close to a 15 to 20-year-stretch of a woman’s life when life should be really good and things should be fantastic and the kids are grown and out of the house and women are just miserable. Again, the question, from your patient experience, if you had to answer that question which is worse, what would you say?

Dr. Davidson: I would say, it’s not really a simple answer. Like I said, everyone’s different, but I would say menopause, in some ways, is obvious, right? There are some real main symptoms with hot flashes, night sweats, and then you stop your period if you have a uterus. But, perimenopause, I think, is a little bit elusive and a little bit kind of like that… people don’t realize that “I don’t have to feel this way.” Or “Is this really my new normal?” So, a lot of people with perimenopause, it’s like they don’t feel gray[?] but they still just sort of trudge through it as, “Hey, this is life.” Or chalk it up to stress or aging or not sleeping enough. But at the same time, I feel like perimenopause, in some ways, can be worse because it’s like a lot of women are just like, they don’t want to complain. They don’t want to be the complainers. They don’t want to say they don’t feel well. They don’t want to say, “Well, I don’t understand why I can’t lose weight.” Or “Why I’m gaining weight?” Or “Why do I feel this way?” A lot of times, they just are quiet about it.

Dr. Maki: Well, yeah. I also think too, like you said, menopause, in some ways, they’re both- You know, some women have a really tough go with things in both instances — perimenopause and menopause. I would say though that there are a few more treatment options for menopausal women than there are for the perimenopausal, which is why we’re kind of focusing on the perimenopausal because as you just said, that’s kind of more of the trickier ones. And the options that they have available are much more limited. So I would say, just from that standpoint, giving women some relief, I would say perim- And I’m a man so I really don’t know anything, right? Take what I say with a grain of salt, but I would say from that standpoint that perimenopause would be a little bit more of a transition. A woman’s body is working just fine. They’re doing all the things they have to do. And believe me, the patients that we see, they’re doing a million things on a daily basis which in some ways, is kind of adding to their symptom picture. And then all of a sudden, it’s almost like overnight, their bodies just stopped cooperating. Maybe it’s the surprise of that. They’re expecting all of that stuff to happen in menopause but it happens maybe 5 or 6 years early and they don’t know what it is. And even their practitioner — they go see their doctor, their gynecologist, their GP, whatever. They don’t even know what it is necessarily. So, if I had to pick one, and just some of the feedback we get, I would say that perimenopause is probably a little bit more challenging to deal with. It can be a bit more, at least in the beginning of it, a little bit more debilitating.

Dr. Davidson: You’re right. There’s not really a lot of treatment options and it’s not a disease. Menopause isn’t a disease. These are just the changes as we go through our lifetimes. But I do think that those hormonal changes can really impact how someone’s feeling. Like you were saying, 40 years old, when you look at the treatment options, someone comes into their physician, their gynecologist, their primary care, and they say, “I’m not sleeping. I’m really irritable. I’m freaking out. My hair is doing funny things. My hair has changed.” Because you will see a lot of hair changes in hormonal changes. I put on 15 pounds over.” Do you hear that? That’s our little buddy. Chewing on his elk. What is that his little elk thing?

Dr. Maki: Yeah, his elk antler. Yeah. Our little co-host down there.

Dr. Davidson: Sorry for the interruption, but he sure is adorable.

Dr. Maki: It happens every time.

Dr. Davidson: Like I was saying, they see their practitioner and they’re saying, “I don’t feel well. I’m having night sweats. My periods are all over the board. My libido ran out the door. I gained 15 pounds which feels like it happened overnight even though I’m exercising and eating well.” And then, what does a practitioner do? I understand it’s not a disease, it’s either- And the last thing you want to do is put a female in their ’40s on birth control pills, and then there are antidepressants and anti-anxiety medications and sleeping pills. And the last thing you want to do is get medicated like that.

Dr. Maki: Yeah, right. And honestly, I know that antidepressants, anti-anxiety medications, or birth control pills are really the only options that are available. And I think all of them, in some ways, have some potential downside to them.

Dr. Davidson: Yeah. I mean, in certain situations or circumstances, oh, my gosh, they can turn someone’s life around — antidepressants and whatnot. But, I don’t think that’s something, you know, when someone’s coming to you saying, “My periods are- I have two periods in a month and they’re really heavy. And all of a sudden, I have fibroids. Where did those come from? I’m not sleeping at night and I’m kind of grumpy with my husband –” Don’t even wink at me. Yes, I am in my ’40s.

Dr. Maki: Yeah. I’m living the perimenopausal nightmare myself.

Dr. Davidson: The perimenopausal dream.

Dr. Maki: Yeah. I know. It’s all good. From some of the things I hear, and we just got a comment the other day from someone on the website. It wasn’t really a question per se, but someone said, “Perimenopause is hell.” It was really dramatic, but at the same time, it’s like-

Dr. Davidson: But it can be.

Dr. Maki: Yeah, right. I mean, she was even saying how bad she feels for her family — her husband and her kids. One minute, she’s happy and the next minute, she’s pissed. In the next minute, she’s crying and it’s all over the place and no one knows what’s really going on. I was actually doing a bit of research before we started recording this episode, looking up just some keywords and different things. And I found one, it said “Perimenopausal Guide for Husbands” Or “Perimenopausal Resources for Husbands” Or something like that. And I’m like, “Yeah, they have no idea.” It can be a little bit of a hurricane sometimes. You don’t understand what’s going on. But this is also- We had an episode a long time ago, it’s like how hormones affect behavior. If men went through perimenopause and menopause, granted, men’s testosterone declined so they have their own andropause, whatever else. But if men went through the same kind of transitions, there’d be a hundred treatment options to be able to address these kinds of things. But because it’s a woman and it’s not really a disease, it’s not even a- I know you and I have talked about this, there’s not even an insurance billing code for perimenopause. Either you have PMS or menopause, and then there’s really nothing in between.

Dr. Davidson: There’s like endocrine hormonal imbalance, I think, that you can use.

Dr. Maki: Yeah. The whole system is kind of skewed away from dealing with a- And now, granted, perimenopause, like you said, is not a disease. Menopause is not a disease, but they’re both a kind of a collection of symptoms that are very common from woman to woman. I don’t know. I see things online. I hear some comments from patients, and it seems to me, anyway, that perimenopause is a little bit tougher to deal with.

Dr. Davidson: I agree. And even with menopause, like I said, it’s pretty obvious. They’re having the night sweats, having the hot flashes, they’ve no more periods. And then when you tell somebody, “Well, you know, I’m going through menopause.” Or “She’s going through menopause.” Or “My mom went through menopause.” People seem to understand that and they’re like, “Oh, yeah.” You know, they understand what that is, but when someone says, “Well, I’m having a tough time because I’m going through perimenopause.” A lot of people don’t really know what that means, and then they’re like, “Well, don’t give me any excuses. You’re fine.”

Dr. Maki: Yeah. Right. ” You just suck it up. You’ll be okay. This is what every woman goes through.” Now, I will say, stress level- Women are doing a lot these days, right? Women have always done a lot but they’re still doing a lot. They’re taking care of the kids. They’re working full-time. The to-do list that I hear women have to do on a daily basis, it makes me tired just listening to what they have to do, right? Then they can’t sleep and then they’re just kind of running themselves ragged. They’re taking care of everybody else in the family, but there’s no one there to take care of them. They have no time to decompress. They have no time to relax. It’s just this constant “go, go, go” all the time. And that level of stress, I think, over time, is what exacerbates this perimenopausal transition. If that’s, let’s say, normal- and I don’t think anybody necessarily[?], especially with all the pandemic stuff. I don’t think anybody has “normal stress.” I will say though, and maybe if you notice this too, that during the pandemic when people are kind of locked down, some people’s stress actually went down because of the lockdown and some of their symptoms actually got better.

Dr. Davidson: I agree. Working from home, I noticed a lot of my female patients seem to do really well with that. Then my, you know, some male patients are like they can’t stand all, the different- I think as females, we can definitely micromanage a lot more than men can. I hate to be stereotypical right there, but I did notice a lot of females were like, “Yeah, working from home, I felt more efficient. I could get things done. I can work when I want to work.” And then, of course, the kids are at home because where we were at, none of the kids were in school, so they got to help them with their homeschooling or their computer school. So, it’s been really interesting, actually. But like you said- I have to say you’re right. During your ’40s, there’s a lot of stress. Your kids might be teenagers, they probably have a little more autonomy than when they were little. You’re working, you’re balancing. But, it’s like that chicken and the egg because when those hormones change in perimenopause — because they do certainly change. They don’t go… they don’t get extinguished like they are in menopause. But the hormonal balance does change that it can create, probably, one of the biggest things. Of course, it’s the irritability but also sleeplessness. So, you think about it, a human being sleeping for a couple of hours, and then waking up all night, or either being up for 2 hours plus and then waking up all night. So maybe in the morning, they’ve had maybe 4-ish hours. I mean, that’s going to make people feel more stressed, more tired, more forgetful. So it’s like this sort of domino effect, I think, that can happen just from those hormones changing.

Dr. Maki: Yeah, right, yeah. And that’s one thing that we always try to pay a lot of attention to, which is not always easy, right? That insomnia, whether it’s falling asleep or staying asleep, that’s kind of a challenging thing and quite often, actually. But it’s also, as you just said, it’s like the most important thing. Because if you got all these things to do on a daily basis and you have all this psychological stress and pressure, you need to be able to rest and recuperate to be able to get back up and do that again. Your circadian rhythm needs to be in kind of good working order. But then, like you said, that insomnia could literally last at some women a decade or more.

Dr. Davidson: Yeah. So, like I was saying, that chicken and the egg, you would say, stress is going to make perimenopause worse. Yeah, of course, it is. But even when stress isn’t there, it can still be bad because they’re not sleeping. They’re feeling forgetful, they’re tired, they’re hungry, mentally tired. Then they’re trying to exercise to offset the weight that came on. You were saying, stress can make perimenopause. I think, in some ways, perimenopause makes stress.

Dr. Maki: Well, I think you’re right. I think there’s a chicken before the egg or the cart before the horse, right? I think you could say that in both directions. One exacerbates the other.

Dr. Davidson: Or vice versa.

Dr. Maki: Or vice versa, for sure. But just in the 21st century, we live complicated lives. And usually, when there’s lots of stress going on, it seems like those symptoms are kind of magnified. But like you said, when you are not sleeping and you’re irritable and you’re having all these emotional changes and physical changes, that just adds to this because there are so many things you have to get done on a daily basis. It’s a pretty challenging thing. Now, menopause — kind of switching gears a little bit, from our patients, you’re not quite there yet in menopause. But we’ve heard just as many horror stories in menopause as well. But some of the symptoms that women experience are just slightly different, right? They’re not exactly the same. Still, sleepless issues, but in perimenopause, like you said, it’s more of not being able to stay asleep, where menopause, you just can’t fall asleep, right? So it completely changes almost like overnight. The minute their period stops and their sleep quality or their sleep schedule, completely, is different.

Dr. Davidson: Yeah, you can definitely see differences between the two in terms of symptoms. I’ve had a lot of women tell me though that they thought they were in, they’re like, “I’m in menopause. My doctor says I’m in menopause. I’m in menopause.” I’m like, “You are not in menopause. You’re in perimenopause.” So, there’s definitely a little bit of a gray area between the two that I think sometimes gets confused. So, women don’t know where they are, “Am I in menopause? Am I in perimenopause?” But I think it’s only because a lot of people don’t really think about perimenopause or really look into the hormonal imbalance between that. In menopause, it’s just they just throw it under the big umbrella, “Hey, it’s all[?] menopause.”

Dr. Maki: Yeah, right. And even menopause, I know that you talked about FSH a lot or we’ve talked about it before-

Dr. Davidson: Follicle-stimulating hormone.

Dr. Maki: Yeah, yeah. In your new book, there’s a whole section in there about FSH. And that’s really the tool or the objective value that you use to kind of determine where a woman is.

Dr. Davidson: Sort of.

Dr. Maki: Sort of. Yeah, sort of.

Dr. Davidson: Because the reference ranges for a typical FSH, according to your lab, is humungous that a lot of perimenopausal females get lumped into menopause because of the FSH. So yeah, I go into that explanation a little bit. But, if you do have a uterus and you’re having a period, you’re not in menopause.

Dr. Maki: Right. We’re going to do another episode specifically about FSH and kind of breaking that down a little bit. So when you go to your gynecologist or your GP and you get your labs done for yourself, you can kind of tell where you are based on your FSH level. It is a fairly good determinating factor. Now, again, if a woman’s got an FSH of 100, then that’s fair to say that she’s probably either in menopause or approaching menopause. Her period has probably stopped six months to a year before. But in perimenopause, that’s where it can be a little more of a gray area. And there’s not really a firm criterion to diagnose perimenopause. And like you said, that’s why women get lumped into the menopause category all the time because- I don’t think there’s any agreement or you can’t look it up in a textbook or anything like that to say, “Okay, what are the diagnostic criteria for perimenopause?” There isn’t really one. One of our future episodes coming up here shortly is we’re going to kind of dive into that and actually talk about how you would actually diagnose perimenopause.

Dr. Davidson: Yeah, and we have that a little bit in the book too. Because really, we want to give you tools so that we can educate. That’s our big thing — we want to educate so you understand. And then, once you understand, then you can decide, “Okay. Well, what direction do I want to go with this? Do I want to take some of these medications? Or maybe I don’t, I want to do something different.” So, that way, you have the tools and the understanding.

Dr. Maki: Yeah, right. So, what else do we want to say about the difference? Granted, we’re kind of leaning a little more towards perimenopause just because that’s kind of what’s… And honestly, like you said in the beginning, I don’t think there really is a distinction which one’s worse because I think that the woman experiencing either one at the time would say, “That one’s worse.” Right? Because that is the most kind of present thing she’s dealing with. But, my preference or my opinion is that perimenopause seems like it could be at least a little bit more challenging, both for the patient and for the practitioner, as far as dealing with some of the symptoms.

Dr. Davidson: Yeah, no. Exactly, I do think both can have their pros and their cons because once you’re in menopause, you don’t have to worry about getting pregnant. And hey, you know what? Nobody really wants to have a period for the rest of their life, although there are a handful of women that do. And we have that hormonal balance for them too. But, I would say, menopause is not- There are lots of tools to make it a very easy transition, a beautiful time, and then just kind of moving forward. But at the same time, I think with perimenopause, it’s a little bit of a mind game because people are telling you you’re fine. “Oh, you’re fine. You’re fine. You’re fine. You’re fine. You’re healthy. You’re healthy.” But I don’t feel like it. So it’s a little bit of this weird dichotomy that I think a female goes through of “I’m fine. They say I’m fine, but I don’t feel fine.” Or in menopause, they’ll say, “Well, you’re in menopause. Go deal with it.” I think it’s just kind of a different mindset.

Dr. Maki: Yeah, sure. From a conventional perspective- and that was kind of my point at the beginning is that the perimenopause part- Now granted, there’s a little bit more awareness and women are certainly more familiar with the term, doctors are becoming more familiar with the term. But still, there’s a little bit of a lack of awareness and as I said, a lack of treatment options too to help women deal with some of the things so they can just get back to their lives and do the things that they have to do. It doesn’t have to be so complicated or they don’t have to be operating on such a deficit from what their bodies are used to, what they’re experiencing usually with their bodies.

Dr. Davidson: I agree. So even though that was one patient- because we got to talking about this that you had yesterday, and saying, “Which is worse?” We start talking about it and we thought “You know what? I think, sometimes, we deal with so many hormonal issues with our patients” — because that’s pretty much our niche and what we do, that we forget to kind of step back and say, you know, instead of saying, “Oh, what’s your FSH? What are your periods like? What are the symptoms? What are the treatments we’re going to do?” Step back and kind of think about some of those questions that do come up, because it’s true. People are wondering, “If this is bad, is it going to get worse?”

Dr. Maki: Yeah, right. That’s kind of what her question was like, “I feel horrible right now.” Like that comment we had got on the website, “This is hell. Why is this so awful? Is menopause even worse than that?” And I wouldn’t say that it’s actually worse. I’d just say that it’s maybe different. And I keep going back to it, but treatment options, there are quite a bit more treatment options on the menopausal side. When a woman was having hot flashes, that’s a pretty easy problem to solve, you know, sleeping- On both sides, perimenopause, whatever, that might be a little more challenging. But in perimenopause, when a woman is still menstruating regularly, from a hormone replacement perspective, it minimizes the potential possibilities of which you can actually do. And, just giving women testosterone, which I know is another common thing to do, that’s, sometimes, the worst thing that a woman can do. That’s not really going to help her. It’s just giving her a bunch of testosterone.

Dr. Davidson: Yeah. Everyone’s different. It all needs to be a little bit of, what are their particular symptoms? What are their goals or their family history? What’s their personal history? What’s their health history even right now in terms of moving forward? What’s their hormonal balance moving forward? But like you said, conventionally, I would say, there are more options for menopause. Conventionally.

Dr. Maki: Yes. That’s what I mean. Conventionally.

Dr. Davidson: But what we do- my goodness, I would say, when I first started out in practice in 2004, which I was very green and very, very young, I probably dealt more with menopause, that was kind of like- because that was more known about, that was kind of what would walk through my door. And then, now, I would say I probably deal more with perimenopause.

Dr. Maki: Mm-hmm. Yeah, even myself, yeah. I would say, I went through the same transition. Menopause is more front and center, that was what got all the attention. And now, it has definitely shifted- but a decade and a half almost earlier, 10 to 15 years earlier from the typical menopausal patient for sure.

Dr. Davidson: But those patients, we will soon- as I said, in a few years, we’re going to go through menopause. So, let’s create a nice foundation now moving forward. So I, maybe- you know, everybody’s practice is different.

Dr. Maki: Yeah, right. Well, and then also, probably, for the ones that we’re already dealing with that are already in perimenopause, it smooths their transition a little bit. They’re not having to start from scratch. There are already some things in place that make it a lot easier for them. I don’t think we need to necessarily beat a dead horse about this, but it was just a question that came up just a couple of days ago. And I’m like, “You know what? That is actually a really good podcast episode. Which one’s worse?” The conclusion is I wouldn’t say that there isn’t necessarily one worse than the other, they’re both really challenging for women to deal with.

Dr. Davidson: Yeah, and they’re not bad. I mean, everybody’s bodies, you know, we’re not statues. We have different stages in life from birth until we’re no longer on this planet. We’re always changing so I wouldn’t say they’re bad. It’s just, “Okay. Well, what can we do to make the circumstances smooth and easy and make this a good time?”

Dr. Maki: Yeah, sure. Right. So, if you have any questions, you can always reach out to us at help@progressyourhealth.com. That’s an easy way for you if you want to stay anonymous. You can just ask us questions. When we do actually read listener questions on the podcast, we, of course, always change everybody’s name just to keep a little bit of anonymity there so you can ask your question with some discretion. Now granted, this is obviously a podcast kind of designed for women, so we get all these different types of questions and we welcome them. So again, help@progressyourhealth.com. Dr. Davidson, do you have anything else to add or can we call this one a wrap?

Dr. Davidson: Like you said, this podcast is for women but to be honest, like you were talking about the “Husband’s Guide to Perimenopause”, I think it could be for everybody. So we need to do something for the fellows or the partners.

Dr. Maki: Well, I don’t know… but maybe they would. Maybe just with the right title, maybe a husband or a boyfriend or something would actually listen to it. So it’s like, “Please help, what’s going on?”

Dr. Davidson: Or “I just want to be supportive and helpful.”

Dr. Maki: Yeah. Well, I don’t necessarily feel sorry for the men necessarily. But at the same time, I hear from the patients that their husbands will kind of blame it on their hormones all the time. And I don’t think that’s necessarily fair either. They get to use that as an excuse. And believe me, I’m just a dumb man so I know that we can drive our better counterparts crazy sometimes. And I’m certainly guilty of that myself. I think men are just a little bit ignorant and they just don’t understand sometimes the complexities of these hormonal issues. They don’t understand why things are happening. So, hey, if men listen, great. And that’s not really who we’re targeting. I don’t think we’re going to shift that much because I think it would be lots of crickets on the other end. But still, nonetheless, it’s good to get the information out there and hopefully, this was helpful for everyone. We’re going to do a few more, you know, kind of perimenopausal-specific ones over the next few episodes. So, if you do have your questions, please send them in. Until next time. I’m Dr. Maki.

Dr. Davidson: I’m Dr. Davidson.

Dr. Maki: Take care. Bye-bye.

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Can Progesterone Cause Dizziness? | PYHP 113

Dr Valorie Davidson and Dr Robert Maki — Tue, 14 Sep 2021 21:07:04 +0000

Kathy’s Question: I tried progesterone 100 mg pill. I felt dizzy and felt like I could not stand upright. Does a cream have the same side effect? I was also prescribed an estrogen patch.

Short Question: It is certainly possible that progesterone can cause someone to feel dizzy. It is often prescribed to help with sleep issues and anxiety, but some women claim to feel dizzy or “weird” after taking it. In our experience, this is more common with Prometrium, which is an instant-release form of progesterone. Bioidentical, sustained-release progesterone can still cause some of the same side effects but is typically much better tolerated. Progesterone cream usually does not cause some of the same side effects but is not effective for insomnia or anxiety. There is some research to suggest that progesterone is a vasodilator. This effect could lower blood pressure, which could make someone feel dizzy after taking.

PYHP 113 Full Transcript:

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Dr. Maki: Hello everyone. Thank you for joining us for another episode of the Progressional Podcast. I’m Dr. Maki.

Dr. Davidson: And I’m Dr. Davidson.

Dr. Maki: So, again, we have another question. This one’s from Kathy. So, again, in the future, for those of you that are new to the podcast, hopefully we’re getting lots of new listeners all the time. If you are an avid listener, you like what we have to say, please give us a review on whatever platform. We are on all the major platforms. I still haven’t added our podcast yet, or I have had it added to an Audible or Amazon Music, but that’s on the list which I think is cool. But we’re on iTunes. We’re on Stitcher. We’re on Spotify. We’re on iHeartRadio. We’re on all those different podcast platforms. So, please give us a review. That’d be really nice. So, this question is from Kathy. Once you dive in and give it a whirl.

Dr. Davidson: Sure. We always change everybody’s name. We always say that on every podcast too. And these questions come from podcast listeners, and also from our website, from our blogs too. Kathy doesn’t say on here whether she got this from the podcaster or from reading one of the articles or one of the blog’s. So, this is from “Kathy”. I tried progesterone 100mg pill. I felt dizzy and felt like I could not stand upright. Does a cream have the same side effect? I was also prescribed in estrogen patch.

Dr. Maki: Yeah, so there’s a lot. This is a really simple question, which is nice. Right? It’s just a couple of questions and it’s fairly similar. We’ve done a bunch on progesterone. But this one adds a little bit of a different element with the progesterone patch or the estrogen patch. She doesn’t specify, but I would assume that if she’s getting the estrogen patch, that means she’s getting prometrium. We could probably make that as… Would that be a fair assumption to make?

Dr. Davidson: Yes, like you said, this is a short question. It seems simple, but it I like it because we can really extrapolate on it to help other people that might be in a similar situation, because this is really common. The estrogen patch is a very conventional type of hormone replacement. So we know she’s on an estrogen patch. She’s either menopausal, and she’s also on the progesterone. She’s probably gone through menopause and she has a uterus.

Dr. Maki: Yeah. So, we can assume at that point that she’s probably in her early to mid-50s, something like that. She’s probably having the classic hot flashes, night sweats, insomnia, all those…

Dr. Davidson: Brain fog memory, waking.

Dr. Maki: If she’s still menstruating, she’s not a candidate for the estrogen patch. That would not be good. It would just probably cause a lot of frequent bleeding. That’s one of the ways that you determine if someone’s a candidate or not, is their menstrual history. If they still have one, then progesterone is fine. You could do progesterone. Sometimes that’s very necessary. That’s kind of the more the perimenopausal window. But if they are menstruating, they are not really candidates for estrogen necessarily. So, the feeling dizzy and could not stand upright, a fairly a recent episode – I think it was the last one we did – was talking about someone not being able to wake up in the morning, right? These are fairly common side effects, would you say?

Dr. Davidson: Yes, because progesterone is very relaxing. You don’t want to take it in the morning. Although I will have to say, I have two patients that love taking their progesterone in the morning and they feel no grogginess or tired or anything. They are just like unicorns. But for most of us, myself included, if you take progesterone, it’s going to make you a little relaxed, a little tired. So it’s perfect to take it at night to help you sleep. And then progesterone is needed for anyone taking estrogen. They’ve got to take some to take some progesterone because you don’t want to give unopposed estrogen, especially if they have that uterus because that progesterone, I’ve said it probably a billion times, that progesterone is going to help protect that uterine lining when someone’s taking estrogen replacement therapy. But 100mg is pretty much an average dose for somebody with the uterus on menopausal taking hormone replacement with estrogen. So I wouldn’t say that we’d want to go lower because then that would just leave her uterus unprotected. And then at the same time, we wouldn’t want to switch to a cream. And maybe every practitioner knows this is a dance, this is an art doing hormones, but I’ve always found the cream is just not strong enough to protect that uterine lining.

Dr. Maki: Yeah. Right. And the progesterone cream doesn’t have that mental-emotional plane level of relief that the oral capsule does. So yeah, we don’t grant it. We contradict ourselves because we do use progesterone cream with rhythmic dosing. That’s quite something common. But in that case, if a woman has her uterus, now granted we’re really complicating things now, but in that case with the rhythmic dosing and progesterone cream, we want the women to have a period, which kind of goes against the gradual.

Dr. Davidson: It’s like one different kind of therapy. Exactly.

Dr. Maki: Yeah. And we’ve talked about the difference and we’ll hash this out again, the difference between static dosing and rhythmic dosing. What she’s doing and what is most common for most women is they’re doing static dosing. Same dose every day. With rhythmic dosing, the whole point of rhythmic dosing is to basically recreate the woman’s female cycle. So, she has a peak of estrogen on day 12. She has a peak of progesterone on day 20. And 8 days later she has a period. Something similar to that. So it’s the rise and fall or the peaks of those two hormones that initiate that process. When a woman is in menopause, all the hormones have kind of flatlined in some respects. All we’re trying to do is just raise the baseline, which does provide some symptom relief. I will now granted that’s not raising them to what a woman was when she’s in her 30s necessarily, but it does help with the hot flashes, it helps with the night sweats, it helps with all those kind of menopausal related symptoms.

Dr. Davidson: And like I’ve always said, not one situation fits all. Not one pill fixes all. So, some women love that rhythmic dosing and I have a lot of women on that. And then some women don’t love the rhythmic dosing. And we have a lot of women on static dosing. So that’s where you have to have that individual treatment plan. So even for our patients, one patient is on one particular type of dosing for her and her goals, and then another one’s on a completely different thing. I even have sisters and they’re on completely different therapies because we have to individualize this. So I feel like for Kathy that this treatment plan that she’s on with that estrogen patch and that 100mg of the progesterone may not be completely individualized to her.

Dr. Maki: Yeah, and we were discussing this before we press the record button. Even the estrogen patch could cause a little bit of dizziness and maybe not being able to stand upright. That’s certainly more on the progesterone side, but the estrogen could make her feel a little woozy at the same time.

Dr. Davidson: And like you were mentioning, she’s probably on a Prometrium, which is progesterone. It’s bioidentical progesterone, but there’s also a lot of fillers and excipients and whatnot in there, but it’s instant release. So, what she might be doing is taking it around dinner time, sitting down to watch some TV or something after dinner, and then, like, whoa, yeah, I’m feeling a little woozy. Like trying to get up and walk to the bathroom or get ready for bed. Or she might be taking it right before she goes to bed, let’s say 10 o’clock at night, then maybe she wakes up at midnight to go to the bathroom and can’t walk to the bathroom because it’s so close to when she’s taking it because an instant release is just like it sounds, it’s going to instantly release into your bloodstream and peak as high as it can as pretty much as soon as you’ve taken it. You know, 45 minutes after you’ve taken it because you’ve digested it.

Dr. Maki: Yeah. Now granted, hopefully she doesn’t mention it. Hopefully, that would help her sleep well.

Dr. Davidson: Hopefully she’s not taking it in the morning. Kathy, don’t take it in the morning.

Dr. Maki: Yeah. Hopefully, you’re not getting behind the wheel of a car. You’re not driving a car. You have to put like a warning label energy, not operate heavy machinery after taking progesterone.

Dr. Davidson: I think maybe no, it doesn’t have that.

Dr. Maki: I don’t think it does. Some of the other anxiety medications and any depressants, they certainly have those warnings on there. But this is a very common thing that we get from patients all the time and questions. This one, I think, has come up probably at least a dozen times, if not more. So we might have answered this in the past. If we have, sorry, but the repetition is good, right, because we’re getting new listeners all the time and these things, in some ways, the same. We’re trying to pick out the questions so we are not repeating ourselves. But there are always little nuances in every little thing that we can tease out a little bit. And hopefully there’s something that you’re learning or you’re pulling from it that is helping your situation in some respects. And that’s why this one is very simple, very straightforward, but at the same time, there’s a lot to tease apart there. Prometrium and the estrogen patch are just something that we would not do. That is just not the route we would take with a patient. We’ve talked about the estrogen patch and the vivelle patch fairly recently on how relatively strong that patch really is. I don’t think even practitioners even realize when you see the milligram amount, there seemed so minuscule as far as the milligram amount, but the effect that has on the woman is pretty significant in some cases.

Dr. Davidson: Yes, the patch is a lot stronger than doing bioidentical creams. So much more. And like you said, I don’t know if I would necessarily use a patch with her. I have a few people on it that they like it, but I probably wouldn’t, especially since it sounds like she might be a little bit sensitive, taking that 100mg of progesterone and not being able to stand upright. I would say for Kathy, you don’t want to go below 100mg of progesterone if you are on an estradiol patch. That just wouldn’t be protective. But what you could do is switch to a compounded sustained release. So, instead of that instant release just popping way up and you can’t even hold yourself steady, is you could take the sustained release and then it just comes up gently and stays up over the night, so that you can still get that dose of progesterone, get that protection, get the positive benefits from progesterone, but at the same time she probably would not feel dizzy and be able to stand up straight.

Dr. Maki: Yeah. She won’t feel punch-drunk from taking the progesterone. She’ll actually have a little bit more of a normal response. Still more of a sedating kind of a sleep-inducing response, but not one that’s going to make her compromise in any way. Certainly, nobody wants to feel like that if they don’t intend to. This one, like I said, was relatively short. Do we want to say anything else about this one? Or did we kind of cover the bases on this one?

Dr. Davidson: No, I liked it.

Dr. Maki: Yeah, so this one’s very short, but still I liked it because it was very short and there are a couple things to tease apart and some assumptions that were making based on her situation. So, until next time. I’m Dr. Maki.

Dr. Davidson: And I’m Dr. Davidson.

Dr. Maki: Take care. Bye-bye.

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Can 200 mg Prometrium Make You Tired? | PYHP 112

Dr Valorie Davidson and Dr Robert Maki — Thu, 09 Sep 2021 20:19:45 +0000

Danielle’s Question: So, Thank you for this article. I’m having side effects from taking 200 milligrams of oral progesterone. I take forever to wake up and feel really, really groggy. I read where you said that take it early and when I take it early and out in an hour, I can barely keep my eyes open and feel drunk or drugged. So, I usually take it in half an hour before bed. I sleep like a rock but have a hard time coming to the next day. I’m a lightweight when it comes to any medication and always thought that might be due to being clean and sober for 32 years, but I might be wrong. I’m probably just sensitive. So, should I try a hundred milligrams of oral progesterone or change it to a compound? Because currently, I am taking Prometrium. I really love the solid sleep, but it takes hours to wear off in the morning and it seems like I’m just so tired. But I do take thyroid medication and I do have low morning cortisol and take some adrenal glandular as well. So, thank you so much in advance.

Short Answer: The commercially available form of progesterone is called Prometrium. It is an instant-release medication and comes in two doses of 100 mg and 200 mg. In our experience with patients, they tend to be strong for women and not well tolerated. It is not surprising that 200 mg is causing next-day fatigue. We typically prescribe 100 mg of bioidentical, sustained-release progesterone. Some women are still sensitive but is usually very well tolerated.

PYHP 112 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 this morning we’re going to just kind of dive right in. Of course, as we always do we have a lot of listener questions. So, for the future or for those that are listening, if you’re new to the podcast you can always send us an e-mail at help@progressyourhealth.com, help@progressyourhealth.com. That is if you want to keep it somewhat private and discreet. We always change everybody’s name. So, there’s no question about who is sending in the question. You know, we do get sometimes some sensitive female issues. And I’m sure people wouldn’t want that to be kind of public knowledge. So, like I said, we do try to protect everybody’s privacy as much as possible and we love the questions because that means we know people are listening. And you know, it gives us kind of an unlimited amount of topics that we can discuss in the podcast. So, Dr. Davidson won’t you just kind of dive in and let’s go through Danielle’s question.

Dr. Davidson: Sure. Sure. So this question is from Danielle, but just on a quick little side note is we love all the questions. So, if you have any concerns, please write into us. But at the same time if it’s maybe not exactly like a lot of the questions were doing or pertaining to. You can probably hear our little pup in the background. He always gets a little more, I don’t know. When we do the podcast he gets a little more rambunctious or something.

Dr. Maki: Every time. He’ll be sleeping and then we sit down to do these and he turns into a maniac.

Dr. Davidson: He’s the best, he’s the best. But if you have any topics that you’re just interested in like, “Hey, it’s not a question necessarily pertaining to me, but I’m interested in this particular topic.” So, feel free to if you want us to talk about topics or questions about yourselves or whatnot because we do really feel like this information can help others. Like, in particular, Danielle’s question. So, I’m going to jump right into Danielle or “Danielle”. So, “Thank you for this article. I’m having side effects from taking 200 milligrams of oral progesterone. I take forever to wake up and feel really, really groggy. I read where you said that take it early and when I take it early and out in an hour, I can barely keep my eyes open and feel drunk or drugged. So, I usually take it in half an hour before bed. I sleep like a rock but have a hard time coming to the next day. I’m a lightweight when it comes to any medication and always thought that might be due to being clean and sober for 32 years, but I might be wrong. I’m probably just sensitive. So, should I try a hundred milligrams of oral progesterone or change it to a compound? Because currently, I am taking Prometrium. I really love the solid sleep, but it takes hours to wear off in the morning and it seems like I’m just so tired. But I do take thyroid medication and I do have low morning cortisol and take some adrenal glandular as well. So, thank you so much in advance.”

Dr. Maki: Yeah, this certainly comes up quite often, to be honest. We run into these either questions or patient issues. Now, she makes the, you know, as you’re reading it, she makes the distinction at the end of the question compounded versus Prometrium. We don’t use a lot of Prometrium. We have some patients that either requested or do okay with it or want it. We don’t usually read out of the gate, prescribe it on at least from our standpoint. But we do have some that seem to do just fine on it. And I know you said before, there’s like two doses of either 100 milligrams or 200 milligrams. What’s the difference between Prometrium and compounded progesterone?

Dr. Davidson: You know, they both are progesterone and in compounded has a lot of different fillers. Prometrium actually has a lot of kind of weird fillers and excipients that people can be sensitive to. Some Prometrium’s have peanut oil in there. So, somebody’s allergic to peanuts. They could have an issue with that. So, I would say, you know, I do actually have a few patients on Prometrium, they do really well. And then I have a few that I put on Prometrium and they don’t do really well. And I think partly is because with Prometrium there’s very little room for changing doses. There’s only a couple of doses available. So, you know, 200 milligrams of oral progesterone is a lot of progesterone. So like, she’s saying, should I drop to a hundred, because Prometrium also comes as a 100. When you do compound, little cleaner. So, it’s more hypoallergenic. And at the same time, you can do any dose you want to. You can do 10 milligrams. You can do 50 milligrams. You can do 75 milligrams. You can do 85 milligrams. You can do 125 milligrams. You can do 150. You can do 400. There’s so many different doses you can do when you’re doing it with compound and like Danielle said is that she’s sensitive and I do think a lot of us are sensitive because in some regards when you’re doing hormone therapy, it’s not one size fits all.

Dr. Maki: Yeah, right. Yeah, and you know, the other distinction too is that Prometrium is instant release where what we typically use, the compounded is sustained release. And that tends to kind of dial it back a little bit. It’s not quite as strong. Now, the good news is like I said, she’s sleeping like a rock that’s in some ways the reason for taking oral progesterone right, because it certainly does help with the sleep. But you know, clearly, if she’s having that much hard of a time waking up, she could easily try the 100 milligrams per [inaudible]. She might do just fine on that, but you know, our preference are biased in some respects would be to, just go to a 100 milligrams of bioidentical progesterone and start from there and see. Because you still get the same sleep benefit, sleeping like a rock but not so much grogginess the next morning that would be at least from our standpoint or at least from my standpoint the obvious thing to try.

Dr. Davidson: And Danielle’s right, taking progesterone does make you tired. It does make you sleepy. So, that’s why it’s great to take at night. It helps with sleep, you know, progesterone itself helps balance out if she’s taking any kind of estrogen. So, you know, there are a few markers here that we don’t know. We don’t know, is Danielle doing bioidentical hormone replacement? Because she’s menopausal in her 50s and taking some type of estrogen. Then, of course, yes, she needs some level of dosing on progesterone to balance out that estrogen. But maybe she’s more perimenopausal and she doesn’t need any estrogen, but she needs that progesterone because in perimenopause that progesterone just basically floors itself. So it could be that, you know, I always feel like less is best. Start off at 50 milligrams. How is she doing? How is she sleeping? Go up to 75 or double it up to 100. She might be, I have some people that are perfect at 125, not good at 100 and not good at 150. So, it really is a little bit individualized, but to further maybe complicate this is I love to do blood work on progesterone. When you’re taking an oral progesterone at night, there shouldn’t be too much progesterone when you do your blood draw the next morning. So, if she’s doing, taking 200 milligrams of this Prometrium at night and then she does a blood draw, say at 8:00 in the morning and her levels are pretty high like up. Like I’ve even seen people in their 20s, that might be that that progesterone is too high that it’s really staying too high in the morning which would make her tired. So usually, when I’m doing progesterone and doing blood work with progesterone, they take it the night before, maybe they go in sometime in the morning between 7:00 and 10:00 o’clock in the morning. It really should be around, you know, maybe 10:00 or maybe somewhere around there may be a little less than 10:00 because over that I do find the people have a little bit tough time waking up in the morning.

Dr. Maki: Yeah. Sure. Usually at least with bioidentical progesterone sustained release, I typically see it, you know, maybe between 2:00 to 12:00, you know, 2:00 to 8:00 something like that. Now, a menopausal woman taking progesterone, oh, a menopausal woman not taking progesterone. On lab work her progesterone is always going to be less than one. It’s going to be .5, .6, .7. In some ways this is, and I know we’ve talked about this on some of the other Biest or estrogen episodes, when she’s taking progesterone, that’s in some ways, kind of how we know she’s taking it. Because one of our rules, again, if you’re new to the podcast is you never give a woman unopposed estrogen. Now, granted if she has a uterus that’s an absolute rule. If you know, even some kind sometimes a gynecologist, a woman doesn’t have her uterus. They’re not so concerned about the progesterone, but that’s still a rule that we don’t typically break. We’ve always give women both of them. Just because of this, the progesterone does help on the sleep side, helps reduce anxiety, it helps level out the mood. So, oral progesterone still does provide some of those benefits than just taking estrogen by itself. So, the combination of those two certainly has to be taken into consideration. But you know, I’ll throw it back to you. I kind of lost my train of thought there. So, I’m trying not to stumble [crosstalk].

Dr. Davidson: We’re all human, right? We’re all human.

Dr. Maki: I’m trying not, you know, we usually do these without really editing or doing much of them.

Dr. Davidson: Never edit.

Dr. Maki: And I just ran into a wall there. So, I’m going to stop and I want to let you kind of take over.

Dr. Davidson: Well, there is something to be said because I don’t want to confuse everybody but Dr. Maki had mentioned sustained release versus instant release and Prometrium is instant release. So, what I usually find with Prometrium is people take it and it wears off too fast and they’re waking up at 2:30 in the morning and they can’t go back to sleep, which is why I do really love the sustained release. And just for full transparency, I take a sustained release progesterone at night and Dr. Maki is very very grateful for that.

Dr. Maki: I think you need to increase your dose. I say that all the time. I’m just teasing. You don’t need to change it. You’re fun. You’re perfect.

Dr. Davison: Well, thank you. Thank you very much. But I would say with Danielle, she’s taking this instant release and it’s still lingering in her system the next morning, then she’s right. It’s probably just a little bit too high. I would imagine she’s probably not on a Biest because she doesn’t mention that. She mentions the low cortisol and that she’s taking thyroid and adrenal glandulars. So, if she were on Biest or some kind of estrogen therapy, she would have told us on this question. So, I would say reducing that down maybe even keeping it to an instant release because I haven’t back just yesterday, a patient that I have on sustained release progesterone. It is lingering too long when she wants to wake up early at 5:00 in the morning that we’re going to switch it to a compounded instant release. You know, not Prometrium, but I have a different dose that I want to do because like I mentioned with compounds, you can do any milligram you could possibly even imagine. You know, tailored to fit that particular individual, but I would say for Danielle is just backing it down a little bit. And one thing that I actually want to turn back to Dr. Maki, is Danielle mentions that she has low morning cortisol.

Dr. Maki: Yeah, right. Yeah. So, I was a little awkward there a second ago and I had a little lapse there. [crosstalk]

Dr. Davidson: Stop. We’re human. Okay. [crosstalk]

Dr. Maki: But you know, it’s interesting. We used to start doing these, I would get, you know, that would be kind of like a moment to stop and then do it all over. But you know what, you know, who cares? It’s easier. It’s kind of, it’s more conversational. So again, I apologize for losing my train of thought. But lowering cortisol, you know, so I would assume maybe before the progesterone, now we’re just speculating completely here about Danielle’s case, was the morning tiredness, was that present before the progesterone? Or is it just present after starting the progesterone? Now, low morning cortisol that’s what gets us out of bed bright-eyed and bushy-tailed. It needs to be high in the morning, that’s what helps control our circadian rhythm. That’s really important and very common in this day and age to have low morning cortisol. And then in some ways now you’re not sleeping well at night. No, she says she’s sleeping like a rock. So, maybe up till the progesterone, she wasn’t sleeping very well. So, now her body is just a little bit of a transition process because we work with a lot of perimenopausal, menopausal women that the sleep that they have accrued over months and potentially years. It takes a while to work through some of that. Okay. Now, she does say she’s sensitive and so starting at 200 milligrams, obviously. And, oh, that was my point of the thing I was going to say earlier is usually what we would do in a case like this is start them at a lower dose. Let’s say, a 100 milligrams. That’s inappropriate dose for a woman in perimenopause or menopause and we just give them the autonomy to say, you know what after a couple of weeks if your sleep is unimproved, if you’re not noticing any benefit then just take 2 capsules, right? So, now you get a chance to see, they get some autonomy, they get some control over what they’re doing and they get a chance to see how they feel. And believe me, obviously, I’m not a woman. So, there are some things that I don’t understand about how women experience certain things, but a woman, and you could probably explain this a little bit better. A woman knows when there’s taking too much progesterone. They just know, right? You know, they’ll ask what are the side effects like, “Well, you know, you could have this, this or this”, but usually, you’ll just know if it’s too much and then that’s your body’s cue to say, okay, it’s time to reduce the dose. So may 200 in this case, clearly 200 is too much so they can go back a 100 or try something different.

Dr. Davidson: Exactly. And I’m thinking that because she sounds very savvy because she knows about low morning cortisol, you know, not everybody knows about that cortisol. Coming from the adrenal glands, being a diurnal curve. Not a lot of people know that and it sounds like she’s taking some adrenal glandular which is great. So, I would say really that progesterone or that Prometrium at 200 milligrams probably is just too high.

Dr. Maki: Yeah. Yeah. I mean, we’re trying to extrapolate and kind of stretch this question out so we can kind of touch a few different basis. But it’s pretty obvious, 200 milligrams, she can’t wake up. Lower the dose. Just start go to a 100 milligrams Prometrium and see what happens. If that’s still too high, now you still have another option and with the compounded progesterone you have like you said from a dosing perspective you have unlimited options. Now, the point that you made earlier, if she’s on estrogen, you want it to be at roughly, a 100 milligrams minimum of the compounded progesterone. Again, to inhibit the growth of the uterine lining. That’s kind of where we stand. We might go down to 75 for someone who’s sensitive, but we won’t go any lower than that for the most part. And wouldn’t you say 75 is kind of like the cutoff?

Dr. Davidson: Yeah. I have a few people but really, if they have a uterus and they’re on some kind of estrogen therapy, you don’t really go under a 100. And really a 100 is kind of like the usual dose. Very honestly, I have very few people on 200 milligrams of progesterone. I have quite a few on a 150. They do really good on a 150. A 125 seems to be kind of also that perfect number where that progesterone is not too low, but it’s not too high. And then, of course, you got to think about, you know, like Danielle’s saying, she’s sensitive and also she is 105 pounds or a 155 pounds. There’s also a little bit of mass versus dosage.

Dr. Maki: Yeah. Sure. And certainly, liver function, you have to take that into consideration. Some people just don’t detoxify things as quickly and especially if there’s wine and alcohol. Excuse me, alcohol and coffee on a regular basis that can put a little more burden on the liver and kind of slow down some of that detoxification as well too. So, yeah. In this one, it relatively is pretty straightforward. Just try a lower dose, see what happens. But you know, certainly, there’s, in some ways, a lot of different possibilities to maintain that sleep which then will help those adrenals kind of rebound in the morning. Now granted, with usually people have that hard time waking up. Sometimes they’re never great at waking up. But at least they can wipe the cobwebs out a little bit quicker and it doesn’t take them so long to feel somewhat normal, right? You might wake up a little groggy, but once you’re up, you’re up and then you’re fine. You know, so hopefully, that’s what she’ll experience once she tries a new dose.

Dr. Davidson: And then like I had mentioned maybe doing a little bit of blood work would be a great idea just to check the estrogen and progesterone levels in the morning.

Dr. Maki: Yeah. Yeah. Yeah. Like I said, that was what I was getting at earlier when you give a woman estrogen, progesterone and you can kind of tell because that menopausal woman, she’s not going to make any progesterone, right? So, her number is going to be really low. The perimenopausal women would make progesterone based on the time of the month, that it is, right? If it’s, you know, after ovulation, she might make some. If it’s before ovulation, she’s not going to make any so that number is going to be less than one as well. So, the timing of when they go in certainly does make a difference based on the period of life that they’re in. So, Dr. Davidson, do you have anything else to add about Danielle’s question, or are we good for now?

Dr. Davidson: No, this is great

Dr. Maki: Okay. Until next time. I’m Dr. Maki.

Dr. Davidson: And I’m Dr. Davidson.

Dr. Maki: Take care. Bye-bye.

The post Can 200 mg Prometrium Make You Tired? | PYHP 112 appeared first on .

Does Progesterone Help With Perimenopause? | PYHP 111

Dr Valorie Davidson and Dr Robert Maki — Sun, 05 Sep 2021 19:01:55 +0000

Amanda’s Question: I’m 41. I have regular periods every 35 days. I have some anxiety, tiredness, stress, but I do work a lot. I don’t have trouble sleeping, but my doctor checked my serum progesterone level, and at day 21, it was .5. She said it was low. She had prescribed me oral 200 milligrams a day of compounded progesterone. I work at a job that requires 24-hour shifts twice a week. I’m trying to verse myself in information about this replacement therapy and if this is the right way for me to take progesterone therapy. She told me to just not take it on the days that I work, but I’m concerned with things that I read about replacement therapy and increased mood issues and anxiety. I don’t think I could deal with those any worse than I have than what I have. Can you please tell me if I’m on the right path as I’m scared to begin this therapy? Thanks, Amanda.

Short Answer: When women enter their early to mid 40’s, they typically stop ovulating, but continue to have periods. This lack of ovulation usually causes a significant drop in progesterone levels and can lead to many unwanted symptoms of perimenopause. Taking oral, bioidentical, sustained-release progesterone is a simple, but effective way to help deal with many of the unwanted symptoms. We typically start a patient on 100 mg of sustained-release Progesterone and they can increase to 200 mg later if needed. Some women may even need to cycle the progesterone dose. For example, taking 100 mg (1 capsule) from Day 1 to Day 13 of the cycle and then increase to 200 mg (2 capsules), from Day 14 back to the period.

PYHP 111 Full Transcript:

Download PYHP 111 Transcript

Dr. Maki: Hello everyone. Thank you for joining us for another episode of the Progress You Health podcast. I’m Dr. Maki.

Dr. Davidson: And I’m Dr. Davidson.

Dr. Maki: We mentioned in the last couple of times on the podcast, you actually have a book coming out, The Perimenopause Plan. It should be out probably within the next, I would say, probably the next couple of weeks to the next month or so.

Dr. Davidson: Depending on when we post this podcast. It’s all written. It’s just having a little bit of issue trying to make it look pretty- the design process.

Dr. Maki: Yeah. It should be fun. We’re excited about. It’s going to be published in Amazon as an e-book. Perimenopause is something that we deal with all the time and it was definitely a- I know you like to write. You’ve always been the writer. That’s always been your forte for the most part so we’re definitely excited about that. We’ll keep you up to date on that. Now, diving in, we have again more questions. We just have lots and lots of them. So, hopefully, if everyone keeps sending us emails with their questions that I’m assuming that the questions that we’re answering, people are finding some value or enjoying the questions because we just keep getting more of those. So, hopefully, it’s not getting stale or we don’t want to be boring anybody with what we’re talking about. It is very specific. You definitely have to be having some hormonal challenges. This is certainly not a podcast for men by any means. But we know that this kind of information is really hard to find on the internet which is the whole genesis behind the podcast in the first place. So, this is Amanda. I want you to go ahead and read the question.

Dr. Davidson: Okay. So, this question is from “Amanda” because like we always say we change everybody’s names just to try to keep the personal stuff and all that jazz to a minimum. So, this is from “Amanda”. So, Amanda says, “I’m 41. I have regular periods every 35 days. I have some anxiety, tiredness, stress, but I do work a lot. I don’t have trouble sleeping, but my doctor checked my serum progesterone level, and at day 21, it was .5. She said it was low. She had prescribed me oral 200 milligrams a day of compounded progesterone. I work at a job that requires 24-hour shifts twice a week. I’m trying to verse myself in information about this replacement therapy and if this is the right way for me to take progesterone therapy. She told me to just not take it on the days that I work, but I’m concerned with things that I read about replacement therapy and increased mood issues and anxiety. I don’t think I could deal with those any worse than I have than what I have. Can you please tell me if I’m on the right path as I’m scared to begin this therapy? Thanks, Amanda.”

Dr. Maki: A couple of things. So, she works two 24-hour shifts a week. I’m not sure what that is, but that sounds awful.

Dr. Davidson: Well, depends on what it is.

Dr. Maki: Yeah well, it certainly depends on what it is but two 24-hour shifts a week? I mean maybe two 24-hour shifts a month, but the week? That seems very taxing on her body in some respects, right? Maybe she’s a firefighter. Maybe I’m assuming in a 24-hour shift she can probably sleep, but I’ve known people- when I was in college, I used to work at a hospital and people were on call and stuff, and you’re sleeping, but you have one eye open waiting for the phone to ring. I think it was pagers back then because no one had cell phones yet because it was in the early to mid-90s. So, you’re sleeping, but you’re not really sleeping because you’re waiting to be called to something because- so I don’t know. So, you’re not sleeping all that well, plus you have the stress of a middle-of-the-night response that you have to go to just adds to the stress. I’m not sure what she’s doing for a 24-hour shift, but from my experience, I did a lot of overnight shifts. I was a little bit of a night owl back. I couldn’t sleep ever. Working the graveyard shifts in a hospital is brutal after a while.

Dr. Davidson: I couldn’t imagine a 24-hour shift, but you know me. I like my sleep. But if Amanda is, obviously, she’s on call if she’s doing a 24-hour shift, and my goodness. If she’s a firefighter, thank you for your service. We we need you, we need you. And we also need you to be healthy and happy and have energy.

Dr. Maki: And awake.

Dr. Davidson: And yes, and be awake and not have anxiety. So, we really wanted to answer this question. I’m sure a lot of you listening, may not have a 24-hour shift twice a week and being on call like Amanda, but at the same time, I really think that this question can relate to a lot of women because she’s in her early 40s and I would say I’m in my late 40s, hence the Perimenopausal Plan book is very close to my heart near and dear because I’m right in it. But Amanda very well could be in that perimenopausal phase at 41 because it can happen anywhere between the late 30s to the early 50s is that time before menopause, which is almost like a completely different aspect for menopause. Because like Amanda said, and her doctor is spot, on day 21 of her cycle is- Did you hear that little sneeze? That was Bob, our little copilot dog, that goes with us everywhere.

Dr. Maki: He’ll sleep all day, but the minute we sit down and do a podcast, of course, he has to start moving around and making a bunch of noise.

Dr. Davidson: Yeah, he wants some attention, but sorry. Just to get back to Amanda. She’s 41. Her doctor is spot on doing her blood work on day 21, which is that luteal phase of the cycle when that progesterone really should be starting to surge and it is only at .5. So, it definitely is low which is one of the first signs you see in perimenopause is that progesterone drops. The estrogen doesn’t necessarily drop which is why she’s having regular periods, but the progesterone does. And low progesterone symptoms do cause anxiety, do cause trouble- She doesn’t have any trouble sleeping but a lot of perimenopausal women have trouble staying asleep. They either wake up for hours or they wake up multiple times. So, there are other symptoms. I do think taking some progesterone might be a great deal. It might help her a lot, help Amanda a lot especially with that anxiety or if she’s feeling that negative, irritable mood or snarky and grumpy. I think it would truly help. But 200 milligrams might be a little bit much.

Dr. Maki: Especially right out of the gate. Like her first prescription, we usually start for a situation like this, based on her age, based on her lab work, based on her symptoms, we would probably start out at a hundred milligrams, maybe even depending on the woman. Maybe even 50 milligrams, and then work our way up from there. We usually don’t go any higher than 200 just like this case, 200 is about as high as you need to go, but to start a woman on 200 milligrams, this is the kind of response you would expect. You expect them to be a little bit tired.

Dr. Davidson: Wow, that’s a lot, or it’s going to make you tired which is why the doc doesn’t want her to take it on her days off.

Dr. Maki: Which I think is- When you and I are talking about this prepping, I said well, just don’t take it the days you work. I mean, that’s a reasonable explanation, but the 200-milligram component I think is a little bit- That could be easily reduced. Also to whether it’s instant release or sustained release, we always prefer to use sustained release. It doesn’t specify whether it is or isn’t. I’d like to think that it’s sustained release but we’re not really sure about that part.

Dr. Davidson: But you think about in a female cycle, the estrogen is, when you’re having your period, your estrogen and progesterone or low. The estrogen comes up the first part of your cycle. Usually, it spikes around day 12 to day 14, so you have ovulation, and we really don’t make much progesterone until post ovulation. Once you hit that day 14 and you have that ovulation, you’re going to make progesterone thereafter. So, we really only make progesterone for a half of our “monthly cycle”. Now, Amanda has a little bit longer cycles. She’s not the perfect 28-day cycle, but who is. She’s a little bit longer, day 35. So, she might be ovulating a little bit later like around day 18. But on day 21, she should have had some progesterone present. So, I would probably- Usually, what I start with menstruating females, in the beginning, is I’ll start with just having them take that progesterone. I do like the oral. I love the oral in perimenopause. Capsule is for just half of the cycle, just mimicking what would naturally when that progesterone should come up because I find that sometimes when you give a menstruating female progesterone right off the bat all month long, it tends to shorten their cycles because sometimes progesterone can cause a period. So, if you try to give Amanda progesterone all month long, she might find that her cycles get shortened to 21 to 25 days, and then, not everybody wants to have a period every 3 weeks. So, I usually start that last tap. And since she’s only 41, it’s so much easier to start low and work your way up. There is no problem with that. But when you start a little bit too high and then you start to have issues with being tired or puffy or bloated or hungry, it’s really hard to back out of that. So, I would even start her at 50 and then work up to 75, work up to a hundred, see how she’s doing.

Dr. Maki: Now, you mentioned with a menstruating female, for a menopausal female, obviously, they’re in menopause so they’re their bodies are not producing any estrogen or progesterone. The definition of perimenopause is that like you said, that lack of progesterone production usually happens after they stop ovulating which is ovulation is what instigates the release of progesterone. If the progesterone goes down, that usually means that there’s no more ovulation which is going to happen somewhere between the early-to-mid 40s in most cases. Some women maybe a little bit longer than that, but usually, that’s the time frame. The other option for a situation like this to like I said, starting it initially getting them used to the progesterone, or if you started them early and then you cycle it. So, you start them on, not early but on a lower dose, and then they can-What we’ll typically do is we’ll use a lower dose in the first half of the month, and then a higher dose the second half of the month because technically, a woman does not make any progesterone for the first 2 weeks of their cycle. That’s actually true physiology. So, giving a woman progesterone all month long in some ways is going against the grain, but women just typically seem to respond pretty well when they have progesterone the entire cycle.

Dr. Davidson: That is absolutely true. Like I said, start off with half of the cycle and then maybe work up. Like I was saying, I’m 47. Yeah, I’m perimenopause. I sure am.

Dr. Maki: Oh God.

Dr. Davidson: Stop. And just for transparency, I take progesterone all month long. I stop on my period because you don’t want to necessarily take progesterone or any hormones on your period because you want that entire uterine lining to slough off and sometimes progesterone can inhibit that if you’re taking that during your period. But I take it from day 5 to my next period.

Dr. Maki: Are you taking it today?

Dr. Davidson: I took it last night because you want to take progesterone at night. So, that’s where you work into that. Like I was saying, less is best and then you just work your way to that particular individual. I know you think I probably need more progesterone, but I find I’m a little more sensitive to it that I probably take a little bit less on average when you’re comparing other women.

Dr. Maki: I’m just teasing. I’m just teasing. Yeah, so definitely taking progesterone at night. Now, she’s working the 24-hour shifts so I’m assuming on those shifts- I’m not sure what that what her job duties entail. Hopefully, she gets to sleep because that puts a lot of strain on the adrenals and your cortisol and your insulin. Shift work like that is really, really challenging, and especially the older you get. You can do it in your teens and 20s, but you’re in your 40s trying to do shift work like that. That’s really, really, really tough, putting an extra burden on you. Now, she mentions a couple of the negative mood impacts. Now, the things that we typically use progesterone for is exactly those mood issues: anxiety, anxiousness, irritability. I know you’re irritable with me all the time.

Dr. Davidson: That’s not because of my progesterone. [laughs]

Dr. Maki: Well, no, not because of the progesterone, but we know, and we talk to patients all the time and they even say it. I’m just so irritable all the time. And it’s simple things. It’s the way their husbands breathe, and the way they chew, and just those really subtle little things.

Dr. Davidson: Now you’re really embarrassing me. [laughs]

Dr. Maki: Well, I’m not saying you. I have first-hand experience. I talk to just as many people as you do. And they all, I wouldn’t say complain. Complain is not the right word. I’m complaining about them complaining. I’m just relaying the verbiage they use and it’s all very similar from one woman to the next as far as how they feel like they have this internal, one minute, they’re fine. And then their husband or their children will do something, and they’re in a fit of rage in a second, and they feel bad about it because they can’t help this little emotional explosion they have. Progesterone helps to calm all that down. It mellows everything out. It reduces the volatility in their emotions because really when you look at the physiology- This is the interesting part. When you look at the physiology of progesterone, really, when you’re giving a woman progesterone in a case like this- Usually, let’s be honest. Women, when they’re in their 40s and 50s, they got kids, they are working. They got their big kid, the husband. They got lots of stress to deal with. So, when you give a woman progesterone, you’re really helping her adrenals catch up a little bit because there’s a pathway- We’ve talked about this on another podcast, but there’s a pathway called the pregnenolone steal where your body will divert depending on your stress level. Not sleeping at night two 24 hour shifts a week is just like increasing your stress. Your body will divert hormonal attention away from progesterone and divert it directly to cortisol because your body can’t live without cortisol, but your body can certainly function without progesterone at least, maybe not optimally, but at least can function. So automatically, your body’s not making any of it anyways, and then your body’s going to divert what little hormonal energy there is leftover to direct to cortisol, and that’s where some of the insomnia comes from. That’s where some of the midsection weight gain comes from, all because of- I wouldn’t say all because of a lack of progesterone, but that’s really where it starts.

Dr. Davidson: Exactly. So, just to back up a little bit with Amanda taking that progesterone- because progesterone will make you tired. That’s why when Dr. Maki asked me, “Did you take your progesterone?” Yes, today.

Dr. Maki: I was teasing.

Dr. Davidson: No, I didn’t take it today because we take it at night and you know that. You’re just teasing me. [laughs] But now we take the progesterone at night because it does make you a little tired. It does raise up GABA, it helps balance out cortisol, and raise up GABA for the next day, but you take it at night. So, I can understand Amanda. Taking 200 milligrams of oral progesterone, that would make you very tired.

Dr. Maki: For you, you would sleep for 2 days if you took 200 milligrams.

Dr. Davidson: I think for 2 weeks.

Dr. Maki: You are, I will say, you are fairly sensitive to progesterone because that’s where it is. It’s a very individualized thing. And the fact that she’s so tired from taking 200 milligrams, that’s a clear example that the dose needs to go down. You know, honestly, if she’s that tired from 200 milligrams, she might be fine with 50 or even 75 because she’s having such a significant response to a higher dose. Now granted, let’s be honest. 200 milligrams is pretty high, but that tends to be more of a menopausal dose as opposed to an early stage perimenopausal dose, and for a woman that has her period, typically, 200 milligrams is way too much for women that still have their period.

Dr. Davidson: So like what Amanda had written here that she did some research and found that this replacement therapy could cause more increased negative moods and more anxiety, and that’s not necessarily true, I would say, with progesterone. Hey, Google is a rabbit’s hole. We all go down it. But if anything, doing this therapy would help with the mood, would help with the anxiety, but there is a small caveat like I said, progesterone makes you tired. If you take too much of it, it can make you feel almost, like in some ways, not motivated, kind of lethargic. Sounds good, but don’t want to do it. I’m comfy right here. So that’s where you don’t want to do too much. And like Dr. Maki had mentioned, that would be maybe more, even with menopausal women, I don’t necessarily have many on that high of a dose, but maybe that’s just my patient population. Every practitioner has a different patient population. But I would say for Amanda that if she took 200 milligrams every day and then skipped it twice a week, she probably would have out of order bleeding because when you take that much progesterone and you’re not being consistent with it, it can create just like some spotting, some irregular bleeding.

Dr. Maki: Yeah. She gets a little bit of withdrawal bleeding from stopping it and now she’s setting up a whole nother issue for herself. So, yeah. I think progesterone is good. I wouldn’t be too nervous about the mood impact because we use it for positive beneficial mood impact. That’s one of the main reasons. Why we use capsules versus the cream. The creams do not have that brain effect that women seem to respond well to. So, I wouldn’t be worried about her. And if you have any anxiety, it’s going to also help to tone that down certainly. So, I wouldn’t be too afraid about that. I would just, maybe go back to your practitioner and have them adjust the dose just to get acclimated like you said. Maybe just start with 50 milligrams.

Dr. Davidson: Start with 50 milligrams. It’s a great way and work your way up. And for Amanda, because I can understand if she’s on call and she has to drive a truck or a car, or have to be like in all her brain cells or working on par, on point if she was on a 50 milligram progesterone, she could skip that a couple of days of the week and not get any withdrawal bleeding.

Dr. Maki: Yeah, because it’s definitely more of an appropriate range. So, yeah. This was a good one. I’m a little bit empathetic for Amanda’s 24-hour shifts. Hopefully, she does get to sleep. Hopefully, it’s not too crazy. I can’t imagine what that is. But I can only think of either working in a hospital or being a firefighter. I’m sure there’s lots of other shift work that are out there. I actually had one patient a long time ago that used to work at an oil refinery. And the people that make- This is just a segue, a little tangent. But the people that determine the schedules for these jobs- This guy worked at an oil refinery in Southern California. I think Carson or something like that. He worked from 3 o’clock in the morning till 3 o’clock in the afternoon. That was the morning shift. And then they had a 3 o’clock in the afternoon till 3 o’clock in the morning. Those are- You couldn’t have designed a worse schedule for somebody because no matter what, whatever shift he’s on he’s up during the middle of the night, no matter what shift he’s on. Of course, his main complaint when he came to see me was fatigue. He was tired. He was like, you’ve been doing it for like 25 years, and he was just literally exhausted all the time. But literally, you could not pick any worse of a schedule. Maybe you could tweak that a little bit, but 3 o’clock in the morning till 3 o’clock in the afternoon, 3 o’clock in the afternoon till 3 o’clock in the morning, he’s never getting a night’s sleep from dark till dawn ever for 25 years. All right. Honestly, some of these companies, they should be consulting with people that understand circadian rhythm, and a way to understand that you’re not going against the hormonal grain, because honestly, there is research to show people that do shift work, their life expectancy goes down. It’s not necessarily great from a cortisol perspective to be going against that hormonal grain all the time. A little bit, once in a while, no problem, but on a schedule like what he had, oh God, I just felt bad for that guy. And I think that we moved and drifted apart, and I think eventually he retired shortly thereafter. Thank God.

I had another, gentleman patient that worked at a children’s detention center, and his was night shift. And he did that for probably 20 years. I’m not sure if he’s a counselor, a security guard or exactly what he was but his shift for literally, for 2 decades, was to work at night. He finally retired this last March right before the pandemic started. And without doing anything different except sleeping, he lost like 14 pounds from just starting to sleep. That’s why when we’re working with someone, the first month that we were working with a new patient, the first thing we focus on is getting them to sleep better, not partially for that reason, but just for making sure those hormones are heading in the right direction. Just a little tangent there…

Dr. Davidson: We love your tangents.

Dr. Maki: Well, maybe not, but hopefully…

Dr. Davidson: Your tangents are fun.

Dr. Maki: …hopefully you’re not too irritated with me right now.

Dr. Davison: Never. You’re the biggest sweetie pie there ever was.

Dr. Maki: Oh, you don’t say that when we’re not being recorded, that’s for sure. So again, if you have any more questions, please reach, help@progressionhealth.com. Dr. Davidson, do you have any more comments or anything to say about Amanda?

Dr. Davidson: No. Thank you for writing, Amanda, and we appreciate whatever shifts you’re doing because we know it’s probably important.

Dr. Maki: I’m sure it’s very important. So, until next time. I’m Dr. Maki.

Dr. Davidson: And I’m Dr. Davidson.

Dr. Maki: Take care. Bye bye.

The post Does Progesterone Help With Perimenopause? | PYHP 111 appeared first on .

Biest vs Estradiol Patch for Vaginal Dryness | PYHP 110

Dr Valorie Davidson and Dr Robert Maki — Thu, 02 Sep 2021 19:16:51 +0000

Tammy’s Question: Hi. Recently, I read your article about estriol. I’m currently using a Biest Progesterone Vaginal Cream, but it’s compounded, and it’s expensive. I could use an estradiol patch and Prometrium and this therapy could be much more affordable. Would I expect a big change in that?

Short Answer: First off, we don’t recommend using Biest for vaginal use. We use Estriol only for vaginal use, especially if a woman still has a uterus to minimize any spotting or bleeding issues. Switching to an Estradiol Patch and Prometrium will not produce the same results, and could cause some unwanted side effects. Using Estriol is best for vaginal dryness and pain with intercourse.

For more information: read the article about the difference between Biest vs Estradiol.

PYHP 110 Full Transcript:

Download PYHP 110 Transcript

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

Dr. Davidson: And I’m Dr. Davidson.

Dr. Maki: So we’re back in the swing of things. We’re just going to dive right back in. Now, this time, we have a question from Tammy. This is relatively pretty short, but you and I have actually had a couple of recent experiences with the estradiol patch. Let’s just dive right in, and why don’t you go ahead and read the question.

Dr. Davidson: Like we’ve said in our other podcast, we want to say that we always change everybody’s names. We get lots of email questions from people, so we’re really trying to get to as many of them as we can. So we really love that you are sending in those questions, but know that we do change any personal information and all that jazz. Okay. So this one is from “Tammy”. Hi. Recently, I read your article about estriol. I’m currently using a Biest Progesterone Vaginal Cream, but it’s compounded, and it’s expensive. I could use an estradiol patch and prometrium and this therapy could be much more affordable. Would I expect a big change in that?

Dr. Maki: Yeah, right. So her question, she’s using right now a compounded by Biest Progesterone Vaginal Cream which based on our last episode and we are not sure about the Biest Vaginal part. We’ll segue back into that a little bit just as a refresher. So her question is, can she switch completely the types of prescriptions to the estradiol patch, also called the Vivelle patch?

Dr. Davidson: Or CombiPatch. There are a few different names. Now, they have the generic. So Vivelle was around, but now they have generic. So just estradiol patch.

Dr. Maki: They are all still basically estradiol. It comes in a couple of different which seems like – and this is what we’re going to talk about – which seems like a relatively low dose .025, .05, .075, and then, of course, Prometrium. Prometrium is commercially available progesterone, instant release progesterone. That’s something key that we’ll get to in a second. So tell me your thoughts, Dr. Davidson.

Dr. Davidson: Well, she’s using it as a vaginal cream and she’s using a Biest. We don’t know what the dose is because a Biest is a combination of estradiol which is very strong but it’s awesome but it’s strong, and then estriol which is one of the weaker estrogens but it’s really nice and gentle and good for so many things. So, it’s nice to have that combination of the estradiol and the estriol but we don’t know what the dose is. And same with the progesterone, that’s mixed in there with the cream to put up in the vaginal area. So we don’t know what the dose is on that either. But just to tell you from experience using vaginal creams, especially with Biest, it’s probably not a very high dose. So, she’s probably using an 80/20 ratio, 80% estradiol to 20% estradiol combination in that Biest. So, it’s probably not super high and when you put it on vaginally, it does go…

Dr. Maki: Probably 1 milligrams or something like that.

Dr. Davidson: Yeah. It could even be up to three, maybe even three and a half, 4 milligrams. Sometimes even five and that…

Dr. Maki: I’m sure it’s not anywhere close to that.

Dr. Davidson: I know, but I use so many different doses and usually not too low. Anyway, that Biest I would say in some ways is great, but it is not going to be anything near what an estradiol patch is. Estradiol patch is like a shotgun where this would be more like, I don’t know, like a dart. It’s like bringing in a huge tank and trying to hit a small mark. Estradiol, like Dr. Maki said, is when you look at the doses on the milligrams, you think “oh wait, the estradiol is like 0.25 or 0.05.” You’ll think that’s not a lot of estrogens compared to this Biest that looks like it’s 1 milligram or 3 milligrams, but it is like apples and oranges. Estradiol patch is always so much stronger.

Dr. Maki: Yeah. So we had recently a couple of cases as of late with the Vivelle patch and that’s the one that would appear to be really low dosing. You and I are just having a conversation about that because you’re trying to transition someone to BHRT, either a Biest or something. We’ll get to that in a second. I nailed you down like so what is the equivalent of the, let’s say, the .075 Vivelle patch, which is the strongest one they make, which again appears like it’s less than 1 milligram but now translating that to a Biest dose. I ask you and I kind of put you on the spot. What would you equivalent that to a Biest dose?

Dr. Davidson: Oh, I would go— so an 80/20 ratio of 80% estriol, 20% estradiol. I don’t even know if I would use an 80/20 because that estradiol patch is so strong, but if you’re due to the 80/20, gosh, I’d be closed up to like 8-10 milligrams.

Dr. Maki: Of the 80/20?

Dr. Davidson: Yeah. But honestly, whenever I’ve switched anybody from a Vivelle patch or an estradiol patch, I usually go higher on the estradiol component because you’ve got to match, in some ways, bridge that then I’ll actually start with a 50/50 ratio of 50% estradiol. So you have more estradiol in that Biest and 50% of the estriol. And then later, once the body gets used to it, then you bring it down. Same thing with birth control pills. I have had women walk into my office and they are almost 50 years old and they are still on birth control pills.

Dr. Maki: Yeah. Right. Which is we don’t agree with that at all, but sometimes that’s the only tool that their doctor wants to use to control their hormones and we just don’t like that idea at all.

Dr. Davidson: But that’s pretty strong too, so trying to bridge that over. That’s why sometimes bioidentical hormones or Biest get a little bit of a bad rap because people say “oh yeah, I tried. It didn’t work. I felt awful.” And that was only because they were probably underdosed.

Dr. Maki: Which is the trend that we see all the time, is that everybody that comes to us with these questions, the dosages that they are using are so minuscule that, of course, if they go from a commercial prescription like with the patch or something along those lines and they go to bioidentical hormones, you have to switch and increase at the same time, right? So you have to overcompensate. If you try to match up milligrams, which I know a lot of doctors try to do, they try to match up milligrams or at least sort of, then it’s like going backwards. That woman is going to always feel worse. Now, in this case, she’s going from Biest. She’s also on a Biest combo progesterone cream. I don’t love that idea either, right? We don’t necessarily care to do that, keeping them both in the same prescription. Yeah, it’s more convenient. It’s probably a little cheaper, but we would separate those. The progesterone, of course, gets turned into a capsule, and then the Biest would just be more of a systemic cream. Like I said, we always recommend applying it to your inner thigh or something like that.

Dr. Davidson: And not to get into all pricing and numbers and how much this costs and where this comes from and how much this cost, but I do think when you combine all three together, so the estriol, the estradiol, and progesterone. So basically a Biest and progesterone together. I think it cost a little bit more to actually put all three together. A lot of pharmacies already have that Biest separated out. And then if you do a capsule, it probably wouldn’t cost her much more, maybe even less using just a Biest cream and then a progesterone capsule. So I would say, if she’s looking at changing something in this regard, that would probably be a better way to do it just because some progesterone cream is not very strong when you’re working with a perimenopause or menopausal female that the capsules are a little bit stronger and you have a little bit more effect to prevent any kind of bleeding or endometrial hyperplasia in the uterus, and at the same time progesterone capsules seem to have a little better effect on sleeping and on mood and hair, skin, and nails. So with Tammy, I would look at that. I know she’s looking at trying to do that estradiol patch. She is not going to feel good on that estradiol patch. It’s going to be so much estrogen. And like I said, estradiol estrogen is the best hormone in the whole world. It’s amazing. She has so many effects on our system. But with too much, she can be a runaway train. You put an estradiol patch on someone that’s been on a Biest, I hate to say it, a lot of times they usually gain about 6 pounds because estradiol loves to grow things. So usually I see about 6 pounds. They feel a little extra stimulated, sometimes a little anxious, just kind of bluesy and anxious at the same time.

Dr. Maki: Bloated.

Dr. Davidson: Yeah. Almost like permanent PMS. It’s like I feel like a 14 year old with permanent PMS.

Dr. Maki: Yeah. Right. And not to mention the prometrium. The prometrium has plenty of its own issues as well. Some women do okay on it but the majority of women do not tolerate prometrium very well. So, like I said, one of our patients, we would never switch them from Biest and a progesterone capsule to the patch and to prometrium. We just wouldn’t do that because we know from experience that they just more than likely would not feel very good. Now, understand the financial aspect of that. Certainly, compound pharmacies, a lot of the insurance companies do not cover it. Maybe you need to find a new insurance company. I don’t know. To make that shift, the results are going to be very unpredictable, to say the least maybe. Who knows? Maybe she could tolerate it just fine. But there’s a reason why we don’t use those two things, the estradiol patch and prometrium, because women just typically across the board, very few women can actually respond well to that. They just don’t do as well as what we typically do, which is with the Biest, which is weaker in some respects. It’s not as strong or as powerful, but in some ways, that’s the benefit of it. It’s not as strong, so more women have more tolerance to it and they eventually feel better.

Dr. Davidson: Yeah. We don’t know a whole lot of logistics about Tammy like, is she 47? Is she 55? She’s using a vaginal cream. Some people like it more vaginally. It does help with atrophy. That what we’re working on is more atrophy, dryness, or we’re working on more the menopausal symptoms. So not knowing a lot of that logistics, but I would say just from her going on that really nice weak, gentle vaginal Biest progesterone cream to something so strong with the Prometrium and estradiol patch, it’s going to be a huge jump in hormones. Like a huge jump. And even the Prometrium. I have a few patients. I do have quite a few patients on Prometrium and they do great. And I have quite a lot that aren’t on it because they would never do well on Prometrium. But Prometrium only comes in two doses, 100 and 200, and it’s instant release and sometimes that might be too strong for somebody. Where when you’re doing the compounded, you could make anything. You could make a half a microgram change if you want to. Anything conceived, you can create. That’s why in some ways we love compounding pharmacies, because doing bioidentical hormone replacement is not one size fits all. It’s almost like an art or a dance where you have to create this treatment plan for this person but then you create a completely different plan for somebody else.

Dr. Maki: Yeah. When it comes to hormone therapy, I mean, maybe we’re preaching to the choir or certainly I’m preaching to you. Not intended, but you cannot address women that are dealing with this kind of hormonal issues in a revolving door fashion where every woman gets the same treatment. It just doesn’t work. There’s so many different nuances, and every woman’s life is different and every woman has different sensitivities. So, there has to be that level of individuality that is brought into that. And just using the patch and the Prometrium is easy and simple, but it just limits options if you run into problems. That’s why we don’t use it because more than likely this would cause some problems. At least 80% of our patients do not use it. There’s a small segment on both ends of the standard bell curve that is going to be able to tolerate that but those are few and far between. So yeah, I would expect some kind of a change. I can’t predict exactly like you can’t predict either exactly what she would experience, but as I said, it’s pretty…

Dr. Davidson: I would say she probably gained some weight. She probably gained about 6 pounds depending on the person’s body type. Usually, it ends up being about 6-12 depending on what size they are to begin with. And she probably feels bloated. She probably feels a little bit grumpy and moody and bluesy. Like I said, she’ll probably in some ways going to that higher dose depending on is she 47 or is she 57. Where are her hormone levels to begin with? But whenever somebody has too much estrogen and I would put her, she would jump into that estrogen dominant, and then with that extra Prometrium that’s a little bit strong, she would just feel like a moody 14-year-old. Nobody wants to feel like that.

Dr. Maki: Right. So this one was relatively pretty fast, kind of a quick answer. But again also, I think very importantly because what she was on just needs to be tweaked just a little bit and that would actually probably be worthwhile and maybe even raising that Biest dose. Estrogen, as you say, is the best hormone in the world. Estrogens what makes a woman a woman. The more of it she has, the better she feels.

Dr. Davidson: Except in the case of the estradiol patch.

Dr. Maki: Except in the case of the estradiol patch. Bioidenticals, yes to some extent, and we’ll talk more about rhythmic dosing versus static dosing later. That’s where that conversation really gets teased out a little bit. But the estradiol patch, even though it’s stronger, I just contradicted myself and saying more ration is always good, but that estradiol patch is just a little different. It’s just a little bit too strong.

Dr. Davidson: It would be maybe too much too fast. Does she really need that much? And I would say, we got financial concerns. Everybody’s got their budget. So for Tammy, I would talk to her practitioner a little bit and a lot of times even talking with the pharmacy. They give you discount if you fill three months at a time. So once you get the dose that fits for you and you know you’re going to be utilizing that for a while, you could get maybe more at once and then get a discount. You can change up some of. Sometimes those vaginal creams are a little bit more expensive than doing the topicals on just the inner thigh. So there are lots of options. You just need to coordinate and talk to the compounding pharmacy or the practitioner and just coordinate something.

Dr. Maki: Yeah. Right. So this is a really good one because we do get these kind of questions about commercial therapy and trying to replicate commercial therapy with bioidentical hormone therapy, and it just doesn’t work that well, which is why we again, not to beat a dead horse, but that’s why we don’t typically use them very often. So, if you have any more questions, as always, our email is help@progressyourhealth.com. Feel free to send us an email. It comes right to my inbox. I do screen them for the most part. Because we get so many, I do have to pick and choose. So sorry about that. We can’t get to every question, but we’re doing our best.

Dr. Davidson: We’re trying.

Dr. Maki: Yeah, we’re doing our best to try to keep up. But hopefully by answering Tammy’s question and everybody else’s question, there’s some overlap, so other people still get their question answered in some kind of roundabout way. And to be honest, if you send one email and you really want an answer, send it again. Not to make it complicated or anything like that, but like I said, the inbox is definitely filling up, which we appreciate because that means all of you are listening. We are giving you some information that is hard to find. We know that it’s hard to find, which is why we’re doing the podcast in the first place. Because you can search the internet long and hard, and to find these kinds of nuance answers is very difficult, which is where this idea came from in the first place to do a podcast just like this so you can find those answers. Let’s be honest, this day and age of the 21st century, information is everywhere and patients are very savvy, have done their research. They’re very educated when they go into the doctor’s office. And this is the way that we can help with that and everyone expands our knowledge-based so you can make the best-informed decisions for yourself and your family for that reason. So, we appreciate all your reaching out, and we’ll do our best to try to facilitate as much as we can. Dr. Davidson, do you have anything else to add about Tammy’s question?

Dr. Davidson: No, I just appreciate everybody that’s writing in.

Dr. Maki: Yeah. So one little plug, the book is coming out. Dr. Davidson wrote a book called “The Perimenopause Plan“. It’s not quite a formatted in design properly and we’re in the final stages of that. We will keep you up-to-date. Just excited about it. And as always, for now until next time, I’m Dr. Maki.

Dr. Davidson: And I’m Dr. Davidson.

Dr. Maki: Take care. Bye-bye.

The post Biest vs Estradiol Patch for Vaginal Dryness | PYHP 110 appeared first on .

Does Estradiol Work for Vaginal Dryness? | PYHP 109

Dr Valorie Davidson and Dr Robert Maki — Mon, 30 Aug 2021 22:56:06 +0000

Kate’s Question: Hi, I’ve been doing extensive research and I came across your site. I don’t know if you’re still responding to email questions or not, but I thought I’d give it a try. I just completed my first year of no periods. Dryness, I have the beginning of atrophy, is really my only issue. But I was given 50/50 ratio Biest, one gram a day. I do that vaginally as an insertion for two weeks, and then I reduce it to two times a week after that. I don’t do any progesterone, but this is what my experience has been. After the first full week, I started bleeding. After the second week, it became heavier bleeding. So then they put me on it for a third week and I was supposed to drop down my Biest 50/50, but I continued bleeding. So, I do feel great. And now it’s week four, and the bleeding is starting to taper and I’m loving this but worried about the bleeding. So just wondering your about your thoughts. Thank you, Kate.

Short Answer: With our patients, we don’t use Estradiol vagainlly in order to minimize any unwanted spotting or bleeding. We only use Estriol for vaginal use as it is a “weaker” hormone and less likely to cause any bleeding issues.

PYHP 109 Full Transcript:

Download PYHP 109 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 a lot of questions to do. We have, it seems like we just keep getting more and more and more. So we really apologize that we’re not able to keep up with is as many of them as they keep coming. I think it’s a good thing. Alright, we have an unlimited amount of content to talk about. We are gonna dive in. This is Kate’s question. We are changing everybody’s name just to keep it, you know, just to keep it you know. So no one’s, there’s no identifying information. So if you did submit a question, we might have answered it or we were probably going to answer it but the name might be different so you might have to actually pay extra attention to the podcast. So Dr. Davidson won’t you go ahead and we’ll just dive in.

Dr. Davidson: All right, let’s dive in. So this question is from Kate. So, ‘Hi, I’ve been doing extensive research and I came across your site. I don’t know if you’re still responding to email questions or not, but I thought I’d give it a try,’ and this is why we do get a lot of email questions. We get a lot of, lot of questions on the website, but we want to do them for everybody to listen because it actually all this really applies to a lot of people. So, okay, just to continue with Kate here, ‘So I just completely…’

Dr. Maki: Oh sorry, that’s the copilot. Our co-host Bob is playing with his antlers, deer antlers. So sorry about that.

Dr. Davidson: And he loves to talk and make lots of noise. So if you hear that in the background, that’s Bob.

Dr. Maki: We tried, we tried to, like, edit around that or edit it out and stuff. And then he just every time when we sit down for a podcast, he goes a little bit crazy. So we just kind of forget about it.

Dr. Davidson: How can we not have him in the room with us? I mean, he’s just adorable. Okay, so to continue with Kate, ‘So I just completed my first year of no periods. Dryness, I have the beginning of atrophy, is really my only issue. But I was given 50/50 ratio Biest, one gram a day. I do that vaginally as an insertion for two weeks, and then I reduce it to– oh and, for two weeks, and then I do two times a week after that. I don’t do any progesterone, but this is what my experience has been.

After the first full week, I started bleeding. After the second week, full week, it became heavier bleeding. So then they put me on it for a third week and I was supposed to drop down my Biest 50/50, but I continued bleeding. So, I do feel great. And now it’s week four, and the bleeding is starting to taper and I’m loving this but worried about the bleeding. So just wondering your about your thoughts. Thank you, Kate.’

Dr. Maki: Well, to be honest, this is something that, actually this type of question. We’ve done a couple of like these already but this one comes up over and over. So I have a, I have a few ideas about this and I think you and I are going to probably say exactly the same thing. Well, what’s the first thing that comes to mind?

Dr. Davidson: Well, of course, you know, she’s being given estrogen therapy and she has a uterus. So really she does need some progesterone. That’s about that’s probably, precisely where that bleeding’s coming from. She hasn’t had a period for 12, you know, 12 months. So for a year, so giving that estrogen obviously is a direct cause to cause that bleeding.

Dr. Maki: Yeah, right. Now, granted the dosage one milligram is not a lot, but at the same time, you probably wouldn’t necessarily want. And this is also why we don’t typically add any estradiol into a vaginally, used cream like that. Because you know, for exactly this reason, the estradiol tends to be a little bit too strong, which is why we only use estriol in a case like that.

Dr. Davidson: Yeah, if you’re just going to give somebody some vaginal estrogen for atrophy or dryness or pain with intercourse or irritation with intercourse. That and that seems to be really Kate’s only issue going on, which is awesome and remarkable. But then, yeah, we would just do an estriol or an E3 because it’s so much more gentle. It doesn’t necessarily go into the bloodstream as much. It doesn’t cause that thickening of the lining. Now what probably happened is like, Dr. Maki said, is you think ‘Oh, one milligram of Biest isn’t a lot,’ but they’re doing a 50/50 ratio.

So that means there’s point five milligrams of estradiol, to point five milligrams of estriol there. And I can see where they’re having them do it frequently or having Kate do it frequently and then reducing it down to just twice a week. So they’re thinking, ‘Oh, you know, it wouldn’t be too much estrogen to create that lining to thicken,’ but everybody’s different. She might even have some fibroids that she never knew she had. A lot of us have fibroids in our uterus. We don’t even have any symptoms or know we have it, but that estradiol aggravated those fibroids and causing a continuous chronic bleed here.

So I do agree with Dr. Maki if we’re just looking at more of a vaginal application for atrophy, for irritation, for dryness. Just trying to get that resiliency of the tissues and that, you know, and get that, you know, stimulation more blood flow. You know, we would just probably dial it back to a higher dose of an estriol only.

Dr. Maki: Yeah, now just for an example. So we typically do for something like for this exact issue we’ll do like let’s say four milligrams per gram. She’s doing one. We’ll do four milligrams per gram of an estriol cream. So e3 only, no Biest, just e3 estriol. And every compounding pharmacy has something like that. But then we will have them apply a half a gram. So, half a gram would be half of the four milligrams. So they’re only applying two milligrams at night. And then in the beginning, just like she’s doing, we’ll have them do it for one to two weeks, every night, one to two weeks. And after that every other day and then eventually, a woman knows her body better than anybody. She’ll probably relinquish to something like one to three times a week after that, right?

Dr. Davidson: Yeah.

Dr. Maki: Usually it’s kind of how the, how that process typically goes.

Dr. Davidson: So that’s what we would do for that vaginal dryness and that wouldn’t have really necessarily an effect overall in her bloodstream. So it wouldn’t raise up those estrogen levels too much and at the same time, that’s not going to thicken the endometrial lining or irritate any pre-existing fibroids if they’re in there. Now, on the flip side, let’s say it just wasn’t only the atrophy that was or dryness that was bothering Kate that maybe you know, maybe she’s having some hot flashes, some night sweats, some trouble sleeping, maybe some mood or libido issues or mental energy. Then you might say oh, you know what, something looks like you’re having some other maybe perhaps menopausal symptoms that we want to treat. So then if somebody wanted to give one a Biest that does have the estradiol with estriol and they have a uterus, we’d want to do the progesterone as well.

Dr. Maki: Yeah, right. Yeah. So this is where you when you’re trying to address something locally, it doesn’t typically have too much of a systemic effect except for like you said, the proximity of the uterus. You know, they are so, you know they are so, obviously, the vagina and the uterus are so close to each other. And now granted, she’s a year out from having her period. The closer a woman is to her menstrual history, the more likely the bleeding is to happen. So that’s where you might actually have to use progesterone just because of that fact, no matter what she does, even with the estriol she could still have bleeding.

So, she would be kind of, in some ways forced to use progesterone, which is kind of our, because of the uterus we usually do that. Anyways, and like you’re saying, if she had some of those other menopausal symptoms, surprising she doesn’t have those, yet. She probably will at some point then she has to separate those who she has a Biest for systemic issues, hot flashes, insomnia, night sweats, and then she has a localized e3 cream for this particular issue. And then of course the progesterone, at the same time, to prevent the bleeding issues.

Dr. Davidson: Exactly. So I hope that wasn’t too complicated. I do agree with Dr. Maki that if you’re if you’re treating some overall menopausal symptoms, you can do a Biest that would be kind of that treating over the overall picture, but you would need possibly a separate estriol for the vaginal tissues. And that’s because sometimes when you’re treating someone with Biest for just menopause symptoms, those vaginal tissues are last in line to be able to have that biased for them. So, they tend to have a little that dryness anyway, so you have to have that separate. Everybody’s a little different, not everybody needs the estriol and some people do. So you can see that but anytime you’re doing a Biest, anything that has an estradiol like I said, and you have a uterus you got to use that progesterone. So it would probably be a little bit more, you know, just looking at Kate’s question. The fact that she bled so much as I really feel that that’s coming from the estradiol. I know. Dr. Maki had mentioned something about the estriol could cause bleeding. But to be honest, I have rarely, rarely ever have seen estriol cause any kind of a period or a bleeding. I’ve seen it sometimes cause maybe they might notice if they’re doing a little bit too much estriol. Maybe a little puffiness or sometimes, you know, estriol helps wonderfully with the mood. So sometimes they noticed something changing with their moods, but I’ve never seen an estriol only cause any kind of bleeding, truly.

Dr. Maki: Yeah, right. No, that’s exactly why we use it for this type of application because it doesn’t cause the bleeding where the estriol or the excuse, excuse me, the estradiol almost always does. And that’s why we separate them, we don’t necessarily combine them together because no matter what even if it, the ratio is an 80/20 or a 70/30 or whatever, that estradiol is just too strong to be used in this type of fashion. So definitely one that comes up all the time. You know, the prescribing physician should know better than that, right, you know, honestly, this does come up quite often and there’s nothing wrong with, you know, with Kate. It’s not that she’s not tolerant or anything like that, it’s just the wrong kind of prescription, you know.

Dr. Davidson: So, you know, for Kate, like she said, she’s feeling great and she loves this. So it’s obviously helping that vaginal atrophy and dryness. But at the same time, if you’re bleeding all the time. Because a lot of times, okay, you know, we have some atrophy, we have some dryness and so then intercourse is painful so we want to correct that with some type of estrogen therapy. But if you’re bleeding all the time, it’s not to have intercourse in your period at the same time and especially to have that chronic bleeding. So I could see where, you know, we definitely want to nip that in the bud. Even though she says it’s starting to taper, there is a chance that it would come back or she’d have this sort of out-of-sync bleeding. You know, going, you know, going to the highest intervention, I would say with Kate at this point probably doing a transvaginal ultrasound to see if, you know, there is a thickening of the lining that we want to thin down. And I really think with having this response to this, which is common, but to have it for so long and more of a heavier bleed. I bet there’s some fibroids, a fibroid or two in her uterus that’s being activated by the estradiol, and it’s good to know. Fibroids are completely benign. They’re not cancerous, but they can act like little gremlins and cause bleeding and cramping and you know, out-of-sync bleeding and more periods. So I would definitely think doing probably a transvaginal ultrasound just to just to look at that for her would be a great thing.

Dr. Maki: Yeah. I mean, let’s be honest. There’s a lot of times when you’re when you’re using hormones and there’s bleeding that’s kind of par for the course, right? That’s a very common thing. It doesn’t mean anything’s wrong or doesn’t mean anything serious. It just means that dosing-wise, something needs to be fixed or adjusted. Either the estrogen dose needs to go down or be changed or the progesterone needs to be either added in, and this case, or it needs to be increased. No, now like you said having because there’s so much bleeding for a number of weeks. Probably, a vaginal, a transvaginal ultrasounds not a bad idea. Typically, we don’t run into these kind of issues necessarily right off the bat. So we don’t jump to the transvaginal ultrasound right away. But in her case we would never, this never would have under. This never would have happened, if she would have come to us because we would have kind of been prepared for that and would have accounted for that. So we probably wouldn’t do a transvaginal ultrasound. But because we’re not really aware of all the details, just what she told us in the email. That it probably wouldn’t be a bad idea. Just like you said there was so much, so quickly. Now, it’s tapering off because her frequencies going down but this could have been completely avoided in the first place.

Dr. Davidson: But I love the fact that she’s using the Bio-Identical estrogen. Biest is a bio-identical estradiol and estriol. Looks exactly like what we would make in our own body. So I love the fact that she’s open to using that, that she has a practitioner that’s opening to prescribing that. It’s just like Dr. Maki said, the dose needs to be adjusted, something needs to be changed. But at the same time, there’s so many ways to change things and she can still love it and feel great, but not bleed.

Dr. Maki: Now, this was another question. I’m just kind of throwing in here for a second. Someone made a comment about estriol not being FDA approved. And that’s actually not correct. Estriol is FDA-approved. Otherwise, it wouldn’t be able to be used as a prescription. It is FDA approved. There’s just no commercial medications that at least in America anyways, I know I made that statement one time and someone from England or something chimed in real fast on a comment on the website and said, oh there’s Ovestin or something like that over the counter, or by prescription, you know, across the pond. But in America there is and I believe even Canada, maybe Canada is different, I don’t know. That there’s no commercially available estriol cream.

Every time you get estriol it has to come from a compounding pharmacy. So given that fact it is still FDA approved. There’s just no commercial drugs or all the commercial hormone replacement products on the market are all estradiol. And honestly, you know, that sometimes. Now we use estradiol but we use it always from compounding pharmacies, but the commercial ones tend to be really, really strong. In this case, we want the weaker hormone because it actually has the benefit of not causing excessive bleeding.

Dr. Davidson: Now, if any of you have seen estriol over the counter, and there is companies that make it over the counter. Technically, it’s supposed to be a prescription. There are some companies that are reputable and some that aren’t. So you just have to be careful of what you’re, what you’re buying.

Dr. Maki: Yeah, you’re buying something from Amazon. No offense, again Amazon, we live in Washington, but it is…

Dr. Davidson: We love Amazon.

Dr. Maki: …but at the same time, be very careful of what you’re buying on Amazon. We don’t, we don’t really endorse any of those things on there, necessarily just because, we don’t know who’s making it. Or, you know, that can be, that can be kind of a, you don’t know the manufacturer, you don’t know what’s being produced or what their raw materials are. Then, you know, that can be. You know, because it is a hormone it needs to be taken you know, serious, you know. And especially if you’re using it for vaginal use with the proximity of the uterus there, you know, you want to be careful with that.

Dr. Davidson: Yeah, so just be careful what you’re putting on or in your body but other than that, we use Amazon a lot.

Dr. Maki: Well, yeah, the Amazon got the UPS has shown up in the house like, you know, every single day. We were the frequent flyers Amazon, but, but, you know, I think with, especially now these times, I think everybody is, I mean, everybody’s has kind of, in some ways, kind of forced to do the same.

Dr. Davidson: Online ordering, exactly.

Dr. Maki: Yeah, yeah, yeah.

Dr. Davidson: Almost too much fun. So, we have, you have a book coming out fairly soon. The Perimenopause Plan. We actually have a name. I’m not sure if we’ve announced that before. We are still working out some of the design and formatting. So that’s going to be coming up fairly soon. Really excited. Maybe I know you mentioned before, little nervous about that but still very excited about that. So we’ll keep you up to date on when that actually goes live on, on Amazon KDP.

Dr. Davidson: On Amazon.

Dr. Maki: …yeah, on KDP, Kindle Kindle, Direct publishing. And as always if you have any other questions, we encourage you to send us an email. help@progressyourhealth.com. help@progressyourhealth.com. This is, you know, that way you can keep it discreet. It comes directly to my inbox. And I’ll like I said, we have lots of emails so we do kind of pick and choose, unfortunately. I’m not discouraging you from seeing an email but at the same time compliments go a long way. And you know, we do encourage you to keep sending emails because for 2021 we’re making a making a good push to get to as many of those questions as possible. Whether it’s in one podcast by itself or we start combining a couple questions together into one podcast. So that way we can, you know, we can reach as many people as possible ’cause like you said earlier, this question applies to probably hundreds of thousands if not millions of women that, you know, have gone through this issue or at least nervous about it or concerned about it, or had it happen in the past. And now we’re giving we’re giving Kate an answer. But now, you know, hopefully lots of other people were getting that answer as well, too. So, what do you think about your book? Are you, what are your thoughts?

Dr. Davidson: I’m excited. Like you said, it’s written. It’s done. We’re just getting the design process going. It’ll be. Yeah, it’s very, very exciting, so.

Dr. Maki: Yeah, yeah, yeah. So we’ll keep you up to date on that until next time, I’m Dr. Maki.

Dr. Davidson: And I’m dr. Davidson.

Dr. Maki: Take care. Bye. Bye.

The post Does Estradiol Work for Vaginal Dryness? | PYHP 109 appeared first on .

What Should Estradiol Level Be On BHRT? | PYHP 108

Dr Valorie Davidson and Dr Robert Maki — Mon, 23 Aug 2021 21:21:26 +0000

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:

Download PYHP 108 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.

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Does Estrogen Cream Affect Male Partner? | PYHP 107

Dr Valorie Davidson and Dr Robert Maki — Thu, 19 Aug 2021 21:06:51 +0000

Carrie’s Question: I am currently taking, .25ml’s Biest which is 1.25mg, 70/30 ratio per gram. I apply it to the labia and vaginal area at night, every night. About how long do I have to wait for it to absorb before having intercourse? I am getting conflicting reports. My doctor says I do not have to wait at all, as it will not affect my husband but the pharmacist says, it will affect my husband and not have sex for several hours after application. Thank you.

Short Answer: Carrie is taking a very low dose of Biest. However, she is applying the estrogen cream vaginally, so in theory, her partner could absorb some estrogen during intercourse, but Carrie’s applied dose is only about .30 mg. This small amount of Biest is barely enough to affect Carrie, let alone her husband. If the male partner is worried about the estrogen, simply skip applying the cream until after intercourse. If the Biest cream is being used to help with pain and discomfort during intercourse apply about an hour or so before activity. For vaginal use, we typically only recommend Estriol cream and not Biest, which has both Estradiol and Estriol.

PYHP 107 Full Transcript:

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Dr. Maki: Hello everyone. Thank you for joining us for another episode of the Progressional Podcast. I am Dr. Maki.

Dr. Davidson: And I am Dr. Davidson.

Dr. Maki: Well again, we are trying to do our best to get back in the swing of things back in podcasting land. It actually feels pretty good. On the last podcast, we talked a little bit about the book that you have coming out. I would just mention it real fast up for perimenopause plans, going to be available on Amazon. We will keep you up to date when that comes out. If you have any questions, just in general. You can always send us an email at help@progressionhealth.com.

We are going to do another question today again because we took some time off over the summer. We got a whole slew of questions for us to do, this one does come up quite often. Why do not we just dive into it? This question is from Carrie.

Dr. Davidson: We always change everybody’s names and personal information just for privacy, but this is a really good question. We are going to break it up a little bit, give the general answer to it. And then I am going to get probably a little nitpicky on it because I like the math part. But, this is from Carrie. “I am currently taking, .25ml’s biased[?] which is 1.25mg, 70/30 ratio per gram. I apply it to the labia and vaginal area at night, every night. About how long do I have to wait for it to absorb before having intercourse? I am getting conflicting reports. My doctor says I do not have to wait at all, is it will not affect my husband but the pharmacist says, it will. And she capitalizes ‘WILL’, which will affect my husband and not have sex for several hours after application.” Thank you. She is wondering which way should she go?

Dr. Maki: This one comes up a lot and I guarantee you that the husband is worried about the estrogen, right? Men are always worried about little estrogen, It is probably more of his concern, he is more of, what about that estrogen? He does not want to grow boobs or something. To be honest, every man is worried about that, but I do not think it is really that big of a deal. She might not want to apply it vaginally and having her course right away. Maybe allow a little bit of time but, honestly, it is not really that big of a deal for him if they were to do that, spontaneously or something, once in a while, maybe every night. I am sure they are not doing it every night.

Probably once in a while, that would not be a big deal. What are your thoughts?

Dr. Davidson: I think the general answer, exactly. “Hey, if that little bit of cream got on, south area, fellas always concerned about their area down there”. Do not worry. It is not going to turn into something else or as I said grow boobs, or making gets all emotional. But just at the same time, Pharmacist is the smartest people you will ever meet. They are brainiacs. They know everything, they are so smart, but they are also incredibly particular when it comes to things.

They are saying “Hey, it is a transdermal cream, if it is on you, it is on him. It goes to the same place”. But, at the same time, you got to think about, using this biased, which is actually a pretty good dose, in terms of vaginally. But honestly, it is pretty low. The amount of actual hormone, biased is a combination of Estradiol and Estrella, E2 and E3, and when it says a seventy to thirty ratio, that means they are seventy percent of Estriol, which is a very gentle, very weak estrogen. To thirty percent Estradiol, which is the strongest form of estrogen that humans make.

She is applying it to the labia and the vaginal area, which is actually a great place to put it, if you are looking at it, especially for vaginal atrophy, for vaginal dryness, postmenopausal vaginal atrophy would be, like dryness pain with intercourse, lack of lubrication. Applying it vaginally is a nice way to help with those symptoms. It does help also with sensitivity to that area. It would help carry have an orgasm, you have that stimulation there. I love that it is being applied there but I think the pharmacist, just gets a little extra picky.

Dr. Maki: Yes, right. and it is only, that you brought it up. It is only 1.2mg. There is hardly anything there. Anyways, if the husband has a big beer belly. As his body fat, probably making more estrogen than that, body fat creates estrogen. That is why sometimes men when their testosterone turn starts to drop, they start to aromatizing, that is the term in their body, convert that as testosterone and estrogen, and then, body fat alone. I think we have talked about it one time. It makes more Estrone[?] than it does estradiol.

Dr. Davidson: Just E1. And it is true. Adipose tissue is adipose cells, fat cells. It is like, it has its own endocrine organ. It produces all sorts of hormones, but in particular, Estrone[?], you said back, Carie’s dose of 1.2mg of biased, seventy to thirty ratio. 1.2mg would equal to .84mg of Estrariol[?] with .36mg of Estradiol, which is very low. And, she is only using a quarter of that. If I were-. Where is my phone?

Dr. Maki: Are you really doing the math?

Dr. Davidson: I Like the math. Math is the coolest part. Because math tells you, what you can change on someone, what you can raise because we do all ratios, all of the different ways of doing it. If she is on .84mg, She is on .21mg of Estrariol[?]. And then, the .36 mg, it is really literally, so teeny, .09 milligrams of Estradiol. Which on those vaginal tissues, those vaginal cells, they are sacred areas for us, their mucus membranes, they absorb that hormone-like crazy, and be different if she put that on her inner thigh, I probably would not go in very well. And she would not absorb it.

But like I said, it is a low dose, but it is a perfect dose for those vaginal cells, for lubrication, for resiliency, for the stimulation, or getting that blood flow. Being so low, if she put it on, and it was like “Hey, honey, what you, looking good?” And then it would probably just act more like a moisturizer to him.

Dr. Maki: Yes. The dose is low enough for it, would not do too much. That is why she is a little confused because the doctor tells her one thing, the doctor is the clinician, right? They understand these things. Pharmacists are not necessarily clinicians. As you said, they take everything to the nth degree. Everything is by the letter, which is good. You want your pharmacist to be that way.

Dr. Davidson: You want them to be extra particular.

Dr. Maki: Yes. If you have questions about that, usually depending on if it is a contraindication or something. Listen to your pharmacist, but when it is about this kind of stuff, listen to what your doctor says because in this case, the doctor is right. Not that the pharmacist is wrong. Certainly, we would not recommend, having intercourse, right afterward, but, she might need, if she is applying it, vaginally, she might need that. For the intercourse is not painful.

Dr. Davidson: Overtime. Using that cream will help those cells. But, I do not think it is not going to act like a personal lubricant.

Dr. Maki: No.

Dr. Davidson: Use your own personal lubricant.

Dr. Maki: It is not personal. It is not in a moment situation. It is meant to be overtime. For example, when we prescribe, we probably would not do the biased, vaginally, we would just do it, estriol, vaginally. Just straight E3, but she is taking relatively-.

Dr. Davidson: But it has such a low amount of Estradiol that it-.

Dr. Maki: Yes, right.

Dr. Davidson: And sometimes, we will do a little Estradiol, vaginally, in the beginning, if there is a lot of atrophy. And somebody had not been on hormones, or they are post-post-postmenopausal, and they meet somebody, and they want to have intercourse, and it is really painful. We might do that.

Dr. Maki: It kind of speeds up the process a little bit, helps to reinvigorate some of those cells a little bit, and it shortens the course. Because we have had some pretty tough cases over the years, where women were all miserable-.

Dr. Davidson: Can not even have penetration.

Dr. Maki: Not even that, some could not wear pants. They can barely sit down, it hurts to go to the bathroom. All these different things, some women, were contemplating different surgeries that a lot of those types of surgeries do not work very well. But, even for things like prolapsed uterus, and poll prolapse bladders, we have had some success just using hormone cream, but usually, we use a little bit of a higher dose. We want them eventually to get to where they are using it roughly, about one to three times a week.

Dr. Davidson: Yes, so they do not have to use it every day. But this is such a low dose, Carrie is using it every day. I would say if you are having intercourse that frequently-.

Dr. Maki: Good for you.

Dr. Davidson: Yes, awesome. You probably do not have to wait several hours, or you could have intercourse, and then put it on after before you go to bed after you tidy up, but a lot of people will say, “Why does not Carrie, just put it on in the morning?” and I will tell you when you apply cream vaginally, it is a cream. It is a little sticky. There is something down there that, putting it on in the morning, people do not usually like that feeling, of going around the day and they had that little extra cream there, and if you do put it on at night, which is I really do prefer it at night.

That is when ourselves, replicate[?], turnover and our immune systems really rallying[?], that is a really nice time for that absorbency.

Dr. Maki: Yes, right. The husband can rest easy. He is not going to have an influx of estrogen. Now, we have talked about this on other podcasts though, the other direction, when men are doing transdermal testosterone, and then there is going to be skin to skin contact with the wife, or the pets, or the kids. That is a big deal. Right? Because of the amount of testosterone that men used. Now, we do for men, we do strictly a rhythmic dosing method for men, and at certain times of the month, their testosterone level. What they are applying to their skin can be upwards of close to 400 milligrams daily for a few days of the month, that amount for a woman could be really problematic.

She is going to start growing facial hair. She is going to lose her hair. She is going to probably break out like crazy. Women do not want any of those things to happen, and then certainly the smaller the people, kids, and pets. Pets like to sit on laps, the kid likes to sit on laps. If a man is not careful enough. Granted once, we coach a patient and how to do it, it is not that big of a deal, as long as he is aware of it. He will wash his hands with hot soapy water.

We recommend some men actually use a surgical glove, so they can apply with the glove, and take the gloves off. There is no trace on their hands, and then if they are applying it always, we recommend for men and women to apply their estrogen, and/or testosterone to their inner thigh, nothing on the forearms. Nothing like that. And then usually, you can avert[?], pretty much all problems from that point. Men to women is a much bigger deal than women to men. Women to men, not a big deal but men to women certainly, that is where you need to be a little bit more careful.

Dr. Davidson: Exactly and like I said, it is such a low dose and it is really more for the vaginal area. It looks like to me, that it happens husband is going to be okay, but ideally, maybe if you did put it on, you want to wait about, thirty minutes, forty-five minutes and it would be just fine, even up to an hour. Or you could always put it on after intercourse.

Dr. Maki: Sure. But like I said if it spurs the moment and it is certainly celebrating spontaneity. That is great.

Dr. Davidson: Yes.

Dr. Maki: It is not going to be a problem. But, if you have a chance, as you are preparing for that spontaneity, if that is even really a thing. Then like I said half an hour, or forty-five minutes, an hour, it would be totally fun. This is relatively a short one. Do you have anything else to add about this? or?

Dr. Davidson: No. We get this question all the time. All the time. Where to put your creams. How to put it on. How long to wait, even to shower or take a bath, go swimming. We get these questions all the time. But like you said, it is funny with my female patients, their partners, their male Partners will be like, “Okay. I do not want any of that near me. I want to do that estrogen stuff” [inaudible] their southern parts-.

Dr. Maki: And their big babies. They do not realize that it is harmless.

Dr. Davidson: It is really okay.

Dr. Maki: Relatively pretty harmless. Again, we are still trying to figure it out, we would like to ask if you like our podcast, we like to ask for some reviews. We are on all the major platforms such as Spotify, iTunes, Stitcher, I Heart Radio. We are not on Amazon yet but will be on Amazon music, soon enough. Please give us a review. That is how people find us.

That is how we can grow our audience. We are going to promote that. We still have not figured out what that promotion is, to offer some incentives. We will be going to read the reviews on the podcast.

Dr. Davidson: As a thank you.

Dr. Maki: As a thank you, and we will pick somewhere. It would be a really nice way to connect with some people, especially if they like our podcast. And another shameless plug for the book. I know that makes you nervous every time I say it, I can see your face getting uncomfortable over there. Perimenopause Plans can be coming on Amazon as well, fairly soon. We will keep you up to date on that.

It is really, just a culmination of your experience and, how you are been able to help women, and like we said, previously that it is kind of an underserved situation for women that they do not really have lots of options. And we see a lot of them as patients, we get a lot of the questions from them, and it is our way to help as much as we can. Until next time. I am Dr. Maki.

Dr. Davidson: And I am Dr. Davidson.

Dr. Maki: Take care. Bye.

The post Does Estrogen Cream Affect Male Partner? | PYHP 107 appeared first on .

Is an Estrogen Patch Good to Use? | PYHP 106

Dr Valorie Davidson and Dr Robert Maki — Wed, 18 Aug 2021 21:41:34 +0000

Joy’s Question: Is the Vivelle patch good to use? My gyno prescribed it for hot flashes, vaginal burning, vaginal itching, and mood issues during ovulation before my period. I have not tried it yet, though.

Short Answer: Some women do fine with the Vivelle patch. However, in our experience, many women do not tolerate the patch very well, or it does not provide full relief of menopausal symptoms. The key to this question is the fact that Joy was prescribed the patch, but is still having a regular period. We don’t agree with using the patch for women who are still menstruating. There are some better options that we discuss in this episode.

PYHP 106 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 am Dr. Maki.

Dr. Davidson: And I am Dr. Davidson.

Dr. Maki: Well, we are back. It has been a little bit of a hiatus. We had a really amazing summer, right? You know, summer is always a fun time. So we took a little bit of time off on the podcast, but now the weather has changed a little bit. We are into fall, the perfect time to kind of get back into the podcasting routine.

Dr. Davidson: Definitely. Ready to hit the ground running. Although fall was really beautiful here with the leaves changing. So yeah, it is good. I am definitely ready to get back into the podcasting seat.

Dr. Maki: For some reason, when it was really nice out and the sun was shining every day, it was really difficult to come and sit down and do a podcast. It was really challenging, but nonetheless, we kind of decided ahead of time that we were going to do that anyways. But now we have lots of questions that people have reached out to us with. So we have just a tremendous– [laughter] in some ways, we probably should not have taken that time off because now we have so much work to do, but this is good.

These are legitimate questions that people are asking us, and we feel that without coming up with topics of our own, this makes it so relevant when people ask us question because we get to hear our listeners. We get to hear our readers for the blog post. We get to hear what problems they are actually dealing with.

And I think that is really valuable because now we have a chance to sit down, kind of discuss them, give everybody our opinion. So that one person really is helping a lot of people because now we are giving our answer to that very specific question to lots and lots of people.

Dr. Davidson: Exactly. When you write in or email us with your question, know that you are not alone. The question you have, trust me, we have heard it over and over and over again so it is really great to get it from a reader or listener’s perspective, and then when we can apply it to the masses, it helps everyone.

Dr. Maki: Yeah, right. So we are going to dive in this question. Now, we are changing everybody’s name just to keep it so there is no question about identity or anything like that. So the name that we are going to give is not the actual name of the person, but nonetheless–

Dr. Davidson: Just for protection, anything that looks like it would be something that– we would just change even if it is descriptions about themselves or jobs or where they live. We always change all that, that privacy information. Just to keep the question valid but without feeling like anybody has to be pinpointed where they are.

Dr. Maki: Yeah, right. So go ahead. Dr. Davidson, won’t you go ahead and read the question.

Dr. Davidson: Okay. So this question is from Joy. This is actually a question we get all the time over the years, over the span here. “Is the Vivelle patch good to use? My gyno prescribed it for hot flashes, vaginal burning, vaginal itching, and mood issues during ovulation before my period. I have not tried it yet, though.”

So there is a couple aspects to this. One, of course, we want to talk about the Vivelle estrogen patch or the estradiol patch, and then also a little bit about Joy and why she is using it and when she is using it.

Dr. Maki: Right. So there is not a lot of information here, right? So when you just read that question without having a little bit more background like you and I do, this is kind of a loaded question in some respects. I did not catch it the first time until you just read it. I read the first part of it and I kind of just– I did not see the other part.

What I am referring to is the fact that it says “during ovulation before my period.”

Dr. Davidson: I get that question a lot over the years because we are looking– because we do a lot of– we do bioidentical hormone replacement. That is [inaudible]. Everybody talks about HRT, Hormone Replacement Therapy, and that is a big umbrella for all hormones. What we do though, in particular, the bioidentical, and we specifically will use more compounding pharmacy so we can make something tailored to that individual for their particular symptoms.

So it is interesting with this is a Vivelle patch which we are going to get into in a minute is more conventional. You are going to get that from your big box pharmacy. There is four different doses and that is all you have.

Women will tell their practitioner, their gynecologist, “Hey, listen. I feel great this time of my cycle, but I do not feel great this time of my cycle. What do I do?” So they are trying to really sort of take a huge– I would not even say like a one-size-fits-all and try to morph that into something more tailored for that individual.

So of course, during ovulation to her period, that could be from day 14 to day 28. The doctor is trying to give her a little extra estrogen thinking she is needing it, but it is really kind of like taking a shotgun approach and trying to shoot a little dart on the wall or a little pinprick on the wall.

Dr. Maki: Using an elephant gun to shoot the fly off the wall.

Dr. Davidson: Yes. [chuckles]

Dr. Maki: Something that is– one that you actually just kind of made me realize recently. [inaudible] another patient that was dealing with the Vivelle patch on how strong– you look at the dosage. I know there is a 0.5–

Dr. Davidson: There is four different doses. The lowest is 0.025, then there is 0.0375, 0.05, 0.075. So there is a lot of zeros there, but know that the 0.025 is, of course, less strength compared to the 0.075.

Dr. Maki: Right. The confusing part is that those dosages seem really, really low.

Dr. Davidson: When you try to think about it compared to the type of hormone replacement we do, like we might do an estradiol or a biased that has a combination of estriol and estradiol, or estriol E3 and estradiol E2. So when a doctor takes somebody on a Vivelle patch that is on a 0.075mg of estradiol for that patch–

Dr. Maki: Which is the highest one.

Dr. Davidson: That is the highest one. You have to apply it twice a week. So usually you get eight of them a month and then you apply one twice a week. When they say, “Listen. This is really strong. I do not want to be on this Vivelle patch anymore. I want to do that bioidentical things and stuff I have heard about.”

When the practitioner that is not super familiar or maybe experienced with the compounding biased or the creams of the estradiol is all look at Vivelle patch at 0.075, that they are applying this patch twice a week, and they will try to use that same exact dose or compounded cream. They will say, “Okay. We want the estradiol to be 0.075, or a bias to be 0.5 or even 1.0.

They think, “Oh, that could be too high.” That is going to be higher than the Vivelle patch when you are trying to say the dosages between these milligrams, and I hope that this is coming across, okay, or it makes sense, but in some ways, it is not supposed to make sense because when you are trying to transition or somewhat switch someone from a Vivelle patch to an actual bioidentical compounded hormone cream with estriol and estradiol in it, you cannot. I mean, you can, but there is no equation to equivalate for that transition or that changeover.

Dr. Maki: There is no chart that the pharmacy can give you or no conversion that you can do that is equivalent from a Vivelle patch to bioidentical hormones. That does not exist. I know that you have done a very good job over the years of nothing more just observing, but being able to kind of figure out based on the woman’s symptoms, based on how old she is, based on who she is, based on where she lives, based on the stress in her life, based in her sleep, based on her goals, all those things–

Dr. Davidson: And what dose of the Vivelle patch she is on, if it is straight estradiol, and how long she has been on it. Because that is why sometimes, bioidentical hormone replacement or the compounded creams get a really bad wrap because they will say, “Oh, I was on this patch and then I got on that bias cream and I felt terrible.” And that was really because they always end up under-dosing the cream.

Dr. Maki: Yeah, right. So really, when you are going from the Vivelle patch to bioidentical hormones, you have to really increase that dose, and dosing to a dosing level that most doctors, to be honest, are probably not comfortable with which is why we always see people asking us all these questions. “I am on half a milligram.” “I am on 1.25mg.” “I am on one and a half milligrams.”

Dr. Maki: If you are going from the conventional things to the bioidenticals, that is not nearly enough. Of course, they are going to feel worse because it is like they are pulling the rug out from underneath them, going from, let us say, like you said earlier, 0.075 Vivelle to 2mg. Even 2mg of a biased, that is not nearly enough and they are going to feel worse. They are going to feel terrible going that way.

Dr. Davidson: To be honest, I find that the bioidentical hormone compounded creams like a bias that has the estriol and the estradiol in it is much more safe and gentle than a Vivelle. But I can understand a conventional practitioner not really familiar thinking, “Oh my gosh. [inaudible] 7mg of a biased 80/20 ratio.” Or even sometimes, I have to go even change the ratio to 50/50. So there is a little stronger estradiol to really bridge that transition from the Vivelle patch over.

They might think, “Oh, that seems like a lot.” But really, truly, when I see a woman on a Vivelle patch, that is a lot of estradiol. For me, just in my experience in watching how the breast tissue morphology changes, the weight, their symptoms, I feel like– or if they have a uterus or they do not, I feel like that can be pretty much a pretty strong heavy hitter to be on the Vivelle, that if they are going to be on it, that we definitely want to monitor the symptoms. Try to keep it as low as possible.

Sometimes I even have them do it once a week or they cut the patch in half and do that one patch twice a week when we are trying to transition or change or just to really keep that level low. So I know I am kind of digressing away from Joy, but we kind of wanted to talk about the Vivelle patch in particular.

But also kind of like Dr. Maki was saying, the elephant gun trying to shoot a fly on the wall, as I understand her practitioner probably really wants to help Joy feel better from day 14 to day 28, but does not really have a lot of resources available to understand how to bridge that or how to give her a good treatment because if Joy is going to put on that Vivelle patch for half of the month, number one, it is going to down-regulate all her estradiol receptors so that from day 1 to day 14, she is going to feel kind of crummy, and for two, she probably is not going to feel great on that patch.

She will probably sleep better and definitely the hot flashes would be better, but she would have a lot of symptoms of estrogen dominance because you really do not need to give a woman of Vivelle patch which is pretty strong if they are still cycling.

Dr. Maki: Yeah. Pretty much, that was the part that I missed the first time when I just glanced over this, but you are right. I mean, the fact that she is still menstruating, ovulating, and we do not know how old she is, more than likely I would say if she is having hot flashes, vaginal burning and itching, mood [inaudible], she is probably in perimenopause.

Dr. Davidson: That might be in the mid-40s. Probably in her mid-40s, maybe early, but even then a doctor is pretty hesitant about giving a woman in her 40s estrogen. [laughter]

Dr. Maki: Yeah, right, but she is right off the bat. She is really not a candidate for estrogen at all. Maybe a little bit like that is where the bioidenticals would really kind of work well here because they are not as strong as the Vivelle patch. Vivelle patch, even the lowest dose, is probably just not going to make her feel very good.

And like you said, from ovulation to her period, that is more of a progesterone window. That is not an estrogen window. It is going to cause some irregular bleeding and it is just going to make her feel worse.

Dr. Davidson: I was going to say that right there. That extra estrogen would probably make her cycle– as soon as she put it on on day 14, she would probably get a period on day 20. Day 19, day 20, as soon as– and it probably would even overtime thicken the inside of her uterus or that endometrial lining so her periods become, I imagine, they are probably not super great if she is having these symptoms already, but they will get worse. Her periods will get heavier and longer and more painful.

Dr. Maki: So what she needs, just as a side kind of flip the script a little bit. So what will we be doing differently in this case, and for this particular situation, the Vivelle patch, we do not really like it anyways. We have had a few patients use it over the years. Some do okay with it on the lower dosing, not so much on the higher dosing, so we will tend to switch them away because we can control those prescriptions.

Now, they might need more. They might need a higher dose of the bioidenticals, but that is better in some respects because we are able to control the symptoms more.

Dr. Davidson: Exactly. The only time I really find that the Vivelle might– seems like it is a match is when a woman’s definitely post-menopausal, those ovaries have decided not to– they are not working, and really, women that have had a hysterectomy because you think about if they have had a hysterectomy there, you do not have a uterus so they can kind of tolerate a little bit more estrogen because when you think about somebody on a pretty strong form of estrogen and they have a uterus, estrogen loves to grow things.

So it will grow that endometrial lining in the uterus, and that is where you see women in their postmenopausal in their 50s and early 60s having like they feel like their periods are come back, but no. It is only because that lining is inappropriately thick which is a risk factor.

So when you see a woman with a uterus taking a Vivelle patch for menopause, they always have to take a progesterone counterpart if they have a uterus. So that is just on a side note. It is just one thing that I see. If you are going to do the patch, it does seem to fit better with women if they do not have a uterus.

Dr. Maki: Right, right, and we even recommend that woman still takes the progesterone even if they do not have a uterus which is very common that gynecologist say, “Well, you do not have a uterus anymore. You do not need any progesterone.” But we do not agree. We think that they– one of our rules that we never break is you never give a woman unopposed estrogen. You always give them both.

So in this case, we are assuming, making a big assumption here because Joy did not tell us how old she is, but like you said, she is probably 45, probably somewhere between 45 to her late 40s, maybe even–

Dr. Davidson: 40 to 50. 40 to 47.

Dr. Maki: Well, she mentions the word ovulation and before a period. If she is in that window, more than likely she is not ovulating unless she is a lot younger than that. But maybe a lot of women do believe if they are menstruating that they are ovulating. And you can menstruate without ovulating. You can ovulate without menstruating, but you can menstruate without ovulating.

Dr. Davidson: Exactly.

Dr. Maki: Hopefully, that was not too confusing, what I just said.

Dr. Davidson: [laughter] No, that was perfect. So I would say with Joy, since she sounds like she is having regular periods and sounds like probably 28 days, maybe 27, maybe 29, as we test her blood work. We check her hormones. We check her hormones, probably post what would be ovulation so anywhere right around day 17 to day 22, if she is a perfect 28 day cycle.

So you can kind of get that window to find out, well, is she ovulating? Does she had progesterone? Are her estrogen levels actually low the second half of her cycle? So that would probably be the first thing, and then from there, pairing those symptoms up with what the objective hormones data shows us, then like Dr. Mackey said, is we might do some progesterone and then we may even do a very, very low dose of a biased, maybe not even do the estradiol at all. Just do a little estriol or just a very tiny, tiny dose of some estradiol with some estriol.

That is where we, depending on Joy’s age and her symptoms and then her blood work and her, of course, health and family history, that is where we would kind of move forward with that.

Dr. Maki: I was thinking that we would do some progesterone and maybe like an estriol cream for the vaginal burning and itching. Very simple. You think a gynecologist would kind of know that.

Dr. Davidson: Well, you can see they are trying. They really are trying with what they have.

Dr. Maki: With a limited tool belt. They do not really have a lot of– certainly, the hot flashes that makes you think estrogen, but the fact that she is having a period every month or at least what we understand is every month, probably somewhat regular, that tells you that her estrogen threshold is still relatively pretty good because she is still having a period every month.

A little shameless plug for your book that is going to be coming out fairly soon, which is The Perimenopause Plan. This is kind of a classic. They are still menstruating but having hot flashes. For women, that is a really tough place to be because they are not necessarily estrogen candidates like we have been discussing.

Vivelle patch for her is not really the best option. One, it is too strong, and two, it is not really a lack of estrogen because of the regular period. It is more of a lack of progesterone and also looking at stress level. If she has got a lot going on with COVID and everything, who knows. Everybody’s stress is all over the place. For some, that could make some of those symptoms a lot worse. Then the estriol that we talked about, that would just help on a local level, help some of the vaginal issues.

Dr. Davidson: No, thank you. Like I said, you are making me blush because you mentioned the book that we have coming out.

Dr. Maki: Yeah. It is going to be– I am not exactly sure when this episode is going to be posted, but just pay attention. We will certainly let you know when the book is ready to go. It is going to be on Amazon.

Dr. Davidson: Or go ahead and send us your email so we can put you on our list, right? What email would they–?

Dr. Maki: So for the podcast, if you have any questions or if you are curious or you want to be, just send us an email to help@progressyourhealth.com. That way, if you have any questions you want to ask us, maybe we will read it on the podcast. Any questions about the book, any questions about anything.

Dr. Davidson: The book is going to be about perimenopause. [laughter] You know that. Kind of that in-between stage.

Dr. Maki: Because of all the questions that we get collectively, women in their 40s, for the most part, maybe late 30s or early 50s, but women in their 40s are the majority of the people that we treat as patients, and the majority of people that we get questions from on the podcast because I think that is which is the reason why you wrote the book.

For one, you are kind of in that demographic yourself, but two, we think it is really the most underserved demographic of all the different female-related, the age range but also the female-related problems.

Menopause, okay. Menopause, a lot of people understand menopause, but perimenopause is a bit more specific and not quite as well addressed out there in the conventional space.

Dr. Davidson: And what we do, especially like you said, a lot of our patients are in their 40s, but I have had patients that I have been treating for years. So that is the best time is to catch them so we can balance those hormones and then make menopause a really easy gentle transition. So that is the ideal time. So definitely, like I said, what did you say? help@progressyourhealth.com?

Dr. Maki: Yeah. That is the email that we like to use for the podcast. That way we know that if you do send us an email, it has come either from the blog or from the podcast. That way, we cannot get back to everybody. We get too many of them, but we do try to screen them as much as we can and it is a great way to be able to communicate and to be able to answer questions like this.

So for Joy, Vivelle patch is probably not the best option. When you go back to your gynecologist, she is going to probably want to give you perimetrium, which we do not necessarily– that is a whole note. We had some other podcast in the past that talk about perimetrium, so go back and look at our archive about perimetrium.

We would recommend for sure bioidentical progesterone sustained release. Start with usually fifty to a hundred milligrams, something like that. That would be more appropriate for a situation like this as opposed to the Vivelle patch.

Besides plugging the book, do you have anything else to say, Dr. Davidson?

Dr. Davidson: No, this was a great question and I appreciate Joy sending this in because it kind of was able to cover a few things where we could talk a little bit about what Vivelle patch is and the different doses and what we would deem it appropriate for, but then also too for a menstruating female that might be having– they are still menstruating, but they are still having symptoms of what they would consider menopause. Is it truly that?

So it was a good question. I think it applies to a lot of people that are listening because we get questions like this all the time.

Dr. Maki: Yeah, and we are thinking about– we have not really asked for much from any listeners, but we are asking for you, if you do like the podcast, to give us a review on whatever platform it is that you listen to whether it is iTunes, Spotify, I Heart Radio, Stitcher. We are going to be, I think, in Amazon music now. It has podcast. We are going to be putting our podcast on there as well.

So if you liked our podcast, please give us a review. We are going to start a promotion at some time soon where we are going to pick out random reviews that we like and we are going to read them on the podcast. We have not decided like what we are going to offer for that promotion. Some kind of incentive which in some ways is kind of maybe a little bit incongruent. You are giving a promotion to get a review, but at the same time, that is how our audience grows and more people that find us because of those positive reviews. So we are going to offer something in return for that. We just have not quite figured out what that is yet.

We are open to suggestions. If you have any, send us an email. Other than that, if you have nothing else to add, I think this is a good one. It is nice to be back into the swing of things.

So until next time. I am Dr. Maki.

Dr. Davidson: And I am Dr. Davidson.

Dr. Maki: Take care. Bye bye.

The post Is an Estrogen Patch Good to Use? | PYHP 106 appeared first on .

Can BHRT Cause Weight Gain? | PYHP 105

Dr Valorie Davidson and Dr Robert Maki — Wed, 17 Feb 2021 22:12:36 +0000

Mary’s Question: I am 58 years old and lost my thyroid to cancer eight years ago. I am finding it impossible to lose weight and have thinning hair near my hairline and no eyebrows. I started Bi-est cream, 50/50 ratio, 2.5 milligrams; progesterone, a 175 milligrams; and testosterone, 1 mg. About a year ago, it was lower doses and then went up to those as recently my doctor had me using it twice a day, the cream, and then the progesterone, one pill at night, because my levels have shown that my progesterone is 7, estradiol less than 5, – that means it is not even in the bloodstream – free testosterone is 1.2, total testosterone is 6 . I am so afraid I am going to gain weight more or more hair loss from some of the things I have read. Please give me your opinion. I also take Tirosint and Cytomel for my thyroid. Do I have to worry about any medication interactions? Please help. Mary.

Short Answer: Typically, bioidentical hormone replacement therapy (BHRT) is not going to cause consistent weight gain. When starting BHRT, there might be slight water retention, but should not lead to consistent weight gain over time. If weight gain continues once on BHRT, pay attention to insulin status and stress level. For more information on our approach, you can download our Keto Carb Cycling Program.

PYHP 105 Full Transcript:

Download PYHP 105 Transcript

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

Dr. Davidson: And I am Dr. Davidson.

Dr. Maki: So what are we going to do later today?

Dr. Davidson: I do not know. Hopefully, get to go, maybe, for a hike or a long walk.

Dr. Maki: Yeah. Weather is good. It is August in Western Washington. Beautiful. It does not get too hot here. You know, we still have some patience in the Southwest. When I am getting ready to talk to them I look at the weather app and I see those triple digits: hundred and five, hundred and nine, hundred and ten and I have to say, it makes me cringe a little bit.

Dr. Davidson: I remember living in the Southwest and, August, I could not wait for August to be over with, like, come on, let us get to September. Let us get to the middle of September. And now I am like, I just want August to last forever. Please go slow go slow. [laughs]

Dr. Maki: Yeah. It is amazing how much of a contrast in you and I in the summertime. So June, July, August– it seems like, in the Southwest, Labor Day is when everything starts to change. You can feel it. Like you wake up one of those mornings and it is like, “Oh, okay. Summer is just–

Dr. Davidson: It is still pretty warm, but at least you are on the tail end.

Dr. Maki: Yeah, but you can start to feel like it starts to, you know, you get rid of some of those hundred and ten degree days and it will be in the upper 90s, maybe a hundred, and then it starts to gradually trickle down. But I remember you and I used to go to California, we go to the mountains, we go to Utah to try to just get a reprieve from the heat. I remember one time, actually with your sister, we actually went camping in Utah. We were at this place, I think it was Fishlake National Forest or something, just north of this really popular area there called Duck Creek which is kind of by Zion National Park. We used to go to Zion all the time. But even the summer there, it is still blazing hot.

Dr. Davidson: It is still hot.

Dr. Maki: So we either go up to Duck Creek or we went to this one little campground literally at like nine thousand feet and it was like 65 degrees up there in July. It was beautiful. We were actually cold.

Dr. Davidson: I was going to say we were cold. [laughs]

Dr. Maki: And we came down. We came down after we were done with the weekend and we got down to St. George, Utah, or I think it was, maybe, Cedar City or something.

Dr. Davidson: Which I love St. George, Utah.

Dr. Maki: And it was like a hundred degrees. We went from like 65 degrees, come down the mountain, and it is like a hundred and two and it was like, “Oh my God.” That contrast is really hard to deal with, obviously, we don’t have that contrast here.

Dr. Davidson: It is going to be in the high 60s today which is beautiful.

Dr. Maki: Yeah. Bellingham does not really get much above, seventy, seventy-five. That is a pretty nice, kind of a hot day in Northern Western Washington. So stop droning on about the weather. But you know, it is a big deal, it changes all the time. I kind of sound like my dad. My dad always used to talk about the weather and this is well before they used to have the internet and everything. Weather and gas prices; that was the thing that he was always concerned about. Always complaining that gas was too high and he never liked it hot. His favorite kind of weather was fifty-two and drizzling all the time.

Dr. Davidson: Then he would have loved it here.

Dr. Maki: Yeah, he would have been fine– I am not sure why, he probably would have done pretty well in the Pacific Northwest. So this question is from Mary. Granted, we are changing the name of that. We just did a Mary a couple episodes ago.

Dr. Davidson: We are not very creative with the names. [laughs]

Dr. Maki: But again, it is just to, somewhat, try to protect identity; not that we really need to do that, but just for anonymity’s sake. So why don’t you go ahead and read the question from Mary?

Dr. Davidson: Okay, so this is for Mary: I am 58 years old and lost my thyroid to cancer eight years ago. I am finding it impossible to lose weight and have thinning hair near my hairline and no eyebrows. I started Bi-est cream, 50/50 ratio, two point five milligrams; progesterone, a hundred and seventy-five milligrams; and testosterone, one milliliter. About a year ago – sounds like about a year ago she had started that but – About a year ago, it was lower doses and then went up to those as recently my doctor had me using it twice a day, the cream, and then the progesterone, one pill at night, because my levels have shown that my progesterone is seven, estradiol less than five, – that means it is not even in the bloodstream – free testosterone one point two, total testosterone six. I am so afraid I am going to gain weight more or more hair loss from some of the things I have read. Please give me your opinion. I also take Tirosint and Cytomel for my thyroid. Do I have to worry about any medication interactions? Please help. Mary.

Dr. Maki: Yeah. So this is a good one. We have seen quite a few people with thyroid cancer over the years. Thyroid cancer patients, they have usually had their thyroid gland removed, sometimes half the gland removed but–

Dr. Davidson: Hopefully the entire gland all removed.

Dr. Maki: Yeah, right. If you got cancer, you might as well just– at that point, you might as well just take the whole thing out. So they automatically – because the gland is removed – they automatically go into a different category than everybody else that does have a thyroid gland and I think that gets missed sometimes as far as their management goes. So when you and I were discussing this case, she is focusing on her female hormones, and I am like, well, what is her Tirosint and Cytomel dose? She is losing her hair, she has got no eyebrows, clearly, she is undermedicated when it comes to her thyroid medication and which is really common for someone like this

Dr. Davidson: Possibly. She does not tell us her TSH, which is the thyroid-stimulating hormone, or any of the other thyroid function tests such as the free T4, the free T3. But I can tell that she is being treated from the standpoint of trying to replace her T4 and trying to replace her T3 because Tirosint is actually not a bad medication. It is much more hypoallergenic. It does not have the lactose in it such as Cytomel or your traditional levothyroxine because I do not want to have the lactose or any of those excipients in it. So the Tirosint really is not too bad and Cytomel itself is an instant released T3, which we could drone on and on and on about. But the point being that she is being prescribed a T4 and a T3 which in some ways is a good thing. When somebody is just on T4 monotherapy that really is not the best because you want to make sure that T4 is converting to T3. One side thing is – so I am going to go back to the TSH – is the TSH, thyroid-stimulating hormone, in someone that has had thyroid cancer, I always want to keep that suppressed. So there is a reference range of point four-five to four point five and in somebody that has had thyroid cancer and had their entire thyroid removed, is you want to keep that under that point four-five because when you keep that TSH suppressed any little cells that might have not been taken out from her thyroid are dormant. Where when that TSH goes up to two and a half, three, some of those cells start to get activated and then they want to grow and the last thing you want to do with somebody that has had a previous thyroid cancer is have their thyroid start to grow back.

Dr. Maki: Yeah, right. So you and I were just talking about this for another case that we actually have and you suggested that we test their thyroglobulin, not thyroglobulin antibody, when you are screening for Hashimoto’s there is anti-TPO or anti-thyroid peroxidase antibody and there is thyroglobulin antibody. That is for Hashimoto’s screening or monitoring or diagnosing Hashimoto’s but just regular thyroglobulin is what you are referring to.

Dr. Davidson: Yes. So thyroglobulin is another hormone that you test with somebody that does not have a thyroid for previous removal from thyroid cancer so it tells you if it is growing back. So you would do a TSH, a thyroid globulin, a free T4, and a free T3, definitely, to check with this. So like, Dr. Maki said is perhaps her Tirosint and Cytomel might be a little bit too low, so that is inhibiting the thyroid function. I will say from somebody that has had a hypothyroid and they have lost their eyebrows, it is in some ways very hard to grow them completely all back. They will grow back a little bit but it is very hard to get them to grow back. But the hair thinning, once you correct for the thyroid, the hair thinning from low thyroid definitely does grow back. So that was my first stand out in that was Dr. Maki’s first standout was it is probably about the thyroid because, really, the doses of hormones that she is on is not very high and certainly not high enough to cause weight gain or making it hard to lose weight because her testosterone is pretty low, one milliliter, that is not a lot of testosterone but now she is starting to use it twice a day so maybe the two milligrams for her, individually, might be a little bit too high and causing a little bit of thinning. But it is not so much that it would cause trouble with the weight loss. Sure, hormones are all steroids. You take too many steroids, you are going to have weight gain and I have had definitely women gain weight from hormones because they are too high but her doses, really, I would not say that they are high enough to really have an impact.

Dr. Maki: I mean, certainly like you said, okay, too much progesterone, too much testosterone, too much estrogen. Okay, yeah, they can contribute to a certain amount of, what I would call, residual weight gain. You might gain five to ten pounds or maybe even four to seven pounds, but you are not going to keep gaining weight over and over and over because those hormones are not fat-storing hormones. They are steroids, right, so you got to be careful with them, but they are not going to cause perpetual weight gain. So she is afraid of gaining weight by raising the dose, but when–

Dr. Davidson: It sounds like she is having a tough time also losing it.

Dr. Maki: Right, which is every menopausal woman, for that matter, every perimenopausal woman’s problem because when the hormones decline is what makes it so difficult. It is not a matter of having too much of them. Now, I will say as a flip side of that, when a woman’s estrogen dominance, so she is still menstruating, she is producing an excessive amount of estrogen, she has got fibroid, she has got endometriosis, she has got all these things, now, that can contribute to the weight gain and in that situation. But it is not exclusive just to the female hormones. There is usually something else going on either cortisol high stress or insulin that is driving the weight gain. It is not a direct result of the female hormones. And honestly, her estradiol level is less than five, with static dosing using Bi-est where do you try to like to get that Bi-est level to?

Dr. Davidson: It does depend on the person, if they have a uterus if they have fibroids, but really less than five is like nothing in the bloodstream, they cannot even find it in the bloodstream. Usually, I like to keep it between thirty and eighty. When you have it between thirty and eighty that is really a pretty good dose. I have a few women that we have closer to a hundred or a little bit over a hundred but their endometrial lining of their uterus is nice and thin, they feel really good on that level, everything looks good, there is no risk factors associated but on the typical, I would say just in my patient population since 2004 of dealing with hormones, is between probably thirty to forty, up to eighty with 60 kind of being that little magic number for most of them.

Dr. Maki: Yeah. I was going to say fifty, myself. You are right. You do not want that number to be too high, maybe an upper end would be, depending on the woman between if she has a uterus, this is all about if she has a uterus or not, is somewhere between, let us say, seventy-five and one twenty-five as a range. Because if you give her too much, if you give her too much Bi-est, eventually, she is either going to have really uncomfortable breast tenderness, that is usually the first sign that does not kind of go away or regress, or she is going to eventually start having some spotting or bleeding problems. Now, the thing you realize, too, when you are on hormones, bleeding and spotting is kind of par for the course, right? It may happen at some point. It is okay. It is not an emergency, you do not have to run to get a transvaginal ultrasound. If it continues over time, then it is a different story, either the progesterone dose needs to go up, the estrogen dose needs to go down, or something needs to adjust there but those kind of modifications are fairly easy to do, and the woman’s body kind of tells us what the dose is going to be eventually, right? You do not start on a dose and stay on the dose, we always titrate, usually, everything all the time but the woman’s symptom picture and kind of how her body responds will give us an idea of where that dose should be.

Dr. Davidson: And this is a question we get from so many women is when they are going to be put on bioidentical hormones or they are going to be put on hormone therapy, they are terrified of gaining weight. And I get it, it is hard to lose it and I am a perimenopausal female myself at this moment that hey, I do not want to do anything that is going to help contribute to weight gain. And so just to kind of let women know is, the bioidentical hormones, when you are using a Bi-est, when you are using sustained-release progesterone, when you are using a tiny tiny tiny tiny tiny little bit of testosterone, that is not going to make you gain weight. If anything, I find that it helps women lose weight.

Dr. Maki: Right. It might not help with the weight loss directly but as I said a few minutes ago, what is perimenopause and menopause? The female hormones are disappearing, some women have lots of stress in their late 40s to their early to mid 50s so you have this kind of uncontrolled environment where there is no balance between the sex hormones and the stress hormones and really that is why women go through all of these changes because it really comes down to kind of unabated stress response. They do not sleep, they are taking care of the kids, they are working full time, they are exercising too much, all the things that we talked about in this podcast basically manifest in them having this inability to lose weight, keep gaining weight, they cannot sleep. They have all these things going on. It is kind of a nightmare scenario that is because of the lack of hormones, the lack of female hormones, specifically estrogen and progesterone. I want women to think that estrogen, like you always say, I am biased, I think testosterone is the best hormone, but you think estrogen is and for a woman that is the best hormone, right? That is exactly that, that is what makes a woman a woman. In some ways, as long as it does not become a runaway freight train, the more of it she has the better she feels, right? The more of it she has the better she looks within reason, I mean, I am talking weight-wise because estrogen is relatively a slimming hormone that you know helps you keep certain enzymes. There is an enzyme literally called lipoprotein lipase that estrogen basically turns that enzyme off which basically tells our body to store fat and cortisol activates that enzyme. So the more cortisol you have, this lipoprotein lipase– that is why stress makes us gain weight because it activates this enzyme and it tells our body to– and if our insulin is high–

Dr. Davidson: Can you explain that again? You said that hormone – estrogen – turns it on or turns it off?

Dr. Maki: Turns it off.

Dr. Davidson: Turns it off, okay.

Dr. Maki: It turns off fat storage, but cortisol turns it.

Dr. Davidson: Got it, okay. So that lipase, our estrogen will turn off that lipase so they actually have a more estrogen will help reduce the storage of fat.

Dr. Maki: Yeah, right and that is also in the presence of insulin. Insulin is the gatekeeper when it comes to weight gain and fat storage. Now, we do not want to get into the debate. Neuroscience researchers say that weight gain and obesity is all in the brain and then all the low carb people say that it is all insulin. I think, obviously, it is a combination of both of those, it is not one or the other but they just argue back and forth. I heard a podcast on Joe Rogan thing they are just arguing, literally, back and forth, who is right, who is wrong and it was not about how to solve the problem, it was just arguing like a–

Dr. Davidson: Who is right and who is wrong. [laughs]

Dr. Maki: Yeah, right. Who is right, who is wrong as opposed to, “Okay. Well, what is the solution to the thing?” That is what we are all trying to figure out. Okay, we are all trying to figure out how in our complicated 21st-century environment that our genetics do not mesh well with how we live these days. That is why we have all these age-related diseases and it is all based on our lifestyle. All right, all the things that we deal with other patients, everything is related to our lifestyle. We do not sleep enough, we do not get enough relaxation, we do not eat right, we eat the wrong things, we are too stressed out, we are worried about the mortgage, we are worried about work, we are worried about all these things, and that manifests into, eventually, dysfunction, weight gain, disease, whatever you want to call it. So to say that hormones themselves, especially the female hormones, again, we have always say, when you are twenty-five, you have lots of hormone and lots of sex hormones for both males and females, that is when you are the healthiest in your life, right? If estrogen-progesterone actually cause women to gain weight by themselves, then every pregnant woman would literally blow up like a balloon, right? Because their estrogen-progesterone levels are just through the roof.

We do not even realize how high their hormone levels are when a woman is pregnant and to think that, and this is no criticism of Mary, by any means, but to think that a little bit of progesterone, testosterone, and Bi-est is going to cause that to happen, it just does not. Usually, those hormones are actually more beneficial in some respects. So in her case, we think that, not less is always more because there is a caveat to that, making sure that you have enough to make sure the dosing is right so that way her symptoms, whatever those symptoms might be, in this case, the hormones themselves are not going to help you directly lose weight. Although in some cases they can, we have seen that many times but it creates an environment for weight loss to actually happen. So some of those enzymes and receptors and different things get turned on and turned off and now weight loss is possible because you are not just swimming in cortisol all the time. That is really where those hormones kind of come into play and actually provide some benefit.

Dr. Davidson: Exactly. So like you said, when we first saw this question I am sure it made me think about a lot of women that I see, they are, they are concerned about taking hormones and gaining weight. So know that that is not the case. It is about balancing those hormones and then you are not going to gain weight on hormones. Sure, some conventional hormones, some of the patches, yeah, you are going to gain weight on that but when you are doing a Bi-est and doing it various ratios between 50/50 and 80/20, combining that with a little progesterone – or actually a lot of progesterone because I love progesterone, too, that is also my second favorite hormone – and then maybe a teeny tiny testosterone if needed, that is not going to cause you to gain weight. If anything, that is going to help a lot of those symptom pictures, help us achieve our goals, and then you feel better. When you feel better, you eat better. When you feel better and you are eating better, you might feel it and have more energy. You might be inclined to do a little bit more walking or a little bit more exercise. It all kind of comes together.

Dr. Maki: Yeah, right. Now, as we talked about earlier and we started off, the initial response was her thyroid dosing was probably not right or enough because she is still having some of those symptoms. Because she has had her thyroid gland removed, these types of patients always are on the highest dose. If we took a population of thyroid patients that were diagnosed hypothyroid either surgical, in this case surgical, or just diagnosed hypothyroid, they had initially had a TSH above four point five, that the ones that have had their thyroid gland removed are always, at least in our practice anyways because we know how to dose properly, proportionally higher than everybody else. And this particular case, I think that is exactly the same thing is happening. I think that she just really underdose in the thyroid and maybe for this situation, Tirosint and Cytomel might not be our first choice or first option. I know it is becoming very popular, this kind of combination. We like to do that a little bit differently and like you said, too, the TSH becomes almost irrelevant because she does have a gland anymore. The TSH comes from the brain. It comes from the pituitary that stimulates the thyroid gland, well, if there is no more thyroid gland there, we do not need to worry about the TSH. You cannot dose this kind of a patient based on the TSH alone. You have to look at some other data or some other numbers and the free T3 is something that should be– the more important hormone that should be tracked and followed and monitored.

Dr. Davidson: Exactly. So like you had talked about the adrenal glands with cortisol. We had talked about the– basically the sex hormones with the estrogen and progesterone, then we have got the testosterone which on a side note, I kind of consider more of an adrenal hormone for females, and then we are talking about the thyroid. It really is a collaborative process here on making sure all of that is balanced together in terms of getting the goals, especially for weight loss or preventing weight gain.

Dr. Maki: Yeah, right. Yeah, and that is really complicated. Like, seriously, that whole symphony of hormones, really, we are talking lots of different, very powerful, what we consider, metabolic hormones: insulin, cortisol thyroid; and then your secondary sex hormones: estrogen, progesterone testosterone. There is a lot going on there. But always, the hormones we cannot live without; insulin, cortisol, thyroid, those hormones dictate everything else in most cases. So when we are seeing things like this, those have to be addressed in some way. We always kind of talked about that cake foundation. The secondary hormones are there to kind of round everything out and maybe alleviate certain symptoms, but if you do not deal properly enough with those metabolic hormones then you are kind of walking uphill backwards.

Dr. Davidson: So in these types of cases, we would dial back; focus on those adrenals, the cortisol, the insulin which comes from the pancreas; and then focus on the thyroid. Then like Dr. Maki had said, is use the sex hormones, the secondary sex hormones like the estrogen and progesterone, as the frosting on the cake. We have got to build the foundation first, otherwise, they might feel good for a second but then ultimately they are not going to feel good and you are back to the drawing board.

Dr. Maki: Yeah, and even cases like this, and I am not saying exactly in Mary’s case but a case like this, even rhythmic dosing where the estrogen-progesterone doses actually go up quite a bit higher actually can help on that weight loss side and especially if there is changes to the hair. Getting the hair to change the way you want it to, especially in a menopausal woman, is very difficult, right? That is a really challenging problem. But again, that is because of lack of hormone. In this case, it could be female hormones, it could be thyroid hormone, we do not know her stress situation, it could be too much cortisol. So, again, part of a way to offset some of those perimenopausal and menopausal symptoms is making sure that there is a buffer in some respects, the female hormones. I do not know how many times I have heard it because I have asked the question on purpose but the women that are in their late 40s, early 50s that start on BHRT, the female hormones become their stress buffer.

Their stress tolerance goes down, they do not have the capacity they did even a few years ago because those hormones are gone. You give them some of those hormones and all of a sudden now they can start to handle their, sometimes, very chaotic lives. And at least they are able to hold their head above water, they are not drowning. Maybe they are moms or maybe it is the motherly instinct but women tend to give a lot of themselves to everybody else around them and then themselves kind of get sacrificed, right? So they take care of the husband which can sometimes just be a bigger kid, they take care of the kids, they take care of the work, they take care of all these things, and they kind of get sacrificed and that just raises stress and then all these things start to manifest off of that. So BHRT, in some ways, is a way to kind of help empower women, help them give back the tools that they need, in this case, hormones, to be able to kind of run the show, run their lives effectively, efficiently, and hopefully be happy at the same time.

Dr. Davidson: And not to overwhelm the listeners here, so not to overwhelm any of you, Dr. Maki is right. This is really complex, but the cool thing with BHRT is we have so many different options. I have a lot of patience, but I certainly– not everybody takes the same thing. It is so individualized because we have so many options to adjust for that individual. So, definitely with Mary there just needs to be a little bit more adjustment, maybe dial back, look at the picture a little bit differently, look at those adrenal glands – which is what we do with all the patients. So it is just finding that right balance for each individual.

Dr. Maki: Yeah, and I would suggest as just something very simple is just look at the free T3 level on your most recent lab tests. For her or for anyone else that has a thyroid problem, that has a reference range, depending on the lab, of two point three to four point four. Some labs it is two point zero to four point four or four point two. But two point three to four point four, we always want that number to be either high-end normal or in some cases even a little bit above the reference range because especially in a case like this where her thyroid gland is removed, we want that number to be as high as possible so she can actually function in the best way possible. If her free T3, in this particular case, if her free T3 is in the twos, that is part of the problem. That number needs to be in the threes, the low fours, or even the mid fours or above. And I know there is some discussion at some of these different endocrinology associations that they are contemplating increasing the reference range for people that have been on medications, specifically the free T3 level, because the medications kind of change all that.

Unfortunately, doctors, they use numbers a little bit to dogmatically that if your TSH is too low, they lower the dose, if your free T3 is too high, they lower your dose. They do not take the patient into consideration enough. The patient, when it comes to thyroid, the patient will always know when they are overmedicated, always before the doctor does. You do not need a lab test to tell if a patient is overmedicated because when it comes to thyroid, they will have some very classic symptoms: maybe an increase in heart rate, they will have some anxiety, they will have insomnia, they will have some very specific things that tend to show up that are related to that medication that if they do not have those but their numbers do not look right, it could be when they took their medication based on those blood tests. And I know there is some discussion out there, too, about medication timing on blood tests and that is a whole other discussion. I think we just did a podcast on that probably about three or four episodes ago because you cannot just go to the lab whenever you want or take it 24 hours before. There is a whole process there that we run our patients through so we can see the change of a baseline to improvement. And if you are not taking your medication properly the way that we recommend then you are getting skewed results and you might be either overdosed or underdose depending on how that plays out.

Dr. Davidson: Exactly. My goodness, with thyroid, I mean, and all the thyroid testing and we could get into reverse T3, we can get into Hashimoto’s there is so so much which we definitely will and we have not past podcast. But I would say just to kind of wrap this one up for Mary what would you say?

Dr. Maki: Like I said, I would just say go back to her practitioner and I would just have the thyroid kind of looked at a little bit more. She does not list her– the most important thing of this entire question is what is her Cytomel and what is her Tirosint dose and she left that part out.

Dr. Davidson: And that is because, just like a lot of females, they are wondering about the hormones. “Am I going to gain weight?” So, know that bioidentical hormones, when you are doing a Bi-est, I am going to say it again, with that progesterone, it is not going to make you gain weight. I mean, sure, if somebody was, maybe, thirty-eight and taking some of these bioidentical hormones when they do not need them because they have ovaries and they are functioning, yeah, that is going to make, you know– put too many hormones on top of hormones, that could potentially be a steroid effect and cause weight gain. But for a postmenopausal female, that is not going to be the cause of the weight gain. If anything, it is just like, you know. Wonderfully what Mary’s practitioner did was actually increase up her doses to kind of help buffer that

Dr. Maki: Yeah, right. I do like her prescriptions like those prescriptions are actually very good. I would agree with a lot of what she is doing but it comes down to dosing on all fronts. It comes down to the estrin dosing, the progesterone dosing, the testosterone dosing. I like to see her testosterones only at one milligram. That is great. So she is not getting a truckload of testosterone for no reason, but she does not put in the Tirosint or the Cytomel, and in this particular case, because of her history, the dosing of those two things are the most important things to kind of re-evaluate. Focus on those and then come back to the female hormones and then hopefully there is a different result over the course of another one to three months or something like that, so. Do you have anything else to add or is this one good for now?

Dr. Davidson: I think this one is really good.

Dr. Maki: Yeah. So again, if you have any questions yourself, you can shoot us an email at help@progressyourhealth.com. That is help@progressyourhealth.com. Like I say on every podcast, we cannot get to all questions, but we do like compliments, so that might help your chances of– we do kind of look at all of them and kind of decide, and the ones that either relate to cases we already have or ones that we think that we could have a good discussion about, like this one. I think this is a really good discussion. Please reach out and we will do what we can to help. Until next time, I am Dr. Maki.

Dr. Davidson: And I am Dr. Davidson.

Dr. Maki: Take care. Bye bye.

The post Can BHRT Cause Weight Gain? | PYHP 105 appeared first on .

Where Do I Apply Testosterone Cream As A Woman? | PYHP 104

Dr Valorie Davidson and Dr Robert Maki — Thu, 28 Jan 2021 04:33:04 +0000

Monica’s Question: Hi, I have been prescribed testosterone cream and I have been advised to apply it to my inner thigh. I was wondering, in doing so, will this reverse the results of my laser hair removal on my bikini line? As per you stated that someone had a similar experience to this. Should I apply it there or should I apply in another area? Thank you.

Short Answer: Applying testosterone cream to the mid-inner thigh should not affect the bikini line. However, the hair in the area of where the testosterone cream is applied will get darker. There is no real way to avoid the hair from darkening. Switching thighs can help, but it will probably still darken in both areas.

PYHP 104 Full Transcript:

Download PYHP 104 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 summer is moving along very quickly I cannot even believe it is almost the middle of August already.

Dr. Davidson: I know summertime is so fun in Washington.

Dr. Maki: We have got rain in the last couple of mornings which actually has been– We had quite a bit of rain in June at least it seemed like July was really nice and now the last couple mornings we had a really nice stretch with no rain at all. And now it was kind of nice actually with a little bit of drizzle in the morning. We have got this jungle in the back of our house. I know that you kind of went back there with little clippers and trying to– We have this little trail that leads up to another trail and you are back there a couple of days ago trying to clean up the trail.

Dr. Davidson: Exactly. We have a beautiful trail up there and it is funny because I always laugh with my patients that summertime. It is almost, even though it is beautiful, it seems like it is harder to exercise and eat well because it is almost like you are just having too much summertime fun. Where the holidays, you can be a little bit more diligent because the holidays are one day but it seems like summertime fun. So we have been trying to rain it in and do some more exercise and eating a little cleaner.

Dr. Maki: Yeah a little bit more leisure. There is definitely a different mindset. Summertime, you want to spend time outside like we have been doing a lot of hiking. There is this little place down where we are actually able to walk down to the ocean. Literally. It is a couple mile walk but we take the dog down there. He jumps into the- there are little rocks there and he jumps into the water. It is just adorable to see him dive off this little rock cliff and he is just not afraid of little waves out there and he just dives in it. Then we come back. So we have been doing a lot of those kinds of things. But it is kind of easy because of all that nice weather. It is kind of easy to get distracted on the diet and exercise side.

Dr. Davidson: So yeah, we have been working on that the last couple of weeks. Yes, trying to get up to the trail. It has been really fun. I definitely love summer. I hope- I wish it would never end, but I also love the holidays and all the different seasons. Hey, let us enjoy it while it lasts.

Dr. Maki: We are not going to complain too much about the rain. The least is it does not get cold and snowing. The rain, it gets a little gloomy but not a big deal. We still spend quite a bit of time outside. So we are going to dive into a question. Of course, for those of you that have never listened before, we like to do questions. We get lots of them. We would love to be able to answer all of them. But the more we do these podcasts, the more questions that we get. So we are getting further and further behind. But we are hoping that by answering a particular question written in a particular way by a particular person that had actually is able to help many many people at the same time that are listening. So hopefully, we are able to get to your question. If we do, that is great. If we do not, feel free to send us another email or something. We always like compliments. Not that we are judging or not that we are picking favorites. We like to pick questions that are relatively easy for us to answer. Ones that do not necessarily- We do not have to read too much anyway because we are reading them literally almost verbatim. We would change everybody’s name so we can kind of protect the identity that way. But that way it is in the person asking the question. It is literally in their words and then we can we can just kind of discuss it and talk about it.

Hopefully, that provides some value to everybody else that is listening that may have a similar situation or maybe they have a friend or a family member that is dealing with that and “Hey, go listen to this podcast.” That is how that’s how our business has grown over the years. It has always been through word of mouth. You and I- We are making a joke. I think it is from Ace Ventura. “Damn it Jim. I am already-” I think you originally said I thought that was from Ace Ventura and you said it is from Star Trek because you are a Trekkie and I am not. Right? I never really cared for Star Trek. I thought it was from Ace Ventura. I did not realize it actually came from Star Trek. When he was saying, “Damn it, Jim? I am a pool man.” or something. You and I were joking, saying, “Valorie, we are doctors not marketers.” or something like that.

We have a lot to learn on the marketing side. But nonetheless, our podcast, I think, is growing in a very similar fashion. Little by little, more people are hearing about it. We certainly do not have millions of downloads like the Joe Rogan podcast or some of the other big ones. But I think little by little it will start to keep growing. So for those of you are listening, we really appreciate it. We want to keep- Because this information is really hard to find and even within the alternative medicine, functional medicine, natural medicine space, it is even still hard to find which is some of the reasons why we are doing this. So this question is from Monica. So why do not you go ahead and read it for us.

Dr. Davidson: Exactly. We love the questions. If you have a question, trust me, there are lots of other women out there that have that same exact question. So this one is from Monica. “Hi, I have been prescribed testosterone cream and I have been advised to apply it to my inner thigh. I was wondering, in doing so, will this reverse the results of my laser hair removal on my bikini line? As per you stated that someone had a similar experience to this. Should I apply it in there or should I apply in another area? Thank you.” And we like this question because hey it is summer time and we are wearing shorts and bathing suits. Also too, laser hair removal costs a pretty penny. You certainly do not want to reverse that with testosterone cream.

Dr. Maki: Yeah, right. One thing she does not tell us is how old she is. It would be kind of interesting, not that that really matters much. But one thing that we do see, especially being in Southern California in Vegas for so long is that women sometimes that are too young are being given or they are not really the best candidate. They are being given testosterone and now from entering female that can- if they are given too much, that can cause some issues.

Dr. Davidson: Yeah, the cream is pretty gentle. Of course, you never do a testosterone orally because that is just really bad for your liver and your digestion eats it up, you do not absorb it. But the cream is pretty gentle. The pellets, I probably ran into more trouble with women doing testosterone pellets, because once you insert a testosterone pellet into your bum, there is no going back from there. It is just, you got to wait it out. And that is where you see- Because all hormones are promiscuous. If they cannot get into its own receptor site, it will find another receptor site. Hence, create more kind of hormonal imbalance. So I will see those pellets causing weight gain, acne, hair loss, anxiety and kind of feeling very anxious and overwhelmed. Two periods in a month, chronic periods, because testosterone and estradiol are almost very similar in molecular structure. But I would say the cream is pretty gentle and I do do cream in younger women that might be- which I would consider more adrenal insufficiency or adrenal fatigue which is a whole another podcast. But I do find that women with adrenal fatigue tend to have a little bit lower testosterone levels. So I would use the cream. And the cool thing is about the cream is if you get negative side effects, you just stop it. Then you can stop those negative side effects. But definitely, if you are going to apply a testosterone cream, where you apply it to if there is a hair follicle there, it can grow that hair follicle into a dark black or kind of hair growth.

Dr. Maki: Yeah. Usually with the cream, like you said, the benefit of the cream is that it is gentle and you can stop and start it whenever you want which is very good. So then it really depends on the dosing. What would you say- This is a rhetorical question. I kind of know this answer but just so for everybody else’s sake. What would you say is a range, a starting range and an ending range for most women that you prescribe testosterone for.

Dr. Davidson: Well, I always feel like less is best. You can always start off low and work your way up. You do too much of a good thing then you are backing out of these symptoms that you are having and you are not really achieving the goals that you are looking for. But definitely, I would start with even like one milligram of testosterone once a day and some women I go up to two milligrams, two and a half milligrams. Even twice a day, I have some women on five milligrams twice a day. It really depends on their blood work and their subjective goals that we are looking for.

Dr. Maki: Yeah, right. I have also find to you- Some women can tolerate a whole bunch of testosterone and some women are very sensitive to it. Now, like you said, with the pellets. There is a whole kind of list of side effects that can potentially happen from the side effects. With the cream, not so much but there are three cosmetic things which is this question is kind of alluding to. There are three cosmetic things that most women, if they are going to use a testosterone cream, they have to be kind of worried about. Why do not you tell everybody what those three things are.

Dr. Davidson: Well, the first one like I mentioned is hair growth. There is also acne and then you can have now- This is what everyone says. Well, if it causes hair to grow can I put it on my head and cause more hair, grow more hair?No, it does not work that way. It will grow a hair follicle anywhere on your body but not on your eyebrows or your scalp. And then also there is- So I guess there would be hair growth with hair loss on the head, acne, and then there is a fourth one where the cream if you put it on certain locations on your body, it could potentially get on other humans or other little humans or other pets or little fur creatures we have.

Dr. Maki: Yeah, right? Yeah, we have talked about that certainly with men like we like to use a- More so, me because I do with a lot of the husbands use. You and I see the wife and the husband comes later on. And he might be looking for testosterone and we use exclusively a rhythmic dosing method for men’s testosterone dosing and that the amounts that they use on a monthly basis now varies throughout the month. But that is a really big issue for both the wife, the kids, and the pets based on how much the male is using or the man of the house is using versus how much the woman is using. She is using like I say, you said one milligram that is a starting dose-

Dr. Davidson: Maybe 10, the most.

Dr. Maki: Right. Where men are using if they are using a static dose, it might be a hundred twice a day, a hundred milligrams a day. Might be two hundred milligrams a day, could be up to three hundred milligrams a day. With the rhythmic dosing, it kind of varies. That is a very particular schedule that they follow. But at certain times of the month, they might be doing close to three or four hundred milligrams and that could be somewhat detrimental. Now, this is not to scare anybody. This is not to freak anybody out and become neurotic about it. There are just a few things that a man can do. He can either use surgical gloves, take the gloves off, or just wash your hands with hot soapy water. And then there is no problem after that. If there is-

Dr. Davidson: I am going to apply it to the lower half of the body or someplace that would not come into contact, if you were to hug or shake hands.

Dr. Maki: Yeah, right. So she says here, she was instructed to apply to the inner thigh. We always recommend the inner thigh for women, especially women certainly are not going to have usually a lot of leg hair. For men, it can be a little more challenging because they obviously have a lot more body hair than females do. So we might- If a man does have very hairy legs, we might have him put it on the back of his knee something like that. But usually, for something like this and even estrogen, the inner thighs usually is the only place that we recommend.

Dr. Davidson: Now, in the case of Monica. I do this too. It is causing dark hair growth in that area and after you spent a pretty penny on laser hair removal, I do tell them to put it on the fat pad or the back of their knee. Like for me, I am dark-haired and I have got dark hair. So sure, if you are light, fair-skinned you apply testosterone cream, it could cause like a little more fuzzy like blond hair, fuzzy blond hair to grow. But for somebody that has dark hair like I do, you put it on the inner thigh. It could potentially cause a little bit of dark hair to grow on that inner thigh, which you can shave off, sure. But if you have had laser hair removal, sometimes you do not want that to come back then you have to shave it again because you got rid of it for a reason. So I do think that for those women I do say, you know, be careful put it on the back of your knee because we do have a really nice fat pad. But we do have some hair follicles right above that fat pad of the knee that could potentially cause that hair growth to grow. And just be careful if you are wearing a skirt or a dress or shorts where if you sat down on a chair, you could transmit it to some other inanimate object that someone else comes along sits on it and that could be transferred over.

Dr. Maki: Yeah, right, but the likelihood- Now, granted. It would depend on the dosing right? If you are at one milligram, if you are putting on in your inner thigh, it is not going to change the bikini line. It is just not close enough It needs- Usually that hair color change is going to happen. Maybe the growth and the hair color, the hyperpigmentation of that hair follicle is going to happen right where you apply the cream so the inner thigh in some ways is again and like you said unless you are wearing a skirt or shorts or something it is going to change the color especially like I am blond you are dark-haired. If I were to put testosterone on my inner thigh, it might, it does not happen in every case, but it might darken the hairs there. So now if you are blond hair and blue eyes, you are going to have darker patch of hair where you put that testosterone.

Dr. Davidson: You do not- and just hey, for full transparency, you put on testosterone cream and you have no dark hair and you are still just as fair on with that hair on your legs as it ever was. And you are right. And granted you are putting on a male dose of testosterone and it has not changed. So it really depends on the individual too, I think. But like Dr. Maki had mentioned, the dose one milligram of testosterone for a female, even if you have got as dark hair as I do, it is not going to really do too much of a change on your inner thigh as opposed to if you are doing quite a bit of testosterone. I know maybe now, you know here it is twenty-twenty. They do not- Most docs do not use that much testosterone in their dosing anymore. We are way back. I would say, maybe like two thousand thirteen or fourteen. It was very common for docs to give women twenty-five milligrams of testosterone.

Dr. Maki: I do not know if I agree with that because we still get people all the time that other doctors have put them on testosterone and they always use too much. I want to generalize because I think women doctors do that and male doctors do that. Male doctors tend to maybe do that a little bit more. They think that it is good for men and if a woman is complaining of low libido, they gave me a bunch of testosterone. Sometimes, those we talked on some other podcast, that is usually the worst thing to do because it just kind of magnifies some of their symptoms. But I asked you earlier, what is that range? One milligram to what? What is the upper range that you typically used?

Dr. Davidson: The highest I probably go is ten milligrams. Like you said, maybe I-

Dr. Maki: That is a pretty hefty dose though.

Dr. Davidson: But that is only maybe a handful more in menopausal females. I find that those higher doses where they might do five milligrams in the morning, five milligrams in the evening. They might be somebody that had been fairly competitive, athletically competitive in their younger years that they seem to run really well on those higher levels of testosterone. I mean, you are right. I mean, there are a lot of doctors out there still given women twenty milligrams, twenty-five milligrams.

Dr. Maki: Or inject- the pellets are injected.

Dr. Davidson: Pellet injection. I would like to think the trend is they are realizing that the side effects from that are happening fairly commonly that they would start to reduce. I like to think that the trend is going down. But maybe you are right, maybe docs are still putting a little bit too much. Because too much of a good thing, we all know, is not a good thing.

Dr. Maki: Yeah, right. And testosterone is not the predominant hormone and not to bag on anything else, whatever. We are just talking here and we are just basing all this on what we see and how we see women that come to us and how women play out. You have always said that if you are building a cake, for a woman, it is all about the estrogen-progesterone. The foundation is at the actual cake and the testosterone is always the icing on the cake. It is not the place to start. It is the place to finish. That is kind of the- maybe that is more of the trend is that women are being- and again, it is more problematic for menstruating women. Women that are certainly maybe in their early forties, mid-forties, later forties, testosterone becomes a big much more likely at that case, but I think like you said, it seems almost more appropriate for menopausal women.

Dr. Davidson: Like you would say, where you put the testosterone cream and I had said that earlier too is when it touches that follicle, it has the potential to cause hair growth. So if you are putting it on your inner thigh, down by your knee or kind of between mid inner thigh. That is not going to nest and granted, as we all know, the skin is one big membrane that sure that cream can move and change and maybe go to a different location. But it really, in my experience, I do not find that if you are putting that testosterone cream on your middle thigh, it is not going to migrate up to your bikini line where you had the laser hair removal. I do not find that it is going to migrate that far up there and really cause that hair to come back unless someone is actually applying it to that area.

Dr. Maki: Yeah, right, which they would not necessarily do on purpose. It would be a very unusual place to put it. However, like you said about dosing, now granted, ten milligrams seems- that is a one to ten milligrams. I think you are right. That is a range but the average, I would say would be what one hundred twenty-five?

Dr. Davidson: Yeah, exactly. Probably about two and a half, maybe three. But then on a side note about laser hair removal because I think it is really cool and it does work because shaving your legs, especially when your dark hair can be a pain. But some women will actually do laser hair removal to their entire leg. They do not just do it to the bikini line. They will do it to the entire leg. Sure, it is a process. It is pricey but it works that if you were to do like your entire thigh for that laser hair removal. it could potentially- I have had a couple of patients that have done that and that it started to come back.

Dr. Maki: Right. Now, the bigger issue to be concerned about. I think the inner thigh for Monica’s situation is still the best place to put it. It is not going to affect the bikini line.

Dr. Davidson: Or maybe the back of the knee or that fat pad on the back of the knee-

Dr. Maki: Or the back of the knee. Yeah. Those two places are fine. However, the thing that she has to worry about, as every woman using testosterone has to worry about, which is what we are trying to get across here is that it is about the dosing. And it takes usually about four to maybe even up to eight to twelve weeks for those three things to show up. The hair growth, chin, upper lip, sideburns, around the areola and abdomen below the belly.

Dr. Davidson: If it is too high.

Dr. Maki: Yeah, but the abdomen below the belly button. Those are the kind of the male secondary sex characteristics that are predominant in men. That is what happens from that androgen testosterone is an androgen even DHEA. So women that have PCOS, we have talked a lot about PCOS on here. We are going to talk about it in the future. That when a woman is producing her own with the what we call endogenous production for whatever reason her physiology is in a way, usually related to stress and insulin and all these things will talk about later on as well. That her own body is producing too much androgens, DHEA, and testosterone. Both of those can cause those three or four symptoms that we are talking about, hair growth, hair loss, acne. All those things that really women do not want. Those are- In some ways socially unacceptable. I am glad you do not have a beard, right? I am glad you do not have a five o’clock shadow. That would not be something appealing for a woman to have those things necessarily. So like I said, it can happen. If you are experiencing those, they call that hirsutism. That is a direct consequence of having that increase androgen production whether it is endogenous. Like I said, your body is producing it because of a imbalance in the physiology. Or it is exogenous, meaning that it is coming from outside. In this case, it is a prescription that is being prescribed by somebody.

Dr. Davidson: Exactly. So I would say, like you said, the dose is probably number one important. So if it is too high, it is going to cause some of those secondary characteristics you had and side effects you had mentioned, probably the dose. But do not- For females, ladies do not ever put your testosterone in your arms. That skin is too thin. It goes right into your bloodstream and then it is out. You need a nice fat pad to really- because all hormones or have a steroid or a cholesterol backbone, so they are all fat-soluble and trust me, I have seen a few women that came in as new patients sit down in front of me and they got hairy arms. I said, where are you- They are getting testosterone from another doctor. They are switching for whatever reason. I said, “Well, you need to stop applying your testosterone to your arms because that is why they are kind of dark and hairy.” One patient I had, she would only apply it to one arm apparently. So she had one hairy arm and one non-hairy arm. And she could not figure out why. I was like, “It is the testosterone cream.”

Dr. Maki: Well, the unfortunate part is some doctors tell them to do that. Even the pharmacies sometimes tell patients to do that. So we know that is- we are trying to do our public services. You just keep it to your inner thighs. You can alternate. You do not have to rotate too many locations. You can go back and forth. That is fine. You do not have to be changing locations all the time. The inner thighs, you can be a fairly covered area anyway. So if there is a little bit of hyperpigmentation to those hair follicles, you can, like you said, you can shave it off or no one is going to see it. Unless you want them to see it, whatever. But you are right. Even the estrogen cream biased and estradiol and all those things even progesterone, do not apply to your wrist. Some say will kind of rub it on your wrist like you are going to rub in perfume or something. We do not recommend that. The forearm, the upper arm, none of those locations are necessary. I have heard people even say rubbing it into their abdomen. I do not really like that idea much either. The leg is pretty much fat and muscle. As you said, all those sex hormones, DHEA, testosterone, estrogen-progesterone. Those are all steroid hormones. They all have that, like you said, cholesterol backbone. And so they absorb very well into that fatty tissue. Not to say everyone’s got fat thighs, but it is-

Dr. Davidson: There is a fat there.

Dr. Maki: Yeah, there is. There is a certain layer of subcutaneous fat underneath the skin and it absorbs very well. And it is relatively close to the uterus or the testicles. They are the ovaries, right? So you are close but your- I have had a lot of men too. They think, “Well, if I put on my inner thigh should I just put it on my testicles?” Men can be a little dumb sometimes. They should not be putting those things directly on the genitalia. That is just a really bad idea but sometimes you have to kind of- They think they have this wonderful idea but it ends up being a little bit counterproductive at the end.

Dr. Davidson: And just a quick note because I do not want to drone on here for you guys but are for everyone. But the fat pad, sure, that is important. So people say, “Well, hey, I got a little fat on my stomach. Why do I not put my hormones there?” But I think abdominal fat is so different than adipose or fat tissue elf everywhere. It has just a different effect. I think- So I do not like anything on the abdomen. And then just on a side note, it is just for females. It is just too close to the breast tissue. I do not want testosterone, even attempting to migrate or getting on the breast tissue just like even putting it on your arms or people put it on their inner upper arms and let us say, you put it on after a shower. And you might not put on your shirt or your top yet. And your arms can touch your breasts and I just do not wan any kind of testosterone or estrogen or those kinds of hormones touching the breast tissue. Just because that tissue in itself has got its own- But I kind of, I do not consider it volatile but it has got its own harmony that we do not need to have right there.

Dr. Maki: It is not that those hormones are directly dangerous. Right? Our body makes those hormones for good reason. We are very healthy when we are twenty-five. We have lots of hormones. As those hormones begin to decline is when disease shows up. So we are not saying that those things are directly dangerous but just like men putting testosterone on their testicles. We do not want to put those hormones on a hormone-sensitive tissue.

Dr. Davidson: That is a great way of saying it, a hormone-sensitive tissue.

Dr. Maki: Yeah. You would not want to put it right over the abdomen where your uterus is. You would not want to put it on the breast tissue directly. We would not want to put it on all those kinds of areas. So the leg is kind of in some ways like an inert body structure. There is nothing too vital around it. It can still get into the bloodstream which is what we want. And then it can have its kind of subtle effect on the different tissue types in the body. The brain, the breast, the testicles, muscle, whatever the case might be, without having that direct contact with that particular hormone. So now people can be safe and assured that they are doing it the right way. And then there is not all this confusion of all these different locations on where they are supposed to put it. So I think in Monica’s case, I think we have kind of decided or have hopefully communicated well, the inner thigh is still the best place to put it and your bikini line or I am sorry or the back of the knee. And the bikini line should be safe.

Dr. Davidson: I agree.

Dr. Maki: Okay. So again, if you have any questions, you do not want to post it on our- everyone kind of finds our different episodes or blog posts and they write comments. You do not feel comfortable with that, you can always send us an email at help@progressyourhealth.com. Again, that is help@progressyourhealth.com. No, one thing we have not asked before, if we do answer your question on the podcast, please we have not asked for much necessarily, but we would like, if we do answer your question to come back and give us a review on iTunes or whatever platform it is that you are using. That will as it says on our outro, most people do not listen to intros and outros very much. They might skip past them but it does help us kind of grow organically and you find this useful, share with your girlfriends or your family members and we will kind of grow together. And the more that happens, the more people we can help. And that way everybody benefits.

Dr. Davidson: Thank you so much.

Dr. Maki: All right, until next time. I am Dr. Maki.

Dr. Davidson: I am Dr. Davidson.

Dr. Maki: Take care. Bye-bye.

The post Where Do I Apply Testosterone Cream As A Woman? | PYHP 104 appeared first on .

Can Estriol Cream Cause Constipation? | PYHP 103

Dr Valorie Davidson and Dr Robert Maki — Thu, 21 Jan 2021 05:26:09 +0000

Mary’s Question: Hi. I just started estriol cream a couple of weeks ago. I am fifty-three years old and have been told I have PCOS for the past twenty years with a history of absent periods, heavy facial hair growth, and moodiness, and PMS. I have managed my PCOS through diet change, supplementation, and exercise. And I am told I am quite healthy. I began taking the estriol cream for bladder urgency and frequency and for the mucous membrane support for vaginal dryness. Sex had become very painful. I am experiencing some really wonderful positive benefits from the estriol. And in some ways, I realize I have probably been short of this for many many years likely due to the malfunctioning of my ovaries with the PCOS. The skin over my shinbones that has always been flaky no matter how much I moisturize, now, is soft, smooth, and supple for the first time in many years. The skin on my elbows, knees, and heels is softening. And it seems to have helped my skin tremendously. Even my facial hair is coming in much lighter. It seems to be reducing my belly fat in some ways. It is kind of a miracle. And I wish I had known about this years ago. The possible deal-breaker here is that I have become so painfully constipated over the past few weeks. And the estriol cream is the only thing that has changed. I also take bioidentical progesterone in a troche form which I have been taking for about ten years without a problem. The estriol is the only thing that has changed. The only time I can remember being this consistently constipated over a long period of time was during my two pregnancies. Any thoughts?

Short Answer: For constipation, the common advice is to drink more water and eat more fiber. However, for some, this does not work. It may seem strange to think that bioidentical hormones could impact digestion, but it is certainly possible for either progesterone or estrogen to cause someone to become constipated. We look at constipation as being a liver issue. Taking hormones can put a slightly extra burden on the detoxification capacity of the liver, which can slow down digestion.

PYHP 103 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 am Dr. Maki.

Dr. Davidson: And I am Dr. Davidson.

Dr. Maki: So how is your summer going?

Dr. Davidson: My summer is going great, although it is already August. So I feel like it is almost over.

Dr. Maki: Yes. 2020 has been such a roller coaster. But yes. Weather is good. We are surviving everything.

Dr. Davidson: How is your summer going?

Dr. Maki: Well, it is a rhetorical question, because I know exactly how your summer has been, because mine has been pretty much the same as yours. So I cannot complain. But you are right. It is going by way too fast. I cannot believe it is already August. But we still have a couple of months of nice weather before the rain comes.

Dr. Davidson: And even then here in Washington, it is still really beautiful.

Dr. Maki: Oh, yes. Yes. Yes. The rain is not as bad as it sounds. I will take the rain over the snow any day. I will take the rain over the cold any day. And we still get out, and we still do a lot of hiking. Even in the wintertime, we spend a lot of time outdoor. So you bet. That makes it fun.

So on this one, we are going to do a question that just came in, one of the comments in the website, as I thought this would be kind of an interesting one, one of these kind of secondary, very female-specific problems that tend to come up from time to time, quite frequently, actually.

Dr. Davidson: So I am going to go ahead and read the question. This is from Mary. It says, “Hi. I just started estriol cream a couple of weeks ago. I am fifty three years old and have been told I have PCOS for the past twenty years with a history of absent periods, heavy facial hair growth, and moodiness, and PMS. I have managed my PCOS through diet change, supplementation, and exercise. And I am told I am quite healthy. I began taking the estriol cream for bladder urgency and frequency and for the mucous membrane support for vaginal dryness. Sex had become very painful. I am experiencing some really wonderful positive benefits from the estriol. And in some ways, I realize I have probably been short of this for many many years likely due to my malfunctioning of my ovaries with the PCOS. The skin over my shinbones that has always been flaky no matter how much I moisturize, now, is soft, smooth, and supple for the first time in many years. The skin on my elbows, knees, and heels is softening. And it seems to have helped my skin tremendously. Even my facial hair is coming in much lighter. It seems to be reducing my belly fat in some ways. It is kind of a miracle. And I wish I had known about this years ago. The possible deal-breaker here is that I have become so painfully constipated over the past few weeks. And the estriol cream is the only thing that has changed. I also take a bioidentical progesterone in a troche form which I have been taking for about ten years without a problem. The estriol is the only thing that has changed. The only time I can remember being this consistently constipated over a long period of time was during my two pregnancies. Any thoughts?”

Dr. Maki: Oh, yes. So this one, again, women being constipated, of course, is a very common problem. But the fact that she added the estriol in and then it kind of started after that is a little bit not typical for the most part. We would expect her to be constipated before the estriol and/or the progesterone, and the bioidentical hormones actually helping that situation. So I thought this would be an interesting one for us to kind of hash it out a little bit.

Dr. Davidson: Yes. And we are all unique individuals. So what might work for somebody or somebody might have a different symptom compared to the person next to you. Everybody is different. But like Dr. Maki said– and I can even attest for myself. Hopefully, this is not too much TMI. But constipation is really common in females. I do not know if it is so common in males. I always laugh with my female patients saying, “Men can go to sleep. Men can go to the bathroom. And men can lose weight very easily.” Whereas, ladies, we have a tendency to go the other way on that.

But I will just say, just from personal history with constipation, that is not fun. But she is having so many positive benefits from this estriol that really in terms of constipation, we could probably find some other resource to help her with that while she can still continue to use the estriol.

Dr. Maki: Yes. Right. Well, it brings up a couple of things. She mentions that she was really constipated during her pregnancies. Of course, as we all know, when a woman is pregnant, her hormone levels are just through the roof, lots of estrogen, lots of progesterone.

So it makes sense, not only from all the hormonal change at pregnancy, but also there is a lack of space, especially as the growing baby is getting bigger, there comes the space issue. Obviously, I have never had any children myself. But we have talked to a lot of patients. And they have all kind of talked about constipation, when you are pregnant, it is kind of par for the course.

But the fact that she has added in the estriol – and, now, that constipation is coming back – makes me think about liver function. What is going on with her liver? Granted, there is probably some bowel changes from adding in that estriol. But it makes me think that actually – and she does not say what the dosage is; I would be really curious to know what the dosage is – that a lot of times, even though you added anything that it made it worse, it is just an indication that she needs more of it to actually help to kind of alleviate some of that.

But, like I said, there are some other tips and tricks you can do to curb the constipation in the meantime.

Dr. Davidson: Exactly. Estrogen is an amazing hormone, the best hormone in the whole world. And there are three different estrogens: the estrone (E1), estradiol (E2), and then estriol, which we are talking about here, (E3). And it is very gentle.

So what I am thinking with that estriol, it really does not sound like a coincidence if nothing has changed, and she is getting this terrible constipation from just adding this in the last few weeks. It has got to have some connection there.

But, like I was saying, estrogen is a little funny. And sometimes, if you give more, the symptoms go away. And then sometimes, if you give less, the symptoms go away. Estrogen has to be right smack in that nice little balance to get the goals that you are looking for, if that makes sense.

Dr. Maki: Yes. Right. Yes. For example, I had a patient last week. I started her on some estrogen cream. And when the body gets a taste of that estrogen, that is what makes a woman woman. As you say, it is the best hormone. I would beg to differ. I think maybe testosterone might be a little better. But I am biased in my own way.

But when the body gets a little bit of that hormone, it wants more of it. So the cells tend to soak it up very rapidly. And now, your body is asking for more of that hormone. That is why sometimes when you think you should actually cut back, because it made something worse, it is actually an indication to lean into that, and use more.

That is what it made me think when I read this question, that instead of cutting it back or getting rid of it, add a little bit more, try to palliate that constipation in the short term. We will talk about some of those ideas here in a minute.

But she is fifty-three. She never used it before. She has had some wonderful benefits. And for a woman – and this is something that I say all the time; I know you do the same – it is not about using too much. It is making sure, like you just said, that you actually have enough.

And I think that, even from a practitioner’s perspective, there is a lot of fear using estrogen because of cancer and everything like that. But the estrogen itself is not something to be afraid of. You just have to make sure you have enough of it or to do what you really want it to do.

Dr. Davidson: Yes. Exactly, to have that balance. And you had mentioned about the liver function. Mary, obviously, is very healthy. She has even been told she is very healthy. She works on her diet and her lifestyle and supplementation. But when you are breaking down estrogen, as you break down any hormone, it turns into different metabolites that it could be that her liver just needs a little help to process these estrogen metabolites that it did not have to deal with a few weeks ago before she started all these.

Dr. Maki: Yes. Right [clears throat]. Excuse me. I would probably assume as well, too. She is not our patient. If she was, we would not probably be talking about her, because that would probably not be appropriate necessarily. But the fact that this is just a random question and we are all here for educational purposes, we are just trying to educate, right? We are not giving any medical advice or anything like that.

But if she is our patient, we would, like you said, do some palliative things. Certainly, everyone knows there are different forms of magnesium. You can use magnesium citrate, magnesium hydroxide. There are a few things you can use to basically create a kind of an osmotic laxative effect, osmotic meaning kind of basically water. You bring water into the colon by using some of those minerals. Vitamin C can do the same thing. And now, you kind of hydrate the large intestine. And it makes it easier to actually have a bowel movement. You are not, yes, making it so difficult. Or you are skipping multiple days in a row.

I mean I have had. I know you have as well. Women, over the years– and they will sometimes only go to the bathroom one or two times a week or two or three times a week, when literally you are supposed to go every day, if not, multiple times a day.

That is where I think, you said earlier, where men and women are completely different. It is very unusual to hear a man that is constipated. But it is very common to hear that a woman is constipated.

Dr. Davidson: And like you said with that magnesium, I mean I laugh with patients, because I take magnesium every night. Magnesium is literally a girl’s best friend. We all like diamonds. But magnesium is a girl’s best friend.

And like you had said, I like the citrate, in particular, because I do think that is also a nice additive for bone density. But it does help the large intestines pull in that water, so the stool becomes, I guess you could say, more liquidy or more fluid-bound, so it is easier to come out the next day.

It is not like a stimulant like some of the over-the-counter medications for constipation, even some herbs or stimulants, which can cause a lot of cramping and some bloating. But the magnesium I think is a nice, really safe alternative.

Dr. Maki: Yes. Even some of the colon formulas, some of the detox products, they will put Senna or Cascara Sagrada which are actual herbal laxatives. And those things should not be used on an ongoing basis, maybe once in a while, maybe temporarily.

And most of the time, when we look at chronic constipation, it is either a liver issue, right? That is why this one kind of brings up liver for me. She added in something different, even though more than likely that estriol dosage is probably just a couple of milligrams. I am actually surprised that it had such a dramatic impact. But again, that still makes me think about the liver function, in general, because she added in this new variable that was not there before.

Coffee, alcohol, all those things are always putting pressure – daily dietary pressure – on the liver which then can slow down. If you think of the digestive tract, mouth to anus, it is kind of like a conveyor belt. The liver is kind of the rate-limiting step. It controls how efficiently that conveyor belt moves. If you put too much pressure on the liver, then that conveyor belt does not usually work as efficiently as it should. And now, things get slow down. As a result of that, people get constipated.

Dr. Davidson: And we are exposed to a lot of stressors in our life, fumes, car exhaust. So working on your liver or doing a nice liver support can help anyone. This might be a good thing to use with women that have constipation when they are taking estrogen or estriol.

Dr. Maki: Yes. Right. Even hemorrhoids, hemorrhoids is a really common problem. And there is not really a lot of good treatments for that. But the same thing, if you have hemorrhoids, the approach to that – or, at least, part of the approach – is to fix your liver.

Now, when I say fix the liver, there is not necessarily a disease there, right? You can do blood work. And liver enzymes are normal and all that kind of stuff, at least, most of the time. Sometimes it is not. Maybe somebody has some kind of minor liver thing going on. But you help to improve what they call the functional capacity of the liver making sure all those enzymes of the liver has to deal with in process and hormones and food and all those different things. You are just helping the efficiency of the liver. So now, again, that can very well just able to work effectively.

And if you got hemorrhoids, people think that hemorrhoids are related to the constipation. But I think the hemorrhoids are somewhat a result of the constipation. But you can have hemorrhoids and not be constipated. And you can be constipated and not have hemorrhoids. It can kind of go both ways. One does not necessarily cause the other.

But the liver is a central component of both of those, at least, in my opinion. If you can look at the physiology, you will understand how the physiology works. And we are not going to get into that right now. But it certainly plays a role there.

Dr. Davidson: And in talking about detoxification when you are thinking estrogen, estrogen metabolites, that doing some DIM or – what is it – the Indole-3-Carbinol, it is a great way to help with estrogen metabolites. And they are all basically derived from cruciferous vegetables. So that can be another option to help with women that have that constipation from estrogen.

Dr. Maki: Yes. And the other thing, people automatically– if you go to your doctor because you are constipated, the only thing they tell you is to drink more water and to consume more fiber.

Now, the water part, maybe true, right? But all we ever really tell our patients is as long as your urine is clear, right, there is no yellow to it. Maybe the first or your morning urine is a little yellow. Then as you start drinking water through the rest of the day, then your urine is going to be basically a clear color. Then you know that you are not dehydrated, and you are probably not necessarily overly hydrated. I do not think that people have to worry too much about being overly hydrated, maybe in some circumstances.

But the fiber component, you start using psyllium husk which is what most fiber products are. If you are already constipated, that usually just makes it worse. You want to be a little careful with consuming all that fiber, because you want things to be moving before you add all that fiber in except maybe some gentle plant fibers like some cooked vegetables or figs or dates, things like that. But the psyllium husk, it can be like a big blob of– it just does not work very well. It does not have that kind of cleansing process. It can just kind of make things more backed up than you really want them to be.

Dr. Davidson: We have mentioned about the magnesium. That is bringing the water into the large intestines. A lot of doctors will recommend trying to almost, in some ways, make the stool a little bit greasy. So I will say, “Hey, take some coconut oil in the morning.” Sometimes that can be enough to kind of get a little bit more of that greasiness. I hope that is not a weird way of saying it.

But for the stool, a lot of them, doctors, will recommend MiraLAX which you do not want to take a bunch of MiraLAX. But the goal behind that is to kind of lubricate the stool where I think you can just do that from good essential fatty acids or medium chain triglycerides like coconut oil or MCT oil.

Dr. Maki: Yes. And not to mention, too, when you consume fat like that, whether it is butter or coconut oil or olive oil or avocados, you are forcing the liver to release bile. And bile, by itself, is a wonderful laxative. In some ways, that is where it really makes it easy. And that is why people that have gall bladder problems, they might be constipated before they get their gallbladder out. They are really constipated after the gallbladder is removed, because that bile surge is no longer there anymore.

Based on her overall statement, Mary, I am sure her diet is probably fairly good supplementation. So she was able to kind of whittle it down to this one variable. But she kind of refers to it as being a deal-breaker. If her lifestyle is that good, some of those dietary things are not there – not too much coffee, not too much alcohol; there is not a lot of pressure on her liver – then she should be able to remedy that with a couple of things we have already said.

Dr. Davidson: No. I think that is a great thing, because, like you said, estrogen, like I said, it is the best hormone in the world. So we would not want to necessarily take that away and then lose some of the benefit. At the same time, like you said, finding some healthy tips and some ways around it.

And we have lots of women that are constipated that are still menstruating. So you cannot take their estrogen away from them, because they are actually making it. There are lots of little tips and ways.

And I really appreciate Mary sending that question out, because sometimes I think we see a lot of these symptoms all the time. But when we got the question, I was like, “Oh, yes, of course. Right.” But we do not put it together to talk about it on our podcast.

Dr. Maki: Or we take it for granted sometimes, because we are always dealing with these kind of challenges. But yet, this is something that probably millions and millions of women are dealing with or, at least, hundreds of thousands. How many women that we talked within our practice are having this kind of digestive issues? That is why when you go to the drug store or the grocery store, there are two rows full of digestive relief products whether it is on the upper end or the lower end or everything in between.

Dr. Davidson: They are probably two aisles, right?

Dr. Maki: Yes. Literally, two aisles of products that help people with this kind of problems, because they do come up. And they are very very common.

But this one was interesting just because it is a little ironic. Usually, I would expect someone’s constipation to improve with the hormones. In this case, it actually got a little worse.

So Vitamin C can be used a lot of times to what they call bowel tolerance. If you take enough of it, it is going to cause some loose stool. And then, of course, the magnesium is something that we use quite often. And you cannot really take too much, but you have to make sure you take enough. Taking one or two capsules might not necessarily be enough. If you are looking for a milligram amount, what would you say, probably between four to eight hundred milligrams?

Dr. Davidson: Working with women, it is all over the board. Everybody has to have their personal dose. There are some women, 150 milligrams of magnesium citrate does the trick. Other women, 1,000 milligrams of magnesium does the trick.

For me, personally, myself, I usually end up going anywhere between four hundred to eight hundred, of course, depending on how much water I drank and how much fibrous foods I have eaten and if I have gone for an exercise or walk. So everybody is kind of a little bit different.

And on a side note on that, of course, when we go traveling, as ladies, we will always say, “I am constipated.” You can never be constipated. But you go on vacation, and you get constipated, because that is really common. Then I would say, “Well, you increase up your magnesium a little bit more by another 150 or even 300 milligrams.

Dr. Maki: Yes. Right. Like you say, a capsule of magnesium is usually going to be anywhere between 50 to 200 milligrams, at the most. One hundred to one-fifty seems to be more average. So I usually just tell them to do it by the capsule. If you start with two and if it does not work, the next night, then take three. And if that does not work, then take four. And if that does not work, then take five.

Usually, women, capsule-wise are going to be somewhere between two to four capsules which would put them between, what, 300 to 600 milligrams. But I like your range a little bit better. The four to eight hundred, it seems a little bit more appropriate.

Dr. Davidson: Yes. And the magnesium does not cause as much cramping as the Vitamin C. So a lot of women will say, “I cannot take that much Vitamin C, because it causes a lot of cramping.” Or, “I am up at two thirty in the morning with cramps.”

Same thing with the Cascara and the Senna, some women are really sensitive to that that it just causes too much cramping or aloe which I love to use, aloe root, with patients. But sometimes, for some of them, it is just too stimulating. Just like fiber, they take fiber, and they are just bloated. And then they do not go to the bathroom.

So everybody just needs to kind of find what works for them, because everybody is so different.

Dr. Maki: Yes. Right. Yes. I know the one aloe product that we use, there are two dosages. The higher dose, the four-fifty, is usually way too strong.

Dr. Davidson: That is the holy moly dose.

Dr. Maki: Yes. Yes. That one you–

Dr. Davidson: Let us go.

Dr. Maki: Excuse me [clears throat]. That is the one that you use for a really significant problem. You do not want to just give that to anybody, because they are going to have a real–

Dr. Davidson: But then in some women with really tenacious constipation, it is like a miracle. So everyone is so different.

Dr. Maki: Yes. Yes. Yes. So you kind of tread lightly. You kind of experiment a little bit. Be a little cautious. Be a little conservative. But then eventually, you will find the amounts that actually work. And then it is relatively effortless. Then things are just moving. The conveyor belt is moving like it is supposed to. There is no straining. There is no pushing. It is not difficult in any way. It is more normal the way that it should be on a day-to-day basis. So do you have anything else to add? I think we covered this one pretty well.

Dr. Davidson: No. But I think this is really great. Thank you, everybody, for reaching out and sending questions. We might not get to all of them, but we certainly do try.

Dr. Maki: Yes. And if you are looking for some help, like I said, like you just said, we can answer all the questions. But we do like compliments. You can send us an email at help@progressyourhealth.com.

If you want to keep it somewhat private, we will obviously, usually, in almost every case, change your name. We try not to use anything to identifying at all. Identifying, it is not really about that. It is just about using your situation to help as many people as possible, because if you are having that problem, more than likely, there are thousands and thousands of other people that are having pretty much exactly the same problem or, at least, some variation of that which is why we, like you said, we just take this kind of a question. We kind of take it for granted. But now, we turn this simple question into a podcast. And now, we leverage that. And now, lot of people can benefit from it.

So until next time. I am Dr. Maki.

Dr. Davidson: And I am Dr. Davidson.

Dr. Maki: Take Care.

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Can You Put Estriol Cream On Your Face? | PYHP 102

Dr Valorie Davidson and Dr Robert Maki — Wed, 20 Jan 2021 04:35:28 +0000

Allison’s Question: I have opened a hormone wellness practice and came across your blog. You mentioned the application of estrogen cream to the face, neck, and chest to improve skin health. From what I found, it appears that .3% Estriol and .01% Estradiol is typically used. Do you recommend a once-daily application? Can this same dose be applied to the inner and outer labia for improvement of external skin appearance as well as the vaginal entrance to improve vaginal dryness, etcetera? Thank you in advance for any feedback you can provide.

Short Answer: We typically only use Estriol cream for the face and the vagina. For the face, we do recommend using estriol daily, usually as a nighttime moisturizer. As for vaginal use, we recommend daily use of estriol cream for the first 1 to 2 weeks depending on the severity of symptoms. After that, we suggest a frequency of 1 to 3 times per week. We don’t use estradiol for vaginal use. The dosage of estriol we typically use for both is is 4 mg/gram, but apply 1/2 gram with each application.

PYHP 102 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 am Dr. Maki.

Dr. Davidson: And I am Dr. Davidson.

Dr. Maki: So I got an email back this morning from the designer. The kind of the first draft of your book cover. It was in my inbox this morning. What do you think about that?

Dr. Davidson: I think I am nervous as heck.

Dr. Maki: It is good. There are two different versions. I like a couple of things about each one of them. I will show it to you a little bit later, but it just came in right before we sat down to do this. Got to change the color scheme a little bit but so far so good.

Dr. Davidson: All right, and the book is on perimenopause.

Dr. Maki: This is the middle of summer 2020 so hopefully this will be available on Amazon probably, I am hoping within the next month but there are some other things we want to do prior to that. Maybe by Labor Day, I am thinking and to be conservative and to give ourselves a little bit more time to make sure we have all the things that need to be working, working properly. But we will definitely keep everybody posted.

Dr. Maki: So today we are going to do a question that came in from a nurse practitioner. Why do not you go ahead and read the question?

Dr. Davidson: Okay. So this question is from Allison. We change everybody’s names from anybody’s question just to protect their privacy. She is a practitioner. She says, “I have opened a hormone wellness practice and came across your blog. You mentioned the application of estrogen cream to the face, neck, and chest to improve skin health. From what I found, it appears that .3% Estriol and .01% Estradiol is typically used. Do you recommend a once-daily application? Can this same dose be applied to the inner and outer labia for improvement of external skin appearance as well as the vaginal entrance to improve vaginal dryness, etcetera? Thank you in advance for any feedback you can provide.”

Dr. Maki: Yes, so this is good, right? A professional has a hormone clinic somewhere in America and she is asking a question. We have talked about this in previous episodes about literally using estrogen as a kind of a nighttime moisturizer which may be on the surface, it seems maybe a little strange but we have been doing it for a long time. I know a lot of other doctors do that in women. When you say that, they get very excited because of course, the cosmetic industry over-the-counter is huge billions of dollars on an annual basis. But to be honest, nothing quite works as well as putting a little bit of Estriol in there.

Dr. Davidson: Estrogen is amazing for the skin. That is why when it starts to decline you see that elasticity change and then even people will say that the color of the skin changes. And really like females, I talked to a lot of patients and they are like, “I just want to put my whole body in it.” But we do use it for the face, and the neck, and a little bit of that upper chest. What is it called? The décolleté?

Dr. Maki: The décolletage.

Dr. Davidson: The décolletage. It does very well because it helps build collagen. Now, like Dr. Maki was saying is there are tons of over-the-counter serums, and moisturizers, and sunscreens. And trust me, I have a whole cabinet and probably a second cabinet full of all those things.

Dr. Maki: Unfortunately.

Dr. Davidson: Hey, I like that stuff. I have my serums. I have my nighttime, morning time, you know it, and sunscreen which we will talk about in a different podcast about sunscreen. But anyway, you think those are not prescription based so when you think about getting a prescription, granted there are different prescriptions you can get from your dermatologist. I think estrogen just really is not talked about in terms of putting it on your skin and how amazing it can be. Now, just to back up with what Allison is asking here is about the types of estrogen in particular. So there are three different types of estrogen. There is Estrone which we do not use. There is Estradiol which is very strong which she mentions here. And then there is Estriol like Dr. Maki had talked about saying how great it is. And Estriol (E3) is very gentle. So when you are using, of course, any kind of hormone, if we are using it for skin purposes, we do not necessarily want it to go systemic into the body because then it can have its own little effects inside the body. We really just want to affect the skin.

Dr. Maki: Yes, usually, kind of the rule of thumb is when you are trying to, let us say a woman is having lots of hot flashes, right, so you want to use a bias, we have talked about that before, as a systemic hormone replacement to take care of the hot flashes, the night sweats, insomnia, and then you use something locally for the face and or the vagina. And the little trick is is that those creams that can be used, we will get into the dosing whatever, but the cream that you can use for your face can also be and it is pretty much the same thing, can also be used for the vagina as well. Because in some ways, what it is doing in both different tissues is exactly the same, the benefit that the Estriol is providing to those tissues.

Dr. Davidson: Yes, as you had mentioned, Dr. Maki said and a bias which is a combination of Estradiol (E2) and Estriol (E3) is normally used or what we normally use and also in a lot of functional medicine doctors offices as well, is used systemically to go into the bloodstream to help with other goals we might be trying to achieve for hormone imbalance or menopause which would be hot flashes, sleeping, getting memory recall, bones. But one thing that I had mentioned earlier here when we were talking about this is that Estradiol is very strong. So to be honest, I know a lot of pharmacists will talk about using Estradiol on the skin for the texture of the skin like on the face, even on the vaginal tissues which are mucous membranes, they are very thin as I find using the Estradiol a hedge away from because of its ability to go through the skin and into the bloodstream and into the body systemically.

Dr. Maki: Yes, right. And of course, the vaginal tissue is very close to the uterus. We want to try to minimize especially if a woman, let us say she is in her late 40s, these things are starting to crop up. She is using the cream on the face. She is also having maybe some pain with intercourse or something like that that are just starting to crop up. You do not want that Estradiol to be in that close a proximity to the uterus because it could kind of throw off bleeding a little bit and then kind of increase the thickness of the endometrial lining. Just our preference, we prefer to use the Estriol instead of using a combination, or certainly, we would never use just straight Estradiol.

Dr. Davidson: And like what Alison is saying here that that combination that she has found with .01% of Estradiol, that is a very, very low amount. But I have found just over the years in practice when I have used Estradiol topically or other doctors have used Estradiol topically on a female for their skin or their skin integrity, when I have done the blood work it shows up in the bloodstream like I will see I know this is coming from that Estradiol that you are putting on vaginally or topically on the skin that is meant for the skin, not meant systemically. So then I get a little like, we do not really want it to go into the bloodstream. But Estradiol is an amazing hormone, I think it is the best hormone in the whole world. She is amazing for so many things in our system. But Estriol is kind of like an unsung hero when you are talking about the estrogens and what estrogen can do for you because Estriol is very gentle. It is very light. So that is why I do not necessarily, well, I guess with the Estriol because it is so light it does not permeate too much into the bloodstream so you can put it on topically without having to worry about it. Because I have women that have had certain health conditions that they cannot take bioidentical hormones or any hormones whatsoever. And here they are, postmenopausal and they cannot have intercourse because their tissues are too dry or painful or the atrophy. You got to find something to help and when the doctor gives them topical Estradiol or a Vagifem, I still find that it permeates into the bloodstream and you see those levels up. So that is why I use the Estriol because I do not find that it shows up as much when you are using it just for that topical basis.

Dr. Maki: Yes, right. And most of the conventional products or almost all of them.

Dr. Davidson: Premarin [inaudible].

Dr. Maki: Well, for vaginal issues, they are all Estradiol based which tends to make them in our experience just way too strong for exactly everything that you just said. Estriol is still a prescription. E3 is still a prescription. You need a doctor to write it for you. But none of the commercial prescriptions have used Estriol. However, through compounding pharmacies, we can kind of make whatever we want which is again a benefit to the patient.

Dr. Davidson: Now, a quick side note on that because some of you listening are going to be like, “He is wrong.” because yes, you go on Amazon, you can find Estriol on there. If you live outside of the United States of America, you can probably find it, and there are places in the UK that I know that people can find it on their local pharmacist can sell it over-the-counter. I am not really sure about the laws and regulations outside of our country, but I do know that some of those products that are online, I do not know where they come from. I do not know what they are made from. I know they say they are made from this or that and that is fine if you trust that company or you know something about that manufacturer, but we typically use Estriol only as a prescription because we have prescribing rights and certain pharmacists –

Dr. Maki: There are exceptions. You are right. We did a podcast about Estriol and then someone sent us kind of a snarky email saying that “Well, I get it from my chemist in England.” —

Dr. Davidson: Denmark, or something.

Dr. Maki: — or something, whatever. Well, we do not live there so of course, we would not really be verse with that. We practice in North America. And so we apologize if there are some exceptions to that rule. But as far as American prescriptions go, Estriol is not in any of the commercial prescriptions. And I think that is really unfortunate for women because the Estradiol is stronger, provides in some ways more benefit because it is stronger. But at the same time because it is stronger and whatever context you are using it for can create more side effects which is the part that we are trying to minimize as much as possible.

Dr. Davidson: Exactly. And like I was saying, Estriol is so gentle that it does not have that effect to go into the bloodstream but it really is nice for building collagen in the skin. It is great for that tonicity. It helps with wrinkles. The one thing with the Estriol is you can use lots of different doses, but I know Allison here is asking about, “Do you recommend a once-daily application? Do you put it on at night, in the morning?” And honestly, when we are working with patients, it kind of depends on that particular individual. Some people cannot even remember to floss their teeth before they go to bed at night, let alone put on one more layer of cream. Especially as ladies are listening, you have to put on your one serum in the morning. There is a layering effect that you do when you are doing your skin regime. So of course, adding one more thing to it sometimes throws people off. So really you can do the Estriol cream topically on the face morning or evening. You do not need to do it twice a day. I think that ends up just being a little bit of overkill. I think once a day. Some people I only have them do it a few times a week on their face and sometimes I will have them actually mix it with their moisturizer to kind of dilute it a little bit so we can get it spread all over the face, the neck, and the chest. I do think the Estriol is once a day. Now, we will talk a little bit here in a bit about the application vaginally, but I do think for the face, once a day.

Dr. Maki: Yes, so from what she was asking, .3% which is basically the way that we would interpret that or the way that we would write that as a prescription. We will write 3 milligrams per gram. Now, the way that we like to do it and we talked about this again on the previous podcast, as we would like to make sure that when a woman whatever she is applying it for, whether it is on her face, whether it is vaginal, whether it is on her inner thigh, if you are using bias for hot flashes, we always want you to put it on your inner thigh. And then of course, if it is the face or the vaginal tissue, we make the concentration high enough so then she only has to apply half a gram or half a milliliter. We had that question just a couple of episodes ago, half a gram and a half a milliliter or 1ml and 1gram, in this context is the same thing as far as volume of cream. So by using half a gram or half a milliliter, you do not have to apply so much, you are able to get it rubbed into the skin easy enough. They are kind of rubbing it in for an excessive amount of time because there is less cream to apply.

Dr. Davidson: Yes. Now, on the flip side of that, we will talk about vaginally which is important, but on the skin, women are like, “Can I just put the whole thing on. I do not want to put a little half pea-sized thing on my face and I got to get it on my chest.” Some of us, I say, “Hey, there is a little residual on your hands. Before you wash them put them in the crooks of your elbows.” because we all know the tenacity and the crooks of the elbows can decline a bit as we are aging. Like Dr. Maki was saying, I still do agree with him that you want to do half a grammar or half an ml and now this is what you call it disclosure or not meant for medical advice, educational purposes only, whatever. I think 3 milligrams of Estriol might be a little bit too much. Usually, I find about 1 to 1 and a half milligrams for the skin of the face is plenty. It is still 3 milligrams, that does not necessarily go into the bloodstream but it is just when you are looking at the cost of all the fun stuff we use on our daily basis, we are kind of complicated and a little bit of high maintenance is, “Hey when you use a stronger dose, you are able to apply a half a gram, it can last longer.” So then the cost that you are paying for it is less because this stuff is not necessarily usually covered by insurance at least most, probably 99.9% of insurance companies would not cover it even though it is a prescription. If you can cut it, do a half a gram, the price is a little bit less, and then if you have a little bit less at the dosage where I feel like one and a half milligrams works just fine. There is a little bit of a nice price aspect to that too.

Dr. Maki: Yes. So in this case, if the prescription was written for 3 milligrams per gram and you are applying half a gram as, let us say a nighttime moisturizer then basically you are getting 1 and a half milligrams as your nighttime application dose. If you are using the same thing vaginally, now, I do not know what dose you typically use but I usually do at least vaginally is 4 milligrams per gram and they apply half a gram, so they are getting 2 milligrams with each application if they are using it vaginally.

Dr. Davidson: So just jumping real quick to the vaginally, that really depends on the patient. So if someone is having a little vaginal dryness, maybe a little pain with intercourse, the tissues are not tearing those, there is no bleeding, no infection post intercourse from the atrophy. I might do a little bit of a lower dose even like 1 milligram if there is a female that had a hysterectomy and had not had a hormone replacement for years and years and years. And trust me, I have seen this before many times where they have not had intercourse in a few years and they meet somebody, fall in love and, “Hey we want to get it on.” and they cannot have penetration because of that atrophy for so many years, then I might use a little bit of a higher dose and use it a little bit more frequently.

Dr. Maki: Yes. I have to tell a story about a patient. She used to be a retired judge and she is a little spitfire and she knew this gentleman for years and years and years, her husband, unfortunately, passed away a few years before. She just thought kind of that chapter was closed and she is just going to move on. She met this gentleman and they end up getting married and she was having some really significant vaginal issues. Like you just said, they kind of tried and no penetration. It was not working. It was just uncomfortable, awkward, kind of ruined the mood and then we started working with each other, and lo and behold. We are having a point one day, she calls me up one day and she goes, “We did it.” She is all excited. You have to know her to understand. I am a man, she is a woman but she had no shame, she was just telling me everything and it was refreshing because she was just open about it. [inaudible] and we are just so excited. It took a few months but she went from not having any potential whatsoever by using a little bit of Estriol cream. It is not exactly perfect and I will say she is in her mid-70s so she is not like 40, 45, she is in her mid-70s and they are having a great time. And we have had a couple like that where women were, they could not wear pants, they can barely sit down there, they are having all this discomfort pain, burning, and then a little bit of Estriol. And we will talk about how to do it a little bit but really kind of transformative as far as their success with it.

Dr. Davidson: It is really so nice to get those patients that are so grateful. It is so wonderful to hear. And might some of you might be thinking what is estrogen got to do with your vaginal tissues? Once our hormones drop, especially that estrogen, those little cells, and the vaginal cells turn into immature vaginal cells called parabasal cells and they will just stay that way. So estrogen actually feeds the parabasal cells to turn into mature vaginal cells which is why you have the resiliency, you have the lubrication, you have the nerve sensitivity. But when you have like a lot of women that might notice on their pap smear report that might be post-menopausal that will say significant pair of basal cells which is normal because they have the lack of estrogen from menopause. So when you add that little bit of Estriol to those vaginal cells, those parabasal cells, those baby vaginal cells grow up to mature cells. And that is why Dr. Maki was saying, with this patient, it took a couple of months but that is great because it took a little time for that cellular turnover to happen to create those adult vaginal cells.

Dr. Maki: Yes. I even had a couple of women that have had bladder and uterine prolapse and they actually improved by using pretty much the same. Now, those might have been a little bit higher concentration as far as the hormone goes to really help kind of move that along as opposed to what you are talking about a few minutes ago like a starting dose, we started there and kind of worked our way up. One woman was contemplating surgery and she is doing all this research and this research, the procedures that they are using some kind of mash of some sort, those are not perfect and she was worried about it and this, that, whatever and I said, “Well, let us just try this in the interim you. Let us try it for a good six to nine months.” and it got to the point I do not know exactly how long it probably took. Honestly, probably took six months to a year at least if not a little bit over that where she did not ever even end up having to have the surgery. Now granted, that is not for every woman. You are not going to necessarily have that situation in every case but at least for the few that I have a low moderate or significant level of prolapse or I think both of those. There have been a few of them. They were probably in the low to moderate range probably not a high level of prolapse, they are actually able t improve their situation significantly.

Dr. Davidson: Yes, Estriol can be great for the bladder. It is also really good for the urethra. So if some women in some cases are having a little bit of urinary incontinence, sometimes that Estriol actually helps because the urethra is like an elastic waistband. When the hormones drop the estrogen in particular, the urethra kind of expands a bit and it does not have the tenacity that it once had which is why once you hit 45, you do not really want to do any jumping jacks or sneezing or laughing. And sometimes in certain cases, if you just use a little Estriol vaginally which the urethra is right 12 o’clock when you are looking at the vaginal canal is it can help kind of tonify and help a little urinary incontinence. So that is a good point to bring out. I know we were talking a little bit more about what Allison was asking, but I totally forgot, we use that all the time for a little bit of urinary incontinence.

Dr. Maki: Yes, and you know, I have had quite a few women and I am sure they will all tell you the same thing. They go to their gynecologist and nothing against her gynecologist, but they go to their gynecologist looking for solutions to these problems that are for women that are in there I would say their mid-40s to from there and beyond. From their mid-40s and beyond, there is not a lot of conventional options, and if there are some options, I do not consider them very safe options. Now, this hopefully will kind of open up the conversation a little bit, not real but just give you some ideas that there are some possibilities out there for this kind of uncomfortable situation that does not have to be complicated. These things just go into your nighttime, daily routine, and just a little bit of time. And things do change quite significantly.

Dr. Davidson: And one aspect, I guess to kind of differentiate. Using it on the face like I mentioned I say, I mix it with the moisturizer and you put it on your face, that way you can spread it all over and it works well that way and you can do it daily. But with the vaginal application, once you kind of get those cells hydrated and got that resiliency, you got that lubrication, you got that sensitivity is you do not have to use it every day. In fact, I usually start off having women use the Estriol vaginally and usually I say at night just because when you put it around the vaginal opening and then you waltz off for the day, sometimes that cream there can be a little uncomfortable. So I usually, “Hey put it on at night.| It is one big mucous membrane. It goes up into the vaginal canal and around the inner labia there. But I usually say start to take it for about five to seven nights and then after that, you might do it twice a week and then as those dishes get more hydrated, intercourses more pleasurable, then you might do it once a week. And some people do it once every other week, some people forget to use it until they get a little dryness back. When you are using it vaginally for the hydration for those parabasal cells to turn into mature vaginal cells for pain with intercourse, you do not necessarily have to use it every night.

Dr. Maki: Yes, right. So I usually tell them to use it every night for the first week. Use it every night again for the second week if you have to. If it is a pretty severe case then they can go every other night and then eventually depending on the woman, depending on the severity of the situation, they are going to end up somewhere between one to three times a week. And if that still is not helpful at that point, that means we got to change things together. We got to change the concentration. So now they can get down to just that little bit on a weekly basis just to help maintain what they have already been achieving, would have already achieved from that loading phase. If there was any risk, and again, we are talking about the lining of the uterus, if they have their uterus, we are trying to minimize some of that but still give them the benefit of using the hormone.

Dr. Davidson: And some women will tell me, “Well. Oh, okay. I will put it on at night.” and you might do it like you said one to three times a night. And just on the side note —

Dr. Maki: One to three times a week.

Dr. Davidson: I am sorry. One to three times a week. Just on a side note, if you have a male partner and, “Hey, I put on my Estriol and I am getting ready for bed.” and then spontaneously, “We had sex.” Do not worry, if it got on your male partner, they will be fine.

Dr. Maki: Yes, that little bit of estrogen for him is not going to really cause a problem.

Dr. Davidson: Estriol in particular which is also why I hedge away from the Estradiol because it is strong, it can penetrate through tissues. But the Estriol, if you have a male partner and you put it on vaginally and then later that night, “Whoops. Here we go. That was fun.” Because the fellas get a little weird about, “I do not want to go anywhere near that estrogen.” but nothing would happen.

Dr. Maki: Well, it is really unfair especially if men are taking testosterone and have viagra and women are not properly able to have intercourse is really unfair to the women because men are walking around with big erections all the time and they are ready to go. And a woman is just a little bit hesitant because it is painful, it hurts. So there are lots of options for men and there are really not that many for women. This kind of levels the playing field. So now there is a reciprocation on both sides, everyone is going to get their needs met and it is not going to be necessarily a one-sided conversation because women will not be so hesitant or reluctant because now they are in a similar situation and now they can come together in that intimate fashion that maybe they were able to do even maybe a few years before. But as time goes on, we have talked about this in many ways, her hormone levels are they are declining all the time, In that case, we definitely are restoring them to some level. Now, they are compatible again.

Dr. Davidson: You are right. That is actually a really good point to bring up. I have talked to a lot of female patients in they will say there are lots of other acts you can do other than penetration but at the same time, their male partner does not want to hurt them. They will even say they are reluctant because they do not want to hurt them so then it ends up you do not have that intimacy that they are looking for. Granted as I said, there are lots of other things that we can do, but I do think this sheds a really nice aspect on women especially once their hormones drop and you have that vaginal atrophy.

Dr. Maki: Yes, and this is one of those things that does not really get talked about a lot. And even from a climax or an orgasm perspective, this can even help with that and there are some other things we can talk about later that actually help with women achieving orgasm but usually, this is actually the first step to that process. So hopefully, this kind of pulling the curtains back a little bit giving women some ideas and some options to think about. Thank you very much to Allison for the good question and it is. It might seem a little weird but the same cream you put on your face as a nighttime moisturizer you can apply vaginally. Now, if the doctor or practitioner is going to write that prescription, you want to take the dosing into consideration so it can be used in both tissues. Now, it saves you from having to get two prescriptions. We do that for women all the time.

Dr. Davidson: I know we are dragging this on, sorry, but I just wanted to say there are so many different types of creams that you can apply vaginally, on the skin, inner thigh, anywhere. There are different bases. There are hypoallergenic bases. There is a non-alcohol. So many different. Because I have had some patients that have very very sensitive skin so we have to get a particular very very hypoallergenic cream that works for them or someone else. You can slather on anything. Know that you have those options.

Dr. Maki: So here we go. Now I am going to drag it on. Now you made me think of something else. You are right, some of the bases that they use can be a little irritating so sometimes it can actually burn more in the beginning. Just talk to your pharmacy and they can kind of work out some other bases that help minimize the irritation. Another thing I have noticed is that women use the cream vaginally for the first few times and they can get a yeast infection right away. That is somewhat normal just because of the Ph change and all the things that are going on down there. It is normal. We use boric acid suppositories. Yeast infection means it Is kind of irritated, itchy and there is going to be a white curdy discharge kind of like cottage cheese, that is how you know that it is a yeast infection.

Dr. Davidson: Oh, yes, trust me, us gals know about yeast infections.

Dr. Maki: Well, there is in between BV or vaginal —

Dr. Davidson: Bacterial Vaginosis

Dr. Maki: Yes, bacterial vaginosis sometimes there can be some discrepancy there. There are some antifungal medications. We do not really ever use those because —

Dr. Davidon: They do not need to.

Dr. Maki: — they are a little too strong, the boric acid seven days usually. Even the Monistat like over-the-counter stuff is usually pretty good. But if those do not work, then we usually go to a boric acid suppository and those are gentle enough to get rid of the yeast infection but not going to disrupt the flora too much like some of the prescription things. They are like an elephant gun to shoot the fly off the wall. They are just so strong and it is going to potentially set you up for reoccurring infections by using those things too much.

Dr. Davidson: Yes, we do not want to scare you saying, “I do not want to use the Estriol.” because trust me, no lady wants a yeast infection. But if there were a little bit of some itching or uncomfortableness then the pharmacy can just change the base. There are so many different bases you can use for those creams. So know that there are lots of options.

Dr. Maki: Yes, hopefully, this gives you some insight. And now you want to say anything else like —

Dr. Davidson: I could do on and on. No, this is great.

Dr. Maki: Okay, until next time. I am Dr. Maki.

Dr. Davidson: I am Dr. Davidson.

Dr. Maki: Take care. Bye-bye.

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Can I Take Progesterone All Month? PYHP 101

Dr Valorie Davidson and Dr Robert Maki — Tue, 12 Jan 2021 23:45:32 +0000

Question: Hello. I am forty-five, perimenopausal diagnosed by blood work. I have my uterus and I am taking 200 milligrams of bioidentical progesterone each night orally by capsule. I do not take anything else for hormone balance other than evening primrose oil and some adrenal support. Neither of these is new to my regimen. What is new is the administration of the progesterone orally. Previously, I was using a progesterone cream, 40 milligrams per night. All nights of my cycle, no break. Doc suggested that I needed to be more cyclical with my administration and then I try oral progesterone instead. I am doing this. I go to sleep well but toss and turn a bit more than I used to, then wake up around four thirty-five and cannot sleep any longer. My body temperature seems to be all over the place. At some nights around that same time, I wake up hot, not really a hot flash per se but just hot, but the very next night, I can have on the same bedclothes, sheets, house temperature, et cetera, and will not get hot. She has me doing fourteen days, fourteen to twenty-eight, taking the oral progesterone. My trouble is the fourteen days I have to wait to take it, I have all the trouble sleeping and all the other symptoms while I am waiting for that fourteenth day to come so I can take my oral progesterone. My question, can I take it full-time during my cycle and never take a break or does that go against all medical wisdom and/or would be bad for my body not to have a break?

Short Answer: Based on a woman’s physiology, it does make sense to only take progesterone during the second half of the month. Typically, progesterone is produced from ovulation to the period and usually peaks around day 21 of the cycle. However, many women feel better when they take oral progesterone all month long. Oral progesterone helps reduce irritability, reduces anxiousness, and can improve sleep. Because of this, we most often prescribe progesterone to be taken all month long. Sustained Release Oral Progesterone is usually very well tolerated, but sometimes it can change a woman’s cycle. Based on how the cycle changes will determine if the dosage needs to be cycled or not. For example, we might prescribe 50 mg for the first half of the month and then increase to 100 mg during the 2nd half of the month. Then we have our patients stop the progesterone during menstruation.

PYHP 101 Full Transcript:

Download PYHP 101 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: I am Dr. Davidson.

Dr. Maki: We have another question we are going to answer. This one is someone that is recently diagnosed perimenopause and progesterone. Again, this one is very appropriate. This progesterone conversation comes up all the time. Why don’t you go ahead? We will just dive right into it. Why don’t you go ahead and read the question?

Dr. Davidson: Sure. I will read the question. This is from Eileen, but we do change everybody’s names just for privacy. Again, we are calling her Eileen. Hello. I am forty-five, perimenopausal diagnosed by blood work. I have my uterus and I am taking 200 milligrams of bioidentical progesterone each night orally by capsule. I do not take anything else for hormone balance other than evening primrose oil and some adrenal support. Neither of these is new to my regimen. What is new is the administration of the progesterone orally. Previously, I was using a progesterone cream, 40 milligrams per night. All nights of my cycle, no break. Doc suggested that I needed to be more cyclical with my administration and then I try oral progesterone instead. I am doing this. I go to sleep well but toss and turn a bit more than I used to, then wake up around four thirty-five and cannot sleep any longer. My body temperature seems to be all over the place. At some nights around that same time, I wake up hot, not really a hot flash per se but just hot, but the very next night, I can have on the same bedclothes, sheets, house temperature, et cetera, and will not get hot. She has me doing fourteen days, fourteen to twenty-eight, taking the oral progesterone. My trouble is the fourteen days I have to wait to take it, I have all the trouble sleeping and all the other symptoms while I am waiting for that fourteenth day to come so I can take my oral progesterone. My question, can I take it full-time during my cycle and never take a break or does that go against all medical wisdom and/or would be bad for my body not to have a break?

Dr. Maki: Yeah. This is a really good question. Obviously, that is why we are answering it because this one does come up a lot. Now, we do like the idea of cycling hormones. We use cycle hormones all the time, rhythmic dosing, different types of things. Her symptom picture – she is not having a hot flash, she is just hot. Night sweats in this perimenopausal phase is a very common symptom. She is still having a cycle. She is not really a candidate for estrogen to take care of the hot flashes. What would you say about that?

Dr. Davidson: Really, with perimenopause, it is different than menopause when it comes to hot flashes and night sweats, where in menopause, those ovaries have ceased to work. They retired rightly so. They deserve it. That estrogen has dropped. That is going to cause an issue with their internal body core temperature, and they have the hot flashes and the night sweats, where in perimenopause, women are still making estrogen. It might dampen a touch but really, as in the case with Eileen, which is completely understandable, is in perimenopause, your progesterone plummets to the floor like there is nothing. That is why it is nice to replace that and that does help with the night sweats. Like Eileen says, in perimenopause, they are not really night sweats. Some people are more sweaty than other people but it is that hot. You wake up hot. It can be one day, I am hot, and the next day, I am not. A lot of times that does seem to be [inaudible] where you have that heat or that flush while you are sleeping about anywhere from seven to ten days before your next period, which is when that progesterone is supposed to come up.

That is why it makes sense in her question. Her doc is having her take her progesterone from day fourteen to day twenty-nine, which is really when we are cycling females, that is when we make progesterone is the last half of the cycle. We do not necessarily make progesterone or much progesterone the first half of the cycle. In, I guess you can say, physiology respects or in theory, that is exactly how you should do it, but what we found over time is exactly what Eileen is running into is well, I feel good for those two weeks I am taking it, but what do I do about the two weeks I am not taking it when I do not feel good?

Dr. Maki: Yeah, right. We usually have women take it all month long, maybe not in every case, or we might actually depending on how the progesterone affects their bleeding. There are actual periods because progesterone is a beautiful hormone in the fact that it can make a woman start bleeding or it can make it stop bleeding depending on the situation. For example, in perimenopause, when a woman is in her mid to late 40’s, she can start having a lot of heavy bleeding. That is a perfect sign or a classic sign that that progesterone level is actually decreasing, but she still has lots of estrogen. As we talked about on other podcasts, she is pseudo-estrogen dominant but there is not enough progesterone to control the bleeding. If you give them some progesterone, now the bleeding is a little bit more under control. Now, if you give them too much progesterone like in this case, 200 milligrams, for some women, it could be too much. Now, that could create the same problem. It could create more bleeding. You really do not know how a woman is going to respond to a dose like 200 milligrams until they actually take it, and then depending on how their cycle changes over the next one to three cycles, that will determine whether or not you can stay at that dose or go down. You and I do not usually ever go any higher than 200 milligrams. That is about as high as we go.

Dr. Davidson: Yeah, that is pretty much on the top end there. Like Dr. Maki was saying, progesterone is great for keeping that lining of the uterus, the architecture, nice and solid, more compact, not so sloppy, so that it can help with heavy bleeding. On the flipside, progesterone, if you give it to soon, let us say we gave Eileen that 200 milligrams of oral progesterone on day six of her cycle, because usually if I am doing progesterone all month, I do have them take anywhere between three to five days off during their periods, just not having those hormones allows the lining to slough off and having just a few days off. You do not really have any major symptoms in that three to five-day period.

Let us say we are going to have her start taking her progesterone on day six of her cycle. In some people, if you do too much progesterone, oral progesterone, is that can cause a bleed to come sooner than that twenty-eight days. That is where you get women saying, “My period is coming on day sixteen.” My period is coming on day sixteen or day nineteen or day fourteen. That is when you know starting that progesterone a little bit too early or maybe it is the dosage is causing their cycles to get too short. That is another reason in theory that a lot of docs say, “Do not start your progesterone until day fourteen, so at least it does not shorten that cycle, and you can still get a twenty-six to twenty-eight day cycle.”

Dr. Maki: Yeah, right. Now, some cases, again, just to complicate it even more, in some women like we talked about, depending on the dosing, how they tolerate to progesterone, we might do a lower dose than the first, let us say, day one to day eleven, which kind of contradicts what you just said a little bit about not taking it during their period.

Dr. Davidson: Like you said, a lower dose.

Dr. Maki: Yeah, a lower dose. You still have the full sloughing off of the uterus but enough progesterone there to give them, like in her case, some sleeping relief because that is one of those classic insomnia, classic perimenopausal symptoms, so you cannot take the progesterone. Most women do much better when they are able to take some dosing of the progesterone all month long like in her case. Can she take it the entire month or can she not? She would love to be able to take it the entire month, which is why we do it that way, or like I said, we might do let us say for example, 50 milligrams and 100 milligrams, or 75 and 150, or for some women, 100 and 200, depending on the woman and depending on the severity of their symptoms. Again, there are lots of possibilities there. It makes it really confusing for a woman to know how much is the right amount for her, but we usually determine that based on how their cycle changes once they have implemented. They feel good. They feel good. No news is good news. They are just doing just fine, but if they come back and report, “My cycle has changed in this way,” now, it helps us determine what needs to happen with that progesterone dose.

Dr. Davidson: Just to put that out there a little bit for Eileen, and this is very common because she represents pretty much all of our perimenopausal, and I will tell you I am forty-seven, even though I treated women for years with perimenopause and menopause and hormone imbalance, there is nothing like going through it yourself to really understand how that treatment works. Really, the sleep is probably the big issue and that may be why her doc suggested to do the oral progesterone because oral progesterone seems to have more in effect with the cortisol and the GABA at night and helps you stay asleep better because that is usually the typical thing is perimenopause is you can fall asleep but it is really difficult to stay asleep. That oral progesterone, we find, helps women stay asleep in that perimenopausal phase as opposed to the cream. It does not have quite as much an effect on ability to stay asleep. That may be why the doc suggested that.

Dr. Maki: Yeah, sure. We do some other things to assist the sleep. Progesterone does a pretty good job on the sleep side, but like you said, they still might be waking up a few times at night. We hear women say all the time, “I am hot, cold, hot, cold, hot, cold.” Covers are coming on and off because they go through this cyclical pattern over the course of the night. Now, like you said, it might not be every night. It might be that seven to ten day PMS window. There are some very good adrenal adaptogen herbs. We use glycine. We use PharmaGABA. We use a bunch of different things that granted there is not one supplement that works the best when it comes to sleep. It just has to be tailored, again, to the woman and a little trial and error to try this or try that or try a couple of different things. No one, at this stage of their life, is ever going to get great sleep. I think that is pretty rare. We are just hoping that could get them to at least good sleep. I ask a question at least on my intake form. I have them grade their sleep A to F. A, they sleep great. F, they sleep terribly.

Most of the time, most women in perimenopause and into menopause, they would grade their sleep, which is their own subjective opinion, a D to an F most of the time. Some are maybe in the C- range. Very few of them are in the A and B… No, I do not think I have ever seen an A. Maybe a couple of Bs here and there. If they are in that D to an F range, we want to get them to a B range. That means at least what I would consider is they are able to fall asleep easy. A reasonable bedtime for most adults is going to be about ten o’clock. They sleep for three or four hours, preferably no restroom, and then they are able to just reposition, go back to bed, and sleep again for another three or four hours. At least that way, they can wake up to face their day with at least somewhat of a feeling of rejuvenation that they have actually had some decent sleep that night.

Dr. Davidson: Oh, yeah. There is nothing better than getting a good night’s sleep. It is almost like you know you are an adult when you want to make sure you get a good night’s sleep where when you are a teenager, it does not really matter. You might stay up until three in the morning, but definitely for perimenopausal women, sleep is important.

Dr. Maki: Yeah. Women these days are stretched thin. They are taking care of the kids. They are working full-time. They got so many things to do and and probably trying to exercise on top of that. We have talked about that before too. It is obvious how important sleeping is, but the frustration that I hear from women when they are not able to sleep, something that is so innate into human beings, and when you are not able to do it, the night seems like it lasts like an eternity when you are not able to sleep. The hours just go by so slow. Some people cover up their clocks so they do not see the clock, and there are people who see the clock because they are hoping they have more time so they can get more sleep before their alarm goes off or they have to get up for the day. For whatever reason, everybody gets their best sleep in that last hour to two hour window, or five o’clock, right before they have to get up and they finally actually sleep in. When they do wake up, they are exhausted because that cortisol circadian rhythm sort of thing is a little bit messed up. We will talk about that on another podcast, but progesterone certainly need relief all month long. This is a big problem.

Dr. Davidson: Maybe let us go ahead and throw another wrench into it and complicate it is, Eileen has her uterus so it kind of makes it easy to understand how you are going to cycle progesterone because hey, you get your period, you are back to day one, but what about women that do not have a uterus?

Dr. Maki: Yeah, right. Well, like we said earlier, taking it all month long, then it really does not matter much.

Dr. Davidson: In some respects, but then at the same time, with women that do not have a uterus, you automatic… Whenever a female does not have a uterus and they had a hysterectomy. It is usually because of heavy bleeding or irregular bleeding, and really the perimenopausal time, which is late 30’s to very, very early 50’s, I mean, perimenopause can last a long time, is that is when you see a lot of hysterectomies happen because of that drop in progesterone which causes the irregular bleeding, not heavy bleeding, chronic bleeding, painful periods. That is where you see that. Any time a woman has said, “Oh, yeah, I had a hysterectomy,” I will think, “Oh, they probably have low progesterone,” or as we will get into other podcasts is low thyroid, which low thyroid can impact that heavier bleeding for women that get a hysterectomy. Some women that have hysterectomies, we might cycle it a little bit too, but I find that just like with Eileen is women feel better when they pretty much take that progesterone all month long.

Dr. Maki: Yeah. Now, not to confuse things, again, the theme of all bioidentical hormones is there is not one way to do something. There is a lot of different ways and it really does depend on the patient’s situations, not the doctor’s opinion necessarily, which that comes up a lot. Doctors have their own style, their own way to do things, but it really depends on how, one, the patient’s situation and how they respond to help the practitioner determine what needs to be done. It is tailored to what the patient wants, which is symptom relief, to be able to sleep at night and maybe not be so hot, but sometimes, the response of the patient, it helps the doctor make those decisions. Rhythmic dosing which we have talked about before too, we can do that one both ways. We can do that one with capsules or with cream. It is designed to do it more with cream. We prefer capsules with the static dosing because it has that brain effect. It has the sleep effect. It kind of lowers anxiety. It reduces some of that irritability that women have. The cream does not necessarily do that as much. Rhythmic dosing would be more for menopausal women than is opposed to perimenopausal women. Now, I am curious. I have my answer in my brain but it says perimenopause diagnosed by blood work. How do you think that her doctor diagnosed her by blood work?

Dr. Davidson: If they did blood work, they probably did an FSH and an LH. Those are follicle-stimulating hormone and luteinizing hormone. Those reference ranges are so vast a lot of doctors do not really know what they are looking at. They are just looking to see are you in menopause or are you not. Maybe more of a progressive doctor might have done her blood work for progesterone anywhere between day fourteen and day twenty-eight because typically, in a perfect twenty-eight day cycle, the progesterone is highest on day twenty-one. When a perimenopausal woman is having a regular period, which is not always the case, but if they are having a regular period, then I usually try to get that progesterone tested somewhere around day twenty-day. It does not have to be perfect but around day twenty-one. If it is non-existent or it is low, then you can say, “Oh, yeah, you are in perimenopause.”

Dr. Maki: Yeah, right. Usually, when we have a woman going for hormone testing, we want them to go either on day twelve, depending on what dosing schedule she is using, or, like you said, day twenty-one because if you just do it randomly, now granted, you and I can look at a blood test and say, “Oh, they are probably at this part of their cycle or that part of their cycle,” if they are having a cycle. If they are not having a cycle, then those numbers do not really mean much of anything. A thirty-year-old woman going into the lab and you do not know what day she is being tested on, those hormone values are changing literally every day of the month practically. Every week, those hormone levels are different and estrogen is going to be high in the first fourteen days. Progesterone is going to be high in the second fourteen days. All the time, we do blood work on perimenopausal women, and their progesterone will be less than one. It will be like point five, point six, point seven. Now, once in a while, you will see one. Let us say forty-seven, forty-eight and her progesterone will be three, four, or five. She still have a fairly good endogenous production, meaning, that her body is still producing some progesterone.

Dr. Davidson: Which is great, but if you were going to say what is the optimal, regardless of age, if you are looking at somebody’s twenty-eight day cycle and they are day twenty-one, what would their progesterone be if it were the creme de la creme? That would easily be in the teens. Even like eleven, twelve, thirteen, fourteen kind of thing.

Dr. Maki: Yeah, sure. You can see that decline. Now granted, you and I have never done exactly that but we see women in these different periods of their life. Like you said, if they are twenty-five, their progesterone is going to be quite high on day twenty-one. Women in perimenopause, that number has already declined quite a bit where if you did it on a menopausal woman, if she is not taking progesterone, it will always be less than one. If she is taking it, then it will be… Usually, I see it with, and they are taking an oral progesterone like this, usually it is between two to eight. Is that the range you see the most where you see the progesterone level when they are taking progesterone?

Dr. Davidson: Again, it depends on if they are taking it orally or if they are taking it as a cream.

Dr. Maki: Yeah, orally.

Dr. Davidson: Orally, if I am dosing them and we are doing, again, to make it more confusing, a sustained release progesterone oral capsule, usually, you will see it in the morning. If you are doing a morning draw around nine or ten or eleven, it is usually around three to four. You do not really want it too much higher than that when you are doing a replacement just because progesterone is really relaxing. If your progesterone as a replacement as you are giving them as a dose, if it is higher during the day, sometimes that can just make people tired or lethargic.

Dr. Maki: Sure. Yeah. Some women absorb it really well so their numbers jump up there a little bit, but if that number is a little too high, that means they are probably still producing some of their own and the progesterone that they are taking as a prescription is bolstering that number. Day twelve, day twenty-one, those are landmark days to go to the lab. It does not matter in every case but depending on what we are looking for, we might specify go to day twelve, go on day twenty-one. It puts those numbers into better perspective. I was going to say it was probably an FSH level. For perimenopause, what is your FSH level range?

Dr. Davidson: If a woman is in perimenopause, the follicle-stimulating hormone, the FSH, if they are in the very early-early because with everything, perimenopause is a phase. It is not like I am in it or I am not in it. It is a phase. In the very early part of perimenopause, you might see it at fifteen to twenty-five. That is the early part. When they are in the throes of menopause, you see that like twenty-five to thirty-five. When you are going up higher than that, then that is usually the beginning of menopause.

Dr. Maki: You said the throes of perimenopause, say it again. The beginning is fifteen to twenty-five.

Dr. Davidson: Yeah, and usually anywhere between twenty-five to thirty-five, that is the main part of perimenopause. If you look at a reference range on LabCorp or Quest an FSH of twenty-five, it will say postmenopausal. That is not correct. I have women that come in and their FSH is at twenty-five and they are still having a period. They are not postmenopausal.

Dr. Maki: Yeah, the reference ranges. You develop your own reference range as you kind of just ignore whatever they say on there. When a woman goes into menopause, where is the typical starting point for menopause?

Dr. Davidson: Postmenopause – anything over a hundred on FSH. They are pretty much past menopause. They have not had a period for a year. They might have a hot flash here and there but nothing extreme. Their symptoms are probably minimizing. When you see someone’s FSH and they might be around sixty-five, that is when you are like, “Oh, yeah, they are probably having hot flashes during the day, multiple night sweats at night. Their [inaudible] ran away. They are gaining weight.” That is menopause and that is unfortunate because those reference ranges because that is what docs do is they just look at the reference range. If the reference range says this, they just follow that. The reference range is… You do not want to hang your hat on that. There comes in a lot of where you got to take into consideration that individual. I will have women that will tell me that their doctor tested their hormones and they had numb. They are on menopause. They have no estrogen and progesterone, and then I will ask them, “When did you get tested? Were you on your period?” They will say yes. I am going to say, “Well, of course your estrogen and progesterone would be low. You were on your period. They are always low day one to day five.

Dr. Maki: Yeah, timing. That is what we specify, usually day twelve or day twenty-one. Do not go to the lab on your period because those numbers are going to be… Those things are never really communicated to them. We communicate to our patients but…

Dr. Davidson: You do your best because it is like Murphy’s Law. I have so many women I will say, “Hey, can you go get your blood draw around here?” They will do and then they will call me and say, “You know what, I got my period on the way home from the blood draw. It was day twenty.” I am like, “That happens, Murphy’s Law.” Just like we always get our period when we go on vacation. It is just one of those Murphy’s Law. It does happen, but that is where you have to take into consideration not just the objective data from the blood work or whether you are doing saliva or urine, but that the patient is well in their goals, and their health history, and their family health history. There is a lot to take into consideration with that when you are putting it together, but that is the cool thing with the bioidentical hormone replacement in the compounds is you can do anything for that patient. It is not just a cookie-cutter. Everybody gets the same dose. That is where it can be so individualized.

Dr. Maki: Yeah. We say that all the time that it is very much tailored. Now granted, that causes sometimes some issues because everyone’s different. It is very difficult to scale that or to see lots and lots… The conventional medical system is just a revolving door of the same treatments. Everyone has a certain condition, they get a drug. Everybody that has that condition gets the same treatment style. We alluded to the fact that every woman we see, there is a lot of tendencies. There is a lot of similarities from one patient to the next, but each case is looked at as an individual, and their symptom picture their lifestyle, their genetics. All those things are taken into consideration that determine what they are going to be using, and then how they respond once they are on the hormones or on their particular prescriptions obviously will determine where they stay and how those doses change over time.

They always change over time. It seems like a lot of women, they get on certain prescriptions whether it is conventional or not and they are just on the same thing forever. Maybe there is a business model behind that to some extent from a conventional perspective, but we are in the business of trying to optimize how people feel. We are not trying to achieve certain numbers on lab tests necessarily. We use the lab test to help guide decisions and keep people safe, but we are more concerned on the subjective. We want them to feel better. We want their symptoms to be resolved. We want their health to be optimized in the best way possible.

Dr. Maki: If you have any questions, you can send us an email at help@progressyourhealth.com. Again, help@progressyourhealth.com. Dr. Davidson, this was relatively quick. I think we threw in a couple things but the answer is that she can take her progesterone for the most part. She can take it all month long.

Dr. Davidson: Okay. Discuss it with your medical doctor. Disclosure, disclosure. Disclaimer, disclaimer. She could easily take it pretty much all month long or a patient that were like Eileen could take it all month long. They could do a different dose like Dr. Maki said one half of the cycle and a different dose later. She could do cream for half of the cycle and then capsules for another half of the cycle. We are confusing you again, aren’t we?

Dr. Maki: We do not want to go against what your doctor told you, but we prescribe progesterone for our patients all month long because, like you said, you need that relief. You need to be able to sleep. That is one of the main reasons why you give a woman progesterone in the first place is to be able to sleep. Hopefully, that shed some light on it. It does get a little convoluted and complicated, but at least for this question, which does come up a lot, hopefully we were able to answer that for you. Until next time, I am Dr. Maki.

Dr. Davidson: I am Dr. Davidson.

Dr. Maki: Take care. Bye-bye.

The post Can I Take Progesterone All Month? PYHP 101 appeared first on .

What is a Common Biest Starting Dose? | PYHP 100

Dr Valorie Davidson and Dr Robert Maki — Fri, 07 Aug 2020 22:15:25 +0000

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 help@progressyourhealth.com. 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.

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What Are Symptoms of Thyroid Problems in Females? | PYHP 099

Dr Valorie Davidson and Dr Robert Maki — Thu, 30 Jul 2020 20:06:52 +0000

Question: What are symptoms of thyroid problems in females?

Short Answer: There is a wide variety of thyroid symptoms in women. Some of the more common are fatigue, weight gain, constipation, and dry skin. Based on our experience, we have noticed many other hypothyroid related symptoms as well. These symptoms include heavy periods, infertility, anxiety, low libido, hair loss and low mood.

PYHP 099 Full Transcript:

Download PYHP 099 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 officially a little bit past the beginning of summer in Washington, although looking out the window right now, it certainly does not look like summer. It is raining kind of heavy right now.

Dr. Davidson: I would say even though it is supposed to be summer, it seems like spring has officially started because it is really beautiful with the little deer out and the flowers are blooming, and I think it will clear up a little bit later.

Dr. Maki: Yes, you know that I sent you the picture you saw but for the listeners, I was sitting here, you were upstairs and I was looking out the window and I saw a female deer and then she just took a picture of it. You know, that is great. A deer walks through the yard all the time and then she moved and there is a little, literally like a little fawn, a little Bambi right next to her and kind of following along and she hit the little white spots on the side and there. Eating little weeds in the yard and they walked over to the little garden over there and ate some things out of the garden.

Dr. Davidson: I was so happy to see that picture because I saw that little fawn a couple. I think a couple of weeks ago right after it was just born with its mom walking through the driveway and then I did not see them again and well, little baby still. Okay, so it is really neat to see him or her a little bit bigger with those little white spots on the bum.

Dr. Maki: Yes, right. That was that was nice. You know, we do not see the deer hardly at all winter long and then it seems like June, I remember where we lived. Now we moved in here lack last year and June came literally like June first I will send, the deer came almost every day. We are having deer come through the yard and sure enough, here is June again. I do not know where they go.

Dr. Davidson: Only because we do not cover up our garden beds. So we basically are growing a garden to feed deer. [laughing] Which is fine.

Dr. Maki: That is okay.

Dr. Davidson: They need to it.

Dr. Maki: That is all right. Make sure the little one gets the gets a meal here and here and there. So on today’s episode, we are going to talk about thyroid. This is a question, this is actually a specific question from somebody but it is something that comes up all the time that we get answer or people send us questions. So we just thought we would kind of do this a little bit more of a– if you are curious or if you are wondering about your thyroid or if you already have a thyroid problem, some of these things that we are going to talk about will make some sense. This is really based on our experience. This is not something from Google or anything like that or any of the websites. This is just from our experience and what we have noticed, that depending on their lab work and all that clinical data. These are the situations and the symptoms that tend to improve once they have been on the right medication for them.

Dr. Davidson: Exactly, because you know, gosh, we have been in practice since you were 2003 and I am 2004, and me being a female, I have mainly worked with females. So when it comes to thyroid, I have a lot of women, wondering about their thyroid, wondering well, what are the symptoms of thyroid? Because my conventional doctor just tells me it is about being tired and looking at my lab work. When really there are so many other symptoms involved with having a lower thyroid or having lower thyroid function or hypothyroidism with women that sometimes people do not really connect.

Dr. Maki: Yes, right. There are some basic ones, certainly, we are going to talk a little bit about weight gain, certainly you said being tired, maybe the third one would be constipation.

Dr. Davidson: Not even constipation. A lot of people are not even aware that constipation is an issue with hypothyroid with females. Not so much that I noticed with the men but you know, like I said, with our own experience, I probably have seen more women than men. But if you want to just jump right into it, I would say constipation is one that people just look at you kind of starry-eyed when you ask them. Well, how are your bowels and the women say, well, I have a bowel movement every other day or twice a week or it just does not feel complete. That really can be impacted from a low thyroid.

Dr. Maki: Yes, right. Well, if you think about it, the thyroid kind of controls everything. It has an impact. It is one of those major metabolic hormones that has an impact on every functioning system in the body. So if your thyroid is a little bit under functioning then the potential, as we are going to talk about the list, that is going to have an impact on how you feel and how everything else functions. So when you think of it in that context it would make sense that– and certainly you look at some of the textbooks that constipation certainly on the list, but I think you are right. I think that nowadays when it comes to thyroid in general, if your TSH is normal then nothing can be related to your thyroid if your TSH is below 4.5 and I do not really agree with that whatsoever. I think there is a limitation to the testing because we see it all the time. We see people that have reasonable numbers, kind of high normal TSH but they have a whole list of hypothyroid symptoms and I think that testing a lot of times, you know people they go underdiagnosed and all that happens on a regular basis.

Dr. Davidson: I mean wonderfully there are more online forums, more blogs, more videos, more books written about thyroid. And so I am glad that it as a real talking piece in the last few years, but you are right conventionally, they are just looking at medication and your levels. Unfortunately with women, because I do think with low thyroid, women have not the typical– I know I say not the typical but they are not common signs that you would kind of relate with thyroid. When you are looking at women and trying to work on their thyroid function because we have so many other hormones going on in our bodies. Yes, we are complicated but we are so worth it. But we have so many other hormones going on in our bodies that when that thyroid function is starting to drop, you will see manifestations in the female reproductive system, you will see other manifestations that you would not necessarily say “Hey, you know what that is coming upstream from the thyroid.”

Dr. Maki: Yes, right. Medicine in general as it has always been is very reductionistic. I think thyroid is kind of looked at even though it is very complex and it affects as I said pretty much every aspect of your being in some in some ways, is looked at in a very kind of narrow lens, so to speak. Even if you have all the symptoms we are going to talk about in a lot of women we deal with, maybe that is why they eventually find us because we have heard the stories over and over. People go to doctor after doctor. Knowing that there is something wrong with them. They know how they feel, but again if their TSH is below 4.5, they are like “Oh you are fine. There is nothing wrong with you.” The patient always know before the doctor does. Nowadays, our philosophy has always been to treat the patient first, the lab tests second. In medicine, not just thyroid, but that is one that we see most often, is that it is lab tests first and the patient second and I do not agree with that at all.

Dr. Davidson: So let us jump into our list, but before we do, if any of you listeners here kind of a weird like clunky sound and we have said this before like a little clunky clinky sound, It is our, our dog is having a great time putting his bone on top of the base of the table with his little dog hands wrapped around it. So he is having a great time. He is always at our feet. But if you hear that little clunky sound, I am sorry about that.

Dr. Maki: Like he is literally laying. I am sitting on a stool and he is literally laying on one of my feet as he is chewing on this bone over the side railing of the table. That is pretty typical. If this is a video podcast you could actually see him, it would be really cute but you know, nonetheless if you hear a weird noise in the background, it is always him at our feet.

Dr. Davidson: Always our dog, Bob.

Dr. Maki: So let us just dive in. So again, this is a list that we kind of just, actually fairly quickly, just kind of ran through and we did research if you want to call it that quote-unquote but as we said this is really just from clinical experience. The things that we see over and over so why do we not just start with the, maybe the most common one that is not just thyroid but certainly the thyroid can play a role in it if it is present.

Dr. Davidson: Yes, like you said, fatigue and weight gain. That is the first thing people think of when they think of thyroid whether it is females or males, fatigue and weight gain are definitely number one. I guess you could say one and two but what I think is not noticed as much because this is why this funded to this on the podcast, is try to give you some pearls that would say “Oh my gosh. Yes, that is a thyroid issue” especially in females, but with women, they will notice it is not just weight gain, but it is like water weight and bloated. They will wake up and be one weight in the morning and by the end of the day, they could be easily up between three and six pounds for really no dietary reason.

Dr. Maki: Now, I do not think that that is related to the thyroid necessarily. I think you and I could beg to differ about that. You are right. Your weight is going to fluctuate day to day, from one day to the next. It is going to bounce all over the place. So using that as a gauge, I do not think it is necessarily a valid point.

Dr. Davidson: But I do think it is. An important symptom point out because–

Dr. Maki: Oh sure.

Dr. Davidson: Because everybody wants to fit in their pants at the end of the day and I do not want to go run off their stretchy pants or unbutton the top button.

Dr. Maki: I do not have actual numbers, but I would say the average person probably gains casually from the time they are in high school or even in college, until the time they are in their forties. They probably gained really, I think statistically like to 5 pounds a year. They gained like 20 pounds by the time they get to their twenty-year reunions something like that. So a little bit of that weight gain is going to be year by year is going to be somewhat normal, but if someone is putting on a large amount of weight in six months, something is going on there that is driving that extra amount of weight loss, especially if you know caloric intake does not necessarily meet that. Now if you are in COVID lockdown and you have been eating like crazy, which I know a lot of people have been doing, you might have put on some weight. But then once we get out of lockdown, whatever now some of that weight should come right back off relatively easy. But if you have seen this kind of, either a three-six or even a twelve-month time span, a considerable amount of more weight than that, the thyroid certainly does need to be considered in that respect.

Dr. Davidson: Yes, because that metabolic activity drops down and then of course, if you are tired, the last thing you want to do is let us go work out or let’s go exercise granted we know a lot of people that force themselves to and are very unhappy when they notice they are not losing weight. So definitely that weight gain and that fatigue and like I mentioned feeling puffy and bloated. Us as girls, we know when we are puffy. We are like, “I feel puffy today, why?” That can you know, the thyroid does hold onto water that is one of the things when little babies are born with myxedema or their thyroid dysfunction or they do not have a thyroid. Not that common but you can find that in the history books of medical history books. These little babies come out of the womb and their little faces are so puffy. You cannot even see their eyes or it is just so puffy and that is because of a thyroid issue. So that water weight and that puffiness is truly just happening. You are right. It can come from other issues, with your adrenals, with free more hormones, where you are in your cycle, but you know that thyroid being low will put on some water weight.

Dr. Maki: Yes and we could kind of parse out stress-related weight gain and tiredness or fatigue, thyroid-related weight gain and stress and fatigue or fatigue. But in reality because the thyroid and the adrenals are somewhat connected, there is an access there between those two, you cannot really have one without the other. If you have a thyroid issue, you are going to have an adrenal issue and vice versa. And let us talk about 2020 so far, it has been stressful. It has been a stressful year to say the least wherever the entire country. So it is really hard to relate both of those, just a tired but it is on the list of the things that you are going to see for sure.

Dr. Davidson: While stress can make you lose your hair, having lower thyroid function will definitely cause hair loss and that is a scary thing for a lady. We do not want to lose our hair. It is scary and what they notice is it is not so much androgen derived, like you would see with male pattern baldness, but with a low thyroid, a woman will notice their hair is everywhere. I mean, they are terrified to wash their hair because there are just coming out in handfuls and it and what it is, is it is not breakage, but it is coming out at the root. So sometimes you can even see that little punctum at the end of the hair shaft because it should not, I mean we are supposed to lose hair everyday. That is common but it definitely seems like an extraordinary amount of hair loss.

Dr. Maki: Yes, right. And we hear that is a big complaint. We hear the hair loss issues. And really there is, conventionally, there is not really a lot of good treatments for it. Now, it is funny. They relate a lot of– and men they relate a lot of hair loss to testosterone. But why do women lose their hair when they do not have any testosterone. So I do not– I think that for women I think the androgen, certainly DHEA testosterone can drive some of that hair loss. I think for men it is a little bit more on the cortisol side than it is on the androgen side. Maybe if you are getting–

Dr. Davidson: And the genetic side.

Dr. Maki: And genetics too, of course, I mean certainly it does get passed down. You see it kind of in the family tree, there is a certain–

Dr. Davidson: Look at my dad.

Dr. Maki: Yes, yes. I have never seen your grandfather. But does he have hair?

Dr. Davidson: It was not on my dad’s on the father’s side. It was more on his grandfather. So I guess you could say my grandmother’s dad. That is it. It came from the from the female side, with the hair loss but definitely his brothers, all my uncles.

Dr. Maki: Yes, there is a little bit of a trend there.

Dr. Davidson: So yes, it came from his mother or my grandmother’s side, the maternal side.

Dr. Maki: Something is going on. My grandfather on my mom’s side, he was I remember, my dad had actually decent hair, but my dad my grandfather on my mom’s side actually had hair kind of like your dad’s. You had the crown in the middle.

Dr. Davidson: Well you have gorgeous hair. You have lots of hair and your mom and dad both have lots of hair. So nobody feels sorry for them.

Dr. Maki: Yes, but hair loss is a tricky one. Certainly, the thyroid can play a big role there again, it helps things grow, you start to notice if you get the thyroid right that you start to get some of that undergrowth at the base of the scalp and where the hair meet and that can be very encouraging for someone that has been struggling with hair loss issues. I have had quite a few people that go to all these different hair specialist and they want to do inject steroids and do all these things and I am not really sure how effective some of those treatments really are.

Dr. Davidson: I think a lot of them are based for females. More on those androgen derived. So doing the steroid injections into the scalp around the temples in the top of the head is supposed to downregulate that testosterone that might be accumulating in the follicles, they say. I am saying a lot of doctors will say, “Well, just go, wash your hair with Rogaine.” And Rogaine does have an effect. But the thing is it only works when you are using it. If you stop using those hair loss formulas for shampoo and conditioning, then the hair just goes back to where it was originally. So the whole goal is to get that hair growth because in hypothyroidism, the hair follicle is not dead. It is alive, it is just in some ways kind of dormant or that the hair does not want to stay in the follicle. So definitely like Dr. Maki said is once we kind of get that thyroid balance and balancing some hormones, that hair does grow in and it is cute. They get bangs because it is growing in and around the hairline, it is different lengths but like you said people are very encouraged by that.

Dr. Maki: Yes, you get the thyroid if functioning right you reduce some of the stress hormones and for a female’s case, get rid of some of the androgen certainly if she has PCOS so she has higher testosterone higher DHEA, you know certain that would want to be addressed in some respect as well, but thyroid tends to be kind of a foundational piece to that process. All right moving on. Next one of course, we kind of mentioned it, constipation. It used to be kind of on the list of all the classic hypothyroid symptoms. Now, I think constipation kind of gets– maybe because it is really common. Everyone is somewhat constipated to some extent or has some kind of digestive issues that it kind of gets reclassified as either as IBS or some other kind of digestive issue when sometimes it can just be a sluggish thyroid.

Dr. Davidson: And you think, like you would mentioned earlier, the thyroid has a role in everything. So if things are moving well, hey things down south with the colon are moving well too but if things are moving slowly then you will see that constipation and then to what I also noticed with hypothyroid more so with females than men is one of the amazing things about the large intestines or the colon is its ability to draw water out of the stool. So if I did not have water around and so I would not die from dehydration. It will pull the water out of my stools to try to supply me with some hydration, even though in hypothyroid what you will see is, even though I am down in the water, the colon, for some reason still has an ability to do that that it pulls the water out and then that is why the stools end up being dry. So a lot of women with hypothyroid will complain, not only am I constipated it but it is almost like this stool is, sorry if this is too much TMI, but like rabbit pellets, they are hard and they are dry and that is because of that dehydration. So working on the thyroid is great and we have got a lot, there are so many other tricks and tools for constipation because it is really common in females just in general.

Dr. Maki: Yes, yes. You do not see her too many men that have constipation problems–

Dr. Davidson: No, do not.

Dr. Maki: But a lot of women have that problem. I think the liver function plays a big role in that and we can expand on constipation later.

Dr. Davidson: We could talk about. I could talk about it forever because it is so important. You know you are an adult when you want to go to the bathroom every day.

Dr. Maki: Yes. Sure. Well, when I was a little growing up in Minnesota, Wisconsin. I had a lot of older relatives and they are always talking about Auntie Bibi and Auntie Fanny, Auntie Helen and all the people, they are always talking about their bowel movements. It is like “Geez really,?” and their whole day was ruined if they did not have a bowel movement. At that time, I was a little boy, they were probably already in their 70s and 80s, so they were definitely considered to be now by today’s standards some of them would not be considered elderly, right? We have patients that are in their 70s and 80s that are just amazing, still working and still doing some, living a very active lifestyle. When you and I were little, seventy and eighty was– they were considered old people at that point. I mean they were definitely geriatric and that is just kind of what they talked about. They all had prune juice in the fridge and some of those little tricks they needed because their whole day in some ways revolved around going to the bathroom and it was not easy. Sometimes it was a little bit of a miracle or a happy day when those things happen.

Dr. Davidson: Well, I would say its a happy day for those of us not in the 60s or 70s or 80s to have a bowel movement.

Dr. Maki: Well sure but it was just something that I noticed when I was little. It was just this, they would all be sitting around and crocheting and knitting and doing other things and that was the topic of conversation. I mean, maybe not like the entire conversation but they would certainly be sharing their little tricks and tips and what would work and it just kind of was kind of like a running joke so to speak but they are always talking about it for sure.

Dr. Davidson: Well, you see my parents, they are between seventy and eighty and they do not stop and they go everywhere.

Dr. Maki: Yes, right.

Dr. Davidson: They run circles around me.

Dr. Maki: Yes, right. So comparing your parents to when I was little, it is striking contrast. And really I think that is the good thing about their quality of life in America is that we are kind of pushing back that envelope, life is a lot. We have a lot more conveniences and now the aging process does not hit us as hard as it used to. I think that is good. I think that so what we are all trying to do live a really high quality of life for as long as possible and not have the– we are not really old for thirty or forty years. We were robust and vital and healthy for as long as possible.

Dr. Davidson: All right, so moving on to some more symptoms. So one thing that a lot of people really are not aware of, especially with females with low thyroid function, is their periods. Women that have hypothyroid or a low thyroid function, they actually will have heavier periods, longer periods, which then makes them more crappier and painful periods. But that is one thing that a lot of people do not really try to kind of talk about. I mean granted having heavy periods can run in the genetics like “Hey, you know, my mom had heavy periods la la la.” But a lot of times once you can work on that thyroid, get that thyroid level to an optimal level, you will notice that the periods are not quite as heavy. And everyone always says day two and day three are usually the heaviest when you are having your period. I mean I have some women they do not leave the house without wearing white. Do not go on a road trip, go make sure you know where the bathroom is for every hour. So it is really great for a quality of life for a female to be able to work on their thyroid, get it an optimal arranges and then make those periods be tolerable as opposed to all the different conventional medications birth control pills and all that jazz for trying to work on– or hysterectomies for trying to work on heavy periods because it is a symptom. Hey, someone is having heavy periods. Sure there might be a genetic component to it but let us look into it a little bit deeper to find out why are they so heavy?

Dr. Maki: Yes, sure. It could be a progesterone problem, really high stress. It seems like it always affects the female cycle and there are some actual pathways and how that is. We do not need to get into that. But I am certainly, just like we said, as you improve thyroid function, then everything tends to get better and that is something that we have seen time and time again that once their thyroids optimize, their periods kind of fall back into alignment and they kind of ease out a little bit. Another one that you would not necessarily connect, low libido. Libido for a woman is well, you should be talking about that. I mean, that is a really–

Dr. Davidson: You can talk about it too.

Dr. Maki: That is a really complicated one, just in general, right? There is not really any conventional treatments for that at all like there is for men.

Dr. Davidson: Yeah, female libido is truly complicated. I wish it were easy, but it is not. It is really more the collection or the balance of hormones. But I do find with lower thyroid, there is a low libido. It has an effect on the female hormones. So thyroid is always upstream from the reproductive hormones. So when thyroids off then you can see those reproductive hormones off, like the estrogen and progesterone, like Dr. Maki had mentioned about the progesterone which then could contribute to the heavier periods. So there is a lot of aspects with that but also too, I think with thyroid, women are tired and we have a lot to do. We have a lot to do. Twenty-four seven that by the end of the day, they are just tired. They would rather go to bed than have sex.

Dr. Maki: Yes, sure. Well the stress level, just like we talked about with the weight gain and some of the fatigue and lethargy certainly stressed. What you gain was we said kind of the thyroid, the adrenals are kind of connected in that respect. The higher their stressed, the lower the libido is, in almost across the board. Like you said women are busy they are working. They are taking care of the kids, they are taking care of the house, they are trying to do it all and the last thing that is on their mind at that point literally is–

Dr. Davidson: More work.

Dr. Maki: Yes, yes. Any kind of sex drive of any sorts–

Dr. Davidson: And then too, we will talk about it a little bit as well as thyroid has an effect on your mood. So if your mood is not great the last thing you want to do is have fun and fun in the sack.

Dr. Maki: Yes, sure. Mood, definitely, there is definitely a correlation between, maybe not clinical depression, but certainly a depressed state. A lower mood, little melancholy, kind of like the sky is ill but cloudy and gray all the time. Thyroid kind of help, kind of uplift that a little bit when it gets optimized for sure.

Dr. Davidson: Oh, yes. If you want to go ahead and jump right down the list to the low mood. Low mood is like one of the biggest things I see with hypothyroid that people are not aware of. I do not want to jump into all the different clinical words and depression and all that jazz, but definitely that lower mood people, they are sad. They can be sad. They are still doing everything they need to do and they get things done, but they can be sad which that is a huge impact on that. You know with that mood. I do not think it has to do necessarily with energy because when you are tired, and I am sure your mood might not be great, but a lot of times once you get that thyroid up, especially that freeT3, their mood is so much better.

Dr. Maki: Yes, right. And it is not again, we do not follow a TSH. We are not even really, I mean we are concerned about TSH. We do test it. But really it comes down to that free T3 level. That is the active hormone, the active thyroid hormone, the T4 which is what most of the conventional medications are really the body does not do anything with it except convert it to T3. T3 is where the attention needs to be put and that does not really happen on the conventional side very much. But you know, there is some research to support that between T3 and mood, that there is a definitely a correlation between those two. Now again, we could make that correlation between low mood and stress, there is a little bit of a theme there that those two are definitely are intertwined and just like we said going from low libido, the low mood, as you said too, those things are definitely related. The lower your mood, the lower your libido. What is the common denominator there? Of course, it is kind of the busy stressful fast-paced society. And now some of our emotions are kind of blunted in that respect and we just maybe have a little bit of a flatter affect or just do not have the emotional up and down. that is normal, right? We are supposed to have highs and lows but just making sure that those highs and lows are positive highs and lows if there is such a thing as a positive low so you are not too high, you are not too low and you are actually able to find some joy on a daily basis.

Dr. Davidson: And we are not saying the thyroid is completely compartmentalize, like when you are treating somebody with the thyroid, we definitely want to look at what you had been talking about with stress in the adrenal glands. We are looking at the reproductive hormones, we are looking at the neurohormones, but definitely on, you know, if I were to just kind of give a broad statement is that when I see low levels of free T3, and low thyroid function, that mood is impacted.

Dr. Maki: Yes, for sure. Now, if you are saying someone is depressed, the one thing that goes along with the depression a lot is anxiety. Depression anxiety kind of like brother and sister, they kind of run together in some respects. You have one you are going to have the other. And anxiety, certainly we see that a lot in the Hashimoto’s people. The ones that actually have the antibodies, the anti-TPO, the anti-thyroid, and the anxiety tends to kind of rear its head a lot and it can be one of those kind of key symptoms that people notice when they have a thyroid problem.

Dr. Davidson: And anxiety, you would not really picture to go along with hypothyroid. You think “Oh, well, maybe hyperthyroid they would be anxious. But hypo are they not just tired and lethargic?” But I do find that and I do not want to call or label it anxiety, but there is this angst or this wound up, stressed out feeling when you have this in congruency of the things you need to do in the day and the energy that you have to expend for that is less. So there is like, they know they are just not going to get what needs to get done today. And it creates this level of angst that always seems to be perpetuating around. So a lot of times when you can raise their energy and they feel better, then that anxiety or that stress level does drop down.

Dr. Maki: Yes. That is something that, in some ways that becomes, that anxiety becomes almost like a barometer. Like they can kind of tell where things are and they can kind of navigate and manage their stress level based on that. What exacerbates it? What makes it better?, all those things and you are right. That is something that you would not, and we are not really big fans of anti-anxiety medications at all. That is in some ways, it is kind of like a rule that the last thing we would ever do, that we prescribe those things, anyways. But we do certain, basically talking about benzodiazepines. The last thing you want to do is prescribe something like that for someone that actually has anxiety. Even though that is what they are intended for, It only causes–

Dr. Davidson: It is the thyroid. Because really it is about the thyroid

Dr. Maki: At least in this context.

Dr. Davidson: In this context. That is why did not want to label it quote-unquote anxiety, but you see that level when it comes to somebody when their thyroid is low.

Dr. Maki: Yes, sure. So moving on, the other ones that these are again going back to female issues certainly fertility, a woman is having a hard time conceiving. Certainly the thyroid has to be optimized. A lot of times, I know that we have seen it with some of our patients and we co-manage them with OBGYNs that they are concerned about that once the woman is already pregnant, they want to make sure that TSH stays low. They are very concerned about thyroid function, maybe not in exactly the same way that we are and they do not look exactly at the same numbers, but they are certainly concerned about that. If a woman is trying to get pregnant, let us say maybe she has got PCOS or something, part of increasing her fertility is optimizing that thyroid.

Dr. Davidson: Oh, absolutely. When you have that thyroid optimized, it is great for helping with ovulation, it helps with the female reproductive hormones particularly the progesterone and then on that flip side, like Dr. Maki had mentioned. Yes, once somebody is pregnant, your OBGYN is very concerned about your thyroid and rightly so because when your thyroid is low being pregnant, it actually increases up your risk of miscarriage. Mainly more in that first trimester before the placenta implants and your hormones are going skyrocketing, but usually in that first beginning part, especially even up to week 10 is, I think I am super concerned about making sure that that thyroid is level, is optimal in the very beginning part of pregnancy. I always say as soon as you find out you are pregnant, you let me know because I am going to make sure that those levels are good and that we are optimizing that thyroid because of that, because yeah low thyroid does increase up the risk for miscarriage.

Dr. Maki: Sure, yes, and that is not a fun process.

Dr. Davidson: No, it is terrible. Devastating.

Dr. Maki: Especially if they have a history going in then we are going to take even more, make sure there is more attention to make sure that that thyroid stays that way prior to and then immediately like you say once they find out. And those are the things that you would not really pay a lot of attention to because it is considered to be a female issue. But in our experience, improving fertility and thyroid in some ways, they kind of go hand in hand. It is almost like one of those things that just needs to be done. And for whatever reason it seems like the ones that are having trouble on the fertility side, they always have under functioning thyroid. So there is definitely a correlation there. It is not just magically made it up. And I am sure we have not looked at, you know, really dove into any of the literature. It is more from observation and clinical practice, but I do not know how many times people have had a really tough time getting pregnant and then they– six months, nine months, they are like, “I am pregnant.” I mean, it is always very nice when that happens.

Dr. Davidson: Yes. It is definitely a joyful time. That is always wonderful to hear that. And then of course, kind of moving on a little bit is the dry skin. People complain, women, I mean it happens to all humans but us, ladies are more concerned about dry skin, but with cellular turnover, the thyroid has such an impact on our cells turning over so you think about are epithelial cells or our skin cells. That turnover process can really be kind of in some ways degraded. So you will see a lot of dry skin.

Dr. Maki: Yes. I mean that is you know–

Dr. Davidson: And nails too but mainly the skin.

Dr. Maki: Yes, yes. Sure. You can see changes to the nails, certainly the nails maybe not grow or they are not as hard that you know where the hair come in because the hair and nails are pretty much kind of the the same tissue for the most part. You know the skin on the lower limbs, like on your shins and stuff having almost like if you rush the skin and you get this kind of flakiness that comes off.

Dr. Davidson: If you are wearing black and you take off some black leggings and then there is skin, white skin flakes all over it.

Dr. Maki: Some of that is normal. Like the dust in the house, dust in your house, a lot of that is–

Dr. Davidson: Or winter.

Dr. Maki: –is skin.

Dr. Davidson: Or dry, you know living in the southwest or midwest winter or the low humidity but definitely, dry skin is really common with low thyroid so I would not rule it out.

Dr. Maki: Oh, no, I am not saying you rule it out, but you are not going to make a diagnosis of someone with hypothyroid just on that. Usually if they have a thyroid issue, they are going to have a few other things besides just dry skin, but certainly if they have some of the things we talked about and the dry skin now you have this complete picture of what really is going on. You can make an accurate diagnosis that way. Now this is also a little bit more, what would you say, a function–

Dr. Davidson: Subjective? Objective?

Dr. Maki: Yes, functional, maybe not necessarily, you are not going to bring endocrinologist body temperatures, but certainly looking at core body temperature, there are some protocols and how to take your temperature in the morning and if it is consistently low, in some ways that body temperature 98.6 is normal, right? So if you are always running a little bit lower than that, that can indicate an under functioning thyroid as well.

Dr. Davidson: And I think it is kind of an interesting symptom or aspect, or even in some ways objective data to take your temperature. Because with hypothyroid though I say, “Oh, yes, they are cold or have a little body temperature.” and then they just blow it off and say “Hey, wear a sweater because you know being cold is not going to kill you. It is not a disease” but it is something to take into consideration saying “Hey, you know my body temp is running always a little bit low, or I am always the coldest one in the room.” It is one way that at least you can say, maybe I should look at some of these other symptoms that I was not aware of and that way, like you said putting it all together. It is not like one symptom. I am going to treat someone’s thyroid because they have dry flaky skin, but putting all the symptoms together give you kind of a picture of what direction you want to go in.

Dr. Maki: Sure. Some of them might be a little bit, you know ambiguous or a little bit convoluted, but then there are some other symptoms that people have, it is just classic.

Dr. Davidson: And I do not– to be honest you and I see the testing all the time, I do not trust the testing sometimes. I really do not. I mean it is what it is. The numbers are there but you know their numbers will come back a certain way and they clearly have all these things going on but yet, you know just because their TSH is under 4.5 and they are technically not hypothyroid. I just, again you have to do it from a clinical perspective and lab testing. It cannot be one or the other. It has to be– not in every case, but someone who has got a TSH 17, it is pretty obvious, but a lot of times it has to be using both parts of that information. You have to use the subjective along with the objective information. Subjective is the patient’s complaints. The object of is data labs or diagnostic imaging or some kind of testing of some sort to really be able to do that effectively. And I think that conventionally it relies more on the the objective than it is on the subjective. Now this one so a little story about that. So when I was in college actually back in Duluth, we had a really great physiology teacher. His name was Doctor Czalo[?]. They call him Dr. C and he used to teach all the anatomy physiology classes, all the pathophysiology and this guy was just, he was like a biker right? He had long hair, used to wear Harley Davidson T-shirts or sweatshirts all the time and big biker boots and it was like a private catholic school and you know in Northern Minnesota. He did not really fit the mold necessarily, but he was just an amazing teacher and he was talking about thyroid function and that the Army used to do some studies on body temperature and they would put soldiers in cold weather to try to stimulate thyroid because the thyroid is very sensitive to body temperature. And if you think about it on an annual basis our temperature than our environment is really the same all the time whether we are in the summer time, in the winter time, our temperature that we are exposed to does not really change that much.

Dr. Maki: So actually when I was in college at the time, I was probably what, my early– late teens early twenties and I used to in Minnesota, I used to go as long as I could in the winter, or the fall into the winter without wearing a jacket so I could stimulate thyroid function. Now, I never did any testing or anything because it was not really available back then but it would have been interesting to see and sometimes I get into like November with no jacket, be you know, lower, thirty degrees or less and I would not have a jacket on because I was trying to do what he said in class and trying to stimulate my thyroid function.

Dr. Davidson: Oh my goodness. Growing up in Washington with our temperate weather. I wear a jacket in November. [laughter]

Dr. Maki: Well now that we lived in Las Vegas for so long and what would happen when I did that come January, February when the temperatures got really cold and I was never really that cold. I mean, I never really had that bone chill cold where now people it will be even in Washington where it is pretty mild for the most part and people are freezing all the time. But when we lived in Vegas, we kind of, we got re-acclimated to– now I cannot tolerate, I probably could now we have been in Washington for a little bit.

Dr. Davidson: I do not think you could tolerate your hometown, in the midwest. That gets cold.

Dr. Maki: Well, yes. I mean if we were there for a little while we certainly could but you are right, your body does adapt and I would imagine if we mapped out thyroid issues, there would be probably proportionally, and I am sure this, I think I have heard this somewhere that there is proportionally more hypothyroid in the southwest, in the warmer climates than there is in those cold climates because of the weather change. I think there is something to that. That is where I think even like cryotherapy, hydrotherapy, using hot and cold, saunas and cold soaks, I think you can stimulate thyroid function that way because of the contrast. That cold temperature taken an ice bath. I do not know if anyone has ever taken an ice bath before but holy moly talk about invigorating or I am a big fan of saunas, all the rule is always after the sauna is you have to take a cold shower. Not a warm shower, not a lukewarm shower, but a cold shower, and that contrast, it gets your heart racing, your breathing increases and I guarantee you that that is having an impact on thyroid. We could probably go find some studies that would actually say exactly that thing that TSH levels are going to go down because of that contrast in temperature. And in our society because of houses and furnaces and ways to heat ourselves or cool us off, we do not really have that temperature fluctuation like we used to.

Dr. Davidson: Well then I think we should definitely go outside without jackets on. Granted it is July but it is kind of cold out.

Dr. Maki: Yes. I know it is a little nerdy but hey, he was a really good teacher. I think he is still teaching there. He teaches the nurses and he teaches that the medical school and pre-med and all that kind of stuff. He was a really, really good teacher. That is kind of what where all this nerdy science stuff came from because he was really that good. All right moving on, but that was just a little digression where I kind of learned about thyroid even well before you and I were doing anything medicine related. Another one that– this one is kind of known about at least on the doctor side maybe not so much on the patient side is high cholesterol.

Dr. Davidson: Oh, yes, absolutely. High cholesterol. In fact more so, with cholesterol, you have your total cholesterol, you have your HDLs, your good cholesterol, your LDLs, your bad cholesterol, the lower the better and then your triglycerides. What I notice with thyroid is when you optimize someone’s thyroid, ensure they might be feeling better. So they are not eating the comfort food or whatnot, but their cholesterol does go down. Particularly I noticed more the triglycerides than the LDLs but over all the LDLs and the triglycerides go down, but I noticed the triglycerides go down much more significantly than the LDLs.

Dr. Maki: Yes. And I think there is a of confusion I think about cholesterol. We have been doing some CT coronary calcium scores lately, particularly when people that are having these abnormally high cholesterol levels and a coronary calcium score basically looks at the plaque formation in your coronary arteries and using that as a way to look at someone’s cholesterol levels to say is this, do they need lipid management or cholesterol management and using a CT score like that coronary calcium score to kind of help make that decision and time and time again. I have had a couple of carnivore patient’s doing in the carnivore diet. Their cholesterols are off the chart, but they have these CT scores come back and they virtually have no atherosclerosis whatsoever. Even though like their cholesterols are on the high 300s or the low 400s which we listen to conventional advice, that would be super dangerous and they should have plaque in their arteries all over the place and they really do not. That is not every case. I have seen it the opposite way where someone has actually good numbers, good cholesterol, do not need any lipid management and now their cholesterol scores are off, their CT scores are off the chart. And then I have seen some that would kind of, they got high numbers and high score, low numbers, low score. So you see kind of a few different profiles there but there is no real reason to it. You cannot predict based on someone’s cholesterol who has– this is the part that I think people need to be aware of. You cannot predict based on their cholesterol who has the higher, the higher the score the worse it is. You cannot predict based on their cholesterol who is going to have the plaques, worse plaque score, than who does not. That is where I think the disconnect is. So I think that the argument or the claim for using Statin therapy or lipid management in general, I think it is going to change a lot over the next ten to fifteen years. If not in the next few years because there is this discrepancy, especially with this new imaging type of study.

Dr. Davidson: Well, I would never hang my hat on cholesterol being the marker for a cardiovascular event or cardiovascular risk, but I am definitely, I will have patients that maybe decided they did not want to take their thyroid anymore and they “hey I can do without it” or maybe they forgot to take their thyroid medication or ran out or something and then we will run their blood work and I will see their cholesterol go up and I will say that I did not change my eating, I will say that was because your thyroid went up so you definitely see that clear correlation. Like I said more so I find between the triglycerides and thyroid but you are right. We would never, I mean, cholesterols just one marker to look at when you are looking at any kind of objective value. I would never base that on any kind of risk for future cardiovascular events.

Dr. Maki: Yes, but everyone has been kind of led to believe, even doctors believe if your cholesterol is over two hundred it needs to come down and I do not think that is the case at all. I think you cannot, like you said you cannot base that decision on that one number of your total cholesterols two twenty-five or two-fifty or two seventy-five, is that really enough to put somebody on a Statin drug? And I do not really think that it is. I think there needs to be more information than that because the correlation between that and having a heart attack or having a stroke, the correlation is not very good and the CT scans that I have been having patients do lately, as kind of proving that out and it is almost random. You cannot tell between the two and I think that you know, creates a little confusion. All right, so–

Dr. Davidson: And yes, and before we finish up here, I definitely want to talk about joint pain and thyroid. I know if you Google, hypothyroid you will see muscle weakness and pain, but really I do not think doctors really kind of correlate that that low thyroid really truly causes joint pain.

Dr. Maki: Yes, sure. I know that we have seen it happen kind of in the reverse way. Like someone does not take their thyroid medication all of a sudden they get this kind of bone fatigue, that you just kind of get bone tired and it hurts. They go back on their medication and they are osteoarthritis or whatever their joint pain was. It just kind of miraculously goes away.

Dr. Davidson: And that is the interesting thing about the joint pain in hypothyroid or low functioning thyroid is it is not really osteoarthritis. It is more like “Hey, I am just achy, like my shoulders are hurt, my neck and then a different day, my hips and my low back is kind of achy. I just feel achy.” And it definitely is the joints, “My wrists. I do not know why I did not do anything but it is just achy” and it moves around as opposed with osteoarthritis, you are looking at through, the little parts of their joints and they are enlarged or they are hurting or they are red or osteoarthritis in the hip, it is going to be there every time you get up and you move. Where it is, with the low thyroid it creates that kind of joint irritation. I do not think it is really so much inflammation. It is probably a combination between the muscles and the nerves, the innevations, but it really is that achiness and when you get that thyroid optimized they really feel good.

Dr. Maki: Yes, sure. Their pain level or their discomfort, like you said you and I are in our mid-forties, certainly by the time you get to your forties, you definitely have some aches and pains, usually a lot more you did when you are in your twenties and thirties, maybe it is a little progressive to some extent but you are right. It is just kind of like this– and I have noticed it in patients, not so much beforehand, but really when they stop it for some reason or they run out and all the sudden that discomfort kind of comes roaring back and kind of gives them a good reference point to say “Hey, my thyroid this is important and that is not fun to live with, pain on a daily basis”

Dr. Davidson: And we do a lot of supplementation with thyroid. So when you are looking at optimizing thyroid, like, Dr. Maki had mentioned earlier, it is not just “Oh just one pill fits all, here take some medication.” There are so many different types of medication. There are so many different types of supplementation. Depending on someone’s goals. So with all the list that we went over here. You think somebody might have, four out of all of them and those are their main goals they want to work on. I have lots of patients with low thyroid and they have no weight issues but at the same time they have a very low mood or their hair is falling out and they have constipation but they do not have any weight issues. I have had other hypothyroid patients that actually have lots of energy, but they have really high cholesterol, that kind of related to that low thyroid, they have joint pain so everybody is a little bit different on how we manage and treat this so it is not just medication. Like I said supplementation, there is lifestyle, there is dietary, there are types of exercise, there are so many different ways to kind of embrace working on optimizing someone’s thyroid.

Dr. Maki: Sure. Even we have talked about before, even caloric intake, being on a perpetual diet is going to lower your thyroid function, even some of the keto and intermittent fasting, some of those things people drop their calories too low, and your thyroid function is going to go down. So maintaining an appropriate amount of calories, not maybe not on a daily basis, but certainly over time. So you are not at a chronic deficit for too long. That can actually have a major effect because we cannot over supplement or sometimes over prescribe or whatever, a diet that has too few calories in it. Then that becomes a really big deal. Thyroid is very sensitive to temperature and food that is why I was telling the story about not wearing a jacket in Minnesota, and certainly caloric intake. That is what the body is trying to protect us against sometimes. So this was kind of a long list. Usually this one usually were at about thirty minutes. This one is running a little long.

Dr. Davidson: We kind of got out on some little tangents but they were important but we just wanted to let you all know that with hypothyroid, there are so many other symptoms that come and play with it and there is a lot of kind of symptoms you would not expect especially with females when you are trying to look into thyroid function optimizing the thyroid and what goals we are going to have moving forward.

Dr. Maki: Absolutely. So I think that this gives everyone if you are concerned or you are questioning or you are not really sure, you keep getting different answers, you are looking on different resources online. Hopefully this will give you more insight as to what we see as the real common thyroid problems. As always you have any questions you can send us an email helpatprogressyourhealth.com. Check out our website progressyourhealth.com. Until next time. I am Dr. Maki.

Dr. Davidson: I am Dr. Davidson.

Dr. Maki: Take care. Bye-bye.

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What Diet Is Best For Perimenopause? | PYHP 098

Dr Valorie Davidson and Dr Robert Maki — Thu, 02 Jul 2020 22:38:34 +0000

Question:

What diet is best for Perimenopause?

Short Answer:

One of the most common complaints we get from women in perimenopause is unexplained weight gain. Their lifestyles have not changed in years, but all of a sudden, their weight keeps increasing. And if they try to lose the weight, their efforts fall short and often gain more weight in the process. An observation we see quite often is that many women are still tyring to “eat less and exercise more.” This might have worked when they were 25, but for women in their 40’s, this weight loss approach often seemed to backfire. Women in their 40’s typically have a good deal of stress already, so trying to exercise the weight off only adds to their stress. This makes the weight loss process very frustrating, if not seem impossible.

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PYHP 098 Full Transcript:

Download PYHP 098 Transcript

Dr. Maki: 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 on this one, we are just going to dive right in, and we of course have a lot to talk about. We cannot not talk about perimenopause or menopause without discussing diet and weight loss at least to some extent. Would you agree with that?

Dr. Davidson: Absolutely when women, hit their 40s, they especially perimenopause and menopause. They always say it is like I put on 10, 12 pounds overnight like it, just where did it come from and they will point right to their stomach. I have had women, I love them dearly they will even grab their stomach and say, “I have never had a belly before where did this gut come from?” And things are different, of course, we all know obviously from when we are twenty, to when we are forty, to when we are sixty, we are always changing but it definitely comes from the change in hormones.

Dr. Maki: Yes, right and believe me that is very complicated and you and I, we have been doing this a long time and we certainly do not have all the answers when it comes to diet and weight loss and especially perimenopausal weight loss or menopausal weight loss for that matter. But the purpose of this episode is to kind of just shed some light on some of the observations that we have noticed and in some ways what does not work for people, we do know some of those things. Everyone is still trying to follow the same advice eat less, exercise more all the time. They are just trying to basically starve themselves and exercise a bunch and that strategy right there and we will kind of dive into that, what that strategy looks like little bit more specifically but that strategy clearly does not work. And in some cases that actually make their situation worse, they actually gain more weight. They are exercising five, six days a week and their weight is going up.

Dr. Davidson: Yes, you will see that I mean granted I was a child of the 80s. I remember the 80s and the 90s, if you were going to go on a diet, you just stopped eating or you just restricted your food or you keep it to like one Snickers bar a day. Everybody has had that caloric restriction put in their brain almost like its theory but now we are realizing that we want to eat food to lose weight, we want to eat more calories, When you under eat sure you might lose a few pounds initially and people say, “Oh, this is awesome. I lost 8 pounds, I lost 10 pounds.” But it always comes back and I work with a lot of women, especially with hormones is when you do that, sometimes I do not want to say it messes up your metabolism, but it is really hard to come back from when you have done a crash diet or chronically restricted your calories.

Dr. Maki: Yes metabolism, that term metabolism. Like I do not think anybody really understands what metabolism is like it is this kind of really obscure metabolism. What is that? Now granted, we could define that in a couple of different ways, but really kind of your resting metabolic rate. How much energy does your body utilize while you are just sitting there watching TV, right? Now that is your resting metabolic rate that is in some ways metabolism is a moving target. It does not stay static. It is very dynamic based on the information that your body is receiving your stress, your sleep, your activity, your diet your food, all these things that your body is taking in is then being translated into whether your weight management, whether you gain weight lose weight or maintain weight and that message is always kind of being re-evaluated. So and one thing I will say more from a biology perspective or from a survival perspective, you are on a chronic diet. The body is very, very sensitive the brain, the hypothalamus that is kind of the master gland in the brain. The hypothalamus is very sensitive to a significant drop in calories. It does better with an increase in calories. It does not do very well; it starts going to which we will talk a little bit about compensation mode when those calories drop too low for too long.

Dr. Davidson: And then like you had mentioned like we always know is, “Hey, I am going to eat less then I am going to exercise more which exercise is great, exercise is great for the body.” I love to exercise but especially Dr. Maki is very much an advocate of, you need to change the way that you exercise especially in your 40s and 50s if you are trying to lose weight.

Dr. Maki: Yes, right, and granted this is not a criticism. I really appreciate how disciplined and how dedicated a lot of women are. I mean literally they are working their butts off trying to achieve something, trying to achieve their goal, and they just get so frustrated because they just follow that same advice. Go on a 500 or 1,500 calorie or less calories a day they are measuring it in there MyFitnessPal or whatever app, they are using. So they are meeting that caloric goal and then they are exercising four to six days a week at doing some kind of a boot camp or some cardio class or some spin class or something along those lines. And months will go by, they might lose a little like you said, a little bit of weight initially then either it comes to a screeching halt they lose no more weight or they have been doing that for six months and they have gained 10 pounds. It completely is baffling as to why it works that way.

Dr. Davidson: And granted I like cardio, cardio is fun. It gets your heart rate up. You feel really good afterwards. You feel like you actually did something. So I love cardio but like you always tell me is, “Hey, you got a back down and do the weights.” And then I say, “I do not want to do the weights, weights are hard” But you are right, I need to do the weights.

Dr. Maki: Well, I think that by focusing a little bit, now granted this is not just about focusing on weight training and trying to convince women that weight training is the way to go but we talked about that metabolic rate, that resting metabolic rate. Women specifically because that is who you and I talked to most often and even some guys they kind of do the same thing. Guys can get away with it a little bit easier until they get to their mid-40s and 50s, and then they have the same challenges that women do. What used to work when you are 25, no longer works anymore. Now for guys and for some of your husband’s out there whenever they try to actively try to lose weight, they will lose double, triple what women lose which only frustrates them. They just have to stop drinking the beer, or some of those, Sunday NFL football tailgating foods and all of a sudden, or they do keto and they lose 20 pounds in a month and a half, that just frustrates women to no end because they are able to drop weight so rapidly. But from a long-term success perspective, how rapidly you lose it in some ways only guarantees and how quickly that weight is going to come back.

Dr. Davidson: And just like you are saying and I hear it all the time, too like, “Hey me and my husband, we are starting to walk a little bit more and we are eating better and course he loses 15 pounds.” And the wife will say, “I lost one.” You hear it all the time, so it does make you say well, “Click, click, click, light bulb, light bulb.” It must be a hormone issue going on which yes in some ways, female hormones are different. We have more estrogen and progesterone. As humans, we all have the same hormones it is just as ladies we have more estrogen and progesterone than men do, is that change in that estrogen and progesterone can facilitate that but there is so many other hormones that come in to play with that.

Dr. Maki: Yes, right. Now, we know that nowadays that keto and intermittent fasting are both very popular and we kind of aligned with both of those strategies. We like the lower carb strategy. We like intermittent fasting. Combining together it can be extremely effective. Unfortunately, what I think a lot of times those things translate into on a day-to-day basis is basically, another version of a low calorie diet. A keto diet and an intermittent fasting are not necessarily meant to be just basically another form of low calories. But when you are removing a whole macro-nutrient carbohydrates, inevitably for most people especially women calories are going to go down. Now, we wrote a little short e-book about this called A Keto Carb Cycling Program kind of in some ways intended to protect women from themselves. We wrote it for women because that is who we deal with most often. I think it can be very effective for guys, maybe more effective for guys. But it was intended for women because we see this; exactly what we are talking about right now is we have seen this happen over the last 10 to 15 years. As we have been in practice that this low-calorie thing always creeps back in your figure, as long as you are under 1500 calories, you are going to lose one to two pounds a week and you are going to meet your goal in three months. When we say that metabolism is kind of a moving target, we think people should focus more on stress level and sleep quality before they kind of dive into all of that because the results can be kind of compounded in a negative way.

Dr. Davidson: And one thing, ketosis, keto diets are really popular a couple of years ago. Intermittent fasting is super popular now, Now macros are back in the business, where it used to be macros worth of super in all. All this with dietary stuff, it is always changing and there is always different kind of things out there which is nice because not one thing works for everyone. But we did notice with doing ketosis, one of the reasons why people drop their calories, is your appetite goes down.

Dr. Maki: Yes, right. Now there is a few things there like you said your insulin drops, you are taking away the carbs and probably a lot of sugar for that matter out of that. In sugars one of those things right, the more you have the more you want. It is kind of like this feed-forward mechanism in your brain, so the more snacks and things and the sweet things you eat, the more your brain just wants to eat that stuff. You eliminate that and then it takes a few days and all sudden now your cravings are relatively gone, unless you are at a low calorie state for a long period of time and that long period of time is somewhat dependent on the person and dependent on the rest of their lifestyle. How well they sleep, what your stress level is and how much activity they do. How many women out there are exercising like crazy and you get done with an exercise session or in the evening after doing that on a workout day? And also, now you start getting the munch because you want chips, you want crackers, you want cookies, you want carbs–

Dr. Davidson: Sugar?

Dr. Maki: Yes, you want sugar and carbs galore. In some ways that activity basically tells your body to eat those things. So you are kind of battling against your own body’s innate mechanisms to protect itself from, starving to death and running from a tiger, right? That is what most women are telling their brains or literally on a daily basis they are starving and a grizzly bear is chasing them down the street. That of course is going to make your body respond a little bit of a different way than in a very calm relaxed environment and then that is when the weight loss tends to happen the most. It is not going to happen and that consistent day in day out, fight or flight response.

Dr. Davidson: Exactly because doing more cardiovascular like I said, it is really fun, I like it but it does rise up your cortisol. And when you rise up your cortisol, cortisol is a hormone from the adrenal glands, it has a connection with glucose and then which also has a connection with insulin so we could go down that rabbit hole. But one thing about that is when you raise up that cortisol and mess with your insulin and glucose, it makes you want to have sugar later on, I mean always does. I have women we talked, we giggle about it and say like eating in the evening time can be like an extracurricular activity because at 10:00 in the morning, nobody wants a brownie. Nobody wants and that is why a lot of times women will not even eat much during the day because they are running from that grizzly bear but come nighttime my goodness, it is a it is a free-for-all and willpower never wins, biology, you always want to bet on biology because willpower is very short-lived.

Dr. Maki: Yes, these mechanisms that we have in our body, between our liver, in our hypothalamus and our fat stores and all these different organs that regulate this, it is extremely complicated. Now, if you talk to the low carb people, they will say weight gain is all about insulin. If you talk to the neuroscience people, they will say that it is all a brain issue. I think that it is a combination of both of them. It is a peripheral, kind of insulin-based issue. Now insulin, I think it is a bad rap sometimes, I certainly any kind of bag on insulin but insulin is a critically important hormone. You need insulin for its anabolic or its energy storing effects. You need insulin, it is not necessarily about having no insulin whatsoever that is what a Type 1 diabetic is and they do not live very long. Insulin, I think was invented or discovered as a medication like in the early 20th century before that people had Type 1 diabetes, they live like two weeks. They do not live very long. So insulin is an essential hormone that our body actually needs. We just need to be able to manage it well and make sure that the body does not become resistant to insulin. And granted that is a whole other topic, we will talk about later on. But there is a lot of things under that insulin umbrella, PCOS, fatty liver, high cholesterol, high blood pressure, of course weight gain. Maybe more on the obese side of weight gain as opposed to what we are kind of discussing is people that are trying to lose, 20 25 pounds or less, right? I would not necessarily consider anybody in that category. If you had to ask of all your patients maybe not anybody specific but the common weight for a perimenopausal woman, what would you say it is?

Dr. Davidson: I would say for the perimenopausal patients, they do want to lose what I call them is vanity pounds. And really it is because their health is great, their blood work is great, their blood sugar is good, their liver enzymes are great, their cholesterol is good but that extra, 15 to 25 pounds that they never had, even though they eat better than they did back in their 20s that is what they are looking for. So, we giggle about it calling it vanity pounds, but in truth it kind of is because it is not something that is deterring from their health. It really is so we can feel good about ourselves and wear the clothes we want to and be able to get the results that we want.

Dr. Maki: Yes, right. Now granted if that is a left unabated as that process continues, I think it can turn into way more issues like I said high blood pressure, high cholesterol, all the things that lead to age-related disease diabetes, heart disease, Alzheimer’s, cancer, you know weight of course. Especially now with all the coronavirus stuff as well people have been talking about some of these other underlying risk factors that increase our susceptibility to those types of things. So, 15 20 pounds at some point turns into a bigger problem later on, so there is no diminishing the health effects of losing that 15 to 25 pounds. It has a significant impact on the overall health of that person.

Dr. Davidson: And I want to kind of go back a little bit to that caloric restriction, is you can see sometimes on blood work when someone is calorically restricting because when you lower your calories for a long period of time like, Dr. Maki says is your body goes into compensation mode is you will see the thyroid low. And it is not necessarily it looks like there is thyroid disease or diagnosable hypothyroid but you will see the free T3, which is the active form of thyroid drop down. It will easily be in the twos and I can usually look at that and say, that is because you are trying to calorically restrict and then it is dropping your thyroid function and then they wonder why they are so tired. And also you think thyroid has a huge, contributing effect towards weight loss, so if the T3 is going to drop down it is going to make it even harder to lose weight.

Dr. Maki: Yes, right. We are talking metabolism at T3 or thyroid function is not necessarily your metabolism specifically but it contributes to it, right? So on blood work, like you said exactly we want to see that free T3 to be high normal that means in some respects that their metabolic fire is kind of running nice and hot. So when there is energy coming in food your body is going to be able to utilize that energy very well and we are not doing something that is forcing the body, over-exercising and under eating or maybe not sleeping, maybe all three that is your typical we see that your typical perimenopausal women. They do not sleep, they have high stress, they under eat and they over exercise. Those are the four things we probably should have started with that. Those are the four things that we see all the time. So over-stressed, do not sleep, over exercise and under eat that is the four things that they are doing. So if you are doing those things to try to lose your weight, focus on the sleep and the stress first, lower your stress as far as the best you can that is easy for us to say but very hard to do, right? We all have stress but manage it well and part of managing stress well is just improving your sleep quality. We have got a quite a few blogs and podcasts that are about sleep quality, if you have not listened to those pay attention because that should be your number one focus. If you cannot reduce your stress, then you have to maximize your sleep quality that has to be number one because otherwise when it comes to losing weight, you are just basically walking uphill backwards. Weight regulation basically happens at night, all the hormones that keep your weight in check basically are related to having a good night sleep on a regular basis. Now the occasional bad night, okay, that is fine, right? But as long as the majority of your week is getting to bed at a reasonable time, falling asleep easy, staying asleep most of the night and then waking up feeling at least moderately refresh. Now the ability for your body to lose weight effectively you are having that effect on the nervous system from fight or flight, to rest and digest. We want that switch to happen a little bit easier than it does for most people.

Dr. Davidson: You are right. Yes, definitely with the sleep. We have patients that, I tell them do not get up at four in the morning to go to the gym, just keep the sleep because they are too busy, they are too stressed, they are going to bed at 11:00 11:30. And then they are trying to wake up between 4 and 5 to get to a cardio class. I said just take the time to sleep. You will probably notice, not only feel better, but that it is easier to lose the weight because nobody can get by on that little sleep.

Dr. Maki: Yes, right. Yes and not perpetually maybe short periods of time. Okay fine, but ongoing when you are having a sleep challenge anyways and you are forcing yourself. And you hear it from people, they say they are really gung-ho they are doing it, they are very disciplined, they are very consistent for a while and then little by little, the little voice in their head starts telling them, “Oh, I want to get up on a sleep little bit longer little bit.” So it goes from six days a week to five and then from five to four, and then from four to three. And then little while longer, they just do not have the energy to exercise at all. They kind of peter themselves out because their energy balance is completely out of whack. There is too much going out, too little coming in. Now granted that model energy in, energy out, we do not really agree with that necessarily. It is not just about calories. But in this context, it is about making sure that you are eating enough food, which is completely counter intuitive to a weight loss process thinking that you have to eat just the right amount in order to lose weight. And it is not really the right amount on a daily basis; it is the right amount over time. And when it comes to weight loss we all want, you included we want immediate results right away. We want to see that scale changing either daily or weekly. Otherwise we get demotivated and we do not want to continue or we have to think about kind of changing our strategy which with most people do is they just either increase or exercise or decrease the amount of food they are eating which then just sabotaged them even faster.

Dr. Davidson: Exactly and we definitely see that in females because especially once they hit right around the late 30s that early 40s and then menopause, too. Menopause is a huge aspect where they are talking about that weight gain. So definitely we ladies are quite a bit different than the boys.

Dr. Maki: Well, I hear the same thing for men. I think they do not focus on it as much. I think it is more socially acceptable for men to carry a little bit of extra weight. It is almost like; it is just normal where women are just that much more focused on it. They are trying to maintain something. They are little bit more urgent about that process. Men will finally get to that point of frustration, something will happen, some events, some scare, some whatever. And they will make a change where women just seem to be a little bit more, and maybe that is bias just because you and I are majority of the time, we are just talking to women, right? So they are little more hyper focused on that, on achieving whatever goal they are trying to set. Like I said that 15 to 25 pounds, they want to lose where men, we just do not hear it as often partially just because we are not dealing with as many men as we are women. We are dealing with more men; we probably hear the same thing. But percentage wise, we hear more from the wives versus the husbands.

Dr. Davidson: And I love the dedication, women, trying to exercise, five times a week trying to count their calories, see what they are eating, trying to eat healthy which you love that dedication. I just think like we talked about just making a few little changes like, “Hey, let us get a little bit better sleep, maybe would cut back on that cardio and like I need to do and you always tell me.” Let us work on a little bit more of the weights, doing some squats, working on that upper body, doing a little bit more weight training and then maybe not having to go to the gym so frequently because I think we need that rest and relaxation so we are not constantly feeling like we are being chased by a grizzly bear.

Dr. Maki: Yes, right. Yes, I think the recuperation and recovery part is drastically over missed all the time. And people do not realize you just cannot go, go, go all the time and then eat 1200 calories a day. Eventually, in some cases you are going to develop some serious symptoms from that, kind of like over-training syndrome, which is actually a real thing. You cannot push your body physically as much as you want with eating so little food and this is also very counter-intuitive. But again, if you are doing this keto or intermittent fasting on a regular basis and you are not getting the results that you want, then you need to eat more food. If you have been doing something for a while at a low calorie state and you are not, this is also what the KCCP kind of emphasizes, is if you have been doing that for a while and you are not getting consistent results on the scale, then you need to go through like a re-feeding process, you need to increase your calories, so now those hormones that are compensating against you, your body can resettle those hormones and then it is like taking a step backwards in order to continue to take a step forward. And that is an evolving process that happens on a consistent basis whether you do it, every couple of days as a re-feed or in a sense that is what carb cycling is. That is why we called the book the Keto Carb Cycling Program because keto people drop calories, carbs come back in calories go up. So it is this inevitable, kind of ebb and flow to your caloric intake that allows for weight loss to happen over time because the body never really, as we said metabolism is kind of this moving target. You are really not ever shutting off your metabolism or not, shutting off the fat burning process you are able to maintain that over time. So instead of eating less, exercising more we always is recommending to eat more and exercise less. That is hard to do, that is really hard to pull off would not you say?

Dr. Davidson: Oh, yes, hard to wrap your brain around it. It sounds like, “What does it make sense?” But as you are saying it is the body is very adaptable that is why we are so incredible. As human beings were just so incredible, we are so adaptable that if you are a changing up your calories, maybe on a weekly basis over all like you mentioned over all the caloric intake for that week might be a certain amount but you are kind of each day is a little different then your body cannot get adapted to it. Because that is one part that we always talk about with that starvation diet is your body becomes adapted to 900 calories and then oh my goodness you start to eat like a normal human being and then of course the weight comes right back on. So if you are always changing that there is a little bit of some viability to that to be able to get the goals that you want. And also be able to maintain it, nobody can maintain, a thousand calories for the rest of their life. They always end up binging or holidays or whatnot. We got to make this a lifestyle change. So it is maintainable and you can go out with your friends or cook dinner with your family or go have a family dinner or have a holiday or birthday party. You want to make this a lifestyle that you can adhere to.

Dr. Maki: Yes, right and I think and agree this is semantics, what everybody thinks it means something is based on the strategy. When you are trying to lose, 15 to 25 pounds or whatever the number is for you, it is really not about weight loss, it is more about body recomposition. We all want more muscle, less fat. Okay, maybe guys want more muscle, but they certainly want less fat. Women just want less fat. But the way you get there is by having more muscle that is where the resistance component comes in because when you are doing aggressive cardiovascular work all the time, you are talking about cortisol. Cortisol is a very catabolic hormone; it breaks down your muscle tissue. So the higher your cortisol is because of your stress level, your lack of sleep and you are over-exercising and lack of food. All you are doing is breaking down your number one fat burning tissue, which is your muscle mass. And I do not even know where I heard this, I heard this not that long ago might have been on a podcast or something and I have to look up this research to kind of validate this so take it with a grain of salt but it is one of the number one again, on a research level so it is not necessarily very practical on a day-to-day basis. But I remembered it kind of caught my attention and wherever I heard it, I know that was a fairly reputable source, is that one of the number one factors of aging is what they call Sarcopenia. Sarcopenia meaning Sarco meaning muscle, so penia meaning less, so losing muscle over time is one of the fact is one of the major contributors to the aging process. So I think there is going to be a shift over the next few years where in some ways strong is the new sexy kind of thing. I think that CrossFit try to do some of that, where women were lifting weights. They were getting ripped and jacked, in some respects in a very female sort of way. But they are increasing their metabolic rate and now the 23 and a half hours that you are not working out that resting metabolic rate is where you are burning all those calories so you do not have to kill yourself in the gym all the time. That is the advantage of doing a resistance based training workout versus something that is cardio where you do not get that back in benefit.

Dr. Davidson: That is really interesting especially I like that strong is the new sexy.

Dr. Maki: Yes, I saw something like that, while it kind of died off but I think that maybe it is not going to be the trend but I think it needs to be the trend–

Dr. Davidson: Mm-hmm.

Dr. Maki: I think it needs to be the trend because women we see it all the time. You are not going to exercise the weight off. It is about being consistent. If anything like we said, it is about eating more, exercising less but making sure that the exercise you do has that long-term advantage to it or that long-term impact which is by increasing muscle which then raises your metabolic rate. So on a scale, if you have more muscle mass comparatively, you might weigh a little bit more on the scale. You might not get down below 140 pounds, you might be at 145 or maybe at 147 but might be leaner than you were at a 130, and you have proportionally more muscle. And therefore, your clothes are going to fit quite a bit differently the leaner you are that is what everyone is trying to accomplish. It is just that how they go about that is almost exactly the opposite. There is a way to gain weight, everybody is doing it in that particular fashion, starve yourself and exercise a ton and then never sleep that is a recipe for disaster in some respects.

Dr. Davidson: Definitely and I think you made a really good point there about do not let the number on the scale be your goal. Everybody is, “I want to be 123. I want to be 127. I want to be 138.” Everybody has got this number and the scale is evil. So if anything I think you all should take it out back and bury it and have a nice little rite of passage.

Dr. Maki: Yes, it is nice to have some way to monitor success or monitor progress, right? So the scales and easy way, but when you are really close to your ideal weight anyways within 10 to 15 pounds and number you decide what your ideal weight is just I mean you have made up in your head. It is not really the real number because you are relatively close to that number anyways, but looking at percent body fat, that is why doing a DEXA scan, you can find some imaging centers around the country. If you are in a major metropolitan area, Seattle, Las Vegas, Los Angeles, Chicago if you are in a big area like that or even a suburb of a big city. You are going to find an Imaging Center that does body composition testing with the DEXA scan. And then now you get a real percentage of what your lean body mass is, your muscle, your bone, and then of course what your percent body fat is and now that can be tracked over time. And I think they do scan like that for a hundred bucks–

Dr. Davidson: Yes, I think when we have done it; it is like a hundred dollars.

Dr. Maki: Yes, hundred dollars, hundred and fifty dollars you do that. Maybe in the beginning to do it every three months just to see that as long as that body fat percentage is going down whatever strategy that you are employing is working. So that number will continue to go down if you have been doing something for three months and you have not seen any change that means you need to switch things up a little bit. And that just looking at your overall routine and modifying some things always we stress, stress level and sleep quality. Reduce your stress as much as you can and or increase sleep quality. Sleep quality has to go up and then the exercise two to four days a week at the maximum, four days a week so it could be done every other day or you could do two days with a day off and then two days. So you are allowing for enough rest to happen in there, especially if you are busy, you are taking care of the kids, you are working full time, you are taking care of the kids and working full time. It does not leave a lot of room for some of those things which we hear it all the time. Women are just trying to pack so much into their day and their week and they wonder why they are not having any success.

Dr. Davidson: And I know that we kind of originally started this podcast or this episode about, perimenopause and menopausal weight gain, but honestly everything I think we have talked about especially what you have talked about. Dr. Maki can apply to anyone that is really looking to lose to lose some weight, so just some thoughts there.

Dr. Maki: Yes, right. I think it certainly translates because everybody is trying to follow the same strategy, but this one is specific to this category or this demographic of people that is really having a tough time. So if you have any questions, this is a very complicated topic. We know enough to be dangerous but we do have some very specific things and how we approach these types of topics. So if you have any questions, you can send us an email at help@progressyourhealth.com. Do you have anything else to add Dr. Davidson?

Dr. Davidson: You had mentioned about the KCCP, the Keto Carb Cycling Program. Do we still have that available as a free download?

Dr. Maki: So if you just go to the website progressyourhealth.com/KCCP then you can find the download there. There is a part in there about putting butter and coconut oil in your coffee, it is optional, you do not have to do that. Well, what I have found is that most women do not enjoy that part. It is really intended as a way to bolster caloric intake especially if you are doing kind of a keto diet. So if you do download it, you can completely ignore, “the adding fat and into your morning beverage.” We have found it not to really be that popular with women anyways, that part is completely optional but the rest of it kind of summarizes some of the things we have talked about emphasizes making sure you eat enough. One last thing before we finish this, I think is important. The average male his maintenance level of calories on a daily basis is probably between 3,000 to 3,500 calories for the average male. Women are probably somewhere between 2,000 to 2,600 calories as their maintenance level, that is the amount of calories they need over time to survive. And when a woman is on a 1,500 calorie or less diet or 1,200 calories or less that is not even taking in any exercise. She is potentially under-eating biting or between 500 to a thousand calories. So if you do not have to count calories, but if you just focused on eating four meals a day 500 calories each, you would be at basically 2000 calories, which is I think kind of a ballpark where most women need to be. The more activity you have then the higher that number should be not lower. And if you did that, focus on that over time, I think you would have end up having a lot more success than 1200 calories doing that for months and exercising 6 days a week.

Dr. Davidson: And I am sure a lot of you ladies out there and myself included are probably like. “What that is a lot of calories, I have never heard, I am supposed to eat that much calories.” But it is true so we are changing some of those theories.

Dr. Maki: Yes, right. Yes, so now granted we are not going to eat that every single day that might ebb and flow a little bit like it is supposed to, some days are more, some days are less that is kind of what the premise of the KCCP is in the first place, is getting people to kind of think in those terms. So it is a feast or famine, you eat, you overeat, under eat, overeat, under eat and our DNA and our genes and everything is kind of evolved over time to respond very well to that environment. We do not really respond well to three square meals a day necessarily. So hopefully this was helpful, hopefully this was not more confusing. Hopefully this gives you a little bit more insight and until next time. I am Dr. Maki.

Dr. Davidson: And I am Dr. Davidson.

Dr. Maki: Take care. Bye, bye.

The post What Diet Is Best For Perimenopause? | PYHP 098 appeared first on .

What Supplements Are Good For Perimenopause? | PYHP 097

Dr Valorie Davidson and Dr Robert Maki — Fri, 26 Jun 2020 19:07:23 +0000

Question:

What supplements are good for Perimenopause?

Short Answer:

The conventional treatment options for Perimenopause are limited. Most often, women are offered birth control and other habit forming medications. None of those options are very effective in providing women relief of their symptoms.

PYHP 097 Full Transcript:

Download 097 Transcript

Dr. Maki: Hello everybody. 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 on this episode, we are going to continue our talk about perimenopause. We are going to talk about some of the supplementation that we use in helping people deal with some of the symptoms of perimenopausal.

Dr. Davidson: Exactly. We have talked about perimenopause many times in other podcasts and blog posts as well. Like we always say, there is really not a lot of answers out there, especially conventionally. The last thing you want to do is take habit-forming or ineffective medications, but at the same time, we also want to have some help so we can kind of transition and feel good during this time of perimenopause.

Dr. Maki: Yes, right. Now conventionally, like we talked about the past, really, the only options for this window, this demographic, this ten-year span, ten-plus years span for women.

Dr. Davidson: Possibly.

Dr. Maki: Yes, right. Let us say from forty to fifty, if we just kept it to that, but I think there is an overlap into the late thirties and even the early fifties. So we are looking at a really good solid decade. In some ways, a really highly productive time frame for women where they need to be on their game. They have lots of things, are juggling lots of different parts of their lives and we hear it all the time. Women get to this certain point and all of a sudden, their bodies just stop cooperating. They cannot sleep. They have anxiety. They are irritable. They are gaining weight. They have all these things that are happening that they have never really experienced at that point. They really do not know what is going on. They go to their gynecologist. They go to their primary care doctor and no one really has any answers to be able to help them.

Dr. Davidson: Yes. Like you were saying, probably the most common medication is birth control pills, which the last thing you want to do is be in your forties taking birth control pills. So, that is kind of frowned upon. I mean antidepressants, a lot of doctors will offer perimenopausal females antidepressants. And they will say, “Well, I am not depressed. Sure, I do not feel well. I am irritable. I am not sleeping. I have a lot of brain fog. My short-term memory is not right.” They have a lot of these symptoms but it is not necessarily a disease. So, a lot of conventional practitioners do feel like their hands are tied. Even like anti-anxiety medications are extremely habit-forming. The last thing you want to do is put somebody on some kind of prescription that they are not going to be able to get off of it. We had also talked about in another podcast, IUDs are very common. And I do think an IUD is a good form of birth control, but it does not really do a whole lot for the perimenopausal hormonal changes. Sure, it can help with those irregular periods, the chronic spotting, the heavy bleeding but it does not do a whole lot for some of the other symptoms that go along with perimenopause.

Dr. Maki: Yes, right. The IUD, like you said, has some benefits to it and it and when it comes to birth control, that is a whole other podcast, which we probably will never do. But the other things that women are dealing with, that does not really solve all their problems.

Dr. Davidson: Like with anything, there is no one magic-pill-fits-all, one magic thing is going to take care of everything or you wave a magic wand and everything is gone. It really is sort of a multifactorial process and that is why we thought hey, you know what? There is a lot of really good natural non-habit-forming supplements that women can take depending on what their goals are in perimenopause. Some women just want to sleep, some women want their libido back. Other women want their periods to be more balanced or get rid of this unusual, never-had-before perimenopause acne. So, depending on the goals, there really are some nice supplementation to be able to help with that.

Dr. Maki: Yes, right. Yes. So in conjunction with some diet and lifestyle things, the supplementation can be added in to help them make life a little bit more functional, a little bit more productive on a daily basis. And that is where we usually start with sleep, number one. Sleep, as we talked about before for anything whether it is weight loss, whether it is perimenopause, thyroid, adrenals, anything, sleep – Now granted this is maybe obvious, but sleep has to be somewhat foundational in our busy 21st-century society with all the devices and screens we have to look at all the time. And all the ambient light that is around us constantly. It is no surprise that we have some trouble sleeping, to say the least.

Dr. Davidson: Granted this female’s hormones start, they are always changing. From the second we enter pre-puberty, puberty, and then all along, our hormones are always changing. But one particular hallmark in perimenopause is the estrogen and progesterone balance. So in perimenopausal females, you will see that progesterone drop down, which has an effect on, like Dr. Maki was talking about, with sleep by causing the cortisol levels to go up at night.

Dr. Maki: Yes, right. Or again, we talked about before, people having this kind of flipped curve, right? So, they have more cortisol at night. They have less in the morning. And for whatever reason, they cannot either fall asleep and or they cannot stay asleep. It becomes this kind of nightly process where something that is so innate in all human beings becomes a real struggle and when you got to get up at five, six o’clock in the morning to either take care of the kids or go to work or go to school or whatever. That gets very exhausting. No pun intended, gets very exhausting very quickly. You are almost kind of dreading the evening where you are kind of getting ready for that process of sleeping, but you know you are just not going to be able to do it. That is a really big deal.

Dr. Davidson: So one thing that we focus on with the sleep is that trying to balance progesterone because that is dropped and then reducing cortisol at night. One thing that we use a lot is Vitex. Vitex is a great herb. I think what is the common name? Chaste Tree Berry. It is actually a really pretty plant. It is actually almost like a shrub kind of tree-like thing. But, it helps balance progesterone without actually giving you progesterone. So if you can help balance a perimenopausal female’s progesterone, that will help bring down that cortisol at night to help them stay asleep.

Dr. Maki: Yes, right. Yes. I mean that is what we have talked about in the past on perimenopause, the lack of progesterone, or the decrease in the production of progesterone. For most women, when they were menstruating, they only produce progesterone for half the month anyway, but when that progesterone production either drops off or stops completely, it really has a dramatic impact on how that woman feels. So now, that balance, like you say, between the estrogen-progesterone you have, still relatively maybe not an excess amount of estrogen, but they become almost kind of pseudo-estrogen dominant because they have a lot of estrogen but no progesterone to balance that out. They just do not feel as well. They do not feel as “balanced.” No pun intended. They do not feel as balanced that way because one of those major reproductive hormones is missing.

Dr. Davidson: Yes. So the Vitex, there is not a lot of negative side effects to it. What it does is it stimulates luteinizing hormone, LH, which is a stimulating hormone from your brain, which is supposed to, in some ways, kind of tell the ovaries to make a little bit more progesterone. So that is one nice way in like you would mention too with perimenopause, you can get this sort of pseudo-estrogen dominant. It is not that their estrogen is surging really high like it might be in a teenage girl when their estrogen is trying to come alive, but you notice because of the lack of progesterone, the estrogen sort of runs the show because there is no one reigning her in that we might use maybe some DIM or some indole-3-carbinol which both are made from cruciferous vegetables like broccoli or cauliflower, which is really nice, but it helps bring down those estrogen metabolites, which can also be a little bit stimulating not just for sleep, but just in general.

Dr. Maki: Yes, right. So you kind of curb some of that inevitable changes to the cycle that women are going to experience, right? With our patients, we have seen a lot of people in their late thirties, even going into their early fifties. They start having this increase in bleeding. Now, granted that is a normal process is when the brain and the ovaries are still communicating, your ovaries are not really responding. The brain is kind of demanding the ovaries do something and all of a sudden, now you get excess bleeding. That obviously goes in conjunction with this decline in progesterone. Sometimes it is kind of seen as being dangerous for the woman. It is really somewhat common. We see it all the time. What we were talking about with the DIM and the indole-3-carbinol certainly can help kind of curb that a little bit.

Dr. Davidson: I do not know if we are supposed to throw a disclaimer out here, not meant for medical advice, educational only. But it really is a nice way to kind of work on balancing those hormones without having to use a prescription or having some negative side effects. So, they are definitely worth a shot. Other things that I know Dr. Maki loves especially for sleeping as he loves glycine. You always talk about glycine with patients.

Dr. Maki: Yes, especially when you have that racing mind. We were talking to your mom one time and she called it motor mind. You have the racing thoughts. You wake up in the middle of the night, all sudden you are thinking about the To-Do List you have the next day. You just have these kinds of repetitive, racing thoughts in your mind. Glycine works very well to calm some of that down because it is effective. It has been reducing cortisol. We do not need to get into necessarily that but something that is very simple. It is not habit-forming. You can kind of use it as you need it. But when you are dealing with some of those sleep issues, it can be very effective.

Dr. Davidson: I personally really like Pharma GABA. Pharma GABA is a great way to kind of raise up your GABA levels at night. And by raising up Gaba, can kind of bring down cortisol and then you can get a better night sleep. So like you were mentioning, my goodness, in our forties. Hey, I am in my forties, forty-seven to be exact. We are busy. We got a lot of stuff going on. I do not want to have two extra hours at night wide awake, staring at the ceiling. I would rather have two extra productive hours during the day. So, if we can get that better sleep, that definitely helps obviously with energy and reducing fatigue during the day.

Dr. Maki: Yes, I mean you see a lot of things coming off that the worse your sleep is, the worse everything else is. The worse your waistline is going to be. The worse your energy is going to be. The worse your mood is going to be. All those things are going to be impacted, so that is why we always focus on sleep as being the number one. Honestly, for most women, if they just did nothing else, but just focus on their sleep and then include some of the lifestyle stuff to reducing caffeine, doing a lot of crazy cardiovascular exercise, making sure that your caloric intake is adequate, so you are not creating an environment that forces your cortisol to go up. I know intermittent fasting these days is really popular. But for some, that increases cortisol and adrenaline or epinephrine, and that can make it challenging to get to sleep at night, especially if you are already kind of somewhat age-predisposed, is what we are talking about.

Dr. Davidson: Speaking of those catecholamines or adrenaline or that fight or flight is in perimenopause. It is interesting. You do see a lot of, I do not want to call it anxiety because anxiety is such a loaded word, but a lot of angst, worry, stress, kind of feeling real edgy or wound up, that is really common. I think that is coming from some of those catecholamines, from the adrenals, not being buffered by the female hormones, and then having that threshold for patience just gets really short. People tell me, “I have no tolerance for stress anymore.” And that is not that they do not have tolerance. It is just almost like their fight or flight reaction gets thrown for any little thing.

Dr. Maki: Yes. We talked about this on the last when we were just kind of introducing this perimenopause topic, why is it so awful.

Dr. Davidson: It is not awful. It was a catchy title.

Dr. Maki: Yes, it was just a keyword. But it is a good title. But no, honestly. Granted I am not a woman obviously, so I cannot relate necessarily. But you are in perimenopause, a lot of our patients are in perimenopause and we hear these comments all the time. They are just kind of at their wit’s end. They do use the word, horrible, awful, and miserable and this is ruining my life. They make these lot of kind of dramatic statements because of the impact that it is having on them that as I have said earlier, they never really experienced before. And they get even more frustrated, like we said earlier as well, when they go to their different practitioners conventionally and they really do not have any help for them. So that is why we are talking about this. It is just something from an observation perspective. This is just the things that see in what people are dealing with on a consistent basis.

Dr. Davidson: Every practitioner does have their favorite herbs or vitamins or supplements to kind of help with that stress or feeling like you are real edgy. But I have always had patients use L-theanine. I think L-theanine as an amino acid is very innocuous. It is very safe. But at the same time, it can kind of take the edge off of that anxiety. Lately, I would say probably in the last maybe more like two years, I have been using a lot of folate. I find that folate actually kind of helps balance some of that mood out without being overly you know. It does not make you sleepy but it does not make you extra stimulated. It is just something to kind of level things out. So, just some thoughts there.

Dr. Maki: Yes. So, folic acid is what we usually are aware of, but methylfolate is a little bit different for all those that have MTHFR mutation.

Dr. Davidson: You all know about methylfolate.

Dr. Maki: Yes, the real word for that for those of you that do not know is the methyltetrahydrofolate reductase enzyme. That is a mouthful, right? That is why they just abbreviated the MTHFR because who wants to say that all the time? That mutation basically encodes for this particular enzyme and if you have it, there is actually two specific mutations that your folate metabolism becomes somewhat diminished. So, you actually need more folate in your diet or through supplementation and to be able to make sure that that methylation pathway actually works, one of our colleagues actually, Dr. Ben Lynch, he of course is kind of like the methylation expert. We both have learned quite a bit from him and even from our patient, our patients are pretty savvy these days. Everyone is kind of honed in on methylation. It is really in the liver and in pretty much all the cells in the body. It is a major pathway that has an impact on immune function. With all the coronavirus stuff, that is a big deal: energy, mood, DNA and RNA replication, being able to turn over and make new cells. That is a really big deal.

Dr. Davidson: Aside from the MTHFR, I think just in general for perimenopause, even if you have MTHFR, if you do not have MTHFR, I think doing kind of higher levels of folate does kind of take the edge off for that mood because I will tell you. Being a perimenopausal female, you can get a little irritable, right? Maybe a little. [laughs]

Dr. Maki: I did not know. I have never noticed. I have never noticed. Yes. Yes. I have never noticed. So we are kind of approaching this nothing specific exactly, but from a vitamin, mineral, herb perspective, even amino acids. We have kind of all the different categories covered. The things that we have seen that have shown a kind of a track record of getting results with people. At the end of the day, there is a lot of supplementation out there. I think that supplements, even some of the marketing for some of the supplements, I think it is done in a way especially to the public, that a supplement is going to replace a drug. That you are going to be able to take these supplements that kind of got a clever name on it and it is going to replace your drug. Supplements do not work like drugs do. We cannot compare them on the same level because they have completely different mechanisms of action. Supplementation is kind of derived from other nature. A lot of drugs are derived from other nature as well, but they have different impacts on the body in different ways. We will be the first to say when it comes to supplementation, there is not one supplement that is going to solve some issues. Usually, like you have said, it is kind of a combination of a few different things because you are approaching that from a few different perspectives that one supplement is not going to necessarily cover all those bases at once.

Dr. Davidson: Or even dose-dependent. Somebody that weighs 110 pounds is going to maybe need a different dose of a supplement than somebody that weighs 185 pounds. Everybody is different. There is that little dose-dependency because a lot of people will say, “I have tried that supplement. I have tried supplementation. It does not do anything.” And then, I look at what they are taking it. Probably, honestly, the brand they might have might not actually have anything in there. So, you have to make sure that you are using a quality brand reputable. Or you look at the dose and say, “Well, this dose is so low.” Or you are not using the active ingredient that would be considered in that dose. So, there are definitely some aspects when you are looking at supplementation with that.

Dr. Maki: Yes. As humans in America, we are used to taking a pill and it is solving a problem. But like you said with supplementation, it is about how much of it you take, what the active ingredient is. Excuse me. I am sorry, I got a little frog in my throat. Those are all very important considerations. A lot of times with some of the things that we use with people, you cannot just take one or two capsules of something and expect that to have the impact that you want. And that is really where the clinical experience part comes into play. You are able to recommend something that is actually going to be effective and get someone some results.

Dr. Davidson: On the flip side, sometimes supplementation will go awry. Like for example, DHEA is a very common over-the-counter supplement. It has been around forever. But a lot of times, women will say or somebody will tell them, “Hey, you should take some DHEA for your hormones. It is a prohormone. It can convert into other hormones. It could help you with your symptoms,” but they do not realize DHA is an androgen. It actually has some tendencies that, if you take too much of it, will make you feel even worse.

Dr. Maki: Yes, right, especially if you have some anxiety, it can really be exacerbating anxiety. Always on a public shelf, you go to the local vitamin store, you are only going to find 25 milligrams. 25 milligrams is really a male dose. That is usually almost, across the board, always too much for a woman. We usually do 5 to 10 milligrams.

Dr. Davidson: If needed.

Dr. Maki: Yes, very rarely do we go above that. And usually, it takes roughly anywhere from a month to eight weeks or so to see the three cosmetic issues, breakouts or blemishes.

Dr. Davidson: Acne.

Dr. Maki: Yes, acne, which of course no adult woman wants to deal with, not only teenagers do not want to deal with that but certainly, adult women do not want to deal with that. You are going to see hair growth in unwanted places like on the chin, the upper lip, maybe the sideburn area, maybe around the areola, and on the abdomen below the belly button.

Dr. Davidson: And then, unfortunately, hair loss.

Dr. Maki: And then of course, yes, hair loss.

Dr. Davidson: On the head.

Dr. Maki: Yes. No women want to be growing any hair where they do not want to, they do not want to be losing any hair where they do not want to. Sometimes, almost inevitable across the board that at a 25-milligram dose, that is going to happen. Granted there are some women that maybe have long due stress for years and years and years. Maybe they have a really low DHEA. So there is a few exceptions where you could probably get away with 25 milligrams for a short amount of time to kind of boost up that level. But most women, if they just take 25 milligrams, it is not going to take long before they start having some issues with them.

Dr. Davidson: And we do make DHEA as females. We make DHEA mainly from our adrenal glands, which then can convert into testosterone. So in perimenopause, like I said, you will notice that progesterone drops. The estrogen can kind of drop a little or stay the same. But when that hormonal balance is off, our DHA and testosterone usually does not change too much in perimenopause. Of course, it is based on the individual. A lot of times you will see, just in general in the forties, is maybe, “Oh, my hairline is thinning or the temples are thinning. I am breaking out and I never used to break out.” Or feeling “testy” and that really comes from those unbalanced androgens because of the drop in progesterone. So, a lot of perimenopausal female may not need those androgens or the DHEA. If anything, we do a really good hair, skin, and nails formula that has some good minerals in there like zinc, copper, manganese is a really good one, silica, and of course biotin, which is more of a vitamin. Everybody is very familiar with biotin. Instead, we do that to really work on the hair, or evening primrose oil is probably one of my favorites for the hair. I usually had a lot in teenage girls because it kind of helps sort of balance the hormones without being a hormone, but it is great for the breast tissue, and it is really good for hair thickness.

Dr. Maki: Yes, right. Evening primrose is a is an essential fatty acid. Part of it is actually an omega-6 fatty acid. We always think of omega-3s, but it is actually omega-g or contains an omega-6 and that can have kind of some anti-inflammatory effects, which can be be very effective for a variety of different things. Now the other part, we did not talk too much about adrenals. When we are talking cortisol, that is kind of synonymous. When we are talking DHA, that is kind of synonymous with the adrenals. I think everyone is fairly well aware of some of the adrenal-specific things. Everything from glandulars on the higher end all the way down to vitamins. Vitamin C very popular, as of late, from an immune-stimulating perspective. Pantothenic acid, vitamin B5, very adrenal-specific. And then of course, all the herbs that are in the middle. One of my favorites, of course, has always been licorice root. You have ashwagandha. You have all the different types of ginseng. There is Chinese ginseng. There is American ginseng. There is Siberian ginseng. There is a bunch of different types of ginseng. Holy basil, these are all the different adaptogenic herbs that can be really helpful. The worse a woman’s symptoms are, in some ways, related to their stress level. How much their adrenals are being taxed will kind of translate to their level of symptom severity for the most part.

Dr. Davidson: In something you had alluded to earlier in this podcast was about perimenopause in the waistline because when you hit perimenopause, it is like, oh my gosh, 10 pounds just came out of nowhere. Where did that come from? And a lot of women are very concerned about that. That is just one piece of the puzzle. It is a whole lot of pieces to the puzzle when it comes to metabolism and weight gain and weight loss but one piece of the puzzle is improving thyroid function, not that someone has thyroid disease or they have a thyroid problem. But hey, anything we can do to possibly help with thyroid function, can help with that metabolism during perimenopause.

Dr. Maki: Yes. The first thing to understand or know about thyroid function is that it is not all about iodine. We see this quite often that people are recommending or taking relatively high doses of iodine. The RDA for iodine is a 150 micrograms. And we see people that are taking tens of thousands of micrograms of iodine. Now granted there is a thing I think it is called the Chaikoff white effect or the Chaikoff-Wolff effect of the Chaikoff effect of some sort, some doctor, where iodine can make your thyroid function either go up or down, but you cannot predict necessarily who is going to have that impact. Like with Hashimoto’s, they say iodine is contraindicated because they can exacerbate. Hyperthyroid, it is contraindicated. That may be true kind of for the layperson but we use iodine especially the higher-dose iodine in more hyperthyroid cases as a way to tone down thyroid function. We use smaller amounts of iodine as a way to stimulate thyroid function. There is a key distinction there. You do not want to be taking these huge mega doses because when we do lab work on people and if they have been doing that, sure enough, their TSH will be actually elevated. It will be actually abnormal, and they have been kind of hurting themselves in the process.

Dr. Davidson: Exactly. So you want to be careful with iodine. I think one unsung hero of thyroid function is tyrosine or the amino acid L-tyrosine because that combines with iodine to help the formation of T4. I think tyrosine is a great thing to implement and there is really not a lot of negative side effects to it. But it has the idea of being able to push forward and produce thyroid hormone.

Dr. Maki: Yes. Now of course for everybody that does not know that you are Japanese-American. Your mom is actually from Okinawa. We have talked about on the podcast before. Whenever we go over to your mom’s house, she is always putting soup in front of me and she makes this amazing clam soup with Kombu Dashi which is using seaweed, kelp, and then Dashi which is basically bonito flakes. She makes it literally in five minutes. It is the greatest. One story I think I told way back on a podcast a long time ago. You and I were driving from Las Vegas actually up to Washington. We are in the process of moving. This is a number of years ago and we had driven. It took us like two days or three days or two nights, three days, and two nights or whatever it was. We stopped in Eugene, Oregon the day before so we drove from Eugene all the way to your parents’ house. They live in basically Bellevue in Washington. We got there about noon and kind of felt there is this one spot on I-5 which is the main freeway that goes all the way from San Diego all the way up. Actually from I think Los Angeles all the way up. We got some traffic around Tacoma. It was an accident or something. There is always this one Tacoma stretch where the traffic is just horrendous. I was a little grumpy

Dr. Davidson: Yes, a little.

Dr. Maki: I was a little grumpy because the road was just kind of stressful and your mom is always trying to feed me all the time. And at that point, I was just grumpy and tired. And then, she just kept insisting about this clam soup, and then she put it in front of me. I am like, “Oh, my God. This is like the greatest soup I ever had in my entire life.” So now she knows this is my favorite and she puts little shiitake mushrooms in there and my point of that… Why are you laughing?

Dr. Davidson: [laughs] Because you are like, “my point in that” twenty minutes later. No, I am teasing you. It is a really good soup.

Dr. Maki: It is a very good soup. But my point of that is that it is a vehicle for the kelp which is where the iodine comes from. If you are eating, and again from a food source, besides sea vegetables, maybe some seafood, there is really no good iodine sources. That is why they put it in salt for the most part because otherwise, people would be deficient. And for an iodine, the T4 is for iodine molecules. T3, which is the other thyroid hormone, is just one less iodine molecule. Iodine is a critically important nutrient, so to speak, for proper thyroid function. We feel that or at least I feel that way that the Kombu Dashi is a great way to get a very steady nutritional supply of that on a regular basis, highly absorbable, tastes really good, only takes you five minutes to make it.

Dr. Davidson: All right. everybody, come on over. My mom will you soup.

Dr. Maki: Her name is Mako, by the way.

Dr. Davidson: Mako will make you soup.

Dr. Maki: She is just fantastic. So anyways, we will move on from iodine. But just be careful with iodine in general. That way you cannot really over supplement. I do not think. I mean, you could not drink enough kelp soup, unless you are just drinking it all day long. But certainly, be a little careful with those milligram doses. If you are taking those milligram doses, maybe have your thyroid checked to make sure your TSH does not go above four and a half because it happens more often than it does not.

Dr. Davidson: Exactly. Another mineral that I like is selenium for thyroid function. That helps with the conversion of T4 to free T3. We all know free T3 is the active form of thyroid pretty much. So if you do not have a good level of that free T3, you are still going to have a little bit of a lower thyroid function. So selenium is great for that. And then, one thing that I am sure a lot of you know about with thyroid is thyroid glandular. They are very, very popular. But you think glandular means it is made from an actual animal, and not everybody wants to take something that is an organ from an animal. So it kind of depends on the person, but glandulars do work very well.

Dr. Maki: Yes. And when we say glandulars that way, we are not referring to prescription NDTs, natural desiccated thyroid. We are talking to non-prescription NDTs, which is a little bit different. Obviously, you need a prescription to use those and we use them all the time because they can be just enough of a boost for people, to give them that extra little support that they need to make sure their thyroids are functioning. So, as we mentioned in the last episode, you are actually getting ready to publish a book on Amazon about perimenopause. That is part of the reason why we are actually doing some of these podcasts. We will keep you up to date on when that is actually going to go live. we are still kind of in the editing process and getting some formatting and designing done. If you have any questions in the meantime about perimenopause, certainly send us an email at help@progressyourhealth.com. We always love the feedback. If there is something we can answer for you on the podcast, we will be more than happy to do that. Now granted, take in mind, we do get a lot of requests that way. And unfortunately at this point, we just have to kind of pick and choose on which ones are applicable or which ones we are able to facilitate. We try to do as many as we can, as you have heard from some of our other episodes. But, certainly, feel free to send us an e-mail, none the less

Dr. Davidson: Sounds great. No, thank you.

Dr. Maki: Yes, so do you have anything else? Sorry, I did not mean to leave you kind of hang in there a second. Do you have anything else to add about perimenopause and supplementation or do you think that we have covered the majority of the base?

Dr. Davidson: I think this is good. I think this is really good. And thanks for introducing the book. I am kind of blushing because I am a little humbled and nervous and kind of embarrassed about it. But I think it is really good and really, it comes from everybody that has listened, all of our listeners, all of our patients, all of our clients definitely helped with the contribution to this. So, I am looking forward to it.

Dr. Maki: Yes. Sure. Until next time. I am Dr. Maki.

Dr. Davidson: I am Dr. Davidson.

Dr. Maki: Take Care. Bye-bye.

The post What Supplements Are Good For Perimenopause? | PYHP 097 appeared first on .

Why Is Perimenopause So Awful? | PYHP 096

Dr Valorie Davidson and Dr Robert Maki — Thu, 25 Jun 2020 19:58:15 +0000

Question:

Why Is Perimenopause so awful?

Short Answer:

We work with a good number of women in their 40’s and most of them do complain about how difficult Perimenopause is for them. As female hormones begin to decline, but stress levels are high it can cause a wide variety of symptoms. The most common perimenopausal symptoms are weight gain, irritability, and insomnia.

PYHP 096 Full Transcript:

Download PYHP 096 Transcript

Dr. Davidson: Thank you for joining us for another episode of the Progress Your Health Podcast. I am Dr. Valerie Davidson and I am here joined with my co-host, Dr. Maki.

Dr. Maki: Good morning. How are you today?

Dr. Davidson: I am doing great. Thanks.

Dr. Maki: We are experiencing a little bit of almost a torrential downpour this morning. Looking out the window, it is, unfortunately, raining a little bit too hard.

Dr. Davidson: But it is not that cold. So June, June in Washington, Western Washington. What do you expect?

Dr. Maki: Hopefully the sun will come out later this afternoon. So in this episode, I think that we are going to answer a question but it is not an actual specific question. We actually wrote a blog post a while ago. Why is perimenopause so horrible? So we are just kind of playing off that a little bit. That is a blog, this is going to be a podcast, obviously. Why is perimenopause so awful. The same idea, just a little bit of a different title. As of the last few years, I think, the perimenopausal demographic, women in their late thirties to early fifties is probably the majority of the people that we see on a regular basis.

Dr. Davidson: I think you know with perimenopause, it is a little bit of an under-represented, I guess, demographic because it is, you know, it is not menopause but it is not your typical PMS. It is somewhere right in between. So a lot of times women sort of getting blown off and perimenopause is exactly what it sounds like before menopause. It can happen, you know as late as you are in your late thirties and it can last even you know, thirty or early fifties depending on how a female’s ovaries are performing, and when they decide to retire or work part-time or work full time.

Dr. Maki: And their stress level.

Dr. Davidson: And their stress level exactly but I always kind of you know, I do not want to make it so negative. You know, why is perimenopause so awful or so horrible. It is not a negative thing but a lot of women will say that to me like, “This is really awful, what do I do? I cannot stand it. Nobody else can stand to be around me.” But it really has to do with those hormone imbalances. So working on those hormones is completely different in perimenopause than it is with menopause.

Dr. Maki: Yeah, right. Conventionally, in the medical community, no one is really equipped or prepared to deal with it. Given a woman in her late forties birth control to deal with her menstrual symptoms, there are a lot better options than that. I do not really agree with that really much at all. Because usually, by the time a woman is in her late forties, she is not ovulating anymore, right? So there is no real risk of pregnancy. Her hormones are declining anyway. Giving her birth control in some ways, it is kind of compounding on that problem and there are some safety issues there too. By giving a woman that is forty-eight and giving her birth control, you know, the IUD that is obviously a really popular remedy for some of the bleeding things that happen. Sometimes those are decisions that are made quite frequently, but we feel that there are better options for women out there that are struggling with some of, you know, some of these real common symptoms we are going to talk about today.

Dr. Davidson: Because it really is not one size fits all. Like, “Here take this pill and you are going to be all better.” It is certainly not like that and then, everybody, for females and men too, our hormones are changing from when we are twelve to twenty-five to thirty-five to forty-five. But one distinction between perimenopause and menopause is, in menopause, the ovaries are done functioning. They are not producing any estrogen or progesterone rightly, So they retired, they are done. Wherein in perimenopause, a lot of women, if you still have your uterus, you are still having a period. You are still cycling to some extent making that estrogen and progesterone, but you are not making it in the same way that you had been, perhaps five, seven, ten years before. So that time before menopause, people just sort of, getting kind of pushed to the wayside or just deal with it, you are getting older or as Dr. Maki had mentioned, offering birth control pills. Sure if you are nineteen and you really need to prevent birth, then that is a great option. But if you are forty-nine, forty-seven, forty-six, forty-four, that is not necessarily a great option to take birth control pills. As Dr. Maki mentioned, an IUD could help with some of the symptoms but not all of the symptoms. Then, of course, a lot of women we see, they get offered antidepressants. They get offered counseling. They get offered therapy. They get offered anti-anxiety medications or offered nothing and then sort of pushed on their way.

Dr. Maki: Yeah, right. Yeah. So I mean that is why we are talking about this because it is kind of an underserved community. Now, maybe it does not get as much attention in the medical community is because it is not really a disease. There is not an insurance billing code for it, there is sort of for menopause, there is definitely for PMS. But this period of time for a woman could anybody anywhere from a few years, let us say five years to almost fifteen years for some women. An easy good decade from forty to fifty or thirty-eight to forty-eight. We see women all the time that are in those age ranges that are dealing with these symptoms for a very long time. Usually, that is when they have children, they are working full time, they are busy. In some ways, that is part of the problem- is that there are so busy. They have so much on their plate. They are doing so many different things. That is what creates, in some ways this kind of horrible, this awful transition because their bodies just do not cooperate anymore. On paper, we have this conversation with patients all the time. Their lives on paper are really good. They have a great family, they live in a great neighborhood, kids are doing really well, got good jobs, money is no problem. But yet, they are just not quite either fulfilled or happy, or they are overwhelmed or stressed and it kind of detracts how good life could actually be.

Dr. Davidson: In some ways, I kind of understand what you are saying there. That stress level is going to make everything worse. You think about when the estrogen and progesterone or imbalance, they are not going to be able to buffer those extra stress hormones. So things seem really exacerbated. But one thing you had mentioned is “Hey, I am in my forties and so that is why.” I am forty-seven.

Dr. Maki: You are in the throes of your menopause.

Dr. Davidson: Well, you have known that for several years.

Dr. Maki: Do I ever know that?

Dr. Davidson: Oh, you first stop it. But like you were saying, when we are in our forties, life is good. The kids are a little bit older if you have kids. You might be more established in your career. You might be more developed and settled in your environment, in your home, and where you live. That life is actually pretty good. Where I have women that tell me in their forties, “Hey, life is pretty good. Why am I so tired? Why do I have all these symptoms? Why do not I feel well? When I was twenty-seven years old, I had two kids, divorced, working three jobs and I juggle it all just fine. Why cannot I juggle it now and my are older and they have more autonomy. I should be feeling better.” Sure, we need to get done because that is just what happens. I tell these women when they tell me that it is not you, it is really just those hormones, that if we can balance those hormones, it is a little bit like the chicken and the egg. We balance those hormones naturally, effectively, safely, and then you feel better. Then things kind of look better. When they look better you treat them a little bit differently, see it a little bit differently, and you get the ball rolling.

Dr. Maki: Yeah, right. I do think that the amount of stress that people have, that women have particularly, they spread themselves too thin all the time. They got to go here and they got to go there, they got to do this, they got to do that. They just take on too much stuff which I think then creates a little bit more of a perpetuating kind of vicious cycle. But you are right. Their bodies are in a major transition when they go from menstruating years to that perimenopausal window to post-menstruating years that as you say, their hormones are declining. The hormones, the sex hormones tend to be kind of this buffer to the stressors of everyday living. So like you said, when you are 25, you can handle anything. Most twenty-five-year-olds really do not have that much stress necessarily. Maybe they do nowadays. You know, we live in some crazy times right now. But proportionally, people usually have more stress in their forties and fifties because they just require more responsibility. We hear it all the time, they are just not able to handle it necessarily as easy as they did even a few years ago. Or like you said, they have less stress, things are a little more settled, but they feel ten times worse than they did before when stuff was really crazy. Now, they cannot even handle a little bit. They just kind of go off the edge because they have no more reserves in the tank. So you kind of see both bull scenarios.

Dr. Davidson: Yeah. As you said, their stress tolerance has really minimized with that threshold has really narrowed, which is really common that you see especially in women. Men are a different story because you know men’s hormones, their testosterone, their sex hormones, or adrenal hormones, they are changing over time. We will do a little bit of a podcast a little bit of Men-o-pause or something, what not on how that works. But for us ladies, when we are in our forties, that threshold for stress really does narrow and there is not only that, but there are those other symptoms that are coming along with perimenopause. Women will tell me, which is very true, once they hit perimenopause, it is like they put on ten to fifteen pounds overnight. Like where did it go? I eat better then. My kids, and you know kids in their twenties, you know, when you are twenty-five, you can have milkshakes and french fries and throw it down with a bunch of burgers and wake up the next day just fine. But when you are in your forties, you have some chips and salsa, maybe a glass of wine and you are up 5 pounds the next day.

Dr. Maki: Right. Yeah. That is probably… I mean we will go through a little list of the symptoms but probably number one is that unexplained weight gain. Their lives have not really changed, probably very much in the last five to ten years, their lifestyles are very similar, whether they are doing activity or diet or any of that, but yet their weight just continues to go up, and usually, it is always around the midsection. Women proportionally do not usually put weight around the midsection, men have you know, the proverbial beer belly. Women usually put weight around the hips and thighs. That weight around the midsection though, you know, the muffin top, that is in some ways, cortisol redistributed the weight gain. It is not really supposed to be there, from a gender-specific standpoint, but that is probably number one. What would you say are the next like three to five symptoms that you hear the most?

Dr. Davidson: Definitely, sleep. Trouble sleeping at night. Not so much falling asleep but staying asleep. A lot of women, “hey,” they will say, “I put my head down I am out and you know less than a minute, but come anywhere between three to four hours later, I am up.” They will say you are usually up for an hour to two hours or they might even just sort of wake up periodically, you know, five-plus times plus times a night throughout for no reason. It is not like there is anything noisy out there. They are just waking up throughout the night, which of course, then comes morning time, you know, that is not going to be very refreshing sleep that is not going to be great for daytime energy.

Dr. Maki: Yeah, right. So, on another podcast and even some blog posts, we talked about the different types of adrenals, adrenal fatigue, or adrenal dysfunction. We call it adrenal fatigue, but adrenal dysfunction, how it manifests. What you just described, the person that can fall asleep okay but cannot stay asleep, as you described it as your ghost?

Dr. Davidson: Yeah. They fall asleep, they wake up periodically through the night or unfortunately, which is no fun for like an hour, an hour and a half in the middle of the night. That really is like we had talked about on that last podcast, is the bouncing up of cortisol at night. So you had mentioned earlier that cortisol is secreted from the adrenal glands in a diagonal fashion, it comes up very high in the morning so your bright-eyed bushy-tailed sharp and ready to go and then it comes down at night so that you can fall asleep and stay asleep for the night. What you end up seeing, especially in perimenopause is because of the drop in progesterone. So in menopause, you have a drop in both estrogen and progesterone. But in perimenopause, you mainly have more of a drop in progesterone. That drop in progesterone creates cortisol coming up at night. So that is why they are waking up in the middle of the night. If you are perimenopausal female and you are in your forties or even late thirties and you are perimenopausal female and you find that you are not sleeping at night, usually they can even trace it back to saying, “It is like a week to two weeks before my period,” if you have a uterus “that I am not sleeping well at night,” because that typically seems to be where more the issues lie. It is not PMS. It is perimenopause.

Dr. Maki: Right, yeah. So really, a way to define perimenopause, at least the way that you and I to talk about it or define it is really when a woman stops ovulating which is not exactly clear on when that is. Some women can tell when they ovulate, some women cannot. But usually when a woman stops ovulating because when a woman does release an egg, there is a part of the ovary called the corpus luteum. I do not know what the Latin is for that but it is a yellow body or something like that.

Dr. Davidson: A yellow moon.

Dr. Maki: Yeah. Yeah.

Dr. Davidson: Yeah. Yeah. Yellow body.

Dr. Maki: The remnant of where that egg is released from the ovary is what secretes progesterone. So when a woman stops ovulating, which is in some ways genetically determined for women, I think stress level can speed that process up. But usually, that is going to happen to mom, grandma, great-grandma. They are going to have a similar… They all go into menopause roughly about the same time. When they stop ovulating, that progesterone production basically disappears and now the ovaries are supposed to pick up the slack. As we talked about from a stress perspective, most women’s ovaries cannot pick up the slack. So there is this huge gap, they have plenty of estrogen because they are still menstruating, but virtually no progesterone and leaves them kind of lopsided so to speak because that balance, that monthly balance they need from those hormone fluctuations is no longer there.

Dr. Davidson: And trust me, estrogen is the best hormone in the world. She is great. But without progesterone to buffer her, that estrogen loves to grow things so that is partly where a lot of that weight gain will come from, where the thickening of the endometrial lining of the uterus. So a lot of times women in their forties, that is when they are getting hysterectomies because their fibroids are growing, being aggravated, they are having heavy periods, they are having periods for three weeks long, they are becoming anemic. So that is where you see that because estrogen is like I said, a great hormone, but tends to grow things. One interesting kind of side note to that is as a perimenopausal female, your estrogen is pretty good. It might drop a little bit in your forties, maybe a little bit. There is a few percentage that I see where that estrogen really surges in perimenopause, but for the majority estrogen drops, maybe a tiny bitter stays the same. Progesterone will drop dramatically. But if you look at the hormonal balance of a young female just going into puberty, starting to get her first couple of periods. When you see those gals, usually between ten eleven, twelve, thirteen, maybe fourteen, when they first got in their periods, they have the same hormonal balance as a female in perimenopause, because their ovaries are trying to make all this estrogen. They may not be ovulating because their body has not gotten used to you know cycling, so it takes some time to understand how to cycle and get that cycling under their belt. So you have seen that same imbalance with the higher estrogen or maybe you know good estrogen but no progesterone which is why they have some of the same symptoms. A little bit of a muffin top and maybe a little pudgy and then they grow out of that. Then the irritability, that is the other one.

Dr. Maki: Yeah, right. That would probably be right up there at the top with the weight gain. Weight gain and irritability would be number one and number two, depending on who you talk to, and then insomnia would be like the third. The second or third on that list. So you are right, so mom is having the same hormonal profile as her daughter. No wonder why they do not.

Dr. Davidson: Everyone must run, run fast.

Dr. Maki: The men in the household are like cowering in the corner, right? Because no wonder why the mom and the teenage daughter are clashing all the time because their hormones are you know, it is just like you butting heads constantly. I mean, of course, the family dynamics and you know, whatever, but certainly hormones are driving a lot of that behavior on both sides.

Dr. Davidson: Which you know, as a lot of females know when we are around, other friends or females or family members that are women, we tend to cycle together. We just kind of fall in line like that. So yeah, then the fellows in the family need to run.

Dr. Maki: Yeah, and men sometimes, I hear some from wives right there, they say you need to go get your hormones fix. You know, it is all about your hormones. That is a little bit unfair for men to be doing that.

Dr. Davidson: Certainly. Truly.

Dr. Maki: Men have their own hormonal fluctuations. They have their own issues. They cannot just blame hormones on women. That is very unfair. That is the easiest excuse, right? It is an easy thing to blame. But let us be honest. Men sometimes can be lazy, they are like big children, they are teenagers. I know you yell at me all the time for all the things that I do and that is just the difference between males and females.

Dr. Davidson: You are not a big baby.

Dr. Maki: I am not a big baby but I might be a kind of a pseudo big teenager sometimes. I might be a little messy, you know, compared to your standards. I think those kinds of things happen, I hear about it. I know you hear about it all the time. I think some women kind of feel a little guilty about that. They think that it is really all about them. I think some of it might be, especially the irritability part because one minute a woman will be totally fine and then something very simple, for the most part, that is very innocuous, not a big deal at all and then she is just in a fit of rage. It is like a flip of a switch and she cannot really control that, at least that is what we hear. She cannot really control it. She feels bad about it. She feels guilty. She is probably apologizing all the time. It becomes kind of like this thing in the family or around friends or even co-workers. They know to kind of tiptoe little bit because, “Oh yeah, you know, so and so is a little bitchy today.” But there is a hormonal reason why some of those emotions cannot be curtailed or they cannot be controlled necessarily.

Dr. Davidson: Exactly. nd granted, we all have ups and downs in life and our hormones are always changing. So when I am talking with a female, we will talk a little bit about her symptoms and I will say well, how bad is it? Like is it tolerable? You get maybe one night sweat at night or if you wake up one night a week for a couple of hours, is that okay? Are you able to deal with that or with the mood? Are you able to deal with that? I will say yeah, I am fine. That part is fine. I am really more focused on weight. The weight gain that I did not want to have. So it is really kind of thick, you know, looking at those goals. But if things in perimenopause, if the symptoms really are kind of like, you know what this really is affecting my quality of life. I do not enjoy this. I do not want to deal with this. I have had lots of women go to their primary care physicians, especially their gynecologists and they do not really get a lot of answers. They just get told, “Hey you just got to deal with it” or “Go see a therapist” or put you on as you said, birth control pills or IUDs or anti-anxiety medications or antidepressants. Oh my gosh, the list goes on. So they get frustrated which is understandable and then they just feel like they do not have any answers. I want women to know that there are answers, that we do have some things that we do whether we do supplements, lifestyle, nutritional changes, or even bioidentical hormone prescriptions. We have lots of options depending on the female that we are working with.

Dr. Maki: Yeah, right? Yeah. That is where, again, we have said this all the time. It does have to be somewhat tailored because you could have ten perimenopausal women and you have to address each one of them slightly different. Now, most of the time, for most of them again, insomnia being a big one. That is something that we focus on first and foremost because if you are not sleeping well, then everything else is going to just perpetuate because of the role that cortisol plays in that insomnia. Everybody in America to some extent, most, not everybody, that I am being a little bit fictitious there. But so many people in America have this flipped curve, that flipped diurnal curve where the cortisol, as you said earlier supposed to be high in the morning and low at night but that is almost exactly the opposite. It is low in the morning and it is high at night or either bounces around all night long. That needs to be a foundational step to work on that and you cannot take a sleeping medication even something over the counter to really affect that. It has to be done in a little bit different way, that you know, medications, except for what we use a lot is progesterone. Bioidentical oral progesterone does a very good job for these types of situations, calming them down, leveling out the mood, and then helping them get to sleep. Not to mention as you say, the variety of different sleep or cortisol balancing. I would not say reducing necessarily. I would say cortisol balancing type of hormones and that is kind of achieved in a couple of ways by raising cortisol in the morning so they get out of bed with a bit more energy and that automatically in some ways lowers it at night. There are some other things you can do in the evening to help with that. Now, other things can start to kind of branch off once their sleep is improved.

Dr. Davidson: Yes. Many of you probably know, waking up in the middle of the night from one-thirty to three-thirty is not fun. Who would not love to have an extra two hours during the day let alone you are wide awake in the middle of the night for two hours. So you are right. Definitely the sleep is number one, which kind of domino effects into everything. But other symptoms with perimenopause is not just the weight gain, the insomnia at night, the irritability, but we do also notice acne. Like a lot of women will come and say I have never had a pimple, not even when I was in high school and now I am breaking out. That is also a common symptom because when the estrogen and progesterone drop, we still are making her androgens. We, as ladies, make testosterone as well. Not in the nearly the levels that men make it but we make testosterone a lot, a little bit through the ovaries mainly to the production of the adrenal glands to creating DHEA, and then that can turn into testosterone. So DHEA is also another androgen. So when you go into perimenopause, when the progesterone drops, the estrogen might drop a little bit. That testosterone and DHEA do not necessarily drop in perimenopause. So they end up being kind of like the leaders of the hormonal chain gang or you know, they are top of the hormonal pack. So then those excess androgens will cause breakouts, which as you can see in teenage girls, they kind of have the same thing too because their bodies are not making enough progesterone, maybe some estrogen and they are making a bunch of androgens because our bodies are just trying to figure out their own hormones.

Dr. Maki: Yeah, right. We see, you know, it is interesting about DHEA and testosterone which are both considered to be androgens, right? We see both scenarios. We see almost a surge of testosterone and DHEA, almost like a pseudo-PCOS. They never really had that problem before and all sudden their DHEA and testosterone is either high normal or elevated, or again for the one that is really stressed out, that has been stressed out for a long time, there DHEA and testosterone, like you will see testosterone of three, right? It will be very, very, low. Their DHEA will be lower, or DHEA sulfate will be less than a hundred. That is why we test for those two hormones specifically because you will see both scenarios and sometimes it is really hard to tell by their symptoms which way their androgens are going. Are their androgens high? Or their androgens low? As you said, they are both made by the adrenal so it is a way to infer the adrenal status but you get kind of mixed answers sometimes or mixed information by testing those hormones. You see it in both scenarios and it is really hard to predict.

Dr. Davidson: Yeah. As you had mentioned earlier, you have ten different women in perimenopause. You got it, almost in some ways, treat them ten different ways because some might have higher androgens. They might have low normal androgens. They might have really low androgens. Their estrogen could be high, could be moderate. But for the most part, the progesterone we all know is low. That is one classic part of it. But depending on those ten women, they might not have all of the symptoms, somebody might have the weight gain, the irritability, and the sleeplessness, and somebody else has the sleeplessness and the acne. Everyone is a little bit different. But it is interesting that you are talking about the adrenal glands because one unsung hero coming from the adrenal glands and we always talk about is pregnenolone. So pregnenolone or pregnenolone, tomato, tomato, you know, however, you want to pronounce that but I pronounce it pregnenolone. It is secreted from the adrenal glands and that can actually drop dramatically and I think it is more with the stress like Dr. Maki was talking about. The adrenal stress, the environmental stress causing that pregnenolone to drop because one other very common symptom in perimenopause is women will say “I feel like I am so forgetful.” Like. “My short-term memory is gone, but I can still remember exactly what I wore to a wedding in 1988,” you know and the ship matching shoes and who I sat next to at a table, but I cannot even remember where I parked my car what I had for lunch yesterday.

Dr. Maki: Yeah, right. I hear all the time, they have lists everywhere, they have post-it notes all over their kitchen or their office or at work. They cannot remember anything. If it does not get written down, it does not happen. Because they just cannot remember anything. And they all think of course that that is like an early sign of dementia. But the brain fog kind of goes with that so they are just kind of in this haze all the time. I definitely think that that is a kind of adrenal cortisol, a stress-related issue for sure.

Dr. Davidson: With that drop in pregnenolone. Because pregnenolone, we make it from the adrenal glands. But we make a little bit from our brain and our spinal cord, which makes it very neuroprotective. So that is a great thing about pregnenolone. As I said, I consider it like the unsung hero of the adrenal glands, is it does help with memory. Like when you are twenty-three years old, you have tons of pregnenolone, which is why you can stare out the window, sit in a meeting, not take notes, and look around and still remember exactly what you heard. That pregnenolone, like, you know, your kids and they are teenagers, they remember everything. They have such beautiful memories and brains. But when that pregnenolone drops, it is hard to remember. I read the same sentence as twenty times, I cannot remember it. Or even something that people will say they are interested in, I research some stuff on Google and I am really interested in this but the next day I do not remember what I read even though it was really interesting.

Dr. Maki: Yeah, right, I talk to women too that are… They have to read. They have to read reports, they have to read certain things and they cannot. They have to reread the same thing as they cannot comprehend anything. They cannot sit down, you know, this is not all of them, this is some of them. They cannot sit down to read a book. It is like they read the words but nothing sticks in their brain. You are right, pregnenolone is very helpful in those situations for sure.

Dr. Davidson: I think in perimenopause, it is the pregnenolone with short-term memory. Because just on the flip side, which we will talk about later. I do not want to focus too much on this. In menopause, a lot of women will say that they cannot remember, that they are having dementia. But that is more about the estrogen dropping because we have a lot of receptors in our brain for estrogen. So when menopausal women are talking about their memory, it is really more about recall. Like what is the name of that author of that book you read last month? They will say, I cannot remember the name of the author, but if you come back to me in five to fifteen minutes, I will remember it. It is in there. It is in there but getting it out is more of a low estrogen issue that goes with menopause.

Dr. Maki: Or they see somebody’s face, they recognize the face, but they cannot think of their name. Or certain words they are trying to pull out and they cannot think of the word to use. That is a little bit of a distinction between that perimenopause. Granted these are all subtleties. But if you are listening and you are either in menopause or perimenopause, you can probably relate to that to some extent because we just hear this over and over and over and over all the time. That is partially why we are doing this podcast because we did not necessarily set out. I know you did not necessarily choose to focus on perimenopause. It is just the type of client that would come in to see you and that is you know. It used to be a bioidentical hormone replacement, it used to be all about menopause. Menopause was the driver because women were looking for answers to their hot flashes and there were not really very many. This is back when we…

Dr. Davidson: We are safe, yeah.

Dr. Maki: When you and I are in school, really bioidentical hormone replacement really took off in about two thousand one because of that women’s health initiative study that came out in bioidentical hormones. So really it has only been around for literally not even twenty years. Nineteen years.

Dr. Davidson: Really focused on.

Dr. Maki: But it is good because now it gives women options now and women are still finding out and discovering about bioidentical hormones. But now, at least the way that we do, women of all different ages have you know, there is something that can be done. It is not just for menopause. The new kind of menopausal demographic, it is not menopause necessarily as much anymore. It is the women that were talking about that are, one underserved, with two, there are lots of options that can help them maintain their lives and in some ways maybe have a better quality life, have more joy, more happiness, more energy, better sleep. Life is just better that way because you are not dealing with some of these hormonal challenges that are unfortunately for women or some, are inevitable. They have to happen just because of…

Dr. Davidson: We will complicate it, right? We got a symphony of hormones, right? So when one instruments off, you know, you can totally tell. So we are complicated but we are definitely worth it. So that is why as you are saying, is that underrepresented or underserved demographic of women in their forties. That is what we found because, with our practice, we do not do primary care, we do not do emergency care, is a lot of people would find us after seeing, you know, three or four doctors and not finding the answers they are looking for and then they would find us. Because they are looking in some ways like, “Hey a friend of mine told me about you and you are my last case resort.” So that is how things sort of matriculated for us.

Dr. Maki: Yeah. We have just figured out by accident. Just from listening to people and understanding the situation that we found this little niche between the conventional part and what we do and being able to facilitate that. We are not a replacement for your gynecologist or endocrinologist or cardiologist. We are not a replacement for that. We are in some ways our own subspecialty that makes all of those things, at least the way we feel the way that we try to do it, it is a way to connect all the dots, right? So you still have your cardiologist. We have patients that have their entire team of doctors. They have a GI doc, they have a cardiologist, they have an endocrinologist, they have a gynecologist, and then we are in that team somewhere. We all do our part. It is really for the betterment of the patient. It is really about that at the end of the day. This is a little bit pre-planned, right? We are actually venturing into the Amazon book publishing arena. We are in the process of getting a book finished. It is going to be an e-book on the Amazon Kindle, Perimenopause Plan. We are just going through the finishing touches and we are getting ready to launch that. We do not have an official launch date yet but it is coming fairly soon.

Dr. Davidson: Now, I am blushing and feeling a little bit embarrassed. But yes. I am that age, perimenopause. But we have been dealing with lots of women of perimenopause age for years and years and years and really it is near and dear to our heart. So that is why it is our first kind of venture into the Amazon book. But the Perimenopause Plan should be coming out soon. If you have any questions, or you have any questions about the book coming out, or any questions about perimenopause, I am more than, ask you, feel free to send us an email at help@progressyour health.com.

Dr. Maki: Yeah. It is just a simple email. We have it on some of our blog posts. It is just a way to encourage some because if you notice, we do like to answer listener and reader questions so we get to hear one in a leveraged way, right? So we can share the question and the answer with as many people as possible, so as many people benefit from that. But we also, to have a better understanding of what people are dealing with. So yeah, help@progressyourhealth.com, send us an email. As these episodes keep coming out, whether we are talking about perimenopause or not, we will have kind of a plan on doing a few of those books. We will keep you updated on when they do launch. It is a little scary but also, you know, a very fun and exciting project.

Dr. Davidson: Absolutely.

Dr. Maki: So I think we kind of hash this topic out pretty well. Do you have anything, any last words to add?

Dr. Davidson: No, no. This was great.

Dr. Maki: Okay until next time, I am Dr. Maki.

Dr. Davidson: And I am Dr. Davidson.

Dr. Maki: Be careful. Bye.

The post Why Is Perimenopause So Awful? | PYHP 096 appeared first on .

What Is Oxytocin Used For? | PYHP 095

Dr Valorie Davidson and Dr Robert Maki — Fri, 19 Jun 2020 21:16:36 +0000

Question:

What is Oxytocin Used For?

Short Answer:

The hormone oxytocin is available by prescription from compounding pharmacies. The most common uses for oxytocin is to enhance female libido and mood. Also, research has shown that oxytocin may also be helpful in weight loss. More research is needed to better understand how oxytocin can be used as an effective therapy for obesity.

PYHP 095 Full Transcript:

Download PYHP 095 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 on this episode, again, we are going to introduce something that we have used quite a bit with our patients. We are going to talk about a hormone, actually, a hormone prescription called oxytocin. I know a lot of people have heard of that before, right? It is considered to be kind of the love hormone. But it can be used, it can be turned into a prescription and we use it quite often.

Dr. Davidson: Yeah. I have actually used it a lot with patients. When it works, it works really well and the great part to it is there is not any necessarily, negative side effects to it. So if it works, awesome. If it does not, then okay, we are back to the drawing board. Those of you that have heard of oxytocin, they think of it as like the love hormone. But it is. You know what, it can help with female libido and that is probably a cup. Probably the two reasons that we use it or I use it is for working on female libido because we know that that can be a tough one. Because school rules are complicated. The other part that I use it for is just a sense of well-being. It does kind of help bring up that mood. We live in a stressful world. We live in a sympathetic, adrenal fight-or-flight world, whether it is watching the news, or driving your car, or getting to work on time, or working with family, things are stressful that I find that oxytocin can really push you over to the other side to help bring that joy back so you do not always feel so rushed and overwhelmed.

Dr. Maki: Yeah, right. I would agree that those are the two main things that you and I use it for. We are not really big fans of antidepressant medication in general. We never use them. That is fine if people want to take them, but we are not necessarily going to prescribe those things. That is just not what we choose to focus on. Oxytocin is kind of our version of something like that. It has very good, as we are talking about one of our previous episodes, the cost-benefit ratio oxytocin, also has a very good cost-benefit ratio. It works great. You get some benefit from it. There have been a few where they just do not notice anything or the effect of it is not substantial enough for them to notice any subjective improvement. Again, it is very subjective. Libido, maybe not as subjective either, your libido increases or it does not. The mood can also be kind of an up-and-down roller-coaster. There are good days and bad days that it can also be a hard thing to gauge or quantify over time if it is actually helpful or not. But the ones that it does, I had a patient to talk to earlier this week. Now, this is where it gets complicated. There are a few different types of dosing forms. All of them were had to be refrigerated that has some issues. But now they have some sublingual, they have a nasal spray, they have some I know that do not need to be refrigerated like a stable tablet. She has three different ones and she uses them all for different situations. When she took the original one, the refrigerated form, she noticed a dramatic difference in six days. Ever since, she is like, I love it. I think it is great. She is a business owner. She has got a lot of pressure, a lot of stress relatively and it just gives her that little bit of pick me up to be able to get back up and do it all over again.

Dr. Davidson: Something you had mentioned earlier, it certainly is not a replacement for antidepressant medication. We do not use it in that way. We are not big fans of antidepressants you know, in the right circumstance. Absolutely, it is so necessary. But that is where we are part of a health care team. We work all together as a team. So we all know what our patients’ other doctors are doing with them and what prescriptions they are on. Now, granted our patients’ other doctors, like their GP or a gynecologist or psychiatrist, do not exactly understand what we are doing, but that is okay. We are still on the team together. But the neat thing about oxytocin is, let us say somebody is on some other types of medications, there is not a lot of contraindications with taking oxytocin. Even with vitamins. Like if someone is on a blood thinner, you do not want to put them on too much vitamin D with vitamin K2 in it because that could then their blood some more. Even vitamin C or fish oil can thin the blood. You would not want to take 5-hydroxytryptophan and maybe some mucuna to raise up your dopamine if you are on some kind of SSRI or anti-depressant medication. There are so many different contraindications when it comes to medications. The neat thing about oxytocin is, regardless, is we can give it a try. If it works awesome, if it does not, if you do not notice it, that is okay. Like Dr. Maki was saying as I do think we should probably go back to and explain a little bit about the dosages and how you take it. So originally with oxytocin, when we would use it, it always came as a nasal spray which was not the funniest thing to do. It is almost like you put it up to your nose and you spray it, kind of like Flonase or Afrin or something. But it comes in that little container. You have to keep it in the fridge. It does sting a little bit in certain people’s mucous membranes. It stung mine. Because I have tried everything. Everything we do, we always try. We got to experiment.

Dr. Maki: We are our own little guinea pigs in that respect.

Dr. Davidson: I am not going to give anybody anything that I would not do myself. y

Dr. Maki: That is true. I used to coach some nutrition students and I tell them the same thing. f you are not willing to do it, do not tell your clients or your patients to do it just because you have the experience. When it comes to diet, nutrition supplementation, medication, all that kind of stuff, in there is a little bit of, kind of trial and error to understand how the experience of trying something.

Dr. Davidson: Exactly. Well, we have tried the nasal spray and it does work. The nasal spray is more absorbable and that is why they had it as a nasal spray because oxytocin is very hard to digest. That is why the capsules because they do come in capsules, oxytocin capsules. Because we did eventually end up using the capsules more often than the spray. But once you take that capsule, your stomach acid really does destroy a lot of it. So you have to do kind of a higher dose, kind of like you do more. So whatever it destroys, whatever is leftover, you are able to utilize. So now, more recently, which is really nice, is now there are available, the sublingual tablets. I do think the sublingual tablets are really awesome. They do not taste bad. You do not have to spray it. You can technically travel with it. Ideally, you want to keep it cool. You certainly do not want to put it in the glove box of your car in hundred-degree weather. But at the same time, I do think the tablets are much more absorbable than the oral. In some ways just as absorbable as a nasal spray but much easier to use.

Dr. Maki: Yeah, right. Like the patient I was talking about just a few minutes ago, she travels quite a bit and she uses one for at home, the refrigerated version. She keeps that one in the fridge. I was trying to ask her which one do you like the best and she goes well, it is not really which one I like the best. If she had to pick one, it will be the refrigerated one because that was the one she started with. She noticed an improvement within six days. But the other ones allow her to be able to take it in when she travels because it is heat stable or temperature stable. Even the sublingual like you said, she will take half of the tablet of the sublingual and use that at the moment if she is having a stressful day or whatever. She really finds a lot of benefit from that.

Dr. Davidson: I love that we are doing patient examples when you are talking about this. When you say she found an effect within six days, she noticed an effect, she takes it to get a particular effect. What effect are you talking about?

Dr. Maki: Well, she just said that she just noticed that she felt better.

Dr. Davidson: Mood-wise. Not like her libido is crazy and she is chasing down everybody on the street.

Dr. Maki: Exactly.

Dr. Davidson: She does not do that.

Dr. Maki: Yeah. I think she did say there was some libido improvement. For women, we deal with women in perimenopause and menopause. Libido just disappears. I am probably preaching to the choir here for women that are listening. That is one of the biggest complaints that we hear and it is one of the hardest things, you know, to kind of help resurrect a woman’s libido. A lot of times women in their forty’s and fifty’s are stressed. They got a lot of things going on there. Maybe they are over-exercising, they are not sleeping and the libido just disappears. So some of those things, all of the things have to be aligned properly for that libido to come back. That is originally what the oxytocin was kind of intended for. It is a libido enhancer. But with this particular patient, her benefit was from the mood standpoint. She could tell it completely. She just had a little bit of a greater sense of well-being. Not in an over-stimulated way but just from a very pleasant perspective. That she is able to do her day and she feels good. Maybe even a little bit of energy from that positive mood enhancement that she experiences.

Dr. Davidson: When it first came out, and it may do still talk about oxytocin for the female libido, and I do think it has an effect on that. But like Dr. Maki mentioned is, us gals are a lot different than the boys. Our minds are going. I mean we can think of 10 different things at the same time. So when you are stressed, you have a thousand things to do tomorrow, I am tired, maybe I exercise, I did not eat enough. But at the end of the day, most women are like I am too tired to engage in extracurricular activities. I just want to go to bed. For fellas are, hey, they could have been sleep-deprived and a leg hanging off and be like, they will be ready. They are up for it. I think if we can get a female to feel good, like with the oxytocin, like your patient you are talking about. Hey, my mood is better. I am connecting better with people, I am feeling joy in the activities that I would normally find joy in. I think that itself would help with the libido. Because we are definitely way more cerebral and cognitive when it comes to sexual drive than men.

Dr. Maki: Yeah. No credit on, I am not a woman. But I just hear this feedback all the time. Women are just giving, giving, giving all the time. They are just you know, taking care of everybody whether it is work, whether it is at home, whether it is friends or family, whatever the situation might be. They do not really have the time or the bandwidth to devote any time to themselves. That is a common thing that I see over and over and over and they just kind of end up spreading themselves a little bit too thin. So bringing the joy back, I think that is a very interesting way to describe it. How do you quantify that? I ask patients a lot. On papers, someone’s life is really good, right? They got a nice family, they live in a nice house, they got a great neighborhood, kids go to good schools, kids are doing well and I asked him are you happy? Then sometimes they pause and take a second and they are like, I really should be but I am not. That I think is a big deal. Like why do we push ourselves so much to have so many things and stuff but we are miserable at the same time. There is a disconnect there somewhere. Maybe now because we have all these different options and how we live in America these days and then people are trying to discover some of those things or figure some things out. But on paper, people should have these great lives according to the American dream but a lot of them do not. A lot of them are stressed and overwhelmed and they cannot sleep and as I said, libido disappears. Ultimately, they do not have any joy or they are just not happy.

Dr. Davidson: With what you are saying there, I think it is a little bit of that chicken and egg scenario. So you think oxytocin comes up when you hug your best friend. When a female has an orgasm, their oxytocin goes up so that they bond with their mate. Your oxytocin goes up when you see your kids doing something super cute. We look at Bob, our little dog and he is laying on his back with his little paws like flailing, your oxytocin goes up. That is oxytocin. But when you are living in a stressful world, even if it is just trying to make it to work on time or you have a hundred emails to deal with today and family stuff. As I said, family stuff or getting the kids to school, that in some ways is stressful. The body does not understand that that is not a fight or flight reaction. It just that our body, adrenals respond to either a bear is going to come and eat me or I am fine and I can eat berries from this tree. So when you are constantly in that stress reaction, the body thinks well, why am I constantly being chased by a bear? The last thing it wants to do is raise up your oxytocin. When someone is at war, fighting another tribe or battle, the last thing you want is your oxytocin to come up so that you bond with people you are depending on or you are attacking. So that is where I think that we do, as a society in the society that we live in, in which we live in a really wonderful world. As you said, we are safe, we have water, we have food, we have a nice home, electricity, we have heat, that we live in a really wonderful world. But at the same time that stressfulness drops is almost like a recipe for oxytocin to be low.

Dr. Maki: Yeah, right. So just to give people a little bit of background, granted you and I are certainly not a neurobiologist or anything like that. But when you talk about the sympathetic side of your nervous system, this is the involuntary part of our nervous systems that do things for our body without us having to be consciously aware of it. We can sort of control our sympathetic, our autonomic nervous system. So you have the two sides. You have the sympathetic which is the fight-or-flight. That is the Monday morning, busy workweek, go, go go. America excels at that part. We do a really good job of pushing ourselves physically and mentally to strive for something. The American dream. The other side of that, the balance to that is parasympathetic which is the rest and digest. How many people when it comes to eating breakfast or having lunch, they are just frantically trying to shove something down their mouth or they do not need anything at all, or they are eating in their car or they are doing this because they are so busy and have so many different things. You cannot properly digest food in that sense. Even from a joy, happiness, libido perspective, if you are stuck in that sympathetic all the time, the fight-or-flight, the rest and digest mode is never going to happen. Nobody gets really good at doing something that is required to do over and over and over. From talking to our patients, we have to actually kind of work at allowing that parasympathetic to actually take over at the end of the day or on a perpetual basis. So there is a balance between the sympathetic and the parasympathetic.

Dr. Davidson: Exactly. Like I said, kind of that chicken and the egg. So I am stressed with daily life, then my oxytocin drops which make me not super happy, that I am more stressed which makes oxytocin drop more. It is almost like this vicious cycle in some ways. A patient I was talking to, she went to Disneyland with her family. They love Disneyland. Some people love Disneyland. Me, I am not really into crowds. But some people love Disneyland and I said, did you have a good time? And she said yes. Oh, I am like, that is awesome. But then we talked about it a little bit but it was not that she did not have a good time but she said she could not understand why which is why I bring up the joy part that she did not enjoy it even though she should have been. It is that part where hey, I am doing an activity that I normally find joy in. Why am I not feeling joy? Why am I just going through the motions? Why am I just putting on a happy face and I am not really feeling it on the inside? I think that does have to do with the oxytocin. It probably has to do with a thousand, million, trillion other things that go on in our bodies and in our environment, but I always say with, hey if we can stop that like just add in the oxytocin, it is safe, it is innocuous. It raises up that level of joy, you feel more connected with people, with your spouse and then it moves from there. So kind of like that chicken and the egg. The oxytocin is up, my life is pretty good. I see some of the joy and the color in it. Then your oxytocin goes up some more and then eventually I have lots of patients and you know, myself included that do not take the oxytocin every day. I mean, I have got oxytocin in the fridge. It is probably been there for a little too long, you know for months. But I say, hey just take it. Eventually, they evolve it to, hey, I woke up on the wrong side of the bed this morning for whatever reason. Or in the afternoon, I got a really nasty email and put me in a bummer mood. Or it is Friday night and it is just us at home. So you can evolve it to where you just use it sometimes.

Dr. Maki: Yeah, right. That is my patient. She takes it. I have a few other ones that are like that as well that they use it episodically but they also use it consistently at the same time. Hers was a bit partially because it was just the most recent. I just talked to her recently and I did not realize exactly that she had three different dose forms. But when we talked about it, I was asking her a lot of questions just to get the feedback. What do you notice? What about this? Which one do you like the best and dosage wise? She said one pharmacy, they reduce the dosage but she like that as much you wanted of a higher dose. So she had a lot of really positive feedback because she had a really good response from it. Again, oxytocin has only been around for the last probably five years. It really works clinically. Maybe ten, but really in the last five years or so when it has gains momentum. I think we are still learning about potential uses for that. We are still at the tip of that iceberg of how we could use it, even getting the dosing right. Right now, I know fifty units is a very common dose. Like I said, one pharmacy reduced it down to thirty. My patient like the fifty. But we might find later that a hundred or a hundred and fifty might be even better, especially for short-term uses. If you are trying to use it on a Friday night, you got a date night or something, a higher dose in a more absorbable form, like I said the nasal spray or a sublingual or something.

Dr. Davidson: Or the in-laws are coming to visit for the weekend or the holidays.

Dr. Maki: Yeah. Holidays in general can be very stressful times.

Dr. Davidson: Monday morning at work.

Dr. Maki: Yeah, totally. So there is a lot of potential applications where it could be used on a perpetual basis or an ongoing basis but also very episodically or very situational basis. I think it gives a lot of flexibility for people. We talked about this a little bit with LDN, but another that we have not really explored too much and I think this is one thing that I would like to and I probably should be doing this and I have not with patients is using it for weight loss. There is actually quite a bit of research surrounding that on how it affects the brain. Basically, in that same context, we are talking with the autonomic nervous system and some other hypothalamic-pituitary signaling. I was just doing a quick, little bit of research and just found that there is actually some food… What do you call it? Some decrease in appetite that is happening. Obesity is kind of a double-edged sword right? It is a brain problem and an insulin problem kind of at the same time. Some people say that it is strictly just to bring an issue and then some people say that it is strictly an insulin issue. I think it is actually both of those. I think it is very complicated in that respect. But oxytocin, again from that cost-benefit ratio, we are not trying to suppress appetite. But if we can modulate appetite for the right reasons, now that becomes a very safe and effective treatment potentially long-term.

Dr. Davidson: Yeah. If you are feeling better if you are connecting with people, you are feeling happy, then you do not always run to the pint ice cream like you would be if you are feeling a little unhappy. So they do not call it mood food for anything. So I could definitely see the aspect for that and you are right. I have not really talked to my patients about, you know, we are always working on weight loss. I mean we are girls. Girls do not want to gain weight. But I have no I have not really talked about the connection with that with some of the patients. So I think I am going to do that in the future. Definitely we use it for female libido and then also for the mood in general. Pretty much most of my patients, eighty-five percent of my patients are female, probably eighty to eighty-five percent. I tried to use oxytocin a little bit with men in terms for mood, I have not really had a lot of success just to be honest about that. Granted my patient population for men, using it is very, very small. So that is not to say it would not work with men. But definitely with the females, when it works, it works well.

Dr. Maki: Yeah, right. I think a lot of times too, even with LDN, because these are both kinds of you know…

Dr. Davidson: The low-dose Naltrexone that we talked about in a previous podcast.

Dr. Maki: Yeah. Both of these are kind of I would say in some ways, kind of fringy prescriptions. Not fringy but they are just not going to find these kinds of uses in a conventional standpoint. So you cannot go to your general practitioner and expect them to understand how to dose it or what it is or what you would even use it for. But we are still trying to figure out those applications ourselves. Because again, that cost-benefit ratio for both of them, it got a very good benefit side, very low downside. The potential uses are unlimited in some respects. I think nowadays, everyone is just looking for a little more joy in their day or just life in general. There is no reason why they should not be. They should be. We could have it if we allowed ourselves. You know here in America, we could really have an amazing quality of life. I think some people figure that out. But I think some people are still trying to… you know, there is something missing in their lives. I think this is very individualized, right? Thinking everybody has to do the nine to five American Dream, that does not work for some people. It might have been the only option there was twenty, thirty years ago, forty, fifty years ago, maybe seventy years ago, whatever. But nowadays, you do not have to necessarily do that. I think some people just do not respond that way. They need to have a different lifestyle. I think in America, we have the autonomy to be able to choose that for ourselves. Oxytocin might just be a way to help people get there. Now, if your life is chaotic and you got stress all over the place, prescriptions like that can only do so much. You can only have so much of a reach. Maybe you have to clean up some of the chaos first before or at the same time, in order to have kind of a little bit of synergy there. But as an option, it certainly is a viable one for sure.

Dr. Davidson: Absolutely. You know with health, and joy and all that, and also working on hormones and hormone imbalance, it is all a big puzzle. Oxytocin could be one piece of the puzzle. It is not going to be the panacea or the huge knock be, the one thing fits all or knocks it out of the park, but it could definitely be a piece of the puzzle as we are kind of moving along. I think you are right. People innately or probably consciously realize they have a great life. They live in a great world here. If they feel like, hey, I have got a really good life, why am I not feeling well about it? Then we say, hey, let us look at the oxytocin. It would be worth a try.

Dr. Maki: Yeah, and granted that is a little bit of a Band-Aid right? You are trying to pharmaceutically have an impact but in the short term, I think that is a very viable treatment option.

Dr. Davidson: As I said, the chicken and the egg. if you can feel better, then things around you change, and then you change and it is just a way to get the ball rolling.

Dr. Maki: Yeah, right. Now, that is interesting that you say that. One thing that we try to do with our patients is, our job is to get them to feel better first. That is why when I was talking about my nutrition students, you do not necessarily want to make things harder for people because their lives are hard already. Anyways, our job is to improve how they feel and then they take care of some of the other things on their own once they feel better first. We take that responsibility when someone comes to us to be a patient. That is what they come to us for. We want to make it easier for them. They notice a change and then they start taking care of life. We have had plenty of people that have literally, once they feel better, everything changes in their life. They exercise, improves their diet, improves their relationships. Maybe their relationships change, maybe their jobs change, maybe their locations change. All of that can happen once a person actually feels better and like you say, the oxytocin can play a nice role in that in the early stages.

Dr. Davidson: Exactly. So I would say it is not a Band-Aid but maybe more of a stepping stone.

Dr. Maki: Yeah. That is a good way to say. Yeah. They are not a Band-Aid. I think that some of the pharma…

Dr. Davidson: …Pharmaceutical medications with side effects become habitual. You are stuck on them forever. That is a terrible Band-Aid.

Dr. Maki: Yeah. That is a good distinction. I would agree with that. I do not think that

Dr. Davidson: Or the stepping stone to see what direction you can go. We are just guiding. We are not like giving them the magic keys. We are just giving them some stepping stones so they can go in the direction they want to.

Dr. Maki: Yeah. We got some good tricks in our bag but we do not necessarily have

Dr. Davidson: A wand.

Dr. Maki: We do not have a magic wand. We cannot do it all. Honestly, stress, we all have stress to some extent. Some of us have more than others. Stress is an obstacle here to cure for everybody. Stress is the big one and we all know that stress is not good for us. A multitude of ways in how we feel, in how we look, in our health and immune function wade and all those kinds of things. But how do we approach that or how do we affect that is really the million-dollar question. I think oxytocin plays a very good role in that potential there. So again, do you have anything else to add or should we call this one a wrap?

Dr. Davidson: I think it was really good.

Dr. Maki: Yeah. Until next time, I am Dr. Maki.

Dr. Davidson: And I am Dr. Davidson.

Dr. Maki: Take care. Bye-bye.

The post What Is Oxytocin Used For? | PYHP 095 appeared first on .

What Is LDN Used For? | PYHP 094

Dr Valorie Davidson and Dr Robert Maki — Thu, 18 Jun 2020 19:43:34 +0000

Question:

What is LDN Used For?

Short Answer:

There are many possible uses for Low Dose Naltrexone (LDN). The common use for LDN is autoimmune diseases but has also been used in many immune system-related conditions, including cancer.

PYHP 094 Full Transcript:

Download 094 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 today, we are going to do not really an actual question like we have been doing on some of the past episodes. But today, we are going to actually something that does come up quite often. So it is kind of a question. It is not coming from one person. But today we are going to talk about low dose Naltrexone or LDN.

Dr. Davidson: Exactly. So LDN, low dose Naltrexone. We have actually used with our patients for a number of years, but we do get a lot of listeners, just people that run across our website, people from thyroid groups looking for low dose Naltrexone, because while it has been around for… Gosh. Naltrexone has been around like…

Dr. Maki: Thirty years. Yeah, late 70s or early 80s.

Dr. Davidson: Yeah, the 80s, you know, doing low dose Naltrexone has not been as, you know, as common wise. Maybe for about the last ten like we have been using it probably for about the last eight to ten years, but it is not very much wide-known. I guess you could say, conventionally, so people will go to their conventional doctor looking into it and then, you know, they then their doctor looks at him like you want to go on Naltrexone.

Dr. Maki: Yeah, right. Yeah. It was originally developed for as the HIV and AIDS epidemic was starting to kind of show up in the early 80s. It was used as a medication to curb alcohol and drug addiction because it has certain effects on the brain. It is supposed to limit your cravings for those types of things, those kind of dangerous behaviors that becomes a little bit too habitual and you have an addiction. But actually, along that path over the early 80s, a doctor in New York – I think his name is Dr. Bukhari – noticed that his, and I am not even really sure how he discovered or how we figured out the low dose part, but notice that some of his patients were actually improved. Their immune system status was improving with HIV. Now, we do not necessarily hear as much about HIV or Aids anymore. It is still around but not nearly as stigmatizing as it was in the early 80s. In some ways, if you think back, even up until the 2000s, you know through the 80s and 90s, you know, HIV and AIDS was kind of, you know, everyone was very fearful of that kind of like they are now at the Coronavirus. A little bit similarities there as how fearful everybody was because we just did not know anything about it.

But low dose Naltrexone, so using it for what it was intended for, FDA approval, that was in doses of let us say 50 to 300 milligrams. What we are talking about low dose Naltrexone if you look it up online and there is some couple of really good websites that have some information about it. It is using doses of let us say 1.5 to 4.5 milligrams. Even I have seen some anecdotal and some research using it up to 10 milligrams and that probably would be based on a few factors. Maybe age, size of the person, you know, a male, a 250-pound male is going to take more than, you know, a 125-pound female and, you know, different things like that. So when we say low dose, that is really not how it was intended to be used, but we will get into kind of how it works here in a second. But like I said, we have been using it for a decade and, you know, we have seen some really good success stories with using with patients.

Dr. Davidson: Like you said Naltrexone itself, I mean is still used in rehab centers for alcohol and opiate addiction. In fact, they have Naltrexone implants because if you were to do your, you know, if you are taking a you know, a conventional level of Naltrexone, which could be anywhere like 75 milligrams twice a day, a 100 milligrams twice a day, 50 milligrams twice a day or having an implant, if you were to do your opiates, you know, take an opiate on top of that you would get really, really sick. You would not die, but you would get really, really sick. So that was kind of the premise with Naltrexone. As you take the Naltrexone and then it reduces your cravings and which when with addiction I do not know how you can reduce cravings, but at least if you did take that offending, you know, addictive chemical substance or opiate, you would get really sick.

Of course, then people would take their Naltrexone and then they would take their, you know, their substance of you know that they were addicted to but that is why the implants are there so they still use it. So when we are using low dose Naltrexone with patients, we are using it for a completely different aspect, but sometimes those get a little entwined. Like I had a patient, you know, I had to run some low dose Naltrexone, and then she happened to google Naltrexone and was like, “What? What is this? This does not make sense.” Or she showed it to her doctor and her doctor said, “Why are you taking this?” They do not realize there is a huge difference between 1.5 milligrams or even up to six. I use 6 milligrams with quite a few of my patients versus 75 milligrams twice a day or 300 milligrams, you know, throughout an entire twenty-four-hour period.

Dr. Maki: Yeah, right. The effect that it has on the body is completely different. Now, LDN or Naltrexone… Let us say Naltrexone. Let us not say the LDN, but Naltrexone itself is what they call a opioid antagonists, are an opioid receptor antagonist, meaning that it basically blocks the opioid receptors in our brains. So if you take an opioid medication, like Percocet, oxycodone, morphine, anything like that, they compete for the same receptors and that is what makes people ill if they combine the two and, you know, something simple. Someone is on LDN because we will get into what it is used for here in a little bit, you know, autoimmune problem or something to go into the dentist or they have some kind of an acute issue. Now, granted we always coach everybody and usually pharmacies that we work with are usually pretty good about catching that stuff. But if they have an acute issue in their given pain medication and they do not realize that you are not supposed to take the LDN with it, they find out, you know… I mean it is not going to kill you necessarily but you get really nauseated and you do not feel very good for a few days.

Dr. Davidson: And it really does, like you said, we work with patients. We talk to them. We coach them, the pharmacies, too. I have only had that happen twice using the low dose Naltrexone with patients. Twice. Once, a patient did not tell me. She said she was not on opiates, but apparently, she was taking some and probably should not have been so there was, you know, an issue that happened there and so and then there was another patient who had an elective surgery and had talked to the doctor about post-surgery. I do not want any, you know, any medications, any opiate medications, any pain medications. It was something very, very minor. I think it was like a little tiny lipo or something but the nurse did not read her chart and then and she loves the LDN so she had been wanted to continue taking it because I have a lot of patients that have elective surgeries and we just stopped it before the surgery and then if they have to take a pain medication then we restart it when they are done with their pain medication.

But this patient, in particular, she loves the LDN. She did not want to stop it and she has a high threshold for pain anyway, so but the nurse did not read the chart, gave her some pain meds, right when she came out of anesthesia, and she was very sick and it was kind of a weird debacle, but it all ended up fine. So, I have only seen it twice. It does not happen that often. That is why you have to have that communication with the patient, and usually patients that want low dose Naltrexone know what it is for. They have been looking for and they come and find us or we are working with the patient because most of our patients are very well-educated. They are doing their own research. They know what is going on in their bodies. So we are just kind of help guiding them. So we really do not run into any issues like that.

Dr. Maki: Yeah, right. I actually was talking with the patient just the other day. We did some testing. We did… She is having some hand pain or, you know, just some generalized joint pain. She had been having it for years. I decided to run, which I am surprised that either did not run it before or one of her other doctors did not run it before, but she came back with a positive anti-nuclear antibody test. You know, so positive for some type of autoimmune disease or at least the autoimmune potential. That is what… That is really the main thing that LDN has gained some momentum for is all of the autoimmune problems that people are dealing with, everything from Hashimoto’s to lupus to rheumatoid arthritis to Ankylosing Spondylitis, MS. The list goes on and on and on.

And actually, in preparation for this episode, I was doing a bit of research and I wanted to be a little more clear on the medication contraindicated list and she just happened to mention that she is using Tramadol for pain and I did not realize at the time when her and I were speaking about it that Tramadol actually is contraindicated with the LDN. So I had to, you know, kind of warned her a little bit preemptively before she started it. Says, “You know what? We have to kind of decide here.” Personally, this is where LDN, I am not a big fan of any of those pain medications, right? I mean those pain medications I think are overused all the time. We know that it is kind of a crisis around the country. People are abusing opioids and I think for chronic pain management, LDN, that is one of the things that you can use instead and I think it has a much better… When a doctor or practitioner is evaluating a medication, you always have this cost-benefit ratio to any treatment, whether it is a supplement, whether it is a vitamin, whether it is a narcotic or a medication of any sort, you are kind of evaluating. “Is this medication worth it for this particular type of situation?” I think that is why LDN has become so popular because it has a really good upside, mean it has lots of benefit but the side effect part portion of it, it iss relatively as long as you avoid these couple of things we are talking about, you know, the side effects of LDN is actually pretty low.

Dr. Davidson: Exactly, and like you would kind of mentioned is for low dose Naltrexone really what we started using it for was for autoimmune disease. There is not a lot of great treatments out there for different autoimmune diseases and a lot of the treatments really are not great prolonged. Like a lot of times with autoimmune like and rheumatoid arthritis, connective tissue disease, you know, autoimmune tissue disease, a lot of times it is steroids. You know, they are taking steroids for years. That is really not a great idea to be taking it for years. So a lot of times, and specially also with MS, a lot of those treatments are, you know, can be pretty invasive. They do have, like you said, weighing those pros and cons on how that is going to work. So the low dose Naltrexone is a really good alternative to be able to work with somebody with some type of autoimmune disease, be able to reduce down that inflammatory component so that you reduce down eventual degeneration.

In fact, with rheumatoid arthritis, it is probably what I find that it works really, really good with and I do find regardless of, you know, males or females at the 6 milligrams and I am generalizing here. But this is just in my own experience that the 6 milligrams is really a good dose for that low dose Naltrexone for rheumatoid arthritis. But for the most part, you know, with training or a lot of, you know, practitioners out there that are training with low dose Naltrexone, the original dose was 4.5, which is what they used, and then they found that even going lower works a lot well in Hashimoto’s and other autoimmune conditions. So of course, like I said, you have been going up to 6 milligrams is nothing like actual Naltrexone 75 milligrams twice a day. That is a completely different use for that medication because lots of medications have different uses, you know, depending. But definitely, you know, the low dose Naltrexone is amazing for autoimmune conditions.

Dr. Maki: Yeah, right. Yeah and the list and I was like I said, I was doing a lot of preparation and the list of potential conditions, everything from endocrine problems, you know, hormone problems to female problems to rheumatological issues to chronic pain to, you know, skin issues. I mean, there is just dozens and dozens and dozens of potential uses. And again when it has that really positive, you know, cost-benefit ratio, it makes it a… We used it enough to know that it is not a Panacea. You know, sometimes it, you know, does not have the impact that you wanted to have, you know, so it is not going to solve everybody’s problems. But and I would think of it when you use it, let us say with one of your rheumatoid arthritis patients, what is the time frame that you notice where once you implement, you know, then that titration – we will talk about the titration here in a second – that you notice that the patient starts noticing some improvement.

Dr. Davidson: It seems like three weeks is that magic mark. Once, and because it does take a little while to get into your system and, you know, it is not like taking an Advil and your, you know, your pain goes away and kind of comes back. It does. It takes a while to build up into the system that I do find that three weeks. So I do tell people, “You know what? Keep taking it every day until we hit three weeks.” Because we will go into a little bit… There are a couple of little bit of side effects, but usually three weeks and beyond and, like you talked about, titrating it because there are some side effects mainly, you know with the gastrointestinal issues like a little nausea in the beginning as you might start a little low and then work your way up.

Dr. Maki: Yeah, right. Yeah. You see, very commonly like a starting point will be 1.5 milligrams then you double it, you go to 3 and then you add another one in there you go from 1.5 to 3 milligrams to 4.5. Unlike you mentioned, you could raise it one more time and go up to six. You and I have never used more than six. You know have you used more than six?

Dr. Davidson: I think I have one patient that were up close to 10 or no, I think maybe a little less than a handful of patients there. So but I do not usually… Usually 4.5 is the most common dose, but you know, you know yourself just like, you know, we talked at length with our patients is I know if someone is ultra-sensitive, we might even start at 0.25 milligrams of low dose Naltrexone or 0.5 and then work our way up. And then some people I know, “Hey, you know what? This person really is not that sensitive.” They are pretty hardy. They need some, you know, their system could probably tolerate something stronger is “Hey, let us jump up and start at 2.5 or even at, you know, even at 4 and you know, you know who you are if you are sensitive and we just kind of work around that and then take the time to raise up and increase up that dose. On a side note, that is why when people are taking Naltrexone for a completely different, you know, drug addiction and opiate addiction is they take it twice a day and that is because Naltrexone really only has about like a ten-hour, twelve-hour lifespan. So when you are doing low dose Naltrexone treatment with somebody for anti-inflammatory or for autoimmune conditions because, you know, it only has that twelve-hour lifespan, we only have people take it once a day. So you take it at night because while your, and you take it with food because like I said in the beginning, usually takes about a week for the stomach to get used to that nausea. You take it at night and then by the time you wake up in the morning, then it is out of your system because the premise behind reducing that inflammation and working on that auto immune component is that is only taking it only having it in your body for twelve hours.

Dr. Maki: Yeah, right. And the mechanism that you are, what you are trying to accomplish there, like you said with the the higher dose Naltrexone, you are trying to keep a steady supply to blunt craving. So you are having this very specific brain effect to curb alcohol and drug cravings. With the low dose Naltrexone, you take it at night. One thing that does happen for some people is you are you are trying to stimulate an increase to what they call opioid growth factor. Opioid growth factor is basically like an internal endorphin that our body creates, almost like its own internal, you know, pain medication so to speak, stimulates the same receptors as the morphines, the Percocet oxycodone, but your body produces that so when you take it at night that you are suppressing the release, you are suppressing the release of that opioid growth factor. So that kind of interaction there can cause some insomnia when people still take in the beginning that can really and it can create some really crazy dreams. You know, so but again, that is also why you start a little bit of a lower dose. Sorry. There is a little banging down at my feet. Our co-host, Bob, is chewing on a beef cheek and he is banging into the desk a little bit. So hopefully it is not and this happens all the time.

Dr. Davidson: He looks really cute though.

Dr. Maki: Yeah. Yeah. Yeah. If you have listened to some of our other podcasts, we talked about Bob all the time. We have a little rug in here in our little podcast studio and he is literally like right at my feet chewing on this big long, about a foot and a half, footlong, beef cheek and it is been going up against the metal desk. It is adorable. I mean, it is really adorable, but hopefully you can not hear that too much on the audio. So I kind of lost where I was there.

Dr. Davidson: You were talking about the opioid growth factor and how when you take it at night, it blocks the receptors. So it basically blocks the opioid growth factor, but then the next morning when it is out of your system, you have this huge surge of opioid growth factor.

Dr. Maki: Yeah, right and that is, that is the stimulation to the immune system that eventually, you know, from a, you know, an autoimmune perspective, we do not really want to stimulate the immune system necessarily because that could potentially exacerbate an autoimmune condition. This is just improving the immune system. So now, the proper anti-inflammatory processes kind of, you know, eventually and we are still even learning. Like we are learning on how all of those things happen and how the LDN actually works. We know that it affects the opioid growth factor, but, you know, even reducing inflammation in general, like like say for example another use of LDN can use it in weight loss or obesity and it actually able to improve because of that anti-inflammatory effect. It can improve improve insulin resistance, which is kind of an underlying component of obesity, diabetes, heart disease, you know, fatty liver disease. I was talking to a patient of the day about fatty liver and LDN. We kind of had a similar conversation there. You know, so there is a lot of potential. The point of this podcast is just if you are not familiar with LDN, just to know that this is a and the good part about it is, too, that it comes from a compounding pharmacy. Like you said, we can custom tailor that dose. If you are a little bit sensitive, maybe you had some nausea at 1.5, you could go down to any a milligram amount and then titrate slowly if you had to, so you can minimize some of that GI problems or whether you are having some, you know, insomnia or some dream issues. You can… You do not have to stick to those three doses. There is potentially unlimited number of doses and then, you know, the practitioner can titrate that as slowly or as quickly as necessary for whatever the situation might be.

Dr. Davidson: And like you said, I mean, it is not a Panacea. Nothing. Nothing is a Panacea or the one pill, fix all in life. But so I do find that some people, it works amazing for. It reduces down their joint inflammation. You can reduce down Hashimoto’s antibodies for Hashimoto’s disease and then other people, sometimes, it does not do anything. I have never had somebody have a negative reaction to it. Other than maybe in the beginning, they might be like, “Oh, I got a little nausea,” but that is fine or like you said a little insomnia and usually that will I will say started on Friday. So if you get insomnia, you only have it over the weekend because it does not last that long, but there is not really any so much negative side effects, but you know, I do have lots of patients that we worked, you know, I worked with. We have done it and, you know, they did not really have an effect we are looking for and then I have a lot of patients that do. Like I said, we are all unique so it would be something. I do think there is just so much potential with the autoimmune world or autoimmune disease world because the conventional medications really, you know, really have a lot of cons. I mean sure there is some pros. I mean autoimmune disease, you have got to do something about that. But at the same time, you know, some of those medications are really harsh.

Dr. Maki: Yeah, yeah. Almost every one of them, almost every single one of them has some type of side effect that is going to be, you are going to have to consider as a possibility at some point. It is not a matter with a lot of them. It is not a matter of if it is a matter of when and the more severe that is where they just kind of keep ratcheting up the treatment. So then you are just that much more likely for having some kind of a crazy side effect because the dosing has to go up or the number of medications has to go up. You know, so when it comes to that, like I say, that rumor that rheumatological autoimmune world, tons of potential. And again, we are just still realizing that it can be used from, you know, so many different things that people are looking for a safe effective and affordable. That is the other thing when you get it from a compounding pharmacy, it is relatively a really cheap medication. Comparatively that is in some ways, makes it a very good option. So even for people out there that you know, maybe excuse me, that are not used to LDN or not familiar with LDN. I am sure a lot of our listeners are. Because like you said earlier, our listeners are pretty savvy. People have heard about it, but it is just a little bit challenging to, you know, conventionally, doctors are not going to prescribe it. They do not even know what it is, you know, but like you say, the last, you know five years or so in the last couple of years has really gained a lot of momentum and we hear about it, you know from colleagues and peers in trainings that we go to for continuing education.

There is always something about LDN to some extent. Always. Even cancer, right? You know, I have a few patients with cancer that we have used LDN before. Leukemia, Lymphoma, you know, blood cancers, solid tumors. There is some good research for, you know, quite a few different things. So yeah, I think the weight loss, the obesity one, I think that is there is actually a commercial medication that uses the Naltrexone side, a little bit of a higher dosage, you know. But we think that even using the low dose actually from that anti-inflammatory response because we do not really, even from a weight-loss perspective, we do not really necessarily want to curb appetite or suppress or, you know, create chloric restriction. We do not want to turn anybody’s appetite off and that is not how you solve that problem but by reducing inflammation and and improving insulin sensitivity, that is how you know, that is how you can have some long-term progress and have an effect on changing somebody set point. You lose 20 pounds, but your body says, “No, we want to be where it was,” and you gained 20, gained back 30, you know, that is that magic set point that our hypothalamus in our brain gets a little bit distorted. We will talk more about that later. Using things like LDN, you know, can be helpful in improving somebody’s set point.

Dr. Davidson: And just, again, on another side note, what you are saying there, you think about those “Oh, so will you take the low dose Naltrexone? You only take it once a day. So you take it at night. It blocks those opiate receptors. And then in the morning, you have this surge or the opioid growth factor,” and like you mentioned, hey, you know opiates are like our natural, you know, helps reduce pain. It helps us feel good. I do not know if there is any research out there, but with some of the patients that I have worked with, when they take the low dose Naltrexone, maybe we are working on autoimmune component. But because that opioid surge in the morning, it helps their mood and you think if you are feeling better, then you do not go for the comfort food. So I have found that patients say, “Hey, it is not that the food does not taste good to me. Sure ,ice cream and a brownie sound great, but it does not… I do not want to eat it. You know, I am not craving it. It is not that my taste buds do not want it. It is just I am not feeling the need for it.” So I do think that there as a little bit of aspect for there. I do not know if there is any research or if anybody else knows anything about that, but I have found that that people do not gravitate towards those carbs in the mood food like they did before the LDN.

Dr. Maki: Yeah, right. Yeah, they definitely think there is the potential there to kind of investigate that further where there is almost like a dual benefit. You are having the anti-inflammatory effect by surging that opioid growth factor, suppressing it and then it rebound. Suppressing it and then it rebounds. Normally, with drug treatment across the board, if you are trying to suppress something, most medications out there block receptors or enzyme. When you do that on a long-term basis, that is usually where the side effects come from and that is almost how all medications work. They block either receptors or enzymes. In this case, we are blocking the release of this growth factor. We are suppressing it, but we are allowing it to surge and come back. That is, you know, kind of, in some ways, using a very, you know, intelligent, a very intelligent use for a medication that creates a response in the body where the body does, you know, does all the heavy lifting on the back end. That is very attractive and I was looking back at some research.

There is research on all tracts and goes all the way back to the 80s on some of these ideas. So this is not necessarily new stuff. There is lots of information on PubMed, both, you know, twenty, twenty-five, thirty years old and also newer stuff. I think that trend is going to continue. People are going to keep looking into it. So the, you know, as you know, medicine, of course, is a practice. It is an art and a science at the same time and you and I are always… That is maybe ironically how we got into what we are doing, but we are always trying to push that envelope to try to figure out how to best serve our patients. What other potential things are there out there. Dr. Bastyr even says, “Use what works.” But also making sure… Dr. Bastyr was, you know, we went to Bastyr University in Seattle. He is a kind of the name, the person that the school is named after. I am sure some of you might know that but a lot of you probably do not. Snd he always said, “It does not matter what it is. As long as it works and really, you know, from a from a Hippocratic Oath perspective, as long as you do no harm.” I think the LDN fits that bill pretty well.

Dr. Davidson: I agree.

Dr. Maki: So I think this is a good little… Maybe next time, we will talk a little bit more about mechanism and kind of how it works. So we will just kind of give a little overview just to kind of introduce people to it if you are not familiar with it. This is more validation for people that are familiar with it, and I think we will leave it at that. Do you have anything else to add for this episode or should we call this one…

Dr. Davidson: No, this is great.

Dr. Maki: Yeah, yeah. I think this is good. So until next time, I am Dr. Maki.

Dr. Davidson: I am Dr. Davidson.

Dr. Maki: Take care. Bye-bye.

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How to Lose Weight During Menopause? | PYHP 093

Dr Valorie Davidson and Dr Robert Maki — Fri, 12 Jun 2020 18:40:38 +0000

Linda’s Question:

Hello, Dr. Maki. I hope you are well. I eat perfectly. I a small amount of organic food daily. No alcohol. No smoking. I bike forty miles a week. I am a 51-year-old postmenopausal woman at five foot eight. I am now 25 pounds overweight at 154 pounds. I cannot lose one pound. My TSH was 1.6 free T4, 1.1 free T3, 2.6 reverse T3, eleven had very low sex hormones. Hence, probably the postmenopausal part, recently began one milligram of biest troche daily and 50 mg capsule of progesterone at bedtime. My worst symptoms are water retention, bloating, and weight loss resistance. I also have aching joints and muscles. This hormone protocol does not seem to be working. I was thinking of switching to an Estradiol Patch.

Short Answer:

Most people trying to lose weight all use the same strategy. They eat less and exercise more. Over time, this approach does not work very well cause the body is forced to adapt to the significant drop in calories and increased exercise. This is especially true for women in perimenopause and menopause. For women to reach their weight loss goals, we encourage them to eat more and exercise less. Bioidentical Hormone Replacement Therapy (BHRT) can be helpful, but it is not as important as how much someone eats, how much they exercise, and how well they sleep.

PYHP 093 Full Transcript:

Download PYHP 093 Transcript

Dr. Davidson: Hi everyone. This is Dr. Valorie Davidson. Thank you for joining us for another episode of the Progress Your Health Podcast. I am sitting here with my co-host and husband and partner in business. I do not know if that is a good thing or not but here we are with Dr. Maki.

Dr. Maki: Good morning everyone. How are you doing today?

Dr. Davidson: It is a very good thing to be married and to work with your husband and have our business together. I did not mean to say that inappropriately. It is a very good thing.

Dr. Maki: Yes well, it was not very nice to say. I like that.

Dr. Davidson: I am very sorry. Not only am I sitting here with Dr. Maki. We are also sitting here with our little Australian shepherd dog who is always our little shadow.

Dr. Maki: Oh, yes. He is always there.

Dr. Davidson: So if you hear a little click-click in the background. That is probably his paws on the wood floor or he is chewing on his little bony.

Dr. Maki: Yes, right. He is always underfoot all the time. So this one we are going to do a question. This one is from Linda. Why don’t you go ahead and read the question?

Dr. Davidson: Sure. Sure. Okay. So we are going to do a reader question. This is from a blog post that we wrote called “What is Biest?” and this is from Linda. “Hello, Dr. Maki. I hope you are well. I eat perfectly. I [inaudible] amount of organic food daily. No alcohol. No smoking. I bike forty miles a week. I am a fifty-one-year-old postmenopausal woman at five foot eight. I am now twenty-five pounds overweight at a hundred and fifty-four pounds. I cannot lose one pound.” It looks like she also goes into her blood work here, which is great. “My TSH was 1.6 free T4, 1.1 free T3, 2.6 reverse T3, eleven had very low sex hormones. Hence, probably the postmenopausal part, recently began one milligram of biest troche daily and fifty-milligram capsule of progesterone at bedtime. My worst symptoms are water retention, bloating, and weight loss resistance. I also have aching joints and muscles. This hormone protocol does not seem to be working. I was thinking of switching to an Estradiol Patch.”

Dr. Maki: Well, I think there is a lot of things going on there. For one, she started one milligram of Biest as a troche. You and I are not really big fans of troche. Troches are kind of like a sublingual form of hormone delivery. You kind of put it under your tongue. You are supposed to let it dissolve. It does not take like twenty minutes for those things to dissolve.

Dr. Davidson: I mean, I have a few patients that maybe do not absorb as well transdermally with the skin because, with estrogen, you really do not want to take it orally. So troche is one way to technically bypass the digestion. So it is like this little sublingual, a little kind of squishy kind of looks almost a jello[?] but it is hard and you put it under your tongue or put it against your cheek. It does not taste great. It does take sometimes up to twenty minutes to dissolve. People get a little bit hurried and rushed and they want to drink their coffee or eat their breakfast and they end up chewing it up and swallowing or just swallow it. So then it ends up being more of a digestive way of getting the estrogen rather than a sublingual way. So there is a few little issues with that but for the most part, some people really do like their troches.

Dr. Maki: Sure. Yes, it is not something that like you say that we typically do. I think dosing wise for a troche is probably fine just because it is a troche. Transdermally, it is very low. If you are putting a cream on your skin in one milligram you might as well not even be taking it at that point. Now, her symptoms seem to be complaining of too many menopausal related symptoms. No hot flashes, no night sweats, at least she does not claim to have any insomnia which are kind of the classic three that most women are dealing with.

Dr. Davidson: I agree, but I wanted to kind of interject a little bit so that one milligram of Biest as you say might seems like nothing. It really depends on what the– I guess the ratio of that Estradiol to Estriol is. So when you say Biest, that is why she found our blog where we are talking about what Biest is. Biest is a bioidentical hormone replacement protocol where you combine Estradiol which is E2 with Estriol which is E3 where conventionally most doctors will do of course the old-school [inaudible] and nobody uses that anymore hopefully or they will do Estradiol which is very strong. So depending on how that one milligram is dosed out in terms of the ratio between the Estradiol and the Estriol can determine how strong it is.

Dr. Maki: Yes, right. So a typical one that we usually start with is an 80/20 ratio. So eighty percent Estriol, twenty percent Estradiol but when we get these questions from people, it seems like the more common ratio that we see are people asking questions is a 50/50 ratio. So it would be equal amounts, so be a half a milligram of Estriol and a half a milligram of Estradiol. Anytime that Estradiol when that amount goes up the side effects are in some ways more likely at that point.

Dr. Davidson: Yes, Estradiol is the strongest form of estrogen but it is beautiful– estrogen is just a beautiful hormone in general and has so much activity in the body. But Estradiol can have some negative symptoms if it is a little too high like, Dr. Maki said even if this was a 50/50 ratio of 0.5 milligrams Estriol, 0.5 milligrams Estradiol. It is still a little bit on the low side but I find some women are very sensitive to that Estradiol and they will have bloating and water retention. That is a classic sign of estrogen symptoms, not so much with Estriol because it is so much more gentle but Estradiol will definitely cause bloating, breast tenderness, ankle swelling, feeling like your pants are tight. So it could be a little bit that she is sensitive to that. And with that said just to jump to the end of her question is I really do not think she should switch to an Estradiol Patch. That is the strongest form of estrogen and a lot of women on Estradiol Patch is it does work incredibly for a night hot flashes, night sweats. Definitely an Estradiol Patch would work with that but typically, for the most part, anybody on Estradiol Patch will put on a few pounds.

Dr. Maki: Yes, is it not like kind of like birth control used to be like eight to twelve pounds something like that?

Dr. Davidson: Yes, birth control pills do not really do that anymore but of course, the old school ones do but the Estradiol Patch depending on the females frame usually you will see around four to six pounds. Trust me nobody wants to put on four to six pounds without actually earning it. So you do see that so I would say for Linda an Estradiol Patch would not help her with her weight loss resistance probably make her water retention and bloating a little bit worse and it sounds like from her, from what we are looking at with her question is she is really more concerned about weight.

Dr. Maki: Right. Well, she did send a kind of an addendum question to this one and said that the water retention had been there four years prior to the current. So the water retention has been going on even prior before she started the hormones. So is that related to the hormones? Which you are right Estradiol could certainly do that. She even said as she was in perimenopause is when some of those symptoms really started to appear. You are right as that Estradiol level increases or she switches to the Patch. So I am going to make those things potentially worse, the progesterone dose of fifty milligrams I think that that might be a little bit too low, but again if she is sensitive that goes up to seventy-five or a hundred to protect your uterus. Now that could exacerbate some of that water retention.

Dr. Davidson: So I would say if I was just looking at this, we do not know a whole lot of background here completely but with that thyroid that T3 level is a little bit on the low side. She does not have thyroid disease. She is not hypothyroid. She does not need thyroid medication. Her TSH is just fine. Her T4 is actually really great at 1.1, but the T3 level sometimes when you see it the free T3 level under 3.0 that can have a little a bit an effect on all moving parts in the body.

Dr. Maki: Yes, right. As we talked about metabolism how hot that metabolic fire is burning to allow or the burning the fat. We want to see that free T3 to be at least in the threes. If not in the mid threes if not closer to four and this is something that you and I both see all the time. We see a reasonable TSH one and a half or less. That is because of her activity. She said she bikes forty miles a week, but now she has a low normal free T3 where we want to see those numbers opposite of each other. We want to see a low normal TSH. We will see a high normal free T3. She says the first line of her questions is, “I eat a perfectly small amount of organic food daily,” that tells me right off the bat that she is more than likely under-eating. So she is maybe not over-exercising but she is exercising forty miles a week. You and I are not necessarily bikers as a form of exercise. I like to bike as a form of recreation would necessarily say that we do that on a regular basis as the [inaudible]. We are not logging our miles so to speak so I am not really sure, forty miles on a bike on a weekly basis. Running that would be a lot. That would be a tremendous amount of miles if you are running. Biking that seems — you and I talked about that before we started recording and you did not seem like that was too egregious.

Dr. Davidson: Doing forty miles in that one day for that week that could be possibly a lot but ten miles four times a week that actually sounds really fun. That sounds really fun. I would not say she is over-exercising which is because if you over-exercise that can drop your T3 level. Now, I am generalizing here but when you look at a thyroid panel like this. When you see a normal TSH, a normal free T4, and then a low free T3, my first thought is there is probably some caloric restriction going on. Now, I am forty-seven years old. I remember the 90s. It was, “Hey, let us drop our calories. Let us skip a couple of meals and to try to lose weight.” That was the whole thing back then was like if I under eat then I will lose weight and we all know from experience. Yes, you might lose a little weight, but then it comes right back with a few extra pounds. Now we know sure[?]` calories have an impact on our weight management and weight loss, but at the same time completely reducing them is going to have a negative impact. So we do not want to just focus on calories and it does not look like she is focusing on calories because she does not put in anything about how many calories I am eating, what are my macros and all that but it does look like she may be under eating and trying to lose some weight.

Dr. Maki: Yes, right and it does not make any logical sense like it is so counterintuitive to think that you have to eat more food in order to lose weight. You and I run into this all the time. I have these conversations with patients on a regular basis and they are all exercising. They have no problem doing the exercise piece. They all exercise diligently and consistently but they all — and I am generalizing here, but collectively there is a trend to under-eat on a chronic basis. RKCCP the Keto Carb Cycling Program, we put that together specifically to guard against the chronic under-eating. So going on a diet for weeks and weeks and months and months on end at a very specific amount of calories. She says a perfectly small amount of food. That means she is probably either measuring it, weighing it out. She eats the same thing on a regular basis, which is fine but when people tend to eat healthy, so to speak so fruits and vegetables, sources of protein that is very difficult to get to what your ideal even your maintenance level of calories is on a daily basis. It is very challenging to do that. Now, with this new popularity of intermittent fasting which is reducing the frequency of your meals. Now the likelihood for you getting to that right amount of calories, enough calories to be able to feel your activity, and to feel the weight loss process. It is that much more difficult to be able to get to that point.

Dr. Davidson: I am sure Linda does not exactly want to hear this and it does sound scary, trust me I am a female too. When someone tells you, “Hey, you have got to increase your calories. You have got to eat more food.” You think, “What?” that like, you said, it sounds counterintuitive but a lot of times when you are in — and I have women patients that will say I eat twelve hundred and fifty calories every day, every single day, and that technically is a very not a lot of calories. That is very very low but when you are eating the same amount of calories every single day, of course, your body is going to get adapted or habituated to it. So actually that is why we like to cycle a lot of those calories or cycle the macros so that the body does not get adapted or habituated to a static amount of food every day.

Dr. Maki: Yes, right. The body is not designed for a static amount of food and when it is a really low amount of food less than fifteen-hundred the magic number is twelve-hundred calories. Every woman thinks if they eat twelve-hundred calories are going to lose one to two pounds a week. Now that math makes some sense. It really does but not in a menopausal woman’s body. It just not make sense in a menopausal woman’s body because of the hormones are all different than the one they were when you were twenty-five. It just does not work anymore. So the strategy of how to get to that point. Now, we will be very gentle here, but she is a five-foot-eight, one hundred fifty-four pounds. She says that she is twenty-five pounds overweight. So in her mind, whatever the math is there that put her at somewhere between one hundred twenty-five and one hundred-thirty as her ideal. So I took her biometric data took her height, her weight, her age, her activity level and I put it into a caloric calculator that determines — there are all over the internet. You can find them everywhere. They are very simple, but they are based on some mathematical equations that give you an idea of what your maintenance level of calories are. Now I will tell you these mathematical formulas are [inaudible] and skewed. They are not perfect but I put hers in at a hundred fifty-four pounds. She needs two thousand and one hundred eleven calories as her maintenance level of calories every day. Now, I put it in at whatever a hundred minus a hundred and twenty-five pounds, which would be the lower anywhere she wants to be. Give or take and it went down to nineteen hundred and seven. Even though that is over a twenty-five-pound difference, maybe like a twenty-nine-pound difference it only went down two hundred calories. The average woman needs somewhere between two thousand to twenty-six hundred calories on a daily basis as maintenance level. Now, if you are at fifteen-hundred less on a perpetual basis, you are under-eating by anywhere from five hundred to a thousand calories. Your body is going to eventually compensate and then that is why we start to see those thyroid numbers start to be so low because your body is trying to slow down your metabolism, which means it is slowing down your metabolic rate. If your metabolic rate slows down, you are not going to burn any fat. It is impossible. You are turning off the fat loss process by under eating on a perpetual basis.

Dr. Davidson: Exactly and granted the scale is evil. One day, it says one thing the next day it says something totally different. If the scale is evil, so a lot of times when we are working with women and I will tell them, “Hey, let us not focus on the scale. So, “Hey, you are one hundred fifty-four pounds right now. As we are moving along just see where you feel comfortable at. It could be one forty-seven. It could be one forty-four, not one twenty-seven and a half.” So instead of focusing on the number let us focus on the health and let us focus on how you feel. Granted, I am sure Linda has some clothes she wants to fit into that she is not fitting into right now and she might be feeling heavy and not quite how she wants to feel in her body and that is okay as we are working on it we get to where she feels healthy and where she feels comfortable. Definitely when Dr. Maki said is that math equation sounds good in theory, but we have so many other moving parts metabolically in our body that that math equation is not going to necessarily work. I mean how many of you or friends that you know of have said I downloaded this app on my phone. I am putting in my macros and my calories and what I am eating and how much I am exercising and I am actually deficient in calories and I gained weight. I hear it all the time because it is not necessarily calories and calories out. I would say definitely Linda is having a struggle right now because that T3 is too low.

Dr. Maki: Yes, right. Yes. I think that that is in some ways kind of a symptom of her strategy and you are right. This is just a kind of repetitive. That is why we picked this one in the first place is because this is a situation. Now granted she is not morbidly obese at a hundred fifty-four pounds. I would imagine she probably looks fantastic. She wants to be under a hundred and thirty. Like I said, the calculator that I use said she should be between one hundred thirty-eight and one hundred forty-one. I mean she can get down to one hundred twenty-five. That is fine. That is her choice, but you have to pick the right strategy in order to get there. We can kind of beg to differ as far as where her ideal weight should be. It also calculates BMI at one hundred twenty-five and put her BMI at nineteen. I think that is a little bit too low. That is not– BMI in the low 20s, I think is appropriate. I think at the even at the one hundred fifty-four had her BMI like 23.3 which is reasonable, but the closer you get to what your ideal weight really is the BMI becomes not really that accurate. It is not really good gauge of anything. As long as your BMI is under thirty, then your risk for age-related diseases, like diabetes, heart disease, cancer all that stuff goes down. It is really hard to know exactly what someone’s number supposed to be. Like you said a minute ago maybe it is more about how your clothes fit or what your pant or dress size is because that is really ultimately what we are trying to exercise for and lose the weight for anyways is so we look and feel better on our clothes.

Dr. Davidson: Exactly. Yes, so I would say, there are like you said there is a lot to this question. Being postmenopausal, being menopausal that does — everybody knows that the metabolism goes down and then it is much easier to gain weight when you are fifty versus twenty-five. There is such a big difference between that. So I do like the idea that she is doing some bioidentical hormones and she is actually doing the bioidentical not any kind of crazy conventional ones that would not be necessarily safe for her and they are very low dose which it is always better to start off low and work your way up. I would say with the hormones being postmenopausal female, the progesterone maybe doing some blood work checking, her progesterone checking, her Estradiol levels may be switching that troche over to a cream and definitely probably splitting it up to twice a day because she says she does the troche daily. Probably once a day that Biest and the bioidentical hormones are a beautiful thing but they have a very very short lifespan. So any time I am doing any kind of estrogen or Bieist is I always do it twice a day because really if you put it on at ten o’clock at night by ten o’clock in the morning pretty much most of that estrogen is out of your system. But if you do it twice a day, you can keep that a little bit level. One thing we had talked about with Linda earlier before I am kind of looking at this question a bit is she might be a nice candidate for the rhythmic dosing which we had talked about in a previous episode.

Dr. Maki: Right, because her goal is weight loss. She is fifty-one. So she is fairly close to her menstrual history. It has not been ten years and for what she is trying to accomplish obviously she lives a very healthy good lifestyle. That is where the rhythmic dosing can be kind of a very good advantage because it raises up those hormone levels. Think of estrogen is when it is in balance, estrogen is a very slimming hormone. That is why when you are twenty-five you weigh less than you do when you are fifty-five because you have a lot of estrogen when you are twenty-five. We can raise those levels physiologically are two physiological levels, one is going to help buffer the stress of the exercise not saying that her exercise is stressful, but exercise is a stressor on the body. You couple that with a low-calorie diet. Now, you are magnifying the stress of the exercise. Now the female hormones can kind of buffer some of that. So now it is just not a cortisol party all the time.

Dr. Davidson: Yes, like we have talked about in other podcasts. The rhythmic dosing is essentially cycling the estrogen and the progesterone to physiological levels of that of like a twenty-eight-year-old female. That is a lot different than doing a static dose of [inaudible] is you at this Biest at 1.0 milligrams. Maybe she goes up or she splits it up or changes up the ratio. Doing a static dose and having a little higher levels of Estradiol can cause puffiness and some weight gain. That is why an Estradiol Patch which you put on twice a week tends to be technically in some ways a static dose. That is why women tend to gain weight on that but when you are cycling the estrogen and the progesterone, you do not necessarily have that same effect.

Dr. Maki: Yes, right and now her symptoms water retention, bloating, weight loss resistance, certainly the water retention, the bloating they could get worse from what she is doing or changing those dose and even from the rhythmic dosing however cortisol as a stress hormone could cause those exact symptoms anyways. So in some ways, I think hers because our hormone dose she just started it. She had been on them very long. The doses are relatively pretty low. She is been having the water retention, the bloating for quite a while but four years, she says were that in some ways to me that seems like it is more of a symptom of cortisol dysfunction as opposed to it being related to her hormonal decline.

Dr. Davidson: Which could also impartly why her free T3 is low. I think it is probably a little bit low because of [inaudible] restriction or a little bit of under-eating but also high levels of just mental stress, whether it is life, family, job, whatnot. Mental stress can also raise up levels of cortisol, which will then lower your free T3 levels. So like you said addressing her cortisol will also help address that free T3 raising up. Changing up her dietary will probably also help address those metabolic hormones as well.

Dr. Maki: Yes, right. So if this one is complicated. This is what a lot of people that come to see us. A lot of questions we get is about this weight loss component and believe me you and I, do not really have all the answers because everyone is different, everyone—there is theories, there is philosophies, there is strategies, there is dietary approaches this that. Everyone has an opinion about some of those things but you have to kind of tweak and tailor them to work, to what is going to work for the individual. We are all the same in some respects. We are also vastly different. We have very different lives and sleep and stress and hormones and all those things in the food we are eating. In the food, we are not eating, all those things factor into what our weight management is going to be. That is a really tough thing to do but the things that jumped out to me, I think we kind of discussed. It is a big deal going for one milligram of Biest to rhythmic dosing. I will be honest that is a big adjustment but the ones that seem to thrive well on the rhythmic dosing their bodies were adapt to it well and it makes things like losing some weight and feeling a little more like yourself again. It makes some of those things a little bit more possible and more accomplishable. So do you have anything else to add or can we wrap this one up for now?

Dr. Davidson: Absolutely. No, this was a great question. I just want to say thank you for all of you for writing in your comments and your questions. We love that from all of our listeners and our readers and honestly, Linda you are doing great. I mean that like the weight thing, a lot of us has to do — we are females. We are concerned with our weight, but I would say even just looking at what she wrote here I am sure she is incredibly healthy that, “Hey, you want to fit a little bit better into our dresses, into our clothes,” but it does look like she really is on a good path, just couple little tweaks here and there like we all could do.

Dr. Maki: Yes, good lifestyle in general but trying to accomplish that goal that she wants. That is why I am always encouraging resistance training versus cardiovascular training because you are not — Now we are kind of getting back into it all over again, but it is not necessarily about trying to exercise those calories off. You are not going to be able to exercise the weight off. It does not work that way. The more you try to exercise that weight off the more difficult it becomes like she said she is been at this for four years so until next time. I am Dr. Maki.

Dr. Davidson: I am Dr. Davidson.

Dr. Maki: Take care. Bye-bye.

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Should I Take Thyroid Medicine Before Blood Test? | PYHP 092

Dr Valorie Davidson and Dr Robert Maki — Thu, 04 Jun 2020 20:04:30 +0000

Question:

A question we get all the time from patients and podcast listeners is if they should take their thyroid medication before a blood test.

Short Answer:

There is not a simple answer to this question. It depends on the patient and their situation. For new patients, we typically want them to take their medication in the morning 3 to 6 hours before a blood test. This is especially true if we have made a recent medication change. If a patient skips their medication the morning of the blood test, it is harder to determine dosing adjustments. The longer someone has been on thyroid medication, the more likely we are to have them skip taking the medication the morning of a blood test.

PYHP 092 Full Transcript:

Download PYHP 092 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: How you doing this morning?

Dr. Davidson: I am doing very well. How are you doing this morning?

Dr. Maki: Well, the skies are blue. The birds are out. Looks like it is going to be another beautiful day.

Dr. Davidson: I look forward to it. It is what, spring in Washington. And even though, it does, it is Washington State it does rain here. But at least the you know; everything is green, and we do get some beautiful days.

Dr. Maki: Yes. We certainly do. Now, granting the summer, people that are not familiar in summertime, there were hardly rains at all. June, July, August, September, does not rain hardly much. It gets kind of dry. But certainly, the spring, the fall, the winter, it makes up for those months that it does not rain for sure. Okay. So, this one is a situation that comes up all the time, for existing patients, for new patients, for questions we get from listeners and readers, the timing of thyroid medication and blood testing. Some say to take it in the morning, some say to take it the day before, and skip it that morning. There is, like I said, there is, you know, there is a couple of opinions and how that is supposed to be done or what say you?

Dr. Davidson: I would say both.

Dr. Maki: Yes. So, you would say that both are right.

Dr. Davidson: Yes. When somebody asks, should I take my thyroid the morning of the blood test, there are times when I say yes, and there are times when I say no. You know, it really depends on how we are going to monitor it now. We are very specific when we monitor thyroid levels. Specifically, we will do the thyroid stimulating hormone, the TSH, the free T4 in the free T3. You know, we want to, you know, those are kind of like my nitty-gritty. I mean, then you can do a reverse T3 and a few others but really, you know, the free T3 is super important. A lot of conventional doctors do not always test the free T3, or somebody might be on a particular type of medication like Synthroid Levothyroxine and they only do the TSH unfortunately, just the TSH, or if they are a little bit more progressive, they might do a TSH and a free T4. So, it really for us since we are so now, you know, so nitty-gritty on how we dose and how we read the blood test. I will do both.

Dr. Maki: Yes. Right. So, a typical scenario that we see all the time, for both of us, for our new patient. They have gone to another doctor there on one of the T4 mono therapy medications, they are on Synthroid Levothyroxine. They do not feel very good. They have been on that dose, or doctor changes their dose up and down and up and down. It was–

Dr. Davidson: Based on their TSH.

Dr. Maki: Based on their TSH. Although, they increased her dose or TSH goes down, now they lower their dose. They still do not feel very good. So, it is this like, kind of back-and-forth musical-chair dosing of the thyroid of the of the T4 medication with really no consideration for how the patient feels. It is solely based on the TSH number. And for those listening, we do not agree with that at all, that is why we typically do not prescribe those medications. So, in a case like that, that patient comes in to see us we would automatically switch and increase, depending on what their labs are the baseline labs, what they were on from their previous doctor. We look at those numbers and we make decisions based on what they were on, coming in to see us. We will switch and increase typically, right, because when you go from those conventional medications to a what we like to do most of the time is compounded thyroid. The compounded thyroid, because it is stain released does not necessarily it does it is not as strong as the instant release commercial medications.

Dr. Davidson: Yes. Because it is sustained release, when you take it, it does not shoot through the, you know, the ozone layer, into your system, it comes up gently and stays gently throughout that 24-hour period. Now, we also do, you know, desiccated thyroid, porcine desiccated thyroid, nature thyroid, armor thyroid, and P-Thyroid and West thyroid. We also do, you know, the porcine thyroids as well, but when somebody is but the compounded T4-T3, which is a Compounded Sustained-Release Levothyroxine and a Compounded Sustained Release combined together capsule, Liothyronine is and the Porcine Desiccated Thyroid, they are like, you know, apples and oranges compared to Synthroid or Levothyroxine.

Dr. Maki: Yes. They are really they are completely kind of two different animals, in some respects. They are not really a fair comparison. When you try to go from one medication, the commercial type to the compounded ones, you cannot match up the dosing. It is completely– Now, some of the farmers, some of the compounding pharmacies, do make conversion charts, but those are even worse.

Dr. Davidson: The ones on the Internet are terrible.

Dr. Maki: Yes. You cannot if you base your new prescription for that patient that comes in if you base your new prescription based on what they are already taking, without increasing and at the same time, they are going to be under medicated.

Dr. Davidson: Or readjusting the T4-T3 based on what they were on, they will feel terrible.

Dr. Maki: Yes. They will, they will kind of regress in a way. So, that is why we typically, from experience, we typically switch in increase right off the bat, because people tend to be across the board. They tend to be under dosed. That is the argument for test, for skipping medication in the morning, is because if you take your medication the morning your blood levels are going to rise shortly thereafter the taking the medication. So, if you see a blood level that is higher after, you know, if let us say three or four hours after taking your medication. Some people think that that is a falsely elevated number. But when you first transition somebody from a baseline before they came to see you and now you are switching them to a completely different medication, you have to see that change in the beginning before you have them skip their medication. If they do not take it for 24 hours, you are basically flying blind. You have no idea what that new medication is doing to their levels and you cannot accurately change or adjust based on those new numbers.

Dr. Davidson: And then, you are just, having to look at the TSH to realize it. So, just to kind of reword what Dr. Maki was saying. New patient comes in. They know their thyroid is off. They have been on some kind of tea for therapy, or maybe they have not been on any therapy before, but they know their thyroid is off. We have some blood work right in front of us saying, “Hey look your thyroid looks like it is off. Let us start you on some thyroid”, you know, some calm either compounded T4-T3 combo or maybe some natural Porcine Desiccated Thyroid. So, we are going to start you off now. And then, you know, if they were on a different dose, maybe you might raise it up. Then we are going to test you after about a month, you know. It takes about three weeks for those therapeutic levels to rise in your bloodstream and become, you know, facilitated into your system. So, I usually do not want to do it any less than three weeks. So, we might test it in about a month. So, I always tell them please wake up in the morning, take your thyroid, and get your blood test, you know, around four to six hours later. Do not do it right away because then it will jump up a little bit too high. Because we need to know if you are absorbing this new thyroid medicine.

Dr. Maki: Yes. Right. You had a baseline from your previous medication. Now, we are transitioning to literally the commercial types of the compound of the natural Desiccated Thyroid. It is none of them are the same thing. So, you cannot one dose of one versus one dose of the other two types, you cannot compare them as even though they are all thyroid medications, they are all completely different in how a person responds to them. But by taking it four to six hours afterwards, you are going to see that rise, it is going to go up artificially, but now you can compare that to the baseline numbers. And for the practitioner, it makes total sense.

Dr. Davidson: Yes. For me to know, like my digestive system is different than your digestive system, which is different than somebody else’s. How am I absorbing this? So, if I see that I give them this medicine and it does not come up, then I will know you, you know, we have got to work on your digestive system because we are always doing that too. But maybe the dose needs to come up. But let us say it does come up. Then I will know that they are able to digest it. They are able to absorb it and it is really more specifically, I would say about the T3 component of the thyroid medication. T3 is an awesome I mean, it is an awesome thyroid hormone, but it is very volatile. It is unstable. It has a short half-life. So, if you had taken your new thyroid medication yesterday and then went to the blood, you know, it is right now with about, you know, 11:30 a.m. or 10:30 a.m. here in the morning. I went and got my blood draw right now. It has been well over twenty-four hours. Since you took that medication, I am not going to get an accurate reflection of where your T3 levels are at.

Dr. Maki: Yes. Right. So, you are taking it twenty-four hours prior. Your levels have already come up and then have basically bottomed back out. So, you are almost, in some ways, when you are looking at that blood tests, you are starting over every twenty-four hours. So–

Dr. Davidson: With the exception of the T4 though. T4 does have a longer half-life. I think it is close to seven days. So, if you did miss it and, you know, took your blood work, you know, today. Right now, and I did not take my thyroid since yesterday, the T4 might be slightly a little bit more accurate, but the T3, it is almost like useless.

Dr. Maki: Yes. Right. And the T3, the free T3, is the number that we are trying to increase. The TSH is going to go down as the dose goes up of any one of those three medications. The T4 monotherapy, the NDT, Natural Desiccated Thyroid or the compounded, the TSH is going to go down as you increase the dose of all those medications. On the T4 monotherapy, the Synthroid the voxel levothyroxine, those are not going to have any impact on the T3. The T3 is not going to change and sometimes it just goes down. Even though the TSH might go down, your T4 might come up. But nothing typically happens to the T3 and that is the active thyroid hormone. T4 is just a conversion hormone. It has no activity in the body, whatsoever. T3 is the one that has all the effect or all the action on the body. That is the one that we want to have. That is the one we want to modulate as much as we can.

Dr. Davidson: Now, with us saying that, you know, I am sure there are those of you out there like, “What? This makes no sense. I never take my thyroid medicine before my, you know, taking my blood test”. Now, if you are on Synthroid, it really does not matter whether you take it, or you do not take it. And really, I would say do not take it. You know, do not take it the morning of your test if you are on Synthroid. And that is what your endocrinologist is going to want and probably will only check maybe the free T4 and the TSH. But if you are on any kind of therapy that has the T3 in it, in the beginning, I always have you take it and then wait several hours to check how your absorbing it. I mean, granted and I will tell you, number one, we do not base thyroid doses on blood tests alone. We do take into consideration, you know, a huge factor of your symptoms. What are your thyroid symptoms? We do take that into consideration for dosing, but it is wonderful to have that objective data of where those free T3 levels are. Once we kind of get things balanced out, then we do will say, “Hey, tomorrow, you know when you go get your blood drawn, do not take your thyroid that morning”. So, we will do that as well because I want to see you without the thyroid.

Dr. Maki: Yes. So, again, if for a for that. So, in the beginning we want them to take their thyroid so we can see the change from what they were taking previously. So, let us say three months, six months, we have made a couple of dose changes in that time. Now, their TSH is actually a little low. Let us say their TSH, the lower end of the reference range is point four-five. Let us say their TSH is point two-five, point one, point zero-one, point something lower than the reference range because they took their medication three to six hours before their blood draw. Now, we will have them say, you know what, the next time you go in to do blood work in a month or three months or whatever it is. Now, skip it that morning. So, now it has been, like you said, over twenty-four hours since they have taken it. Now that, all those numbers should be adjusted accordingly and now we can make a better determination of what needs to happen with their dosing because now we are seeing it. We saw it at its highest point, the last blood test, the numbers were a little bit, you know, abnormal. But now, we are going to see it at its lowest point, and we can continue to maintain, you know to you know, approach the ideal dose for that particular patient.

Dr. Davidson: Yes. So, the answer to the question, because people asked this all the time, you know, “Should I take my thyroid medication before my blood test?”. The answer is sometimes yes and sometimes no.

Dr. Maki: Yes. Right. Now, that again, we have gotten some pushback from people sometimes. “Oh, I am not supposed to take it. I read on the internet. I am supposed to take it. I am not supposed to take it”, because you know, you are seeing these artificially elevated numbers. It is like I said, it is more about the process that we have of why we want to see them in the beginning and eventually those numbers, we want to, you know, they are going to change over time. That is the whole point. A lot of times compounded thyroid kind of gets a bad rap. Well it did. I tried it did not work. It is always a dose-dependent issue. Compounded thyroid is not as strong as some of those other thyroid medication. And when it comes to thyroid, I will tell you, conventionally, everybody is very conservative when it comes to dosing thyroid medication. And I do think a lot of patients, which is why taking your medication the day before, is such a popular recommendation is because people are chronically under dosed. You take your medication the morning, your Synthroid, your TSH goes down, your numbers are too low. So, now you still feel like you have all these hypothyroid symptoms. But now your doctor is going to lower your dose from 125 to 112 or from 100 down to 75 or 88 micrograms. When you already feel you already still have the same symptoms. That is not going to help you very much. So, in that context, yes. Taking your medication, the day before, make some sense. But if the practitioner is chronically conservative on the thyroid dosing, it does not matter when you take it because you are never going to really achieve the optimal dose that is going to make someone feel better which is what we are trying to do with every patient. We are trying to optimize the TSH and the free T3, a low-normal TSH high-normal free T3. Usually the patient feels pretty good in that, in that relationship between those two numbers.

Dr. Davidson: And you think if your thyroids low, we are giving you medication to bring it back up. So, when you say abnormal or artificial levels, I do not exactly consider that when I take my thyroid in the morning sure, you know, I take it at six in the morning by twelve, or you know, I would not call my level i artificial or abnormal. I would call them normal because my thyroid is low and so I am taking a dose to put it at the right high, optimal level.

Dr. Maki: Right. Yes. Totally. And you are right. I would not call it abnormal or artificial because those numbers are dependent on the medication. You have been taking it, you know, for a while. That is your in some ways the medication is your new normal, you know. So, it is complicated, you know, knowing when to take your medication that morning and knowing when not to. The symptoms, the patient sub symptoms, and the objective data, help us determine when we say yes to take your medication the morning before your blood test, and when to say no. So, they are both right.

Dr. Davidson: So, when we were, you know, I was saying that we are very specific in how we, you know, dose the thyroid, look at the thyroid, get your input, when you think about it, especially with the compounded, you are not quite as versatile with the Desiccated Porcine Thyroid or Nature Thyroid, or armor. But with the compounded T4-T3, you can make any microgram, quarter microgram changes in anything that you want based on that individual. Some people so, you think about with a porcine, you know, the pig thyroid which I still love and have lots of people on it, but it is a four to one ratio for micrograms of T4 to one microgram of T3. You really cannot get away from that. But with the compounded form of the levothyroxine and the Liothyronine sustained release, you can do anything. And I have a lot of patients where they really do absorb their T4 fairly well, but they cannot convert it to the T3. So, “Hey, I can raise up the T3 in that capsule”. So, that is why we are so specific with our patients and I think they get a little bit like, “No. I read on the Internet or might, you know, some might, you know coaches or not told me that I should not take my thyroid before”. Sure. Maybe with somebody else. I can understand that, but we are very specific. I need to be able to see it one way, see it another way, so I can pull that together just like Dr. Maki said is we want to have kind of a low normal TSH. And sometimes, we do not pay a whole lot of credence to the TSH because it is just a signal from the brain. But at the same time, we want to have that data, but then have a high normal T3, people feel good.

Dr. Maki: Yes. Right. Yes. So, the recommendation to take your medication that, you know, skip your medication that morning, I think, is fine for a conservative conventional mindset, right. Because they are very conservative across the board on someone’s thyroid dosing. Doctors get a little freaked out by it. We are always trying to optimize those numbers. That is why we say both is, you know, there is not a hard-and-fast rule of skipping your medication that morning. It is very much patient-specific on when we say yes and when we say no. And it is not just, you know random. We actually have a very well-thought-out process of why we do that because those numbers because of the medication types. All those medications are different, and people respond to them differently. So, they start on something, we switch them to something else which is why people typically come to us. They do not want to be on Synthroid anymore. They have heard about some other options, whatever the other options are, you know. But we prefer the compounded thyroid and that is very much dose dependent. So, we have to try to inch a little further closer and closer. But it takes time to do that. You cannot do that in a couple of weeks or a couple of months. It does take sometimes, you know, three to six months to get those doses optimized.

Dr. Davidson: Yes. When I am, you know, where first meeting you as a patient. Yes. It is going to take a little time for me to understand your system because your system is different than somebody else’s system. But once we got it down because, I mean, we have patients, we have seen, you know, since we started practice in 2004 is, you know, I will tell them do not take it. You know, I want to just see the thought, you know, just you, no thyroid that morning. Or some people, I will say, “Hey, listen. If you can, instead of four to six hours later, can you wait and do your blood work after work so I can get a good twelve hours because maybe the sustainability is not there after twelve hours”, you know, I want to know where it is at all different times because we are so specific. So, I have had some patients that got it, you know, little, you know, nervous about me telling them to take their thyroid and know that I got you covered that, you know, we will do it both ways.

Dr. Maki: Yes. Right. Yes. There are situations where both are necessary. And a lot of times, there are a lot of overreaction about a patient’s lab results. Their TSH is little bit too low. They are free T4 or free T3 is a little bit too high and doctors are the patient always knows when their overmedicated. They will start having some symptoms. They will feel jittery. They will feel anxious. They might have some heart palpitations. Usually, it might be heart rate versus palpitations, which is an instant release T3 might cause some palpitations right after taking it. That is also why we use the sustained-release compounded thyroid because it eliminates some of those cardiovascular symptoms. But if you just start on one dose and let us say, “Well, a month goes by and I do not feel better. I might even feel a little worse”. That is why we need some time to get to that appropriate dose because it comes down to the person and the dosage and we cannot do that. We cannot speed that process up, that process takes a little bit of time to get there. So, do you have anything else to add about that or like I said, it really depends on that. Maybe we just confuse it even more, right. Now, people really do not know what to do. But at least the way that we do it we want to see the transition, the baseline for where they were to what we are starting them on and then we kind of decide from there. As you know, as they either improve or do not improve. Now we are able to tailor that, you know, just a little bit more optimized over time.

Dr. Davidson: So, if hopefully we did not confuse you. But if you have any questions, please email us, you know, ask your questions. That helps us kind of decide what to talk about because when we get your questions that gives us input into what people want to hear. So, if any of this about taking your thyroid before your blood test, after your blood test, any questions, just reach out.

Dr. Maki: So, until next time. I am Dr. Maki.

Dr. Davidson: I am Dr. Davidson.

Dr. Maki: See you later. Bye.

The post Should I Take Thyroid Medicine Before Blood Test? | PYHP 092 appeared first on .

How To Cycle Bioidentical Hormones? | PYHP 091

Dr Valorie Davidson and Dr Robert Maki — Wed, 03 Jun 2020 18:55:05 +0000

Question:

How to cycle bioidentical hormones?

Short Answer:

When it comes to BHRT dosing, the two main options is static dosing and rhythmic dosing. Static dosing is by far the most common, but depending on the patient’s symptoms and goals, rhythmic dosing might be a better option. We like to use rhythmic dosing with testosterone for men almost exclusively. We are not fans of injectable testosterone or hormone pellet implants.

PYHP 091 Full Transcript:

Download PYHP 091 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: I am Dr. Davidson.

Dr. Maki: How are you doing this morning?

Dr. Davidson: I am doing great. Spring is here in Washington. It is beautiful. The plants are growing, birds are singing.

Dr. Maki: Yeah. We are getting a little bit of rain but a lot of it has been coming at night. In spite of the lockdown, we are still getting some really nice weather. We have been able to spend some time outside. The plants are growing, a lot of weeds. We have a bunch of, what are they, raspberry bushes or blackberry bushes. They are kind of going a little crazy.

Dr. Davidon: They are blackberry bushes. Blackberry bushes grow like weeds here in Washington, which is fun in August because then you get to pick them and eat them, but I definitely have a lot of scratches on my legs from tramps and throw them.

Dr. Maki: Oh my God, yeah. Then, we played with the dog outside. He likes to play with the tennis ball and then chuck it. We live on a kind of a busy road. They are out in front in our yard, and they kind of kind of create a really nice fence because he is very careful going around those bramble bushes or blackberry bushes. He tiptoes in them very carefully. He does not want to hurt his little paws.

Dr. Maki: On today’s episode, we are going to talk about rhythmic dosing. The title of this one is How to Cycle Hormones but we are specifically going to talk about the difference between or the two options, the two main philosophies for hormone replacement: static dosing which is the more common type, and then rhythmic dosing which is in some ways maybe our favorite, or at least my favorite anyways in the right circumstance. It is not right for everybody but there are certain situations where, I think it is the right situation for men pretty much across the board, but we will kind of discuss some of those. Why do not we dive in? First, let us talk about the static dosing, kind of what that involves and entails, not every aspect of it but just an overview and then we will come back around and talk a little bit more about the rhythmic dosing.

Dr. Davidson: Exactly. With bioidentical hormone replacement, static dosing has been kind of like the norm or probably what people think of when doing the hormone replacement but the rhythmic dosing has been around for a long time, and it is a completely different way to dispense and dose hormones. Like Dr. Maki said it is not that we have one that is a favorite. It really just depends on the individual because with bioidentical hormones in general, I mean, you have to tailor it specifically to that person whether it is a male or female because you can cycle hormones with men, you can cycle hormones with females. In terms of the static dosing, that is where you are taking a particular dose of the hormones every day, same dose, twenty-four seven.

Dr. Maki: Yeah, right. Excuse me. The rhythmic dosing and as with most hormones in the body, if not all hormones in the body, they tend to have literally their own rhythmic pattern. They oscillate. They rise, they fall. They rise, they fall. They rise, they fall. In the static dosing, like you said, it is just the same dose every day. There is no change to that dosage over a course of a given month, or really, you might change the overall dosage from a certain, let us say from 2 milligrams to 3 milligrams, or 4 to 5 milligrams but it just stays the same every single day.

Dr. Davidson: Exactly. You might be doing an estrogen component for that hormone replacement like a biased, and you might be doing like Dr. Mackie said, maybe 2 milligrams twice a day, 2 milligrams once a day, but every day is the same. Granted, we have patients that “Oh, I forgot to take it today,” and that is okay. For the most part, it is pretty easy because you do not have to really think about it. You are just like, “Okay, it is time to take my hormones.” You know exactly what dose to take.

Dr. Maki: Yeah, right. Then, of course, with the estrogen component, there would be a pair with that, some type of progesterone. The way that we prefer to do it with the static dosing is we would provide some type of a capsule progesterone, usually 100 milligrams. Like you said, they would take their bias twice a day, morning and evening. They would take their progesterone at night. Unless we change the total amount of that dose over a course of a week or a month, or until that concentration was increased, the dose would never change.

Dr. Davidson: Now, we are talking about basically sex hormones. For women, it would be estrogen and progesterone, possibly a little bit of testosterone. For men, it would be testosterone. We are not necessarily talking about thyroid doses or that kind of thing, but with the hormone replacement for basically the sex hormones, static dosing is convenient. You can travel with it. You do not have to think about it. It is one way that you can dose the hormones especially for menopause, for menopausal females, because their ovaries are no longer producing hormones. It is a great way to give somebody some hormones without doing too much hormones but just enough to kind of help with the brain, with cardiovascular, with bone density, with anti-aging. Sometimes, I will pick more static type dosing if we are keeping the hormones a little bit to the minimum where we had talked about the rhythmic dosing, that actually is a little bit different because when you think about rhythmic dosing or actually just think about a cycling female, their hormones are being produced. You basically ovulate right around day fourteen. Your estrogen peaks on day twelve. Your progesterone peaks on day twenty-one. Really, in a cycling female, you do not make progesterone until after ovulation. When you are doing a rhythmic style, it is completely different than doing a static dose.

Dr. Maki: Yeah, right. The whole point of the rhythmic dose is you are basically trying to recreate the classic twenty-eight-day cycle for a female, and a female cycle is broken up. If you looked at it, if you graphed it out, and these are all over the internet. They are probably even if you go to the gynecologist office, they probably have these charts on the wall where you see the changes over the course of that twenty-eight days and how the hormones are changing as a result. Like you said, you have a peak on day twelve, that is where your estrogen level is the highest. That is kind of the hallmark of the follicular phase. You ovulate right in the middle, day fourteen, day fifteen, that usually coincides with the peak of testosterone. Then, day twenty, day twenty-one, you have a peak of progesterone, that kind of hallmark’s the luteal phase. Now, granted, that is a lot of moving parts for a woman for her hormones to be changing. That is why the cycle gets, sometimes, that is why there are problems with the cycle because there are so many moving parts. Men still have their own rhythm but it is not quite so convoluted like the female cyclist.

Dr. Davidson: Like Dr. Maki said, in that rhythmic dosing of the female hormones, you really are recreating the same levels of hormones in your blood in your body that you would be as a twenty-eight year old female. If you think, that can be a lot of hormones, and some women do amazing on it. They love it. It is great where maybe there is another individual that is more sensitive or we do not necessarily want to do those levels of hormones, then doing a static dose where you can have a little bit lower levels so when you do test it, their blood work, their blood work is still showing kind of age-appropriate. You just have a little slight increase in the hormones to help with whatever symptoms, and anti-aging, and moving forward with their own personal goals.

Dr. Maki: Yeah. The real big distinction, like how do you decide between static dosing as the practitioner or is the patient, how do you decide between static dosing and rhythmic dosing, and the really big thing, if I mention, and I know you would do the same, if you mentioned rhythmic dosing to a woman and you say, “Well, if you have your uterus still, you are going to get a period,” the majority of women, they do not want to be in their fifties and start their period again. If that is the case, if they are not interested in having a period, then the static dosing is their option. Now, that will work, like you said, as long as that dosage stays relatively on the lower side or if they start having some bleeding trouble because they still have their uterus, in some ways, it might be necessary depending on their symptom level, it might be necessary for them to transition to rhythmic dosing depending on how they respond to the dosing.

Dr. Davidson: Yeah. Like you said, a lot of women are like, “What? I am going to get a period back? Been there, done that, do not want to do that again.” At the same time, when you are cycling the rhythmic dosing of hormones with that female, the period that they are going to get is going to be a nice period, not like, “Oh my gosh, I had horrendous periods back in my twenties. I do not want to go through that again.” You will not go through that again. We cycle the hormones in a nice dose that it should have been level to create just a moderate period, but again, not everybody wants to have a period.

Dr. Maki: Yeah, right. Like you said before on other podcasts, estrogen is a great hormone but sometimes it can be a little bit of a runaway freight train. If a woman was estrogen-dominant when she was thirty-five, when we are trying to recreate what the body does, you are not going to necessarily become estrogen-dominant all over again and have all of those symptoms. More than likely, it is going to kind of balance out. It is going to be a little bit of a smoother transition. There still will be some “PMS symptoms” with the rhythmic dosing as there sort of should be, but the severity of those symptoms, the seven to ten days before you start bleeding, the severity of those symptoms give us a little bit of feedback and some information that things might not be in balance and now all those estrogen, progesterone levels, or something else, the adrenals, need to be adjusted a little bit. That way, she is not having so many PMS symptoms in the middle of the month.

Dr. Davidson: That also comes to testing as well. You think [inaudible] menopausal, the ovaries have retired. They have left the building rightly so. They deserve it. When you are going to test somebody’s blood, you could test it any day because your dose is the same every single day in a static dose. In a rhythmic dose, you are actually recreating that cycle, that twenty-eight-day cycle, that if you are going to test, you have to do it usually around day twelve. You are going to test the estrogen. Around day twenty-one, if you are going to test the progesterone. You actually have to do a little bit of timing there.

Dr. Maki: Yeah, right.

Dr. Davidson: That is our dog. If you are hearing a little clunkiness in the background, he is chewing on a bone. He is stretching. He is laying down.

Dr. Maki: Yeah. He is usually good for the first few minutes and then he gets a little bit rambunctious. Now, he wants to go outside or do something. Hopefully, he does not make too much more noise. Hopefully, it is not…

Dr. Davidson: It does not bother you, sorry.

Dr. Maki: Yeah, it does not [inaudible] but we cannot do this without him. If we left him outside the room or something, he would not rest until he was able to lay at our feet. He is underfoot constantly. If anyone has ever had an Australian shepherd, I think they are all that way. I think it is kind of a breed specific thing. The period is the big distinction, right? In the static dose, and we do not want there to be any bleeding, right, that is what their oral progesterone is there to do is to inhibit the growth of the uterine lining, so that is where we prefer to use a bioidentical sustained release progesterone capsule. Usually, 100 milligrams or something like that. That is going to inhibit the growth of the uterine lining as they are taking the estrogen, and that is enough to usually control symptoms, get rid of the hot flashes, get rid of the night sweats, improve insomnia, and then some of those other kind of, the brain, the bones…

Dr. Davidson: Yeah, libido, sex drive. Remember, the estrogen is always a cream. I mean, some people do some estrogens as capsules but we really avoid that because progesterone is fine to go through the digestive system as a capsule as an oral. For the estrogens, we always use it as a cream because it is very hard when you take it orally. It burdens the liver. You do not really absorb it very well. Know that when they are doing a static dose, they are going to do a separate type of, whether it is a bias or an Estriol, I mean, now, we do not do any kind of Estriol, but usually, it is a combination of Estriol and Estradiol. That is usually going to be a cream, and then you take that progesterone at night, and you have your same dose every day.

Dr. Maki: Yeah, right. Like in menopause, a woman is no longer cycling so her hormones basically fall to a, they kind of flatline little bit. There is no more peaks. There is no more elevation. It is the same all month long, and all we are trying to really do in a static dosing is just raise the baseline. That is usually enough to control symptoms and make them feel better. That is what most women are looking for. Now, if we kind of wrap that up a little bit, and if they are okay with having a menstrual cycle, now, they do not have their uterus, then in some ways, it is kind of the best of both worlds, right? They get the higher levels of the hormones but they do not have to deal with the period even though having the period still gives us some good information. It is a landmark. It tells us that things are in balance because of how smooth that transition is. The day that the period shows up whether it is a twenty-eight-day protocol, if it shows up on day twenty, the levels need to be adjusted. If it shows up on day twenty-five, twenty-six, twenty-seven, twenty-eight, that is usually pretty normal. It gives you, the practitioner anyways, it gives a lot of information, the fact that a woman is having a period. From a safety perspective, the fact that there is a predictable period every so often, that is what makes it okay. Now, that is a part that I think in some way is probably the controversial part. A fifty or a sixty-year-old woman still having a period, that kind of freaks some people out. Why would you do that on purpose? Because she is having a period is what makes it okay.

Dr. Davidson: Yeah, because you are cycling the estrogen and progesterone like it would be when you are cycling when you are twenty-five years old, when you are thirty years old. Having that cycle where you would never use those levels of hormones statically in a female that is taking it every single day and you want to test those hormones, you want to do some type of labs to make sure you are assessing on both sides, we love to do labs. We love to get the objective data, as well as your subjective information as well. At the same time, you are testing, and checking, and making sure the levels are where they are supposed to be, that they are not too high, they are not too low. Both, whether it is static or rhythmic, as long as it is being monitored and you are testing and you are also conversing with the patient to make sure that it is right for them, I would not say there is a favorite either way.

Dr. Maki: Yeah, right. Yeah. As you stated earlier, it is really tailoring it to the woman and what she is looking to accomplish, what her goals are, what her symptoms are, what her lifestyle is, all those factors basically determine which style she is going to use or which philosophy, so to speak, she is going to use and then how she responds later because that is the thing. The first thing you realize with hormone replacement is that every woman is different. Some women need and can tolerate a lot of estrogen, some women are very sensitive and cannot tolerate very much; that also factors into. If a woman is very sensitive, rhythmic dosing is not the right thing for her. She is going to probably not feel very good and she might have some unwanted side effects from the rhythmic dosing because the Estradiol level is actually quite high around day twelve. That might just be too much for some woman’s systems where she would be more appropriate on the static dosing.

Dr. Davidson: Or maybe everybody is different. You have an extremely busy lifestyle. You are forgetting to put on your estrogen. You are forgetting what day you are at because life can be a little wild out there because it is. You have a calendar. You look at what day. “Am I on day twelve? This is how much estrogen I am going to put on today. Oh, I am on day twenty-one. This is how much estrogen I am going to put on and how much more progesterone I am going to put on.” There is a little bit of a factor of you have to look at your calendar and know what day it is. I do think with the females, it is a little bit more complicated so when you are getting started on that, we have to have some good communication. We have to have some appointments. We have to keep a log on how you are doing where the static dose is a little bit where you can set them up and they are pretty much ready to go.

Dr. Maki: Yeah, right. Yeah. There is a little bit more. I would not say the rhythmic dosing is necessarily more complicated, but because the dosing is a little bit higher, the first three months, if they have never been on hormones before, usually that is going to be the transition period as your body is acclimating to those higher levels, and the levels do get quite a bit higher than they do in the static dosing for good reason because we are trying to establish, like you said, restore the hormone levels of a woman that is in her thirties, maybe late twenties or early thirties. On a blood test, her estradiol level is going to go up quite high compared to the static dosing.

Dr. Davidson: Rightly so, us ladies are complicated but we are so worth it. Whether you are doing static or rhythmic, it does take a lot of communication there. Now, with the fellas, you guys are not quite so complicated. Doing the rhythmic dosing for the testosterone I think is awesome. That absolutely I think in some ways I would say, “I would rather do that than the static.” The static is fine, but if a fella can do the rhythmic, I think they get so much more out of it.

Dr. Maki: Yeah, totally. I am not a fan of injectable testosterone. Going into the clinic twice a month or once a week and getting a big injection of testosterone, men usually do pretty well the first three to six months on something like that. They feel really good, like almost too good, almost like superhuman good. They feel amazing. After that, because hormone replacement is all about maintaining a receptor function. We talked about that on some other episodes. When they get these huge amounts of hormone right off the bat, their body is not used to it. Eventually, those receptors down-regulate. Meaning, they disappear. If the receptors disappear and you keep providing that same kind of bolus of hormone, eventually the body stops responding to it as a way to kind of protect itself from being over stimulated for too long. Same thing with pellets. I know pellets were kind of popular for a while. They are still there around a little bit. You do not hear about them as much anymore, but I think that men do not usually do so well on the pellets. It is easy. You get them implanted. You do not have to do anything once they are in, but again, they feel really good in the beginning and then they never feel quite as good as they did the first insertion of those pellets.

Dr. Davidson: So true. Like you said, the receptors down-regulate and they always say, “I felt so great in the beginning. Why cannot I feel that way now?” or “Maybe I have to keep increasing up my dose?” They felt like in the beginning, with a man, when you are cycling their testosterone, because it is moving around, you are basically cycling because men cycle their testosterone just like us ladies cycle our estrogen and progesterone. Your testosterone is changing more on a two-week level rather than a twenty-eight-day cycle. Men are more fourteen days where females are twenty-eight days but you are still cycling your testosterone. If you are cycling it, when the levels go down, those receptors say, “Hey, where did that go?” The body will up-regulate the receptors and then you supersaturate those receptors with the testosterone and then they feel really good. You are basically not letting the body get adapted or habituated to the dose.

Dr. Maki: Yeah. You are maintaining that receptor function. You are keeping those receptors open. If those receptors stay open on a long-term basis, then you are going to receive the benefit of that hormone as opposed to those receptors “down-regulating” and disappear. Once they down-regulate but you are still giving that same dose or have to increase the dose, you are actually creating in some ways more receptor fatigue or you are forcing to down-regulate even more. That is why I see a lot of men that have gone through some of those other types of therapies and their numbers are just chronically low even with the rhythmic dosing. It is really difficult. They might feel better, but to get their numbers to come back on a blood test can be very challenging.

Dr. Davidson: It usually takes a few months for the fellows. The first month are okay, but by month three is when they say they feel really good and men do not have a uterus so cycling it, there is really no negative aspect like the females. We have to talk about, “Hey, listen, we are going to cycle your hormones, and you have a uterus. You are probably going to get a period back.” We have to have that conversation. With men, it is pretty easy.

Dr. Maki: Yeah, right. Now, the thing that I like about the males, I always say this to my patients, women anyways, that the woman’s cycle is based on the lunar calendar. Technically, if you were going to do the rhythmic dosing, you would start on day one of the lunar calendar, twenty-eight days, follow it through. If a woman is still having her cycle, usually she is going to get off of that schedule a little bit. We live indoors. We are not sleeping under the moon so we are not really controlled that much like we used to be. If you look at a male’s testosterone rhythm and you overlay that over the female cycle, a woman’s ovulation peak right around day fourteen, fifteen is right around where a male’s testosterone is going to peak. A female’s libido goes up, a male’s libido goes up and there is more likelihood for intercourse and conception. In some ways, women rule the world, right, and men follow even though men like to think that they rule the world but women actually control men without men even realizing it, which is such a woman thing to do. It is just kind of like the little trick that women actually do control things from a very biological kind of reproductive approach. That is why men follow women whether they like to believe that or not. It is definitely true. I know they have done some studies around college campuses and nightclubs and trying to determine ovulation rates and different things. It is all done by pheromones and all these things that we do not really understand necessarily all that well, but the rhythmic dosing is kind of part of that process.

Dr. Maki: My point of extrapolating there is the man’s dose over the course of the twenty-eight days, it starts out low in the beginning of the month, it peaks out in the middle of the month, and then it lowers back off. You have this nice rise and a fall. Every season, winter, spring, summer, fall, it is the lowest in the winter and it is highest in the fall. You have this built-in, annual cycling both on a monthly basis and an annual basis, which I think is just brilliant to do. Women do not necessarily have the annual cycling. Their dosing stays the same every month but there is different levels. You can start out at the basic level and then you could add on a certain number of lines depending on her symptom picture. The more severe her symptoms, the more lines you add on. Usually, a woman will kind of average, most women kind of average out on the higher end. They do not usually stay in the basic. They usually end up somewhere towards the higher end of the dosing range.

Dr. Davidson: Yeah, because with the rhythmic dosing, just like with static, you can adjust the dose to fit that individual. What Dr. Maki was mentioning which is really cool is when you have a male-female couple come in and they want to do the bioidentical hormone replacement, putting them both on the rhythmic dosing, having them coincide their cycles together, it is just really beautiful the way that falls in line.

Dr. Maki: Yeah, right. You would start the woman on whatever her cycle is, whatever her pattern is, then the man’s cycle would mimic hers. Just like I said a few minutes ago, women control the world. She starts off that rhythm especially if she starts menstruating again, and now, you overlay his schedule on top of hers as opposed to them just doing kind of two random, now granted, that happens sometimes. Usually, you and I will see the wives first and the husbands will come in later. It may be a little bit harder to do that, but again, they both start on day one or whatever her schedule is, then the husband would start at the same time. Now, for the most part, they are kind of blended together at least hormonally from a certain standpoint.

Dr. Davidson: Yeah, no. I think it is really neat.

Dr. Maki: Yeah, yeah. From an anti-aging perspective, again, that is where some of the pushback comes from. For men, the more testosterone they have within reason, the better they are going to feel. The more they feel like themselves. They are going to have a better mood. They are not going to be grumpy. They are not going to be depressed. They are going to have more muscle mass. They are going to have less body fat. They are going to decrease age-related disease like diabetes, heart disease, cancer, dementia. The risk of all those things goes down by maintaining good testosterone levels. Same thing for a woman. Estrogen is what makes a woman a woman. It is not about having too much. It is about one finding, as the practitioners, about finding the right dose and making sure that she has enough. Most of the time, there is this in some ways kind of fear around estrogen that “Oh, you cannot give them too much. It could be dangerous.” We do not really believe in that at all. The female hormones are never dangerous by themselves. It is really more about making sure that she has enough estrogen so her brain, her body, everything works the way that she wants it to instead of being a little bit too conservative and giving her a very low dose of hormones, which really does not help her get to where she wants to go.

Dr. Davidson: Exactly. On a side note with the men and testosterone is taking testosterone, whether you are doing any kind of form, pellets, injections, creams, whatnot, that is going to lower a man’s sperm count. Now, for most of the couples that come in together, they are just fine with that because that is not an issue, but some men, they may want to have a baby or something, so then we usually just have them stop their rhythmic dosing testosterone so that that can get their sperm count to come up, and then they can procreate and all that jazz. Now, that is not a form of birth control because as Dr. Maki will tell you is there has been plenty of couples that have gotten pregnant with a man being on testosterone rhythmic dosing.

Dr. Maki: Yeah. Technically, when a man supplements with testosterone of any sort, you basically are shooting blanks at that point. You are not going to be able to conceive but as I stated, it has happened a couple of times and in a couple of cases. It was where they had really a lot of difficulty with their previous child, maybe it was a few years before. They had a really hard time. I can think of a couple of cases where they had a really hard time with fertility, put the husband on, worked on the wife first, the husband came in later, months later, put him on the Wily protocol or the rhythmic dosing, Wily protocol for men. Within six months, the wife was pregnant and they could not believe on how easy it was even though they had so much trouble before. Technically, it is not supposed to happen, but it does happen.

Dr. Davidson: Anything can happen, and there is probably a lot of different reasons behind that.

Dr. Maki: Yeah. Like I said, this is where it gets confusing. This is where it gets complicated because there are so many different options, but the wonderful part is that you can use all these different options to specifically find something that works directly for that particular person. As like you said earlier, you got three different dosing options. You got to pick one of the three for every patient that comes in. That is just so, I don’t even know, so archaic and so outdated when there is all these other possibilities that can really make people feel better, and not just feel better in the short-term as we talked about because when do people’s risk of age-related disease start to increase when all the hormones are gone? When men are in andropause and women are in menopause, all the risks for all those diseases we talked about, diabetes, heart disease, cancer, Alzheimer’s, that all goes up when the hormones disappear. If we can prolong those hormones to be around for a little bit longer, then we are not only making people feel better in the moment but we are also preventing disease in the future which I think is the best of both worlds.

Dr. Davidson: Exactly.

Dr. Maki: I talked to patients about this too. When I was a little boy, fifty-five was considered a senior citizen. I mean, I think AARP, it still might be fifty-five where you are eligible or something, I don’t know, but sixty-five was considered to be an elderly person when we were both little. Now, we have patients that are sixties and seventies and they are still moving strong and…

Dr. Davidson: They run in circles.

Dr. Maki: Yeah. They are running companies. They are running households. They are doing so many things that even a couple of one generation ago when we were little, that really was not really heard of. People’s quality of life is definitely I would say almost ten to twenty years different than it used to be when we were little back in the ’70s and ’80s.

Dr. Davidson: Exactly. People whether they are, like you said, running companies or they are retiring, they want to feel good. They want to have energy. They want to have a good weight. They want to have a good libido, not feel like they are getting arthritis or bone-density issues or cancer. We are not saying that this is some kind of treatment or prevention, disclaimer, disclaimer, but like Dr. Maki said is when those age-related, they call him age-related diseases. Are they really age-related or is it just a fact of the hormones declining?

Dr. Maki: Yeah, right. This is unfortunate. In medicine, they don’t really put a lot even though this declining hormone levels, which is very well documented, everyone knows it happens, but that is where the hormone replacement in a conventional setting, it does not really get discussed very often. Honestly, I mean, some doctors nowadays are testing men’s testosterone, but if a woman’s in menopausal, they will not even bother testing your hormones. Granted, testing your hormones which is in menopause does not really do much unless she is on hormones because her numbers are going to be, it always say less than thirty. It might be in the single digits. She is not going to be producing any estradiol so you can assume if she is not having a period where her hormones are but you put on hormones, then you test her levels and you can see the difference, and then of course you get the subjective on how different she feels. We have seen some amazing transformations. People come back and tell us. They are like, “I feel like myself again. My mind works. My body is cooperating. I got a sex life back with my husband. All these things happened because of the hormones. How can that be a bad thing and how is it not an important part of that aging population?”

Dr. Davidson: Nowadays, their doctor might not be here this all the time. My doctor said, “Oh, I am just getting older. That is why I gained weight or that is why I feel this way or this is just normal. I have to deal with it.” Nobody needs to do that anymore. That is not an appropriate discussion to say, “Oh, you are just older. You just have to deal with it.” That just does not run right now. Now, it is like, “Hey, what can we do to help with longevity, to help be safe about it at the same time, and then help people feel better?”

Dr. Maki: Yeah, right. In the twenty-first century, just attributing everything to the aging process just like we talked about, people want to be active. Of course, everyone wants to live as long as they can for the most part, but it is really about the quality, not the quantity. I think everybody across the board would agree instead of living thirty years with some kind of chronic condition that minimizes your quality of life, we want to want to go full [inaudible] as long as possible. I think that we can accomplish that in the twenty-first century. That is what we all should be striving for. Practitioners should be striving for that across the board as well is not just being disease-free but thriving in the advanced years and minimizing some of those things that really tend to slow people down. I think people can understand we are a little passionate about it because we see the benefits that it provides people on a regular basis.

Dr. Davidson: Exactly. No, benefits, my goodness. More than that. Granted, what am I? I am forty-seven. You are forty-six. Like you said, a generation before us, you cannot treat it the same. It is 2020. It is 2020. Things have got to change.

Dr. Maki: Yeah, right. We talked a lot about static dosing, that is still the more common option when it comes to hormone replacement.

Dr. Davidson: It is still very good. It is very good. It just depends on the person.

Dr. Maki: Yeah, right. The rhythmic dosing is a little bit more controversial. It has some some pros and cons on both sides. We like it for men. I think it is the best way to go. Personally, it is the only way that I do testosterone for men is the rhythmic dosing. I do not even mess around with any other ones. I do not really encourage the static dosing. It is where you do testosterone cream. Men cannot do anything orally when it comes to testosterone. The doses are too high and it can cause some problems with the liver. Static dosing, let us say a five day on, two day off kind of rotation. You can not take it every day because men will have some testicular atrophy and it is just not a good way to do it. I like to do the rhythmic dosing for men exclusively. For women, they have a lot more options. Hopefully, this gives some insight. Hopefully, this answers some questions. Maybe if you have more, just let us know and we can do another kind of round of this of a little bit of a deeper overview or some of the more finer points.

Dr. Davidson: Oh, yeah. We love everybody’s comments, questions. I know we talked a lot here a lot. A lot of you might not have even heard of rhythmic dosing because it is really not that common. A lot of practitioners do not do it. If you have any questions or concerns, please reach out. Email us anytime.

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

Dr. Davidson: Oh, I am Dr. Davidson.

Dr. Maki: Take care. Bye-bye.

The post How To Cycle Bioidentical Hormones? | PYHP 091 appeared first on .

Can You Take Progesterone With An IUD? | PYHP 090

Dr Valorie Davidson and Dr Robert Maki — Fri, 22 May 2020 18:36:48 +0000

Jennifer’s Question:

Hi there! Thank you for this forum! My sister is using the Mirena. I would like to recommend she starts BHRT as she is 49 and has perimenopause symptoms. Is she able to take Prometrium and stay on the Mirena? Thank you in advance

Short Answer:

The Mirena IUD contains 52 mg of levonorgestrel, which is a synthetic form of progesterone. This is often recommended for women in their mid to late 40’s to control some of the symptoms of perimenopause. The IUD is fine for pregnancy prevention, but we don’t agree with women in perimenopause given birth control to control their symptoms. There are better BHRT options for managing perimenopause symptoms. However, depending on the woman and her symptoms, she could take progesterone with an IUD. We recommend bioidentical sustained-release progesterone, but not Prometrium. There are more dosing options with bioidentical progesterone and the sustained-release form seems to be better tolerated than the instant-release Prometrium.

PYHP 090 Full Transcript:

Download PYHP 090 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 good morning. How are you doing today?

Dr. Davidson: I’m doing great. I’m doing fantastic. How are you doing?

Dr. Maki: I’m doing fine.

Dr. Maki: We have a question. This actually comes up quite often talking about different types of contraception. Although this one isn’t exactly about contraception. But we’re going to talk about the Merina. just a little bit. Anyways, why don’t you go ahead? This is from Jennifer which is pertaining to I believe her sister, which is kind of like an indirect sort of thing, but she wants to encourage her sister and to be HRT, but her sister wants to use the Mirena.

Dr. Davidson: Which yeah, it sounds like she is using it. It says, so this is from Jennifer she says “thank you for this forum. Hi there.” You’re very welcome. We love it when we get compliments. So Jennifer says, “my sister is using the Merina, I would like to recommend she starts BHRT, bioidentical hormone replacement therapy as she is 49 years old and has perimenopause symptoms. Is she able to take Prometrium and stay on the Merina? Thank you in advance.” So this is actually a question or somewhat a little bit of a roundabout question that we get all the time because since you know the introduction of the IUD, which is from gazillion years ago with Cleopatra, but now they have hormonal IUDs as opposed to the copper IUDs, and they’ve been around for a long time. But a lot of people ask well, you know my hormones are awry, things are off, I’m in my 40s, I don’t want to take birth control pills when you’re in your 40s is an IUD a good idea and is that going to eliminate all my symptoms, and I’m going to you know feel like I was you know fresh and 18 again.

Dr. Maki: Yeah, I think that is a very common gynecological option, right. Because you know as we’ve talked about before on other episodes they don’t really have lots of options. The fact that she’s 49 on an IUD, I just find that fundamentally just not right. Now from a contraception perspective you and I are not necessarily big fans of birth control. The IUD isn’t really a bad option, even though when it comes to all birth control, none of them are good options. But if you’re trying to prevent pregnancy, you know, the Mirena, some of the IUDs, there’s a few other ones that we came across the Kyleena, the Skyla and the Mirena, they’re all different dosages of the progestin that’s in there.

Dr. Davidson: Yeah, and I have a lot of patients on you know IUD way back when it be, you know, the copper was kind of popular. But I would say if you’re going to do an IUD, I do think the hormonal option is in some ways a little easier to deal with than done some ways. I would say better. The Kyleena and the Skyla, I have a few patients on those they’re you know, they’re fairly new because they have a lower amount of hormones that are secreted from the IUD as opposed to the Mirena. But when you think of, you know women in their 40s like, Dr. Maki said, you know birth control pills my gosh, you know, that’s probably not a really the best option. Especially looking at family and personal history for taking those kinds of hormones, birth control pills, but with an IUD there is, you know hormones that are released from it, but there’s not as much as taking, you know, the hormone systemically or orally and at the same time. You know, we talked about perimenopause all the time, you know, when you hit your mid-40s you know we’re pretty much you know, I’m there too, you know one of the biggest side effects of perimenopause is heavy bleeding, or irregular bleeding, or chronic spotting, and when you look at a female that’s had at maybe a hysterectomy or an ablation where they blunt down or remove the inner lining of the uterine wall to prevent such heavy periods. That’s usually happening to a female in their 40s because of that hormonal change that happens before, you know in perimenopause. So I don’t think you know, I think having the hormonal IUD would thin down the lining of the uterus to help somebody with very heavy periods. But it’s not going to help a lot with the other symptoms of perimenopause that we’ve talked about, you know, sex drive, sometimes the night sweats, you know definitely the irritability, irritability, irritability, irritability.

Dr. Maki: That’s the big one. That’s the one that everyone feels like they’re just frustrated in their fine one minute and they go into a fit of rage the next and they don’t really understand why I like they just can’t tolerate some of the things they used to be able to tolerate. Whether it’s you know family stuff, for work stuff, or all the above their threshold for different stressors has diminished significantly.

Dr. Davidson: And then of course another probably main common symptom in perimenopause is the inability to stay asleep all night. You wake up, either you wake up many times for the night, or you wake up in the middle of the night for you know an hour and a half two hours and you can’t get back to sleep and of course, by the time you are able to get back to sleep it’s time to wake up for the morning. But I do think the, you know, in terms of birth control, you know, in the 40s an IUD is a great option for the birth control in terms of all the different types of birth control out there and if they’re having some irregular periods.

Dr. Maki: Yeah, right. I think there’s a lot better options for a 49-year-old to deal with her symptoms and to put, you know to give her an IUD. And there is a little bit of a limitation when a woman does have an IUD because of that, you know, the progestin part it does you know, I mean, you could obviously give her some bioidentical progesterone on top of that. Maybe it would be a little easier or better if it was one of the lower IUDs, the Kyleena or the Skyla, but if you really had to. Now granted it is inserted, of course, that hormone that is on, that is contained within the IUD is going to degrade over time and that hormone that’s there, you know, this is where the research and development of those types of devices are you know kind of you know paramount that’s where they’re the intellectual property so to speak of that IUD device and that degrading hormone, you know. How long would you say that hormone is viable for when a woman has an IUD inserted?

Dr. Davidson: Each IUD is different, you know, it used to be 5 years now., they have ones that are 10 years, the ones with the lower hormones like the Kyleena and especially the Skyla’s going to run a little bit shorter to have that, you know due to removed and you don’t know how many women I’m sure you too that I talked to him like, oh, yeah, you have your IUD and of course it was time to, you know to switch it out like, you know a year ago, or six months ago, or I need to have you know because best-laid plans even though they last for a long time. We never seem to follow through right away. So but I do like the fact that you can have that in there for a number of years and then have that, you know have it removed or even I have had several women too that had the IUD and they hated it. You know, they just hated it and then you go back in you have a removed. You know hey, it’s a procedure, procedures aren’t fun as we all know, but you know, you can still do it and it’s pretty you know innocuous and you know, not that invasive to have it removed if hate it.

Dr. Maki: Yeah. Sure. Yeah, and I think that we probably end up seeing, now we, I think we have a balance of both. You know, we have a balance of ones that did not respond well and there’s ones that seem to do just fine on it. You know, I still don’t like the fact that it’s promoting an IUD for 49-year-old. I think that there’s a lot better options mainly just some progesterone, right. Just some you know, like the sister, must be doing some of her own. Now that’s always kind of challenging to encourage family members to do certain things. Hey, you should do this, you should do this. That’s in some ways for the sister to figure out on her own but that’s you know that’s between the two of them. But she’s must have had this the one writing the question, Jennifer. She must have had her own positive experience with, about identical hormones. She wants to share that with her sister and I would somewhat agree. I think that there’s a lot of things that can be done better and differently than using the IUD as an option. If you’re looking for birth control. Okay, fine, you know, there’s the lesser of several evils when it comes to birth control. There’s nothing that’s perfect. Everything. Whether it’s an oral birth control pill, or you know, an IUD there’s going to be some issues on some level. I mean, would you agree? Do you have anything else to say about that?

Dr. Davidson: You know, I would say, you know, I have a just like, you know Jennifer asks about her sister if she can take Prometrium and stay on the Mirena, which is fine in some regard. So Prometrium is a, I guess a commercially available prescription for progesterone. It’s instant release, there’s only you know two real doses a hundred milligrams and 200 milligrams. And in one thing that you do find just with women, you know us, women, in our mid-40s, mid to late 40s is our progesterone is low and I have a lot of women that have an IUD and I have them on progesterone because it helps with the sleep, it helps balance out the moods, the moods in the sleep, you know, and it helps a little bit with some of the weight gain and all that jazz that happens with the wonderful things of perimenopause. But I do think, you know, her sister could, Promethium isn’t my first choice because I find a hundred milligrams can sometimes of the instant release can be too strong. It’s too much hormone on top of hormones and people just feel puffy and munchy, and heavy, and kind of like lethargic, we’re doing the sustained-release or even doing a lower. I usually do a lower dose of a bioidentical micronized progesterone. And they seemed, and that seems to balance well. So wouldn’t you agree?

Dr. Maki: Yeah, like you said the Mirena like 52 milligrams of a progestin plus the hundred milligrams Prometrium. That’s a lot. So by using bioidentical progesterone, you can change that dose to whatever you want 50, 75 you know, even 25, if you needed to. You can always titrate, you can always move around you can’t really do that with the commercial types because there’s so few options available. And if they already have the like I say, if they already have the IUD with the hormone there, you’re just trying to compliment that in the gentlest way possible not trying to jam in a bunch more hormone. That you know, she might make her feel worse, you know, on top of that. So and you know, like I say the IUD is going to control some symptoms, some of the bleeding, and the spotting, and some of those things maybe some of the cramping. But it is not going to take care of the other perimenopausal symptoms that are just as prevalent, and that the IUD isn’t really going to have an effect on.

Dr. Davidson: Yeah, but get to answer, you know your question, Jennifer. I would say the Prometrium, you’d want to you know, probably do some testing on your sister being on it, to make sure that progesterone isn’t like through the roof and of course seeing how she’s feeling. I wouldn’t say it wouldn’t be necessarily like I said, you know, I just think it might be a little bit too strong, but for sure when your sister or anybody that IUDs got to come out and maybe you don’t need the IUD for birth control anymore. They always, I always find that we have to do some higher level of progesterone with those women when those IUDs come out because they have this progesterone dive or if they are trying to get their ovaries to kind of re-function, maybe they got their IUD out and you know, they’re thinking about pregnancy. You know, maybe they had an idea in their 30s and they’re thinking about pregnancy and they get that IUD out. They always have a crash in that progesterone. So that’s why definitely doing maybe a higher level of progesterone when she has an IUD out would make her feel so much better.

Dr. Maki: Yeah, right. Yeah kind of after the fact and try to re-encourage and you know when it comes to fertility and pregnancy, progesterone, and even thyroid as well. We never really talked much about thyroid but certainly, progesterone is critically important in that process and you’re right. When using a, for a woman that is younger than 49, by the time a woman is 49 her progesterone production. She’s no longer ovulating which is where the progesterone comes from.

Dr. Davidson: More than likely, but you certainly don’t want to like hang your hat on that.

Dr. Maki: Yeah, she could be one of those rare exceptions, but you know statistically she’s not going to be necessarily ovulating and that’s where the drop in progesterone comes from. And then of course, that’s when all the perimenopausal symptoms show up. So yeah, definitely, you know, I think that you know, the sister is making some, Jennifer’s making some good suggestion for the sister. Whether she’ll listen or not and you and I, just kind of fundamentally like I said have some issues with that because we think there’s a lot better options that can be utilized.

Dr. Davidson: And I like this question and I have a sister and I tell her what to do all the time much to her dismay, but there’s love there, right?

Dr. Maki: Yeah. Yeah. She doesn’t. No, she listens sometimes, she listens, she listens sometimes. Yeah. So, I think that one covers this one, this Merina issue comes up a lot, right? Because this is a very common issue, no, a common concern of women of all the different decades. Because you know, it’s when we say that is being pushed. But you know, like I said from a gynecological perspective, there’s limited options and women are looking for solutions to their issues and they kind of end up coming towards us kind of in the roundabout direction sometimes. But hey, you know what? Like you say we have plenty of women that do just as they do fine, they do better on the marina than they did without it. Then you know, that was the right treatment. But then like you said earlier too, you have had plenty women that just, you know, they can’t stand it and they have to get it taken out early, you know, or they have some kind of complication which to be honest I’d say that doesn’t happen as much as it is much as you think that it would. So, do you have anything else to add about Jennifer or Jennifer’s sister or is this one good.

Dr. Davidson: No, this was great and I’m sure other people have questions about IUDs because this comes up all the time and we’ll probably see because it is a little bit of a trend that you see in and you know with doctors and gynecology is doing IUDs with hormones on top of them. You just have to you know, test for it make sure it’s individualized and that it’s not, you know too much.

Dr. Maki: Right, right, right. And it all comes down about the parties, the individualization is really the key because you could have 10 women that are having similar symptoms, or similar diagnosis, or similar situations. But all 10 of them might have a different, at least from our perspective anyway might have a different treatment, or a different treatment plan. There might be some similarities, or some tendencies that we, you know, lean towards, you know throughout. But there’s going to be subtle differences sometimes significant differences from one case to the next and that’s like I said before too that’s also the good part but also the hard part. You know, how are you able to collectively help everybody you know in a seamless fashion like that. That’s why conventionally you know there’s just limited options and people kind of fall through the cracks of that all the time.

Dr. Davidson: But I do like that she’s you know she’s asking that question for her sister. Which is so sweet but yeah hopefully this makes sense to everyone. And if you have any questions or concerns just reach out and absolutely all you listeners, we appreciate you listening. And everybody that’s reading our blogs and articles, we thank you so much.

Dr. Maki: Until next time, I’m Dr. Maki.

Dr. Davidson: I’m Dr. Davidson,

Dr. Maki: Take care, bye.

The post Can You Take Progesterone With An IUD? | PYHP 090 appeared first on .

Does Progesterone Help You Sleep? | PYHP 089

Dr Valorie Davidson and Dr Robert Maki — Thu, 21 May 2020 19:19:38 +0000

Laura’s Question:

Dear. Dr. Maki, I read your article about progesterone cream versus oral format. I have used the cream with some satisfaction but not one hundred percent happy. My sleep has been my main complaint for the last six to eight months. I’m 44 years old, still menstruating with a lot of menopausal symptoms. Recently, I found a doctor in the Netherlands who did blood tests on me. She put me on oral progesterone and transdermal testosterone. The testosterone seems a little too high, one percent, but overall helped me a lot. Four weeks into my treatment, the oral progesterone, on the other hand, is driving me crazy! So, shortly after I take it, I feel a bit sleepy and then around two AM, full wide awake. Today, I took it during the day and I still can’t fall asleep in the evening. It seems like I’m converting it into cortisol, the progesterone. Any thoughts about what to do? Thanks very much.

Short Answer:

The first question to ask is if the progesterone is sustained release or is it Prometrium. Sustained-release progesterone is often much more tolerated than Prometrium, which is instant-release. The next consideration of the progesterone is the dose. A typical dose for women in there mid ’40s is 100 mg. However, this could be too much for some. Reducing the dose down to 75 or even 50 mg might be helpful.

PYHP 089 Full Transcript:

Download PYHP 089 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: How you doing this morning?

Dr. Davidson: I’m doing great! How are you doing on this beautiful, sunny, blue-sky day?

Dr. Maki: It is. It was actually raining like crazy overnight in Washington. It’s pretty common this time of year but woke up and looks like it’s going to be a really nice day today. So, be nice to be outside, which will probably go outside a little bit later but yeah time to get a podcast done. So, why don’t we kind of dive into that? We have a question from Laura.

Dr. Davidson: Yes, Laura. So Laura is a reader. So she had read one of our blog posts about progesterone cream versus the oral. So this is her question, “Dear. Dr. Maki, I read your article about progesterone cream versus oral format. I have used the cream with some satisfaction but not one hundred percent happy. My sleep has been my main complaint for the last six to eight months. I’m 44 years old, still menstruating with a lot of menopausal symptoms. Recently, I found a doctor in the Netherlands who did blood tests on me. She put me on oral progesterone and transdermal testosterone. The testosterone seems a little too high, one percent, but overall helped me a lot. Four weeks into my treatment, the oral progesterone, on the other hand, is driving me crazy! So, shortly after I take it, I feel a bit sleepy and then around two AM, full wide awake. Today, I took it during the day and I still can’t fall asleep in the evening. It seems like I’m converting it into cortisol, the progesterone. Any thoughts about what to do? Thanks very much.

Dr. Maki: Again, she sounds waking up at two o’clock. She sounds like she’s a ghost at least to a certain extent, right? So, we wrote, actually wrote an article. We did a podcast about the three different types of adrenal issues. The vampire, the ghost, and the zombie. That waking up in the middle of the night. What are your thoughts? What do you think about, the progesterone, and wake me up at two o’clock?

Dr. Davidson: And you’re going to go there we have to explain what the what are vampire, the ghost, and the zombie are. So that was an article that we wrote on adrenal fatigue on the cortisol levels that get secreted out throughout twenty-hour period.

Dr. Maki: Yeah, episode Sixty-Nine.

Dr. Davidson: Episode, sixty-nine and so with the ghost as you say, the ghost is the cortisol is bouncing up in the middle of the night. When ideally cortisol should be down in the evening so we sleep all night and then wake up in the morning with the cortisol high in the morning, so we’re bright-eyed bushy-tailed. But the ghost, the cortisol is coming up in the middle of the night which is why Laura’s asking is my progesterone converting into cortisol which is why she’s waking up full awake at two in the morning. We also have on that episode sixty-nine is the vampire,` where their cortisol doesn’t come up in the morning. Those are the people that can’t wake up in the morning, but their cortisol comes up in the evening so they stay up late at night. And then there’s the poor zombie, who has very little cortisol throughout the twenty hours period and they’re just literally a zombie twenty-four, seven.

Dr. Maki: Yeah, right. They could sleep all the time, they have no energy, they can exercise, they know they’re the zombies for sure, are struggling a little bit. You just to do some basic functions. I think some people might have some of those tendencies but it’s pretty rare to see an actual, zombie profile. The other two, the vampires and the ghosts, those are really common. Those are the ones we see most of the time.

Dr. Davidson: And I think with Laura, she’s definitely a ghost. She’s waking up in the middle of the night and said roaming the halls. She’s probably roaming her smart phone until she can get tired enough to fall back asleep. But definitely with Laura, she’s saying that she’s 44 years old, she’s still menstruating so she’s still getting her period but she’s having a lot of menopausal symptoms. So, she definitely sounds like a classic case of actually being, I don’t, you know potato-potato. But definitely, she’s more peri-menopause. I wouldn’t put her into menopause but she’s definitely that peri- that phase right before the ovaries definitely stop making the hormones.

Dr. Maki: Yeah, right. And she’s exhibiting one of those very classic symptoms. They get to their early to mid-forties and all sudden, they just at least what they relate to us, anyway, are to me is that they’re just having their bodies, just won’t cooperate anymore. All of a sudden they can’t sleep, they’re gaining weight, they’re, irritable all the time, these very classic peri-menopausal symptoms that show up kind of right around this time in a woman’s life.

Dr. Davidson: Exactly and I love that. We’re here, in the United States. So, it’s nice that having a podcast, having these blogs, having, the website that people from all over the world can reach out to us and so this is this is why we are really excited to do this question because she’s reaching out from, well, outside of our domain.

Dr. Maki: Yes, sure. Yeah. I know that we’ve had some other people reach out from other countries and that is pretty neat. It does make the world a smaller place that way. She’s in a completely different country, but we’re able to help and now we’re answering her question. Hopefully, we’ll give her some guidance and she’ll be able to make some better decisions moving forward.

Dr. Davidson: And that’s why we really liked Laura’s question is because she represents a lot of women like we had talked about. She is peri-menopause, she’s 44 years old, she’s still menstruating but she having a lot of symptoms and one of the main symptoms being in peri-menopause is waking up in the middle of the night. I love that her doctor in the Netherlands did some type of testing on her hormones because a lot of Doc’s don’t do testing on the hormones. In fact they kind of blow off anything that has to do hormonally. Because hormones aren’t necessarily, “disease.” So I love that they tested her hormones and then trying to find an individualized protocol for her, but that’s the fun part in doing Bio-identical Hormone Replacement, is it’s not like the first try always gets it, you’re always, sort of evolving or morphing or changing their prescription so it fits that particular individual.

Dr. Maki: Yeah, right and that’s the challenge both for the practitioner or practitioners. In this country and other countries and for the patient is because when you’re dealing with some of these hormonal issues, there’s not just one pill that’s going to solve the problem. That’s where it becomes a big challenge. Because and I think like you said doctors they don’t test the hormones because they’re not sure what to do with it. And really the only option they have for a woman that still menstruating is given them birth control pills or some other kind of a commercially available prescription but a lot of times it’s more complicated or it’s more convoluted than just giving them a pill and sing them on their way. That’s why women are continuing to look for answers and to find the relief that they want because it’s just not as simple as taking a pill on your own and your symptoms are all gone.

Dr. Davidson: Oh, exactly. I mean here in Laura’s case, one of her main complaints is that she’s not getting a good night’s sleep. She’s waking up after a few hours like our typical ghost. But the last thing she wants to do is get on some prescription medications for sleeping. Like, Ambien, or some of those really har, even just an over-the-counter Unisom or Benadryl ends up being habit-forming it’s not great for our memory long-term, that those are just band-aids that I love the fact that they’re looking into what is the cause which is the hormones.

Dr. Maki: Yeah, right. I mean sleeping, sleeping is a completely hormone-related phenomenon, right? It’s just something I don’t know if that’s the right term.

Dr. Davidson: Phenomenon. I like it.

Dr. Maki: Yeah, right. I mean it’s just a natural thing, right? As the sun sets the light the light disappears. Our other sleep-related hormones Melatonin, Serotonin, all these things go up and it’s this process that is innate within human beings at least a light-dark cycle that we have were not necessarily nocturnal unless you’re a vampire. But for something that so important to us as time goes on it becomes harder and harder to be able to get a good night’s rest. And with all of our patients that something and even on those podcasts we’ve talked about these sleep issues a lot because it’s the in some ways the foundational step like it has to be dealt with. Because if the sleep is left to be you know, if you’re not focusing on the sleep or you’re not improving the sleep then everything else still falls off that they still keep gaining weight, they’re still irritable, they’re still tired. It really just starts to detract from, their quality of life and if it’s left unabated for too long, now that can lead like to seriously lead to some age-related disease down the road. So even though it doesn’t thrill pre-menopause like you say all the time. It’s this limbo-land of hormones that doesn’t really get addressed for women. But if you don’t do anything about some of these things that are relatively, I wouldn’t say simple and minor, but they’re just a sign of dysfunction. They’re not full-blown disease yet. That’s where things get a little gray. No one roles really know how to deal with them collectively. Like you now, like you say insomnia there’s a pill for that. Okay, fine, but like you say, there are some side effects that you have to kind of weigh the cost-benefit is that worth it or not? Is that the direction that somebody wants to go. A lot of times it’s not and especially with the people that are asking these questions. They don’t feel comfortable doing those kinds of things.

Dr. Davidson: I agree. So I would definitely say for Laura her question is, she’s wondering if the progesterone, the oral capsule progesterone that she’s taking is converting into cortisol, and I really don’t think that’s the case. I do think that her cortisol is spiking in the middle of the night which is why she’s waking up at two in the morning wide awake. But I don’t think it’s necessarily a byproduct of that oral progesterone. If anything progesterone does help bring down cortisol levels. Now, like I always say everyone’s unique and different, and there are different experiences, and different environmental influences that can happen. But really, I would say probably more so is that she might be on instant release progesterone. Which is very common, even commercially it’s very common as a bioidentical instant release, so when you take it instantly goes into your system so sure you’re going to get a little sleepy and tired but because it’s so instant it comes out of your system fairly quickly when you’re doing it as an oral form. So it could be by two in the morning, four hours later five hours later. It’s just not in her system anymore and then her cortisol is bouncing back up.

Dr. Maki: Yeah right, sure. It could be related to, like I say they form of the progesterone or it could just be the fact that this is how her body is manifesting this transition. As we’ve talked about before about perimenopause as that progesterone is dropping. she says she still menstruating so we know that there’s this without even doing any blood work. We just know because where she is in her life and the fact that she’s still having a regular period that her estrogen level is still sufficient for her to still be menstruating. But we can assume that her progesterone levels are fairly deficient. Now, when you look at the different sex hormones, they are all they’re all categorized as steroids because they’re made from cholesterol. When you look at the cascade of all the different hormones. You have testosterone and estrogen on one side and then progesterone and cortisol on the other, testosterone and estrogen are very similar in molecular structure, cortisol, and progesterone are very similar in chemical structure. Testosterone and estrogen certainly convert back and forth. When you give a womb progesterone, it’s really intended really to give their adrenal glands a break because they have the stress and just the everyday living type of thing, but it like you say it’s meant to kind of, you know, it’s meant to buffer those adrenals as opposed to igniting the adrenals.

Dr. Davidson: Exactly. So I would say, going back to that progesterone as I do like the oral capsules for a female in her 40s because it just really helps with the mood and the irritability it helps with those heavier periods that she might be having every month because of the drop in progesterone. So I do think to maybe talking to her practitioner about switching it to a sustained release. Sustained release and I’ll tell women, don’t take the progesterone after dinner or when you’re brushing your teeth are getting ready for bed. Take it right before bed. Not before you going to watch TV. If I’m going to go to bed at ten o’clock and turn off the lights at ten o’clock take it at ten o’clock that way with that sustained release. It has the longevity to stay in your system all night, and then, by relaxing the adrenals keeping that cortisol down and then in the come morning time when that cortisol should be coming up, it’s six in the morning. It’s going to bounce back up. That’s what I would suggest for Laura.

Dr. Maki: Yeah, right. Yeah, that way, she’s getting the benefit of that sustained release for the entire night. Now granted there are some other supplementation things that can be done and honestly progesterone by itself in a situation like this isn’t always going to solve the problem. We usually have to focus on some lifestyle things and then as I mentioned the supplementation things that are nice adjuncts to the progesterone and now the night’s sleep waking up at two AM. if she wakes up at two AM but she’s able to just roll back over and reposition and go back to sleep, I think that’s reasonable. I don’t think she says in the question that she’s up to how long she’s awake for.

Dr. Davidson: She says she’s fully awake.

Dr. Maki: Yeah, yeah. So more than likely, she’s probably two in the morning and she’s staring at the ceiling, she’d probably awake for an hour or longer. But if she’s only awake for a short amount of time, that might be the best-case scenario. So she gets a nice chunk of sleep, she wakes up and then she gets another nice chunk of sleep, but the amount of time that she’s awake is very short. I think that the likelihood of her being able to sleep a full eight hours through, for anybody that we deal with I think is in a lot of cases sometimes unrealistic. But if they’re able to get a nice big chunk of sleep, wake up, and then another nice big chunk of sleep preferably with no restroom, need to go to the restroom, but she’s just like I said able to reposition that’s a success. I think that her sleep would be much improved if that was the case.

Dr. Davidson: You’re right. And you’re right about to know like I said when looking into that progesterone as a sustained release instead of instant. But you’re so right, granted this is not medical advice. It’s meant for education. Blah blah, a disclaimer. But looking at some other aspects like you would mention the supplementation. There are lots of really nice supplements. You can take to help bring down cortisol to stay down without being a sleeping pill. Looking at her adrenal glands like, Dr. Maki had mentioned is balancing stress. Is she exercising before she goes to bed, is her blood sugar balance, is her blood sugar dropping in the middle of the night, which is causing her cortisol to go up. So there are lots of kinds, it’s not like you said one size fits all or one pill fixes all it’s looking at the whole environment.

Dr. Maki: Yeah, right and there’s a couple of things like you said blood sugar is a key thing to make sure that your adrenals are in balance. So more protein being selective with your carbohydrates. You don’t have to, I don’t think for most women I think you have to eliminate them. I don’t think Keto necessarily is always the right answer because Keto diets I think tend to become low-calorie diets, which then puts more stress on the adrenals as well. So you mentioned exercise if you’re exercising like what a lot of people do in this country, they exercise after work, so they get done it five. They go to the gym. They’re doing a lot of aggressive cardiovascular work in the evening that’s going to make sleeping a little bit more challenging. So switching around your exercise routine, making sure you’re eating enough food, the right types of foods, as far as your macros go. Those all can be part of that landscape that’s going to foster some really good sleep during the night.

Dr. Davidson: And what’s also not to switch gears here. But what’s also very common in, Bioidentical Hormone Replacement for females, especially perimenopausal females is giving testosterone therapy and you can see that the doc gave her some testosterone. She thought it might have been a little too high for her. That’s an easy adjustment there, but that it helped her a lot. And when you think about testosterone, sure testosterone for males is a reproductive hormone, but for us females. As females testosterone is not a reproductive hormone it’s actually what I consider a little bit more of an adrenal hormone because we make DHEA from our adrenals, and then that will convert to testosterone. We make a little testosterone from ovaries in some other peripheral tissues but the DHEA conversion to testosterone from the adrenal glands is a good indicator that if the testosterone helped her, I would say definitely, it’s not just the reproductive hormones with the estrogen and progesterone that looking at those adrenal hormones.

Dr. Maki: Yeah, right. Yeah and starting off like right out the gate with testosterone. That’s just not something that you and I would typically do. But you’re right, I think it adds some credence that her adrenals if she felt better that way. Well, maybe we could do that in a little bit of a less aggressive fashion by using testosterone but still supporting the adrenals. So for example, you have this kind of diurnal curve to cortisol. So your cortisol supposed to come up in the morning as you mentioned, supposed to go down at night. So, if you do things to support cortisol in the morning, then automatically it’s going to start to come down at night. Plus there are some other things you can do to lower cortisol in the evening as well and now you’re able to sleep well. Like you said she did respond well to it, but who knows we don’t know what the amount was, we don’t know what her blood level is, and the fact that she’s still menstruating, maybe not really the best time for that might have been more appropriate, in a few years.

Dr. Davidson: Or as I said just finding that right dose that fits for her because if she does do well on it, it’s not causing her acne, it’s not causing her hair loss, it’s not causing her to feel testy, you know at testy and irritable then it might not be a bad idea. We’re always a little bit more conservative we think of testosterone like the frosting on the cake, you don’t want to add that little accolade, the little details, the fun details after you’ve established a base. But, like she said it did help her and then maybe dialing it back a little bit and just keep in and the Doc does test her blood it says does some blood testing so you can easily test testosterone on a blood test to make sure it’s not too high.

Dr. Maki: Right, right. So, I think that this one is I think we did an okay job on this one. Do you have anything else to add?

Dr. Davidson: No, no. I think we did a good job. I appreciate Laura for reaching out and taking the time to read our article and give a question that I think can help a lot of people, and reading or listening so you know and especially that it comes from people all over the world. I think that’s really cool.

Dr. Maki: Yeah, right, yeah. Well, thanks for your question Laura and until next time I’m Dr. Maki.

Dr. Davidson: And I’m Dr. Davidson.

Dr. Maki: Take care.

The post Does Progesterone Help You Sleep? | PYHP 089 appeared first on .

Is Prometrium Safer Than Progesterone? | PYHP 088

Dr Valorie Davidson and Dr Robert Maki — Fri, 15 May 2020 19:37:20 +0000

Donna’s Question:

Hello. I’m 62 years old with a uterus. Recently my nurse practitioner switched me from 6% progesterone cream to Prometrium capsules. The amount of cream I was using was 1/4 teaspoon two weeks out of the month. She also added in the Intrarosa vaginal inserts instead of the estradiol cream for vaginal discomfort. I do not have many symptoms other than occasional sleepless nights and occasional hot flashes. My question is are the Prometrium capsules safe? And is the cream safer than the capsules? Thank you, Donna.

Short Answer:

Both Prometrium and bioidentical progesterone are safe to take. However, many women do not seem to tolerate Prometrium very well. Prometrium is instant release, which seems to make it less tolerable for some women. In most cases, we prefer to us sustained-release progesterone, which is typically better tolerated by most women. This is important for women taking estrogen who still have a uterus. Estrogen causes the uterine lining to thicking and oral progesterone inhibits this thickening. Progesterone cream does not inhibit the growth of the uterine lining, which is why we prefer to prescribe oral progesterone for our patients.

PYHP 088 Full Transcript:

Download PYHP 088 Transcript

Dr. Maki: Hello, everyone. Thank you for joining us for another episode of Progress Your Health podcast. I’m Dr. Maki.

Dr. Davidson: I’m Dr. Davidson.

Dr. Maki: How you doing this morning?

Dr. Davidson: I’m doing great. Thank you. How are you?

Dr. Maki: Pretty good. Pretty good. You were surprised by that question?

Dr. Davidson: Yes, a little bit [laughter].

Dr. Maki: Why are you surprised?

Dr. Davidson: Because we’ve been hanging out all morning. [chuckle] Now you’re asking me how I’m doing.

Dr. Maki: Well, we had to start over on this podcast a couple of times, so that’s okay. That’s…

Dr. Davidson: I felt like I had rocks in my mouth. So I’m like, “Just stop it. Let’s start it over.” So I think this one will be the one [chuckle].

Dr. Maki: Yes, yes. So this one is a question we have from Donna. So why don’t you go ahead and read it?

Dr. Davidson: Oh, okay. So yes, this is a listener question from Donna, it says, “Hello. I’m 62 years old with a uterus. Recently my nurse practitioner switched me from 6% progesterone cream to Prometrium capsules. The amount of cream I was using was 1/4 teaspoon two weeks out of the month.” So it looks like they were trying to cycle the progesterone or cycle the hormones. “She also added in the INTRAROSA vaginal inserts instead of the estradiol cream for vaginal discomfort. I do not have many symptoms other than occasional sleepless nights and occasional hot flashes. My question is are the Prometrium capsules safe?” So the safety of the Prometrium capsules. “And is the cream safer than the capsules? Thank you, Donna.”

Dr. Maki: So this Prometrium question comes up quite often. Very, very common from a from a conventional perspective to be prescribed Prometrium. The 6% that she talks about, that’s basically 60 milligrams of a progesterone cream. Pharmacies just always seem to use the percentages like that, so what are your thoughts? What do you think?

Dr. Davidson: Well, I love the question. There’s limited amount of information here, so I’m just going to extrapolate based on what I’m reading here. So it looks like she was using estradiol cream for vaginal discomfort. Now as we’ve always talked about, there’s three different estrogens that our body makes: estrone, which we don’t really make a lot of maybe when you’re young, or fat cells make a lot of estrone, but typically we don’t make much estrone; there’s estradiol, as in the estradiol that she’s using, which is estradiol, E2, is the strongest form of estrogen; and then there’s estriol, which is the weakest, maybe you could call it, more gentle form of estrogen.

So I’m imagining that she was doing the estradiol cream and that she was also doing 60 milligrams of progesterone cream or the 6%, which honestly is a very low amount of progesterone, and she has a uterus. So what I’m thinking on why her nurse practitioner switched her to the INTRAROSA vaginal inserts, which is basically estradiol, so switched her to, I apologize, the INTRAROSA vaginal inserts is DHEA. So she switched her from the estradiol to the DHEA inserts, and switched her from the progesterone cream to a Prometrium capsule, is I’m thinking she was probably bleeding.

Dr. Maki: Yes. So it’s interesting, now we’re getting these questions and as they’re coming in they’re giving us the age and whether they have their uterus or not. We’re training people whether she did that on purpose or not. But that that does make a difference – how old you are when we answer these questions, and whether or not you have a uterus makes a big difference in the eventual determination of what’s going on. So we appreciate the fact that she– granted there’s still some of their other information that we don’t know, but I would agree. Now it’s possible that it could be an estriol cream or an estradiol cream, that part we don’t really know.

Dr. Davidson: It says estradiol cream for vaginal discomfort. So, that is…

Dr. Maki: I know we were talking about this beforehand and I know that it wasn’t spelled exactly quite right, so you weren’t really sure what it is. I assumed based the way it was written because it has the ‘d’ in there, estradiol, that it was E2 and not the E3. If it was estriol, we would never use estradiol as a vaginal cream. That’s just not something that we would typically do.

Dr. Davidson: There are a lot of estradiol gels available that people use vaginally for vaginal dryness, to help with intercourse, with lubrication, with pain with intercourse, so it is common. So I could imagine she was doing the estradiol cream, but the six percent of the progesterone cream only, and even only doing it half of the month makes me think that she may have had a little thickening of that uterus lining, maybe she had some spotting, or maybe they did a transvaginal ultrasound and the lining of her uterus was a little thick, which is why this was switched to the Prometrium capsules. Now, the difference is Prometrium is progesterone, it is a bioidentical form of progesterone. There’s some fillers in there that not a lot of people like: it’s instant release, the doses on their only come as 100 or 200 milligrams. So switching dirt from you know, a tiny, tiny, tiny amount of progesterone cream to a pretty good amount of a progesterone capsule is kind of a change there, but I’m thinking it was probably maybe to protect that uterus.

Dr. Maki: Right. So using the progesterone cream with the estradiol cream. So she wasn’t using the progesterone cream vaginally. She’s more than likely applying that to her inner thigh or something. That wasn’t giving her really any protection. The estradiol cream could easily cause some spotting or bleeding. But you’re right, that’s why we don’t like to use Prometrium because what a lot of women, whether it’s the dosing or the instant release, women just don’t seem to tolerate it very well. I don’t think that there’s any inherent harm or danger to Prometrium, I think it’s fin, and it is commercially available. So your insurance will cover it. But women just don’t seem to do well on it. We’ve had many a women that wanted to try it because their insurance will cover it or something, and they just they just can’t tolerate it. They have to go back to bioidentical sustained-release progesterone.

Dr. Davidson: Which is why I always say hormones are very based on the individual. Everybody is so unique and what’s going to work for one person is not going to work for another person. So on a whole, there are a few people that do well on the Prometrium, but mostly, they really do much better on a sustained-release progesterone. And what I’m thinking here is the capsule that her nurse practitioner, because a lot of times the capsules work much better for sleeping than creams. Creams don’t have as much an effect on helping you stay asleep through the night than the capsule. So the promethium capsule may be looking at protecting that uterus, and then at the same time, helping her sleep better.

Dr. Maki: Right, yes, And if she was using before she’s using the estradiol cream, then some uterus protection, especially if you’re applying an estrodial cream vaginally, that’s exactly why we wouldn’t do that because it’s just a matter of time before she starts having some bleeding or spotting because of the strength of the estradiol. Now we don’t know what the dosage of it is, one milligram, two milligrams, half a milligram. But the proximity to the uterine lining, the likelihood of that causing some issues, is pretty high.

Dr. Davidson: I’m thinking because there’s this ‘d’ in the in here that she’s doing the estradiol. I’m thinking that that, like Dr. Maki had mentioned earlier, is actually doing an doing an estriol, E3, I think would be a better bet for the vaginal discomfort because I know the new INTRAROSA, or they also call it the Prasterone, is basically a man-made DHEA, and DHEA has been very hot, like the new kid on the block in the last year and a half, two years, using that vaginally to help with vaginal dryness because the concept is it’s not estrogen, it’s not testosterone, it’s a prohormone that can convert into estrogen, it can convert into testosterone, and can help with the vaginal dryness. So we’ll see as things move on because I do know some people really like it, it does help with their vaginal lubrication, it helps with their sex drive. But a lot of times what I find is sometimes, it doesn’t work.

Dr. Maki: Right, right. Now, and again, some of that same research that the DHA is supposed to help those things, helps increase libido. I’ve had a few patients where I’ve added DHEA into the estriol cream. So now you can even add testosterone into that. For example, if you have some major issues, a way to complement that is for us to– Let’s say for example a starting dose of an estriol cream would be four milligrams per gram. You apply a half a gram or you would use a half a gram few times a week, and then you would add in a little bit of DHEA, something like 10 milligrams of the DHEA into the same cream. So now you’re getting the additional benefit of having that DHEA there. So it’s interesting, like you say, now that there’s INTRA- I don’t even know how long the INTRAROSA has been around. But it’s interesting that now it comes in a commercial form.

Dr. Davidson: And I’ve had patients that are on it. The nice thing about it is it doesn’t– if you test somebody’s blood if they’re using this DHEA vaginally is that their estrogen and testosterone are still very low. So it’s a way of being able to bring some relief to female without raising up their hormone levels. But at the same time, DHEA is, technically, a hormone. It’s a steroid hormone. It’s not estrogen or progesterone or testosterone, but it’s still a hormone.

What I find is if you’re going to be using the any kind of DHEA vaginally or even orally, you know, lots of people take DHEA orally, is you’ve got to test the blood work for it because on these DHEA inserts, is there 6.5 milligrams, is that can be a lot of of DHEA taking orally, but doing it transvaginally isn’t quite as much. But I have found when I do the blood work on the DHEA sulfate, which is the best way to test for DHEA in the blood, is DHEA sulfate, which is a metabolite, is the levels are a little elevated for their age. And I have found people say that they do have some irritability.

In fact, I had a patient yesterday that was telling me that her husband said make sure that you talk to her about your hormonal rages. Then I had found out since I had talked to her last, her gynecologist had put her on the DHEA inserts, and I’m like, “Your DHEA is higher than it was when I’ve tested it before.” Anybody on higher levels of DHA is going to get a little testy.

Dr. Maki: Yes, right. And for a woman, DHEA is basically their form of testosterone. It is kind of the predominant androgen – DHEA and testosterone are both considered androgens. The amount of DHEA that a woman produces is quite a bit more than testosterone, so it does have a significant impact on how a woman’s going to feel in that respect.

Dr. Davidson: Exactly. So, with Donna, like I said, everybody is an individual. It depends on what works for you. So I’d say monitoring that vaginal discomfort or dryness, if it starts coming back, then the DHEA inserts might not be for her. If she notices she’s getting a little irritable, the DHEA vaginal inserts might not be for her. The Prometrium, like I said, progesterone is very safe. Progesterone can be incredibly safe and very protective of the breast tissue, the uterine lining, so I know she’s worried about the safety between that and the cream, but if she were on any kind of estrogen – she’s not at the moment, because her doctor switched her from the estradiol to the DHA inserts – but if she were on estradiol, then safety-wise, she needs to be on a stronger form of progesterone than the cream.

Dr. Maki: Yes, right. From that respect, going from the cream to the Prometrium capsule was kind of the right move to make if she stayed on the estradiol. And if she’s tolerating the, I’m assuming 100, does it say 100 milligrams?

Dr. Davidson: Well we know Prometrium’s either 100 or 200, probably 100, I would imagine.

Dr. Maki: Yes, probably 100. So if she’s tolerating it, then that’s fine. There’s no real issue there as long as she’s able to handle it. Now, what are the side effects? I think we’ve done a, like I said, we’ve done– the Prometrium thing has come up a few different times. You might get anxiety, you might gain some weight. What are some other side effects that you’ve seen from Prometrium?

Dr. Davidson: For certain individuals, if the progesterone is too high for them, they will be sometimes a little lethargic during the day and cause a little depression because it does relax you. Too much relaxed means you have no motivation, so I do see some depression. And like you said, the weight gain, and I think that has more to do with like water weight. So you’ll see a lot of puffiness.

Dr. Maki: Yes, sure. Right. And those are things that would happen kind of in that premenstrual window, the seven to 10 days before your cycle.

Dr. Davidson: No, she’s not cycling because she’s 62 years old. Right?

Dr. Maki: Right, right. She’s not but I’m just saying in general, the same thing. So the interesting part that we didn’t really touch on, she was taking the progesterone cream for half the month, which in some ways, when a woman is menstruating still, her body really only produces progesterone from ovulation until her period starts again, so her nurse practitioner, she’s trying to mimic that whole idea. But when a woman is taking estrogen, pretty much all month long, you can’t really cycle or should not cycle the progesterone. They need to be taken in tandem. Again, the rule is you never give a woman unopposed estrogen.

Now granted we do rhythmic dosing, which we’re going to talk about fairly soon, rhythmic dosing, you use our estradiol cream and a progesterone cream, that’s an exception. But in that context, the progesterone cream is only used for half of the month because you’re encouraging the woman to actually have– if she has her uterus, like in this case, if she is using rhythmic dosing because she has a uterus even at 62, she would have a period again. Now, she may not want that. That’s more of an elaborate conversation that has to align with what the woman’s trying to accomplish as far as where her goals are, but in this context we would we would recommend for Donna to be taking progesterone all month.

Dr. Davidson: Yes, you’re right. I mean, rhythmic dosing is great, but it is a little bit, I wouldn’t say complicated, but you have to follow the patient. You can’t just give them a prescription and see them next year. You have to follow up with them, see how their cycles are, do their blood work, they get their screenings and all that. So it is a bit of a process if somebody’s going to undertake that, and we do that with a lot of patients because rhythmic dosing works great with some and of course not great with others. It depends on the person.

I would say for Donna, the Prometrium, there are some side effects to Prometrium that, if she’s not on the estradiol at all and she’s just on the DHEA inserts, she might not even need to take the Prometrium.

Dr. Maki: Yes, right, because the DHEA is not going to have an effect on the uterine lining, she just might need the one – she could go from having two prescriptions down to just one. Just use the insert if that– she says she’s not really having a lot of symptoms anyways. A few sleepless nights here or there. Prometrium doesn’t really help too well with the sleep that much.

Dr. Davidson: It might help her sleep throughout the night, but if it’s just a few sleepless nights, I mean we all get a few sleepless nights. I’d say if she was having three or four sleepless nights out of a week, then yes, then she needs to take something to help, that progesterone would definitely be a great way to help her sleep. But if it’s just a couple of times a month, I mean, I think I get a couple of sleepless nights if I watch a scary movie or watch the news before bed [laughter].

Dr. Maki: Yes, I think you get it more than that.

Dr. Davidson: Well, I do take my progesterone.

Dr. Maki: And you’re not allowed to watch scary movies, you can’t watch scary movies.

So I think that we covered the bases on Donna, do you have anything else to add for Donna?

Dr. Davidson: No, I appreciate all of you listeners and readers, especially with your questions. We welcome that, we like to have the conversation, and it’s actually really awesome. So thank you Donna, thank you everybody.

Dr. Maki: Sorry we can’t get two more of them. There’s so many questions that come in. We do try to keep up, and we’re trying–

Dr. Davidson: And I promise we keep them in a vault. We always have them if we need– We’ll try to get to all of them at some point [chuckle].

Dr. Maki: Yes, but as we do these more will keep coming in and we just try to pick out the ones that are you somewhat the most the easiest for us to understand what’s going on, what their question actually is, and the easiest ones that are for all of you to understand as well, and that we can relate to the most amount of people. So that way we, like you say continue the conversation, and then we have really an unlimited amount of content to produce because now we are answering everybody’s questions. It’s kind of like a new modern version of Dear Abby or something. It’s just not in the newspaper, it’s actually in a digital format, and now people are able to get the answers they want.

Dr. Davidson: And know that if we didn’t get to your question, we still write them down and try to put together other podcasts that might coalesce with that because really when it comes to hormones like, like I say, we’re all unique, but we all have a lot of common themes. So if you if you don’t hear us answering your questions, know that we do have it and we try to take it and put it into some form or some kind of content so that other people can have use of it.

Dr. Maki: Yes, so until next time I’m Dr. Maki.

Dr. Davidson: I’m Dr. Davidson.

Dr. Maki: Take care. Bye bye.

The post Is Prometrium Safer Than Progesterone? | PYHP 088 appeared first on .

How Much Estriol Cream Should I Use? | PYHP 087

Dr Valorie Davidson and Dr Robert Maki — Thu, 14 May 2020 19:30:34 +0000

Lilly’s Question:

Dear Dr. Davidson, I’m writing to say how illuminating your article on Estriol was for me. Especially your metaphorical descriptions of the actions of the 3 types of estrogens. I have a question, if I may. I am 49-years-old, I just entered menopause and started taking Botanical Phytoestrogens to help with the once a day hot flash. It helped for a month and then the flashes increased to several times a day. I then took Estriol, 5 milligrams and it helped. But since then that flashes have again increased and I’m using even more Estriol, 2 pumps morning and night. It’s made me feel very, very good, calm and a great sense of well being. My question is, is this too much Estriol to be using? What is the safe upper limit for Estriol in cream form? If I take progesterone and cream form as well, with this dull the good effects of the Estriol? Thank you for the possibility of asking these questions. Very best wishes, Lily.

Short Answer:

Dosing for bioidentical hormones is dependent on the woman. It also depends on if she has her uterus or not. One of the rules of BHRT that we follow is that you never give a woman “unopposed” estrogen. This is especially true if she still has her uterus because estradiol and estriol will cause the uterine lining to grow. This is why progesterone is important because it helps to inhibit the growth of the uterine lining. For women that still have their uterus, we prefer to use bioidentical progesterone capsules, as opposed to progesterone cream.

PYHP 087 Full Transcript:

Download PYHP 087 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, I’m just getting ready to start talking and my mic and my headphones practically fell off my head. How you doing this morning?

Dr. Davidson: I’m doing great. Maybe you shouldn’t wear your Golden Knights hat.

Dr. Maki: Yes, shoutout to everybody in Vegas.

Dr. Davidson: We’d love The Golden Knights.

Dr. Maki: Yes, it’s really ironic. We live there for so long never had any professional sports. And right when they got that team, the season was going to start. And we left pretty much like, right as the season started and they had like one of the, I don’t know if anybody out there is a hockey fan or not I’m from Minnesota. So of course, I’ve liked hockey since I was a little kid. But they had like this crazy season that no one’s ever had before, for an expansion team.

Dr. Davidson: It was definitely inspirational.

Dr. Maki: And it’s funny too, well have granted it’s kind of started off in tragedy with that whole shooting they had there in October. But there are people there, we have patients there. And none of them really care for sports all that much now. Everybody is into the Golden Knights, which is kind of an interest, in which kind of a cool thing. It’s a very much created a very community-friendly environment.

Dr. Davidson: And we wear our Golden Knights gear here in Washington like you’re wearing your hat right now. Which is why your headphones are slipping off but some people recognize it, it even appears in Washington, they recognize the team.

Dr. Maki: Yes. Well, Seattle’s supposed to be, they already been awarded the team but now they’re going to be announcing the mascot here fairly soon or the logo or whatever. I’m not really sure what it’s going to be there’s rumors it was going to be the Kraken, and everyone thought was going to be the Sockeyes. Who knows? We’ll see. So we have another listener question to talk about. Why don’t you go ahead and read the question?

Dr. Davidson: I think actually, this one was a reader. So this is one of the articles or blogs that we had written about Estriol and the different types of Estrogen. So this is a reader, this is a great shoutout to Lily. She wrote, “Dear Dr. Davidson, I’m writing to say how illuminating your article on Estriol was for me. Especially your metaphorical descriptions of the actions of the 3 types of estrogens.” Lily, you’re already my new favorite person. Illuminating metaphorical descriptions of, she’s awesome, anyway. So, Lily goes on to say “I have a question, if I may. I am 49-years-old, I just entered menopause and started taking Botanical Phytoestrogens to help with the once a day hot flash. It helped for a month and then the flashes increased to several times a day. I then took Estriol, 5 milligrams and it helped. But since then that flashes have again increased and I’m using even more Estriol, 2 pumps morning and night. It’s made me feel very, very good, calm and a great sense of well being. My question is, is this too much Estriol to be using? What is the safe upper limit for Estriol in cream form? If I take progesterone and cream form as well, with this dull the good effects of the Estriol? Thank you for the possibility of asking these questions. Very best wishes, Lily.

Dr. Maki: So, there’s a few things there. First off, she says she started off with Botanical Phytoestrogens. So that is herbs like black cohosh, red clover.

Dr. Davidson: Dong Quai.

Dr. Maki: Yes, those are herbs that have, they don’t have hormones in them.

Dr. Davidson: Vitex too. That’s another real popular phyto es- well, that’s more for the progesterone.

Dr. Maki: Yes. that’s more on the progesterone side. But still, definitely, herbs that have somewhat of a, they don’t have hormones in them, right. They don’t provide the body with hormones, but they have a hormone-like effect. The phytoestrogens especially black cohosh it works by affecting the estrogen receptors so you get a similar response. Now granted, when a woman’s going from perimenopause into menopause, the severity of their symptoms will dictate just like in this case, whether those phytoestrogens will be effective or not.

Dr. Davidson: Exactly. So you think, phytoestrogens are actually great to use in both lower hormones like from perimenopause to menopause. And it’s actually great to use also in people that have high estrogen. Because like you said as a phytoestrogen, what it’ll do is that black cohosh or as a phytoestrogen will kind of basically stimulate the receptor weakly like very weak stimulation of the estrogen receptor. So if you don’t have any estrogen in your system, and you have a weak stimulation of that receptor, you’re going to have a little estrogen activity in the body. Hence, with Lily, going into menopause, the phytoestrogens probably helped for a little bit. But let’s say you’re a younger female with you’re making too much estrogen so if you put that phytoestrogen, if they take phytoestrogens, it’ll actually block that receptor and dampen down the big reaction that they’re having from that estrogen dominance if that makes sense.

Dr. Maki: Yes, right. So hormones in the body are produced by certain glands. They go into the bloodstream and then they attach to a receptor that is on basically all of our cells, our brain cells, our muscle cells, our liver cells, our kidney cells, every cell has receptors for these particular hormones. So when a woman’s in menopause or transitioning into menopause in her own hormone production. Progesterone and estrogen are declining, then taking a phytoestrogen in some respects makes some sense because now you’re still going to be stimulating those receptors in a way, but you’re not taking any hormone. But like this question says, or what she’s alluding to is which is what we see. You and I are naturopaths, we love our herbs but sometimes the herbs are just not enough to provide the relief that a woman needs.

Dr. Davidson: Yes, so I like how she’s using basically, the therapeutic working at the very least intervention, at the very lowest therapeutic range. So, you never want to jump up to the top which would be harsher medications or surgery is you always want to start lower with lifestyle, or supplementation, or botanicals so she started at that lower intervention. Notice that it helped a little bit and then it didn’t. And that could be because really, truly if Lily’s 49 and she’s transitioning, she’s probably not necessarily 49, not exactly in menopause she’s between perimenopause just gently gliding into menopause, and the phytoestrogens to help spur a little bit and as her body is transitioning more into the full phase of menopause, she needed to go a little higher on that therapeutic intervention which is where the Estriol came in. And it looks like the Estriol seemed to work very well with her that she actually likes it.

Dr. Maki: Yes Right. So, her actual real question is, is 5 milligrams of Estriol too much? And whether or not adding in some progesterone is going to kind of decrease the beneficial effects. This is where it gets tricky, right. One of our rules of hormone replacement. Number 1 rule is you never give a woman unopposed estrogen, ever. There’s not really a circumstance where that would really be, now sometimes you might do that if a woman’s having some vaginal dryness and we maybe prescribe an E3 or an Estriol cream. But most of those cases, usually there’s going to be some other symptoms involved and more than likely they’re going to have a progesterone prescription as well.

Dr. Davidson: Exactly. So like you’re saying Estriol. Estriol is great for so many things, but specifically vaginal dryness, it works wonderfully for. But if you’re using a very low dose vaginally, it’s not going to go so much into the bloodstream and then create that effect of having too much estrogen without enough progesterone to balance it out. So like Dr. Maki said is if you’re going to do estrogen, any form of estrogen you truly want to investigate and possibly do some progesterone. Now, if you’re going from perimenopause to menopause, or even going into perimenopause the progesterone usually drops first and then the estrogen drops later. So we know with Lily, if she’s going into menopause and the Estriol is working well, we know that her progesterone levels are low and that it would be beneficial to add in some progesterone for her. And it looks like that she’s read probably a few of our articles about why you might need progesterone to balance out that estrogen that you’re taking but her question is, I think she’s worried that the progesterone would negate that positive benefit that she’s getting from the Estriol.

Dr. Maki: Yes, right. And I think that almost just the opposite that there needs to be, now granted, that brings up the other question about progesterone cream versus capsule, her being so close to her menstrual history and we talked about this on some previous episodes. At some point that estrogen dosing could become a problem, right. Because she needs the progesterone to balance and inhibit the growth of the uterine lining. It’s not going to negate anything. If anything, it’s going to create more balance because now you’re, both hormones are present.

Dr. Davidson: And now like I said, Estriol is the most gentle weakest form of estrogen. There’s also Estrone E1 which is not a great estrogen. We, as adult females, we don’t make a whole lot of it, you do make a lot of Estrone if you have a lot of fat cells and also when you’re a young teenager, just kind of our young female just sort of going right into puberty and getting your first few periods, for a couple of years there you might make a little more Estrone but then as the body gets used to cycling, it doesn’t make as much Estrones. The whole goal is to not make too much Estrone but at the same time there’s Estradiol which is E2, that’s the strongest form of estrogen. Estradiol is very strong but Estradiol is an amazing hormone it’s great for your bones, it’s great for your cardiovascular system, it’s great for your brain, but she can be a little bit of a runaway train if you don’t rein in some of her negative effects. Where Estriol like I said, E3 is very gentle. So being that Lily is taking just Estriol, is much safer in some regards because I love Estradiol, I prescribe it all the time but you never want to prescribe Estradiol unless you’re doing some progesterone to offset that because of the strength of it. Like I said, she can be a little bit of a runaway train, so the progesterone kind of helps negate those unwanted side effects you might get from taking Estradiol. Now, on that flip side, I was saying that Estriol is very, very gentle, that you don’t have to be so adamant with the progesterone-like you would be if she were taking Estradiol.

Dr. Maki: Yes, right. Then it’s more dose-dependent which is kind of what her question is. So the more of the Estriol that you’re taking the more than progesterone conversation needs to be had. But it’s not whether the progesterone is necessary or not, at some point the progesterone will be necessary. And whether it’s a cream or a capsule we’re not really big fans of Progesterone cream in the context of using it with Estrogen. That can be problematic at some point.

Dr. Davidson: Now, for you know, we’re no disclaimer, disclaimer, we’re not giving out medical advice and all that. But just in our experience, I do feel like if she’s taking 5 milligrams of Estriol, that’s kind of that upper limit where I’d say 5 milligrams, you probably want to do some kind of progesterone just to balance that out. When someone’s doing 3 milligrams or less Estriol, you know E3, 3 milligrams or less, then I say, okay, we could kind of, let’s talk about whether you need some progesterone or not, it may not be necessary if you’re doing such a low dose like that but when you’re getting up to 5 milligrams, you think, okay, we probably want to put in some progesterone because estriol is very gentle. Progesterone cream may work well for Lily depending on if she starts to because the one thing with that unopposed estrogen is it can cause the lining of the uterus to get thick, and then you get a period back, you get sloppy spotting you don’t want to have an increased lining of your uterus, or your endometrial tissue so that’s actually kind of a risk factor. So, we’d probably want to come down to this, does she have a uterus? Does she not have a uterus? Is she? When was her last period?

Dr. Maki: Right, that menstrual history as a woman is transitioning from her late 40s into her early 50s or from perimenopause into menopause. The proximity of that menstrual history makes a big difference. If it was just a few months ago, less than 6 months ago, and she starts right away on Estriol even at 5 milligrams that could cause her to start having either a full-blown period or to have unpredictable bleeding which is exactly what we don’t want. So, certainly, the progesterone is a good idea. Like I said, the cream versus capsule I think is the bigger conversation there and you cannot get progesterone capsules over the counter, right. Progesterone cream, in some ways, unfortunately, you can. I’m not really sure if I like that idea or not. I think they should be prescriptions because they’re still hormone.

Dr. Davidson: It’s on the company. Who’s making it? How they’re making it? What’s in it? Where did it come from?

Dr. Maki: They’re still hormones, they need to be respected and you need to be somewhat, you can’t just take a hormone-like that. Now, granted, progesterone, I think is a lot easier and a lot, I wouldn’t say safer necessarily, but you’re not going to necessarily have any bleeding problems, necessarily with the progesterone cream like you would with potentially with this estrogen cream.

Dr. Davidson: So I would say in a case like this, let’s say somebody is taking some Estriol, and they’re liking it, it’s helping their symptoms, they’re you know, 5 milligrams. That’s where, and honestly, if you are working on hot flashes or menopause, you probably would and you’re doing Estriol only you probably wouldn’t go lower than 5 milligrams. I usually do 3 milligrams or less if we’re working on more like skin tonicity, vaginal dryness, but really for hot flashes, and that sense of well being 5 milligrams, probably is doing very well for her. That I would say for Lily that taking progesterone wouldn’t dull the effect at all. If anything it would probably complement it and she feels even better. She’d probably feel like she was sleeping better, her hair, skin, and nails were better, anxiety. Progesterone is very calming and relaxing it would probably even more so make her not feel wound up or stressed out. So that I think it would have a beautiful synergistic effect just in that regard.

Dr. Maki: Yeah. Now you’re referring to capsule progesterone, right? As opposed to-.

Dr. Davidson: I would say either.

Dr. Maki: Either, okay.

Dr. Davidson: In this case. Like I said, anybody on an Estradiol or what we call bias that has Estriol and Estradiol together. Then I pretty much and they have a uterus we do progesterone capsules. But in this case, she could probably go either way. Talking to her practitioner or maybe her gynecologist. If she has a uterus doing a transvaginal ultrasound every so often, every year or so just to make sure that lining is not getting too thick if she’s doing the cream. The capsules usually prevent that but the cream, you can go either way with that thickening of the uterus. But just in regards to her question about feeling this calm, this sense of well being, the hot flashes, is doing progesterone in either form would like I said help. It wouldn’t dull the effect at all if anything would probably help enhance it.

Dr. Maki: Yes. right. Certainly, progesterone capsules for sure work on that kind of mental-emotional plane. They help kind of tone down the anxiety, they help level out the mood. So, perimenopause were the classic symptoms of perimenopause, as women are irritable in everything. The way their husband breeze and the way he chews, the way he talks, and just a simple thing that he does and all sudden women are just in a fit of rage, and they don’t understand why. They think there’s something wrong with them. But those hormones are changing and their body is reacting in a way that they’re not really used to. Progesterone can really help to kind of level that playing field.

Dr. Davidson: But it sounds like she’s feeling really great on that Estriol. Everybody’s different that’s why Bioidentical Hormone Replacement, or treatment or restoration, or whatever you want to call it. It’s important to treat the individual because there’s some people that Estradiol is too strong for them. You do their blood work, you do their urine test, you do their saliva test. Hey, you have no hormones, but you try to give them what you think would be a proper dose and it’s just way too much where they’re just too sensitive. And then there’s others where you’re, hey, you know, we’re on kind of a good amount of hormones and they don’t feel good unless the levels are even higher. Everybody is different. Of course, we’re looking at safety and precautions and longevity. But in terms of every female, males included, we’re all individuals, we’re all very unique that if this Estriol which is very gentle is helping Lilly, that’s wonderful.

Dr. Maki: Yes sure, of course. Now, Estriol is FDA approved, it is by prescription.

Dr. Davidson: In this country, I mean, you can find it online. I think other countries because we’ve gotten emails and little comments saying hey, it’s available here down the street at my chemist and they live in, I’m not sure about other countries.

Dr. Maki: Germany or England or whatever, but in this country, Estriol is FDA approved. It is a legitimate prescription, but it is not in a commercial form. So you can’t get it from your most gynecologist or doctors that do hormone replacement but more from a conventional route, there are no prescriptions. We use it all the time for vaginal issues and when you go to the gynecologist complaining that you have some dryness or some pain or some discomfort or pain with intercourse, they don’t give women that option. Honestly, some of the conventional options are not very good. We always use E3 in that respect because it works very well and like you said before E3, Estriol is that weaker hormones you get all the benefit without as much of the risk that you would get with Estradiol.

Dr. Davidson: Now, just for some of you out there listening, you might say, hey, I’m on Amazon right now and I see Estriol available for purchase and I’ve talked to different pharmacists, other colleagues about it. You know every company, you know, you don’t know where it’s coming from, you don’t know about the company, I’m sure we could go in and research. So, I’m not sure exactly how that’s being able to be bought on Amazon or over the counter or at whole foods, but I know that it is available. Just be careful if you do choose to go that route that it’s coming from a reputable company, and the sourcing is coming from a good source.

Dr. Maki: Yes, right. What we’re talking about is by prescription. That’s the world we live in, that’s the world that we operate in. We are not commenting on things that are on Estriol, Progesterone, Estradiol, anything like that, that’s over the counter. That’s not what we’re pertaining to, and you cannot compare a prescription to those things that are over-the-counter, it is not the same thing. I don’t know really exactly how some of those things are able to be sold that way. That’s not for me to decide. But in the context of what we’re talking about, we’re talking about bioidentical hormone replacement therapy, that is by prescription, not what you can find on the internet. Because like you say, when it comes to supplementation, and this is the downside to supplementation.

Yes, everybody has access to it and that’s great but at the same time, there’s not as much regulation on the supplementation side. Anybody can start a supplement company, like literally overnight. You have no idea what is in that supplement because no one is checking from a quality control, or an efficacy standpoint, or even clinical trials of that supplement that you’re buying off of Amazon, or getting it wherever. Now, we use a lot of supplementation with our patients but we use physician only companies that go through the quality control, the QA, the QC, all those things are met. So, that way you know where those raw materials are coming from, you know what the ingredients are, you can feel confident that there’s no heavy metals, there’s no toxins, all those things have been tested for. So, again, just because we’re talking about things that are available online, it’s not really the same conversation.

Dr. Davidson: Exactly. So you can tell we’re definitely very passionate about what we’re trying to tell people to do. We want to advocate for people. So, like I said, if you do go that route of going to the health food store online. That’s your choice and you know a lot of our listeners and readers are very up to date on where things are coming from, and they’re savvy at what’s going on here, which is why we love to answer these questions. You go out on the street and you say, hey, you do you know what 5 milligrams Estriol is? They’ll just look at you cross-eyed, most people don’t know what this means. So it’s really cool to get these questions from you listeners and readers. And you know these numbers, you know what you’re talking about. So that’s why we love this podcast as we can really get into the nitty-gritty of hormone replacement.

Dr. Maki: And we also know too, because we get these questions all the time from our own patients. Is that conventionally there just isn’t really a lot of answers that are given. Doctors just don’t seem to know, they don’t seem to want to know and patients are left to kind of fend for themselves to be able to get and find answers. That’s one thing I would say, in this kind of information society with having access to the Internet and all this information or fingertips. It just people go on Google and they look for answers all the time, and sometimes they just won’t stop until they find their answer, which I think is great. So, conventionally, sometimes there’s doors that are closed, you’re not getting the answers you want. So, that’s why we’re doing this podcast, and that’s why people find us for those exact reasons. So, I think we cover this one. The Estriol is great, Progesterone is a good idea. We would advocate the progesterone capsule versus the cream. Do you have anything else to add to that?

Dr. Davidson: No, I think this was great and sorry if we kind of got off on a tangent, but hey, we love to talk on this podcast.

Dr. Maki: Yes, so until next time, I’m Dr. Maki.

Dr. Davidson: I’m Dr. Davidson.

Dr. Maki: Take care. Bye-bye.

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What Biest Dosage is Best for Menopause? | PYHP 086

Dr Valorie Davidson and Dr Robert Maki — Fri, 01 May 2020 22:05:44 +0000

Nathalie’s Question:

Hello Dr Maki, I am 45 full menopause and currently on biest 80:20 (0.5 mg) and progesterone 200 since July 2018. I was also given testosterone injection at the time and by Oct 2018 I was losing hair so we stopped that and no longer take it. I have been gaining weight steadily and even though we try to increase my estrogen slowly, I get too many side effects (constipation, weight gain, horrible bloating, hair loss-diagnosed with androgenic alopecia). My Thyroid is in normal range. Is it possible that a biest 90:10 would be more beneficial for me? I do like having my brain again and dryness cured but hate the bloating and weight gain. When I stop hormones completely I feel better, my belly fat reduced no more bloating and wgt loss happens. I tried DIM but my weight just kept on increasing. Thanks!

Short Answer:

The Biest dose of 0.5 mg is very low. I would not think this low of a dose could cause any side effects. Issues could be with the 200 mg of Progesterone. Changing Biest ratio to 90:10 would not really help either because dose is slow low already. However, for sensitive women, using just estriol only is an option.

PYHP 086 Full Transcript:

Download PYHP 086

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

Dr. Davidson: I’m Dr. Davidson.

Dr. Maki: Let’s dive right back in. We have another listener question to do. This one is from, actually, her name is Natalie. Dr. Davidson, this one’s fairly similar to what we did recently for Monica’s, we’ve kind of thought this would be appropriate. I want you to go ahead and read the question.

Dr. Davidson: Sure, sure. So, this is from Natalie. Hello, Dr. Maki. I am 45 years old, full menopause, and currently on 80/20 ratio, biased 0.5 mg, and 200 mg of progesterone since July of 2018. At that time, I was given a testosterone injection. By October of 2018, I was losing hair, so we stopped that. I no longer take the testosterone injection. Since then, I have been gaining weight steadily, and even though we try to increase my estrogen slowly, I get too many side effects such as constipation, the weight gain, horrible bloating, hair loss, diagnosed as androgenic alopecia. My thyroid is in normal range. Is it possible that a different ratio of bias, like 90/10, would be more beneficial for me? I like having my brain in the dryness cured but hate the bloating and the weight gain from the estrogen. When I stop the hormones completely, I feel better. My belly fat goes away. I have no more bloating, and the weight loss happens. I did try DIM, but my weight just keep increasing. Thank you, Natalie.

Dr. Maki: Yes, right. This is a challenging one, right. I can understand where she might be frustrated. Even her doctor might be frustrated. She’s on a very low dose, 80/20 at 0.5 mg. Maybe, she talks of bloating quite a few times in that question. I’m thinking maybe it might be more related to the progesterone than it actually is to the bias. What do you think?

Dr. Davidson: Exactly, that’s why we wanted to do this question. We did another question earlier, kind of similar. This is why it’s so important that what’s going to work for Natalie is going to be completely different for somebody else that’s right around the same age. That is why in everybody’s so sensitive and so unique in their bodies that with BHRT or hormone replacement, there really is no one size fits all or a cookie cutter approach. You’re right. With somebody else, 200 mg of progesterone would be great, but I really think that bloating is coming from the progesterone, even though in a perfect world, in the literature, and the research, theory is progesterone helps with that. I find when someone’s taking- a female’s taking too much progesterone for themselves, no matter what the blood work says, that it can cause bloating and puffiness and water weight.

Dr. Maki: Yes, right. Now, what we don’t know, she doesn’t specify. She says 200 mg of progesterone, but she hasn’t specify if it’s Prometrium or not. We’ve talked about that in another podcast too, that 200 mg of Prometrium could easily cause all those symptoms, even more so than 200 mg of bioidentical progesterone, 0.5 mg of bias, she might able not even be taking it. That is such a low dose that I can’t imagine that that’s going to be causing her much of either any relief or causing her any problems because it’s such a small amount.

Dr. Davidson: She could be extra sensitive. There are some patients we have that are so sensitive to the littlest things that it could be that 0.5, really is too high for her. Now granted, she does say when she reduces the estrogen, that her constipation, her weight, or when she increases the estrogen, she gets more weight gain, more bloating, more constipation. While we’re saying that the progesterone might have a factor in this, definitely, from her input here, the estrogen’s having some kind of effect on her.

Dr. Maki: Yes, sure. Yes, right. She asked what a 90/10, a 90/10 ratio at 0.5 mg isn’t really much of a change. Even going to a straight estriol cream, not even bias, just straight estriol, still isn’t really that much of a change because the overall dosage, to begin with, is so low. Now, the thing I’m curious about, she’s 45 and full menopause. Is that from a hysterectomy? Why would she be in full menopause at 45? Now granted, that’s possible, but she’s about six and a half, almost seven years too early for menopause. There’s something that led up to that, that makes me question. Granted, we’re not getting all the information, all the backstories, so we’re trying to speculate on a couple of ideas. A woman, 45 and full menopause, that’s not necessarily very common.

Dr. Davidson: Exactly. That was kind of my first thought, too. Maybe she had a hysterectomy, but I think she probably would have written that in there, that I had a hysterectomy. It could be that she’s technically perimenopausal because like we’ve always said in the past, the blood work for checking for whether you’re in perimenopause or menopause is so misleading when you look at the reference ranges. A lot of doctors just go by an FSH, Follicle Stimulating Hormone, and anything over 25, says you’re menopausal and that’s just not true.

Dr. Maki: Yes, right. Like you said, one of our last ones, we talked about Monica. You watched the FSH on purpose. You see it kind of bounce all over the place, that’s where perimenopause and the menopause, it’s not so black and white. There’s a lot of gray area there and that transition from perimenopause into menopause can take you 10 to 15 years in some cases. It can be a very long period of time for women from their early 40’s to their mid 50’s, that whole time frame could be a woman being in perimenopause, then finally, she transitions into full-blown menopause.

Dr. Davidson: Exactly. Maybe she did have a hysterectomy where they took the uterus out but left the ovaries in, and that can be producing hormones as well. what you said, we don’t have a whole lot of backstory to this, but she is having symptoms. When she raises up that estrogen slowly, she still gets negative side effects. Something you would mention earlier that might not- might actually be a good idea is taking the estradiol out completely.

Dr. Maki: Right, yes. Even though such a small amount, like you said, she might be one of those ones because of where she is in her life. She might just be extra sensitive, a little bit in her case, a little bit goes a long way. That’s why like you said, you can have some starting points for women, just in general, but when you have a situation like this, again, taking all the factors into consideration, it is always a custom prescription, a custom treatment plan for that particular person and situation. You might have 10 women with the same dosage, but how you got to that dosage is very specific to that person.

Dr. Davidson: Exactly. Just from experience and working with a lot of different women with the hormone replacement, I do find if a female is going to be sensitive to estrogen, they’re going to be sensitive to the estradiol. That’s usually the thing that’s causing whether it’s breast tenderness, fibrocystic density, weight gain, bloating. Like we said, the progesterone might have a little hand in this. It might be a little bit too high or their prometrium isn’t the right thing for her. If she is going to be sensitive to something, it’s most likely the estradiol if we’re looking at that bias. Estriol is very gentle, but not that we want to give medical advice, just for educational purposes, I would say even taking that estradiol completely out, but raising up the estriol.

Dr. Maki: Explain that.

Dr. Davidson: She’s on 0.5 mg of a biased 80/20, that’s really, really low. I have to pull my iPhone out and do the calculations to tell you exactly how much estradiol and exactly how much estriol is there. Honestly, if we took the estradiol out and just did an estriol only, but really bumped it up to like 3 mg per gram, where she does maybe 1.5 mg in the morning, 1.5 mg in the evening, even going up higher to like 5 mg of estriol E3 because estrogen- there’s three different estrogens. Estrone, we make that a lot when we were younger, our fat cells make a lot of estrone. We don’t want it, we don’t want estrone. Estradiol is the strongest form of estrogen, E2 estradiol and estriol E3 is very, very gentle. What Natalie’s saying here, is she really likes having her brain back and also probably the vaginal dryness, I’m assuming. Estriol is great for your brain, and it’s great for vaginal dryness. We could use estriol instead, take out the estradiol, and maybe dial back the progesterone a touch, and then she wouldn’t have to deal with the bloating and the weight gain. Trust me, no gal wants to gain weight if she didn’t get to earn it.

Dr. Maki: Yes, right. Another idea too is if you’re using just a straight estriol cream and if she’s applying that vaginally because she’s having some dryness issues, in some of these situations, again, if they’re a non-menopausal age, so to speak, or in that perimenopausal window where their menstrual history is fairly recent, you could do a little bit vaginally. That sometimes gives them enough estrogen to solve some of their problems.

Dr. Davidson: Yes, she could do it vaginally for the vaginal dryness. Then maybe, once or twice a day, she could do it just topically, like on the inner thigh to go systemically. It does help with the brain, that might be an option for Natalie because it looks like she’s darned if she does and darned if she doesn’t. I can understand wanting to try the DIM because that does help reduce down estrogen metabolites, but I don’t usually find that really helps with estrogen dominance, weight gain.

Dr. Maki: Yes, right. DIM, Diindolylmethane comes from cruciferous vegetables. It might be very good in situations like full-blown estrogen dominance, but a woman that is in perimenopause, or in this case, if she says she’s a full menopause, you’re not really estrogen-dominant when you’re in that transition because your body’s estrogen threshold or your estrogen burden, so to speak, is declining anyways. You’re right, I can understand her wanting to try something like that because she’s not handling the estrogen very well. Taking the DIM, in some ways, that’s kind of the opposite of what she really needs, by using DIM as opposed to the estrogen but she just haven’t had any success. I just looked at the question again, and it doesn’t specify whether the progesterone is a capsule or a cream, either. What if you notice with women’s tolerance from her symptoms, the cream versus capsule, which one’s worse?

Dr. Davidson: Cream, I wouldn’t say worse, but cream, being bypassing the digestion, going in, applying it to her inner thigh or something like that. At 200 mg as a cream is really high because when you test somebody with the cream, the levels do go up. You do see it go up. It doesn’t have that protection for the uterus. I find that progesterone cream doesn’t do a whole lot for helping you sleep at night like the capsules do. She’s using a cream, the 200 is just way too much. If she’s using a capsule, I’m thinking the 200 might be too high that she’d want to reduce that down to a hundred. If she’s using prometrium, which is bioidentical progesterone, but it still tends to have a lot of side effects, especially with bloating and water weight, I’m thinking probably more the capsule. Just real quick, just to jump back to that DIM comment that you made, I do find that when I test women in their 40’s and their estrogen is really high, that means their metabolites are high. It does tend to help when it’s really high, when their estradiol level’s up at 400 to 800. Doing the DIM is a nice piece of the puzzle when you’re working with that, but looking at Natalie here, I bet her estradiol, if you tested her blood, is not anywhere near 400 or 800. It’s probably like 32.

Dr. Maki: Yes, right. Just to clarify that, you’re totally right on that. In perimenopause, you have kind of a pseudo-estrogen dominance because you have relatively a lot of estrogen with no progesterone. That is in some ways kind of what our definition of perimenopause is, your body just stops making progesterone, but now you have collectively all of this estrogen floating around. That’s going to leave a woman very unbalanced in some respects. The DIM, in that context, would help to kind of tone down the estrogen a little bit in the absence of the progesterone. In that context, you could use DIM with progesterone. DIM with progesterone would actually be a fairly good combination.

She was kind of on the right track there. She does say that her thyroid is normal. I always like to push back on that a little bit. I would like to see the numbers, more than just the TSH number, because these is where these thyroid issues begin to come up when those female hormones are declining, your cortisol is through the roof. We don’t know what her stress level is. The higher the stress level, the more cortisol that her body needs, the worst is transition is for women. This is an exact physiology with those female hormones tend to buffer some of that stress hormone. When those hormones are starting to leave, now you just have this cortisol all the time. That’s where some of that weight gain comes from that they don’t want. This cortisol freight train that makes her weight just go in one direction. That’s why this happens once women get into perimenopause. Whether that’s their early to mid-40’s and all of a sudden they’re in perimenopause, the weight just seems to keep going up and up and up, no matter what they do.

Dr. Davidson: Exactly, because you’re right. We look at thyroid a little bit different. We always combine the thyroid with some- looking at the adrenals and then the reproductive system. Think of it like a triad. You’ve got these female hormones, the estrogen and progesterone, then you’ve got your adrenal hormones, and you got your thyroid hormones. You want to look at them all. You want to work on them all to some extent. That way, you’re not just compartmentalizing and looking at one thing. I completely agree with Dr. Maki as I would love to see those.

Dr. Maki: Yes, right. I had another woman the other day as a patient actually, and she was 45. Another doctor actually put her on a rhythmic dosing protocol. We’ll talk about rhythmic dosing later. When I did her blood work, as an initial consultation, her estradiol at a 45 year old woman was still 240, meaning that she was still producing. Where usually when you’re in menopause, on the lab sheet from either Quest or LabCorp, it’ll give you either the number, but usually, a menopausal level will be less than 30. Sometimes, it’ll be even in the teens or early even be below 10. Hers was still 240, and the doctor had her on estrogen. That’s just not really going to go well for her and now it’s possible, she’s 45. How was that determined that she’s in full menopause? If it’s a hysterectomy, okay, I get it. But maybe her body is still producing some of, they left her ovaries there.

You said before, this is just how it works with hormones. When your body does not need a hormone because your body is still producing it, you’re not going to feel very well. In that case, the woman told me, she goes, “I like the philosophy of the rhythmic dosing.” It’s called the Wily protocol. She loves the philosophy of it, but she didn’t do very well with it. My opinion was at the time, I said, “Well, to be honest, you’re not really a candidate for it. You should never been on that in the first place, because your body is still producing.” When I saw her, she’d been up on all hormones for two weeks, her level was still 240. So, that’s a woman who does not need any hormones. There’s a few things here that we would just need to ask more questions, so we could clarify. Certainly, it doesn’t mean that the estrogen like you said, switching it. There’s a lot of things we’ve just thrown out about four different options that could be done, that we would easily know what to do if we had some of that backstory.

Dr. Davidson: Exactly, you’re right. We always say it, the hormones are not a cookie cutter approach. For the right candidate, hormones can be great. Like you said, the rhythmic dosing is amazing for the right candidate. For the wrong candidate, it’s not good. It doesn’t mean that protocol is bad. It just wasn’t right for that individual. With Natalie, working with her doctor in finding the right protocol that works for her and then constantly updating and keeping an eye on it.

Dr. Maki: Yes. We didn’t talk much about the progesterone or the testosterone injection. She kind of came to that conclusion on her own. We never would give a woman testosterone injection, it’s just too strong, too powerful, and it’s not the place to start. You do that, like you always say, it’s the frosting on the cake. You do that later, once you have a good solid foundation of estrogen and progesterone. Estrogen is what makes a woman a woman. That is the number one hormone or the main hormone for a woman to focus on in whatever context or situation that is, giving them that strong of a variable right off the bat. That’s why you don’t do too much too quickly because the skin and the hair issues will show up immediately, and then you’re trying to backpedal and undo some of that.

Dr. Davidson: Exactly.

Dr. Maki: Now, I will say one more thing about that, about the hair loss is. Hair loss can also be kind of exacerbated by stress level. As your cortisol is through the roof, in some ways, that’s where that hair loss comes from. Sometimes, especially now with the lock-down and COVID-19, everything that’s going on, everybody’s stress levels is a little bit higher than it needs to be. That is just not a good thing for preserving hair. Lack of sleep, too much job or family stress, too much exercise, aggressive cardiovascular exercise, are all things that can kind of make that hair issue worse, which is a really challenging thing to solve and calm down for women.

Dr. Davidson: Not to keep beating the dead horse, but she does mention that her hair loss was diagnosed as androgenic alopecia. That means androgenic is androgens. That would be too much DHEA, too much testosterone. In some regards, somebody is diagnosing her, saying her androgens are too high, creating the hair loss, which would be in the top of the head and the temples, mainly, when you have androgen-derived hair loss. In some respects, trying to dampen some of that androgenic response, and they’re probably trying to do that a little bit with the progesterone.

[end] – we apologize because some of the transcriptions is missing. We will update shortly.

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Can You Take BHRT During Perimenopause? | PYHP 085

Dr Valorie Davidson and Dr Robert Maki — Thu, 30 Apr 2020 19:07:00 +0000

Monica’s Question:

Hi, Thank you for providing such great information regarding BHRT, this has been a great resource and one of the best sites I have visited. My question is: I am currently going through peri-menopause; while back in July my hormones levels tanked and I started having terrible problems with hot flashes and night sweats, after about 3 mos in and no period blood test confirmed my levels are very low. I decided to go with BHRT cream and within a week I could tell a huge difference. I do have uterus and my cream included Bi-est (50-50) plus P Plus T 1.8 mg plus 200 mg plus 5mg/ml cream. On my second month in I started my period within another 10 days I started bleeding again for about 3 weeks straight. During this time I was given a 7 day supply of 10 mg oral progestin this didn’t help slow down the heavy bleeding and returned to talk back to my doctor. I was told most likely I was not absorbing the progesterone. I explained my concerns of not really wanting to take the oral progesterone and was changed over to 100 mg progesterone capsule finally after about 7 more days this meds had stop the bleeding. While during this time frame of a few weeks of bleeding, I decided to get in with my regular gyno for an ultrasound although I had one in 2018 for a side pain in which everything was healthy and looked normal. I want to make sure I am getting on track and taking the oral progesterone with using the cream is the better safer option. It was also mentioned that I might consider pairing the Mirena insert with BHRT cream I am not really crazy about that idea. I always had a regular cycle with no issues and only took birth control for a short time frame in my early twenties. At age 47 I am hoping I am on the right track to have a well balance and using the least I can and feel confident in making good choices. Any suggestions or feedback is greatly appreciated.

Short Answer:

First off, for a woman new to BHRT, we don’t like to combine so many hormones into one cream. If issues arise and the dose needs to be modified, that inital cream can’t be used. Typically, we will not start a woman on a 50:50 ratio right away. We will start with an 80/20 ratio to see how she responds. We will usually wait on the testosterone for later, once the Biest dose is optimized. Finally, we will prescribe a bioidentical progesterone sustained release capsule, instead of using a cream. This is important if the woman still has her uterus.

PYHP 085 Full Transcript:

Download PYHP 085

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: How you doing this morning?

Dr. Davidson: I’m doing great. How are you?

Dr. Maki: Pretty good. Pretty good. The weather’s nice. We’re still in lockdown, but we’re getting a lot of podcasts done.

Dr. Davidson: That’s certainly are.

Dr. Maki: Good thing, we’re going to do another question. We have a few to catch up on so this is very appropriate. This one is from Monica. Dr. Davidson once you go ahead and read the question.

Dr. Davidson: Sure. I know we’re on this kind of trend answering questions, but we’ve got some really great ones on the website and by email. So definitely I appreciate all your listeners and readers, you know sending in your questions so they can help everybody else. So this question is from Monica. Hi, thank you for providing such great information regarding BHRT in this has been a great resource in one of the best sites. I have visited now, you know why we’re answering Monica’s question, right?

Dr. Maki: She’s very complimentary. I like it.

Dr. Davison: We love Monica. No, thank you. Thank you for the compliment. Monica says my question is I’m currently going through perimenopause while back in July. My hormone levels tanked and I started having terrible problems with hot flashes and night sweats and after about three months and no period, the blood test confirmed that my levels were really low. I decided to go with a BHRT so bioidentical hormone replacement therapy and within a week, I could tell a huge difference. I do have a uterus and my current cream is a biased 50/50 ratio. Plus, progesterone plus testosterone. Does it look like the testosterone is 1 Point 8 milligrams combined with the second of what do you think about this? It says biased 50/50 plus P plus T 1.8 milligrams plus 200 plus 5. I get it. There’s a combination cream here that Monica has where there’s a bias 50/50 ratio. That’s 1.8 milligrams, which would be .6 milligrams of estradiol .6 milligrams of estradiol with 200 milligrams of progesterone included with 5 milligrams of testosterone.

In my second month of this, I started my period, and then in another 10 days, I started bleeding again for three weeks straight during this time. I was given a seven-day supply of a 10-milligram oral progestin. A lot of Doc’s does that to try to stop chronic bleeding. That’s pretty common, but unfortunately in Monica’s case, this didn’t help slow down the heavy bleeding. And I returned to talk to my doctor and I was told I was most likely not absorbing the progesterone which I do think she’s correct because it was a progesterone cream which doesn’t not that she’s not absorbing it. It just doesn’t have that effect on the uterus to prevent bleeding when someone’s taking some kind of estrogen component to it. In some ways, the docs right about that. During this frame of a few weeks of bleeding, I got in with my regular gynecologist for an ultrasound so she did a transvaginal ultrasound, even though she had already had one not too long ago in 2018, but everything was healthy and looked normal. I wanted to make sure that I was getting back on track and started taking oral progesterone. And then using the cream is this a safer option. It was also mentioned that I might consider pairing the Mirena IUD with the BHRT cream, which I understand she says here. I’m not crazy about that. I’m certainly not really crazy about that idea either but she goes on Monica goes on to say I’ve always had a regular cycle and no issues and only took birth control for a short time in my early 20s. I’m 47 years old and I’m hoping to get on the right track to have a well-balanced using the least I can but still feeling confident in making good choices. Any suggestions or feedback is greatly appreciated.

Dr. Maki: Excuse me. This is certainly a situation that we deal with quite often. She has a prescription. She’s she tells us that the end that she’s 47, and that would have been the first thing that I would want to have known when she says she’s in perimenopause giving a woman in perimenopause biased right off the bat, you’re going to probably run into this kind of bleeding issues fairly quickly. I know we always want to know how recent has been there menstrual history been has it been 3 months 6 months 12 months are they are skipping a month. Is it a couple of times a year? Because you put them right on biased right away and the bleeding is going to be potentially unpredictable.

Dr. Davidson: Exactly, she’s 47 I would you know, what a perfect world. I would say she’s probably more perimenopausal than actually true menopausal but she does go on to say she missed three months of a period and that when they did a blood test or hormones were low. So that is showing that she’s probably goes progressing which is what perimenopause is completely understood having those terrible night sweats and hot flashes. She’s not sleeping, she’s feeling bad. Those hormones have tanked. But like Dr. Mackey said is you know, she probably would benefit from a little bit of biased but a 50/50 ratio just you know, looking at everybody a 50/50 ratio of estradiol to estradiol is pretty strong normally in the beginning. We usually do an 80/20 where there’s 80 % estriol the gentler estrogen and only 20% of the estradiol which is the stronger form. For Monica being 47 and she’s put on a 50/50 ratio that might have been a little bit too strong for her to start in the beginning.

Dr. Maki: We would never start a woman that has never been on hormones before especially at 47 years old on a 50/50 ratio. Now the milligram amount does make a difference there. She’s at 1.8 milligrams. It’s only would you say .96, point nine.

Dr. Davidson: That would be .9 exactly.

Dr. Maki: Almost 1 milligram of estradiol. Like you said, an 80/20 maybe we’ve talked about this in a previous episode. Maybe even just a straight estriol cream because all she needs the estrogen for is to stop the hot flashes but not exacerbate any bleeding. Now the other thing that I know that you’re going to probably say this next the other thing that we don’t typically do is especially for our first time BHRT users. We’re not going to put all three variables estrogen are biased progesterone and testosterone into the same cream. We like to separate them out. We don’t like to use the cream at all specifically for this case, which she came to later her doctor gave her the oral progesterone we would have easily started her on the oral progesterone hundred milligrams and maybe with the idea of going up to 200 milligrams depending on you know, whether she started bleeding or not.

Dr. Davidson: Exactly. That’s like kind of two concepts. There is the progesterone as cream and you do it when you do progesterone is a cream you do absorb it through that skin membrane you do absorb it. It does go into the bloodstream, but it doesn’t really have an effect on the uterus like a capsule so that progesterone cream didn’t protect the uterus. And that extra estrogen on top of Monica’s taking made her uterine lining start to get thick hence, she had a period hence, she had another one 10 days later, hence. She had three weeks of chronic heavy bleeding and that’s why the progestin probably didn’t do much is because that had already kind of started that I guess you could say facilitated that cycle already that by the time they put in the progestin which I don’t really like anyway, it didn’t work. So definitely I like Dr. McKee said it is keeping that progesterone has a capsule in a female that has any kind of uterus any kind of BHRT with the uterus. We always use progesterone as a capsule and then like you mentioned is when you put all those variables together with the testosterone the estrogen the progesterone you have no way of balancing it. Let’s say this cream gave Monica ton of acne, got a pretty good amount of testosterone in there.

Dr. Maki: Again, for a first-time user giving her 5 milligrams of testosterone, right off the bat. I guarantee you; she’s going to have some hair issues some blemish problems and maybe start losing hair in a matter of about a month and a half.

Dr. Davidson: Then what do you do? You don’t necessarily want to reduce the cream that she’s taking because then you reduce the progesterone and estrogen component, but you don’t want it if she’s having more hot flashes, but she’s having acne. You wouldn’t want to increase the cream because then she’d have more testosterone. Then you basically have to take that cream throw it in the garbage and do a new one. That’s why we usually separate this out because being a 47-year-old female everybody is different every 47-year-old female is different what works for one is going to be completely different for someone else. Keeping those variables separate allows you to manipulate and be able to find the right dose for that person. And once you do then you can combine it together.

Dr. Maki: Let’s say we change it up a little bit. I guarantee you; I don’t guarantee. I can’t guarantee anything because it’s hard like you said in these situations are challenging. She’s still in that menstrual window where she Is transitioning from perimenopause and menopause her menstrual history is only three months ago. It’s almost a guarantee that you give her some estrogen. She’s going to have she’s going to start bleeding again. Now that is not a concern when you’re on when you’re taking hormones and even when you’re in perimenopause bleeding in that situation is kind of far for the course. It’s a normal process now gynecologist get a little nervous sometimes they want to automatically do a uterine ultrasound or a transvaginal ultrasound, but it’s not necessarily. It’s not really necessary right off the bat because she’s taking hormones so we know why she’s bleeding and looking at the prescription. It’s pretty clear like so from the beginning, let’s say we heard biased was changed when 80/20 ratio 2 milligrams. Just a straight number the progesterone was started out and I do this a lot. I’m not sure how you do the progesterone where she was started a hundred milligrams, take it for let’s say seven days if she feels maybe 10 days if she feels good double it up to 200, now she’s probably one going to help her sleep a little bit better. But right from the get-go, it’s going to protect that lining, she’s not going to bleed from the start as opposed to trying to fix it when it already started bleeding like you said a few minutes ago.

Dr. Davidson: And I completely agree with you, and keep the testosterone out in the beginning because I do like testosterone but I consider testosterone more like I always call it like the frosting on the cake like you don’t want to add the frosting until you created the cake. So that’s like the fun accolades of adding a little bit of testosterone here to really help that picture the help that that woman feel really good, but you don’t want to start off with testosterone because just on a side note is testosterone as a molecule looks almost mirror exactly the same as estradiol. Sometimes, when given female testosterone, it will aromatize and turn into estrogen and then they have more estrogen than they really think that they have.

Dr. Davidson: You’re right, and five milligrams as we already talked about five milligrams to start out is kind of a lot, some women can tolerate a whole bunch of testosterone. Some can tolerate very little, most women that we even have on testosterone. They’re usually not on even five milligrams. They might be on two-three, maybe four very fewer on five or above. Some are tolerated well, but the majority of them, especially when you’re starting out, for the even for the first six months maybe only on a milligram or two as supposed to start them right off the bat at five milligrams. That’s potentially going to create some problems that again you’d have to troubleshoot on the back end of that, two months in when she’s having a male hair growth that acne problems.

Dr. Davidson: And hair loss on the head exactly. And I do understand I’m glad she got into her gynecologist and talked with her gynecologist, and that she had that ultrasound and everything looked good. That’s good to know but you know the idea of doing an IUD a hormonal IUD, which is the Mirena is or the Kyleena or what’s the other one? Skyla?

Dr Maki: Skyla, it’s called Skyla.

Dr. Davidson: They’re all you know, they’re all IUDs. I do think they’re way better than doing birth control, but at the same time, it’s hormonal. You’re adding more hormones into a 47-year-old female that’s already taking some hormones. It just ends up being a little bit too much of a hormone salad.

Dr. Maki: Right, and you don’t like the progestin is anyways, taking bioidentical progesterone again if she would have started out that way with 1 to 200 milligrams of the oral capsule. She probably wouldn’t have been in this situation, to begin with, and we see these women that are approaching menopause being suggested to use an IUD. I just don’t understand that cause, I just don’t understand from a gynecology perspective. They have limited options at least what they’re used to and what they recommend to people and I just think that that’s a really bad option in most cases.

Dr. Davidson: Because the idea here, of course, is that Mirena that hormonal IUD will thin the lining of the uterus and she’ll stop bleeding a lot of women with IUDs don’t have any periods, or if they do, they’re very light because that lining is made thin. I’m glad that her gynecologist didn’t jump right into suggesting an ablation, which is also really common with somebody that’s having chronic heavy bleeding, but I can understand. She’s been bleeding for three weeks heavy. She’s probably anemic at this point for Monica that you’ve got to stop the bleeding. But when you look back on why she’s having the bleeding it’s definitely that progesterone and just like, Dr. McKee said maybe because this cycle has already facilitated itself that doing the 200 milligrams of progesterone might have been a maybe even a wiser idea than doing a hundred milligrams of an oral capsule.

Dr. Maki: Because as I stated in the beginning, she’s 47 her period was only three months ago. You have to take that into consideration. Now if she had not had a period for a full year right the likelihood of her getting a getting some bleeding back is still somewhat dose-dependent. If we put her on some of that let’s say hypothetically Monaco. Let’s fast forward five years. She’s 52. She isn’t a period for a year and a half and we put her on a high enough level of the same thing. We put her all-in-one cream three different things progesterone cream bias 50/50. She’d still have the same problem. More than likely.

Dr. Davidson: It might take a little longer. It might take more like four months before she had bleeding, but she would eventually with the way with having that 50/50 and not having the progesterone as a capsule. She would eventually have some bleeding and we always say don’t freak out about bleeding; we don’t want you to bleed all the time. Sometimes a uterus has a little bit of lining accumulated and just wants to clean house. Three days, once after starting BHRT but not as Monica’s having here three weeks straight. She started bleeding for 10, within 10 days. And then again three weeks straight heavy bleeding, that’s too much bleeding.

Dr. Maki: But I think this is also what gives BHRT kind of a bad rap and then kind of blame it on the BHRT and gynecologists get a little irritated by this kind of situation because they have to you know, fix it with the way they know how to fix it. But to begin with, I don’t think that her prescription was enough variables weren’t really taken into consideration granted. It’s a really tough place to be when you’re having hot flashes. But your menstrual history is still fairly either you’re still having a period or you’ve had one within the last six months, right? Because the bleeding even though it’s not serious. It’s still really inconvenient. It can lead to some anemia. It’s just, not something that a woman wants to deal with because it’s unpredictable, to give her practitioners that she’s going to see now, you know some credence. Because of where she is in her life in the transition that she’s in it’s a really difficult spot and to have all those hot flashes and night sweats and being miserable while you’re trying to work or take care of the kids or whatever. Just trying to be functional. She made the right decision to look into BHRT, but the way the prescription was done, it could have been done a little bit differently, and hopefully, then it would have provided her with the relief that you wanted.

Dr. Davidson: Because she’s an individual so this dose didn’t really work well just like we said, as well and just like she did here which is great, taking the progesterone as a capsule, and then possibly after she’s gotten this into her bloodstream after about a month is retesting those levels because she is perimenopause and that’s the interesting thing about being perimenopause as opposed to post menopause is those ovaries are like little gremlins they want to work full time, they want to work part-time, they want to go vacation they don’t want to work at all and then they come back full blast. Your kind of following them a little bit, as opposed to somebody that’s postmenopausal in those ovaries are like we’re retired were done then whatever you’re giving them is actually that dose. So that’s where I would definitely test her levels again after she’s been on the new hormones for about a month.

Dr. Maki: And initially when she goes into see the practitioner of the first time looking at her FSH level because she’s only 47 or period is three months ago, her FSH if you had to guess where her FSH is what would you say? What would you guess?

Dr Davidson: FSH was probably in the 50s. But this is really interesting is I’ll test a females FSH or the follicle-stimulating hormone. It’s a signal from the brain kind of monitoring the overall ovarian status and the higher the FSH the close to, the lower the ovarian functioning is her FSH was in the 50s where you think a fertile female menstruating cycling just fine and their 20s, they’re FSH is usually around two and a half to five, you know, right around there.

Dr. Maki: Very low.

Dr. Davidson: I would definitely say that hers was in the 50s. But like I said, what’s interesting is I do a lot of FSH is with females. I do it a lot more than I think you do is I’ll see somebody; a perimenopausal female. I’ll see their FSH in the 50s and then I check it again three months later and it’s 19.

Dr. Maki: Right now. Is that after hormones or is that just a change that you notice?

Dr. Davidson: No. That’s just they’re feeling fine hear Monica’s having some symptoms, but let’s say their symptoms are minimal. We’re working on some adrenal things. We’re working on some thyroid levels. And I say okay, let’s you know they might have had a period every other month. I’m like let’s hold off before we throw you into that, hormone soup is let’s hold off for a second and then let’s check it again and we check it again and sure enough. It’s down at 19 and then we check to keep following it and hey, it’s you know, 12, 19, 13 and then it popped back up to 40 and that’s because the ovary sir, they’re vacationing or they’re working full-time or the working part-time. We’re following that because I find that when I give a female hormone that they don’t need right away. They don’t feel that great. They get puffy. They get munchie. They gain a little bit of weight. You know when somebody needs a hormone is when they do feel good when they’re sleeping better when they lose a little weight when their mind is working when their libido goes up. It does sound like Monica liked the overall wellness and her hot flashes went away. Definitely, BHRT is something that’s really good for her. It’s just finding the right dose.

Dr. Maki: You’re right. That’s the difficult part. That’s the part. We have to take all these you could take our stress. You got it to take her age. You got to look at her menstrual history. You got to look at you even asking where mom went into menopause. How old was mom when she went into menopause, was she on the early side, was she a little bit later even grandma will be a similarity between a grandma mom and daughters of when they start to see because perimenopause 30 years ago no one even heard about anything like that. Now, this is the other thing too that happens around this age too because what you’re talking about the FSH. FSH is a pituitary hormone in your brain that is released and that communicates with the ovaries to tell them to produce estrogen and now as a woman gets around this age to their late 40s to the early 50s as that signal as the ovaries like you said are on vacation and stopped responding that deaminated FSH levels keep going up eventually the ovaries kind of kick in and they do what they’re supposed to do. Women very often start having heavy bleeding in their late 40s and now sudden doctors are kind of freaking out when there should be approaching menopause also in their periods heavier than it’s ever been, scaring women a little bit, thinking like there’s a major problem going on again. Going into the transvaginal ultrasound thinking you might have uterine cancer that that’s a normal process that is not a cancer-producing process. It’s just the way the body works, even though it doesn’t seem really counterintuitive that you’re going to have a heavier period right at the end but it’s because of how that feedback loop works between the brain and the ovaries. And again, that’s why you’re probably seeing these FSH levels on lab test jump around so much because the brains doing what it’s supposed to do. The ovaries are just being stubborn and eventually the signal kicks in and all of a sudden now that estrogen threshold is being met and they have excessive bleeding than they used to have.

Dr. Davidson: Exactly, because that is one thing we didn’t mention is in perimenopause is the progesterone always drops, you hit 44, 43, 46 that progesterone plummets, but the estrogen doesn’t always do that at my drop a little bit so that excess estrogen will cause a thicker lining just in general not even Monica or anybody being on BHRT it just that you see in that perimenopausal phase. It might have sort of had in doing this biased 50/50 ratio without oral progesterone might have just accelerated that process.

Dr. Maki: Sure. I think we hash something out pretty well. Do you have anything else to add?

Dr. Davidson: No, thank you, Monica, for sending in your question, and was this in response to a Blog article that she read?

Dr. Maki: This was a blog post. The blog post title is. How does biotechnical progesterone help which is exactly about this issue and we have a couple, other ones that are about cream versus capsule because of these kinds of questions they just keep coming up over and over and over and we look at these prescriptions which we see all the time and it’s not that our way, is the best way there, that’s the one thing when it comes to hormone replacement it is you talk to 10 doctors, you’re going to get 10 different opinions, everyone has their style of how they do it. But at the same time, there are some glaring differences in this situation and all the other ones we talked about. That’s why we talk about them because it’s not that the other doctors are doing something wrong necessarily, it’s just we don’t agree with how they’re how the prescriptions are being delivered or constructed and we’re just giving opinions and I think in this one, at least this one, the fact that there’s something that we can discuss about it. Like there’s something that we can say would have done this different, would have done that different and then that would have hopefully protected from the bleeding. That’s why we talk about these questions because now everybody goes back to the practitioner, like wait a minute, you know, what about this? What about that? They can be informed and ask the right questions because we get a lot of people like Monica, they end up coming to see us as patients because they’ve been through this process and they’re just not getting to where they want to go. They feel better in some ways, but other things come up in a lot of times practitioners don’t necessarily know how to troubleshoot once there’s a problem.

Dr. Davidson: Exactly. Thank you. Thank you, Monica, for reading and for all you, listeners. Thank you for listening. I hope this helps some people like you said help people, learn. We’re all learning, right? We’re always all learning,

Dr. Maki: I know online learning is online everything is going up these days with all the locked-down pockets that’s going on. So hopefully everyone surviving through all of that, until next time. I’m Dr. Mackey.

Dr. Davidson: I’m Dr. Davidson.

Dr. Maki: Take care. Bye, bye.

The post Can You Take BHRT During Perimenopause? | PYHP 085 appeared first on .

Is Insomnia Related to Hormones? | PYHP 084

Dr Valorie Davidson and Dr Robert Maki — Thu, 23 Apr 2020 23:36:37 +0000

Marisa’s Question:

Dr. Davidson and Dr. Maki,

I truly appreciate what you are doing to share your information with the public!! You are helping many people learn more about their body!!

I wasn’t sure the best place to ask this question or where you may answer it, but I found your podcast after I have been digging into how to repair adrenals.

I was elated once I found your Podcast #69 Adrenals affecting sleep. The Ghost, defined me to a tee and I wanted to learn more on how to get better from my symptoms you so clearly described.

My main concern is that I wake up almost every night at 2:00 – 4:00 am and my neck is tight and my heart is beating a little heavier. If I focus on breathing, I can go back to bed shortly thereafter, but some nights it does take a little longer. I may wake up another time or 2 after that as well. Is this hormonal or adrenals?

All my hormone levels are low, except for progesterone is healthy (169.) I have taken the ZRT test with almost normal cortisol levels.

TSH is too high at 5.3, free T3 – 3.2, and free T4 – 1.2.

I take Armour Thyroid at 60mg. Vit D is 60.

I am 44 years old female.
My blood sugar is typically in the 80’s on my morning reading when I check it on a glucometer.
I eat mainly vegetables and focus on all food groups.
I have been focused on adrenals for the past 2 months and have been sleeping at 930pm and sleep for about 8 hours.
I do exercise every other day, but take it easy to not wipe myself out. Body weights and walking.
Pharma Gaba/L’theanine has helped me get back to sleep, but not from waking up.
I also take Ashwaghanda and practice meditation and breathing exercises.

Again, any guidance on what to look at is appreciated. All the tips you mentioned for how to help on the podcast I have already been doing for over 1 year.

PYHP 084 Full Transcript:

Download PYHP 084 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 on this one, we have actually a question from Marisa. She reached out. Honestly, it was a very nice email. She just found one of our podcast and it was episode 69. I believe it was where we went into talking about sleeping with adrenal issues and after that, she sent a very complimentary email and she gives quite a bit of detail, but I felt like it was worthwhile for us to discuss. Not only that she took the time to send us the email but it is also because she does give some detail that I think as we were trying to here a lot of people can learn from her experience.

Dr. Davidson: And on episode 69, we talked about the adrenals and sleep and we have some kind of characters we deemed as part of the adrenal fatigue causing sleep issues. We have the zombie which sleeps all night and all day, could sleep forever 24/7, and then we have the vampire which tough, tough time waking up in the morning but come evening time. They are alive. So, vampire, zombie, and then what Larissa which I’m going to go into her question here in a second is a ghost. So, we have a ghost which is where you fall asleep just fine, no problem, but you wake up in the middle of the night whether it’s once for a couple of hours or several times throughout the night.

Dr. Maki: Yeah, right, and if you look at that, if you listen to that episode, we do kind of break up the ghost into two. The Poltergeist and the ghoul which are two different versions of a ghost. Because of those subtle differences like you said and I don’t remember which one it is, now I have to go back and listen to myself. So which one is the one that wakes up for long periods of time?

Dr. Davidson: So that was what we named the ghoul because you wake up and you’re like roaming the halls as we say on their maze, basically roaming your smartphone in the middle of the night for an hour or more because you’re wide awake. Where the poltergeist is kind of like a little Gremlin, a little mischievous will just wake you up all night. You’re up hour later, I’m up for five, ten minutes, fall back asleep, then I’m up. So you’re waking up here periodically throughout the night. Unfortunately, we do have some people that are a combination of poltergeist and the ghoul, but in terms of being a ghost, being a zombie, being a vampire, on that episode when we’re talking about the adrenals were really talking about the diurnal curve of Cortisol.

Dr. Maki: All right, so I’m a ghoul right and it’s safe to say that you’re definitely a poltergeist.

Dr. Davidson: I have been in the past, I’ve gotten better but being a perimenopausal female, if you look at pretty much overall perimenopausal females, they fall more into the ghost category where younger people fall more into the vampire category and then just very fatigued, very adrenal stress chronically adrenal stressed people over a long time. They end up turning into a zombie. So, if we were to really go into it, the vampire the ghost, will eventually at some point if you don’t do some intervention can possibly they all turn into zombies at the end of the day. So that’s a really neat episode, so as we’re talking about Marissa and her question if you aren’t quite understanding, you can always go back and listen to podcast number 69. So, we wanted to give you a little background as weird as we’re going through it, but basically like I said, the sleep issues on episode 69 come from the cortisol levels, the diurnal curve of cortisol where in a perfect world, your cortisol comes up nice and early in the morning. So, your bright-eyed bushy-tailed and then it stays up and comes down and then really nicely comes down very low in the evening time, so that we can fall asleep and stay asleep. And then that cycle is happening every day.

Dr. Maki: Yeah, right. And putting those characters to it is a little bit of tongue-in-cheek sort of way so they’re memorable so you can identify. Like you just said, when I was in my 20s, late teens and twenties, I was a total vampire. I used to work at a hospital night shift because I was just awake all the time, but then I could literally sleep all day and I did that for a long time. You actually turn me into a non-vampire because you’re always been kind of up early in the morning, and I just eventually kind of followed suit, but I was a proverbial night owl for pretty much my entire 20s even into my early 30s, I think I was a vampire.

Dr. Davidson: We’re not making fun, it just seems easier to talk about adrenal fatigue One, two, three, four, five A, B, C, D. All that is just putting a little bit of some character to it is memorable for somebody to remember and we’re not saying all the ages, early as vampire midlife is perimenopausal females are ghosts and then eventually everybody turns into a zombie. I don’t want to be so distinctive is that like for example, my sister-in-law, she’s a total vampire and she’s in her early 50s. She can’t get up till noon and stays up till 3, even though she says “I really, really don’t want to do this. I really need to wake up earlier. I just can’t”, and it really is because she is a true vampire. She’s turned into a vampire because of the way her cortisol levels are. So in a vampire, your cortisol levels are low in the morning which is why you can’t get up and you want to sleep and you have this relationship with snooze over and over and over but come nighttime, you can’t even remember why you were so tired in the morning because you finally feel awake and alive.

Dr. Maki: And then might not be till like midnight.

Dr. Davidson: Yeah, exactly.

Dr. Maki: Usually after 10 o’clock and now they feel alive and it’s midnight when you should be sleeping and now they finally feel awake. That process and I think with all three of them, but certainly with a vampire and the ghost for sure, if you want to speak in a physiologic language, it’s what they call a reverse diurnal curve, the curve has flipped. So, instead of having high cortisol in the morning and low cortisol at night, you have just the opposite. You have low cortisol in the morning and high cortisol at night and it just completely flips upside down. Now if everybody went camping for a month, that’s a long time to go camping. But if you were in the woods for a while, no ambient light, no cell phones, nothing, which in some ways is kind of little anxiety-provoking even thinking about that to some extent because we’re so attached to our devices that most of those problems would just disappear because there’s nothing that would interfere with those normal circadian rhythms.

Dr. Davidson: Exactly and honestly camping is always very peaceful and relaxing so, taking that stress of life and away from your adrenal glands would definitely help that diurnal curve so that cortisol comes up in the morning and comes down. But for Marisa, her question that I want to read is she’s saying “Hey, I’m a ghost.”

Dr. Maki: Yeah, right, right and she did say that it kind of describe her to a tea. And just from experience, that’s why we kind of put them together that way because we see these patterns over and over and over, and unfortunately when you go see I have a sleep study or goes to your endocrinologist or your gynecologist or your GP. They’re not going to tell you that you act like a ghost or you act like a vampire. So, it’s just a different sort of way for people to identify and once you identify, now what the problem is,

being a vampire is not a diagnosis, but the term adrenal fatigue or adrenal dysfunction is too broad of a topic because there’s a lot of issues and symptoms that show up underneath that umbrella that I think people are not clear with both the patient on the patient side and certainly on the practitioner side. Now granted, in our world being in functional medicine and being naturopaths, the adrenal issue is pretty clear, but conventionally, they don’t even believe that unless you have Addison’s disease, they don’t even believe that any of these problems even exist. So they definitely happen a much more of a functional practical level than an actual diagnosis. So for a lot of people that are trying to get results or trying to get some improvement, that’s a really challenging thing to do.

Dr. Davidson: Absolutely. I mean, we always want to work on sleep and when you look at adrenal fatigue, it’s not just about sleep. There are so many issues that go under adrenal insufficiency, adrenal dysfunction, adrenal fatigue. But you’re right, your typical conventional doctor, you got to love them. They probably aren’t going to view it that way if you go in and say hey, I have trouble sleeping or I wake up in the middle of the night for an hour and a half. They’ll probably say hey join the club, me too, here’s some medication.

Dr. Maki: Yeah, right. Yeah, and we’re not fans of any of the sleep medications because we think that they kind of provide fake sleep and even some of the other anti-anxiety medications and other things they use for sleep, those have kind of a slippery slope where once you start going down that path then you’re going to have some issues there on a long-term basis. If you’re on a plane or if you’re traveling somewhere and you maybe have some jet lag, okay, fine, use them very sparingly, but that’s why we’re going to talk about this just because I think that it’s a lot of people can relate to it, especially with all the stressful things that are going on these days.

Dr. Davidson: So let me go ahead and read you Marisa’s question or her email. It’s a little long, but I think it’s actually it’s very complementary. So, I’m blushing and I love her already with what she says because she says, “I truly appreciate what you’re doing to share your information to the public exclamation mark, exclamation mark. You’re helping many people learn about their body.” She’s so awesome. Thank you, Marisa. And so now it says, “I wasn’t sure the best place to ask this question or where you are or where you may answer it, but I found your podcast after I’ve been digging into how to repair adrenals. I was elated once I found your podcast number 69 adrenals affecting sleep. The ghost defined me to a tea, and I wanted to learn more about how to get better for my symptoms as you so clearly described. My main concern is that I wake up almost every night at 2:00 to 4:00 a.m. My neck is tight and my heart is beating a little heavier.

If I focus on my breathing, I can go back to bed shortly thereafter. But some nights it does take a little longer. I may wake up another time or two after that as well. Is this hormonal or adrenal? All of my hormone levels are low.” So it’s actually pretty great, Larissa goes into her hormone levels here. “So all my hormone levels are low, except for progesterone is healthy at 169. I’ve taken a saliva test with normal cortisol levels. My TSH is high, the thyroid-stimulating hormone is high at 5.3, my free T3 is 3.2. My free T4 is 1.2. I also take Armor Thyroid 60 milligrams and my vitamin D level is 60.”

Marisa goes on to describe she’s a 44-year-old female, her blood sugar is typically in the 80s in the morning when she checks it which is amazing. And then that which is also pretty amazing as she eats mainly vegetables but still focuses on all food groups. “I’ve been focusing on my adrenals for the past two months and have been sleeping at 9:30 at night and sleep for about eight hours. I do exercise every other day, but take it easy not to wipe myself out.” Body weights and walking which is the best thing you can do for your adrenals because you’re not pumping that cortisol all crazy with cardio. Anyway, that was my comment, not Marissa’s. Marissa goes on to say, “I also take ashwagandha and practice meditation”, my comment, love meditation, “–and breathing exercises. Again, any guidance on what to look for is appreciated. All the tips you mentioned for how to help on the podcast. I’ve been already doing for over a year.” And she does say that she takes the Pharma Gaba and the L-theanine which is what we also talked about on episode podcast 69 which helps her get back to sleep, but it doesn’t help her from waking up.

Dr. Maki: Yeah. So a lot of detail, we really appreciate that in this context. Now disclaimer, well, of course, we’re not giving any medical advice, Marissa, of course, is not a patient of ours, this is intended to be educational. So, people that are having similar situations, in our patient base, women that are in perimenopause, so basically women in their 40s, this is kind of a would you say a fairly common case for us.

Dr. Davidson: She’s 44 years old, typically, perimenopause can start anywhere in your late 30s or even to your late 40s, everybody’s different. But right around the mid-40s is when you start to see those female hormones change, so definitely as me speaking as a perimenopausal female myself, is sleep is probably one of the first things that you notice and basically it’s no trouble falling asleep. I mean go to bed in a second but give, 3 to 4 hours later after you’ve been sleeping fairly well, you’re up and then from there on it’s either you’re up for an hour and a half, and then when you finally do go back to sleep, it’s not the greatest sleep, but then you got to wake up or you’re just up periodically throughout the night. So when you look at someone’s sleep schedule in their mid-40s, they really only get about four hours of good sleep, which is definitely a sleep debt.

Dr. Maki: Yeah, right and what we’re trying to do with pretty much every patient, no matter if they’re in their teens, 20s, 30s, 40s, 50s, it doesn’t matter. The sleep in the first 30 days is or maybe even the first three months is what we’re trying to focus on because as you said a few minutes ago, everything falls off the sleep tree. Your insulin sensitivity, your cortisol balance, your energy, your mood, your weight. Everything is going to come off of that and sleep and now granted that’s a midpoint, right? We all know sleep is important, but how do we get there is really the challenge. How do we actually achieve good quality sleep? Our intake forms with a patient, I always ask as a letter grade. If you had to give your sleep quality a letter grade, what would it be, and invariably women just like Marissa always grade their sleep somewhere between an F to a C minus. I’m usually it’s an F or a D on which is part of the reason why they’re coming to see us because they can’t seem to figure it out or improve it anyway and our goal is to get them to a good solid B on a nightly basis. What does that look like? That looks like they go to sleep at a reasonable time. What does a reasonable adult bedtime for most people?

Dr. Davidson: Well, I have a child’s bedtime at nine o’clock or maybe even a little earlier.

Dr. Maki: A little earlier.

Dr. Davidson: Yeah. I like to wake up early. But I would say a reasonable adult female bedtime, ten.

Dr. Maki: Yeah, right. So people work late into the evening, they get home. They got to decompress. Maybe they got to cook dinner. They got to take care of the kids. They got to do whatever, they have to have a little bit of time for themselves, right? And a lot of times people are waiting to get tired. They’re waiting to get sleepy and then that’s why they end up staying up for a few extra hours than they do need to so instead of going to bed at 10:00. They’re going to bed at 11:30 midnight or sometimes even later than that. So, we usually say between 10 O’clock in the morning until five, six in the morning when people have to start getting up that’s roughly about an eight-hour window. We want them to have a nice chunk of sleep. So, roughly three to four hours in the beginning part of the night, if they do wake up, preferably one time, no restroom if possible, then they’re able to fall back to sleep quickly and they sleep again for another three or four hours. That maybe best-case scenario for some people to say you’re going to sleep eight hours straight like in Marissa’s case, that might not really be realistic, but as long as the time that you are waking up is short, you roll over, you reposition, you go back to bed, you drift back off and now you get another nice few hours. From an adrenal perspective, from just good quality sleep perspective, now we’re in the ballpark.

Dr. Davidson: So, Marisa is saying that her saliva test for her cortisol levels were almost normal. And in those in those tests are great, saliva tests are extremely accurate for testing your cortisol levels, but the reference ranges can be a little bit vague because what I tend to find is that especially with the ghost is that their cortisol is actually pretty good in the morning which is why they get up and get going. It drops in the afternoon, which is why ghosts tend to want to get everything done by noon or 1:00 in the afternoon.

Dr. Maki: It’s you. You’re done by noon.

Dr. Davidson: I’m a morning person. But they have that cortisol that drops and then it looks what you’ll see on a cortisol test saliva test for that for the ghost is you see that it drops in the afternoon, but the cortisol is normal in the evening at bedtime. So it goes where you say, “Hey, it’s normal.” But really what happens is when you see it deep in the afternoon, but it comes up to normal in the evening time. That means that it’s bouncing all night long, which is why the sleep isn’t very well and so I would love to have a look at Marissa’s cortisol test because I bet her cortisol at night is normal, or maybe even just a tiny bit elevated, and that’s why she’s saying that her neck is a little tight, that her heart is beating a little bit heavier is when you have those catecholamines or adrenaline cortisol, the stress hormones in your system, that’s what it’s supposed to do.

Dr. Maki: Yeah, right, and when you are stretched a little thin, right? Maybe you’ve got some stress at work you’re at over-exercising. She says she’s exercising every other day, so she’s clearly not pushing yourself physically too much when there’s not necessarily enough cortisol to go around, her blood sugar is listed at 80. I’d be curious to see if she in the past if she’s ever had any low blood sugar symptoms. Shaky, jittery, headache, that hangry feeling, needing food right away. I would probably bet in the past, she probably has. That is very often an indication of low adrenal function. People that get dizzy, they sitting down on the couch, on the kitchen table, whatever, or maybe their desk at work, they stand up really fast to go do something and all sudden, they get a little dizzy. They have to hold on to something to kind of catch their bearings, that’s also a sign, we call that postural hypotension. It’s another sign of low adrenal function. So if that’s the case, that’s why in the middle of the night, she’s having literally a little bit of adrenaline released into her bloodstream, which is why her heart rate increases and her neck tightens up because it’s like an unnecessary sympathetic response at her body really can’t help it so when there’s not enough cortisol go around, for whatever reason, the body dumps in a bunch of adrenaline unnecessarily and you start having these physiologic changes as a result of that.

Dr. Davidson: And just we’re talking about the adrenals with Marisa. So definitely those adrenals we want to balance that cortisol. Bring bring it up more than likely probably that afternoon, late morning afternoon bring it down at night while she’s sleeping, but there’s probably a little bit of an impact on her adrenals coming from her thyroid because her TSH the thyroid-stimulating hormone is pretty high up there, it almost five and a half at 5.3 that’s showing that her thyroid level is still probably on the low end and low thyroid is going to put more of a stress on those adrenals because they work together so finely tuned.

Dr. Maki: Yeah, and she’s on medication already and her TSH is still 5.3. So she’s undermedicated and more than likely with a TSH like that with medication, she probably has Hashimoto’s, she probably has the antibodies either anti-TPO, anti-thyroid globulin. Now that doesn’t necessarily add too much complexity to it, but it gives an idea. Hey, there’s an immune system issue going on here very very common to see a TSH a high normal or kind of stubbornly high and granted there is definitely an adrenal connection to that. Now typically, in a person that got a very active lifestyle, they’re doing all the things right. She’s doing a lot of things, right? We would expect their TSH to be low and normal like right around one even maybe even below one, very common to see that in women particularly women that are exercising a lot. So heard having a TSH of 5.3 which is actually abnormal, average range only goes up to 4.5, I would say huge red flag, but it tells us that hey there’s something going on here. So in a case like that, we would actually switch and increase her medication, we want that TSH to be lower. Now, her free T3 isn’t bad at 3.2. That’s pretty reasonable. So this is a case where we would actually pay attention to the TSH, even though just because obviously it’s too high so that number definitely needs to go down.

Dr. Davidson: So those of you probably already know but to those that may not, is a thyroid-stimulating hormone as a signal from the brain and it works in a negative feedback loop that if the TSH is high that means the thyroid function is low and reverse if someone has a very high thyroid or they have Graves disease or hyperthyroidism, then you see that TSH almost non-existent. So that’s why when you see Marisa’s TSH high at almost five and a half that distinctively says, “Hey, she’s got hypothyroid.” Maybe even Hashimoto’s, she’s probably under dose so, the first thing would be readjusting that thyroid also treating her as an individual not just numbers on a piece of paper, but it’s definitely a signal to say, “Hey, we got to work on the thyroid as part of our treatment plan.”

Dr. Maki: Right, so adrenals definitely supporting adrenals in the morning by raising cortisol in the morning. It automatically lowers it at night right because all hormones in the body have a cycle to them. They rise and fall rise and fall rise and fall. Hormones are never static except when we dosed them in menopause. That’s the only time that hormones become somewhat static is because they’re just not producing as your progesterone anymore. That’s an exception, but pretty much all the other hormones, insulin, cortisol, female hormones, testosterone, they all oscillate over the course of a month in a year and a lifetime. So, by supporting adrenal function in the morning, trying to raise in the morning and lower it at night, eventually, that reverse diurnal curve comes back into balance. So, usually dosing adrenal type things whether you’re using glandulars, you’re using licorice or other adaptogenic herbs you’re doing that in the morning up until noon, so you get a nice rise[?] to the cortisol and then you’re using other herbs and other things like she said Pharma Gaba, L-theanine. There’s a bunch of other things you can do.

Dr. Davidson: [inaudible]

Dr. Maki: Yeah, there’s a bunch of other things you can do. Ashwagandha, you use that night, Magnolia. There’s a bunch of other herbs you can use to lower it at night and now eventually, it takes a while, eventually, that pattern starts to reproduce itself. Now she did say or hormone levels are all low, except her progesterone. What do you think about that?

Dr. Davidson: Well, it’s interesting because Marisa is 44 years old. So she’s probably still cycling, so she’s having a period. So when you do a blood test for hormones, or even a cortisol test or any test, that’s one day of your 28-day cycle. We don’t know where she is in her cycle. So she could have been in the early phase. That follicular phase day 1 to day-12. She could have been in the luteal phase from day 14 to day 28. We don’t really know, but typically most women right around their mid-40s have a drop in progesterone. It’s pretty much across the board. And when you drop that progesterone that tends to cause cortisol to come up at night which is why perimenopausal females have trouble sleeping in the middle of the night. It’s not hot flashes like in menopause. It’s not night sweats like in menopause. Its perimenopause with the estrogen is fine, maybe a little lowish, but the progesterone is low. So even though she says hers is healthy and that it’s normal. They’re at 169. I’m not so certain and of course, I don’t not really sure what the units are with that 169. Usually, it would be interesting to see, but I would say when did you have that test for your progesterone, and I really think it’s probably low.

Dr. Maki: Yeah, right. I don’t think that it’s actually the opposite. It says that it’s healthy but in a 44-year-old woman, that’s just really unlikely especially if she’s having some sleep issues, especially if she’s living an active lifestyle and has just even normal stress like everybody else because this is the kind of situation we see over and over and over and over. So I disagree with the progesterone as you do, it is a little bit of a miracle what alumina thyroid the type, the right dose of the thyroid and some bioidentical progesterone can do for a woman like this.

Dr. Davidson: Yeah, absolutely bioidentical progesterone not conventional or any progestins or any of that garbage but bioidentical progesterone would be really nice and also some people we have a lot of people that can’t take progesterone, they’re sensitive or unique or whatnot is possibly doing some not necessarily hormones but like herbs that help stimulate the luteinizing hormone which then stimulates progesterone which we probably could go on an hour about luteinizing hormone follicular stimulating hormone all that. But really like Vitex, and chaste tree berries a beautiful one that stimulates that can help kind of augment progesterone. I find evening primrose oil, which doesn’t have any hormones in it seemed to sort of balance that a little bit as well. So that might be a nice option.

Dr. Maki: Yeah right. Evening primrose contains gamma-linolenic acid, which is an omega-3 fatty or which is an essential fatty acid. Not omega-3 It’s actually an omega-6 but it’s in that category borage evening primrose. Those are all contained Gamelin again linolenic acid, which has some very significant anti-inflammatory properties also using GLA in the dry eye and that has been coming up. There’s a kind of a tangent. There’s a product that people have been using for a long time called bio tears. And one of the main ingredients in that product is Gamelin is a source of gamma-linolenic acid. So just that’s what like for example PMS, PMS is in some ways kind of an inflammatory process. So you take those essential fatty acids and helps to kind of tone that down a little bit and it actually has an effect on certain and inflammatory enzymes. We’re not going to go into right now, but certainly can be helpful in a situation like this.

Dr. Davidson: In the Pharma Gaba and the L-theanine, so I kind of use those a little bit differently l-theanine, I’ll use in the evening and I use l-theanine all day if you’re stressed out you get an email or you have a chronic issue going on of stress, L-theanine can really calm you. If you have a speech to give you can take L-theanine right before, it doesn’t decrease performance, but it just kind of brings down the anxiousness, it brings down that stress. So that’s a nice thing for people to take if they’re kind of stressed out and they have a lot of things on their mind at night. I love Pharma Gaba because that helps bring down that cortisol and relaxes you sometimes I’ll use Pharma Gaba more in the middle of the night.

So if you’re waking up at 1:30, 2:30, 3:30, you can take a little Pharma Gaba to help you go back to sleep quickly, but then you won’t make you feel groggy or tired if you have to wake up five, six, or seven but so I would say maybe it might not be a bad idea for somebody in Larissa’s case like this where the Pharma Gaba is helping her get back to sleep, but it’s not keeping her from waking up is like we had talked about earlier is doing some other kind of relaxing or calming adrenal supplements. I like phosphatidylserine, that’s a great one to take in the evening time to kind of help keep you sleeping, but just on a side note, as a female in her 40s myself right now, we’re like late 40s, but getting, getting to the late 40s but I wish a lot of us and we’re girls we have smaller bladders. It’s really hard to not have to go to the bathroom once a night unless you’re stop drinking water at 6:30. And then you’re dehydrating you wake up a little dehydration headache. So, I would wake up go, to the bathroom, lay back down, and then go back to sleep. And that’s I think that’s reasonable.

Dr. Maki: Yeah, right. Like I said earlier when we’re trying to get someone, we’re not going to get them necessarily if they’re already having sleep trouble getting quality sleep is probably not going to happen, but that one time of night where they have to wake up and if they do have to use the restroom as long as they get that chunk before and the chunk after, that way, they’re getting as much uninterrupted sleep as possible. That’s the key to be able to get down to those proper restorative stages of sleep that are necessary and we need to get what three to five of those cycles a night and if you’re waking up every 90 minutes or every hour, you’re not going to get to any of that restorative sleep and now that’s going to spill over as we said, and then everything else that we do. Another little trick or another little clinical pearl is using another amino acid besides L-theanine. I like to use it in addition, I like to use glycine, especially if you’re waking up in the middle of the night with those racing thoughts, You wake up, you’re panic, you’re thinking about your to-do list the next day and all the million things you got to get done. Glycine is in a powder form, not capsules, but in a powder form so you can control the dose of a little bit more effectively that can be a great way to, again, have an effect on cortisol kind of calm the mind and now that adrenaline response doesn’t happen the middle of the night.

Dr. Davidson: Oh, yes. Definitely Glycine and it doesn’t taste bad. It comes as a powder. I tell people to put it like in a water bottle maybe drink a little if they’re kind of having some racing mind before they go to bed. They could drink half of the bottle put it by their bedside table. So if they do wake up with maybe their hearts beating and they’ve got some thoughts in their head or feeling a little stressed out for waking up that morning, then they can just reach over and drink the rest of it.

Dr. Maki: Yeah, right. So, we’re kind of following through the way that we think about cases like this. So, we talked about adrenal function morning and evening. We talked about adding in some progesterone possibly, talking about switching and increasing her thyroid medication. Now, there’s nothing wrong with armor. There’s nothing wrong with MP thyroid. There’s nothing wrong with [inaudible]. Those are fine. We do use them quite often. We prefer to use compounded thyroid and in her case with her TSH, the goal for her TSH would be right about 1. So, when you’re switching medications like that, the conversion is not an exact conversion. So you just have to use a little bit of experience and switch an increased simultaneously and then tweak that dose over time. So probably takes about anywhere from a couple of months to maybe up to six months to get that dose right so, when you make that increase, you don’t overshoot the mark and she becomes overmedicated, but her TSH definitely needs to come down.

Dr. Davidson: I absolutely agree.

Dr. Maki: Yeah, so, one last thing that I think would be important just to mention, she says diet-wise, her blood sugar in the morning is typically 80 which is very good.

Dr. Davidson: It’s really good.

Dr. Maki: But it’s almost kind of borderline too low, right? It’s almost when you see, now granted, she fits the profile of where an 80 blood sugar is actually her normal, right? Because that’s where blood sugar is supposed to be in let’s say the 80s anywhere is usually a really good number. Now, occasionally, as I said a few minutes ago, those patients that have hypoglycemic type responses during the day. They go a few too many hours without food and the ones that have that problem know who they are, right? They cannot go more than three or four hours without food. But when in the morning when you see a fasting blood sugar and it’s in the 70s or even in the 60s, now, that there’s something going on there. So she’s right on the cusp of that of it being even though it seems normal, it seems almost excellent, it’s almost too excellent. And that’s where it kind of raises some red flags and cortisol’s main job in the body, cortisol’s number one job, it’s classified and we’ve said this on the other podcast, but it’s classified as a glucocorticoid. So, it is a steroid hormone that affects blood sugar. That’s what cortisol’s job is so, insulin will bring your blood sugar down and cortisol plus a few other hormones will actually bring your adrenaline as the other one will bring your blood sugar up. Okay.

So if there is a lack of cortisol, there’s not enough cortisol to go around, that’s why your body kind of steps in there and dumps in a bunch of adrenaline and now becomes your cortisol rising is normal, right? We don’t become symptomatic from that, but your body dumps in some adrenaline because it doesn’t have any cortisol left. That’s where the symptoms come from. Now. We’re not necessarily physiologists and we’re just kind of talking this little bit off the cuff. So we’re not trying to be exactly accurate. This is more in a practical sense so people can understand we’re not trying to talk over anybody’s head. But we’ve all known someone that fits that kind of situation. I think Marissa, my speculation would be that she probably does fit into that to a certain extent and she says dietary. This is the point that I wanted to bring up. She eats mainly vegetables but focuses on all food groups. From my experience that she is probably under eating on a regular basis. You cannot sustain yourself by eating mainly vegetables. There’s not enough essential fatty acids or essential amino acids in that kind of a diet. Not to mention, she’s probably calorie deficient, and if you are in a chronic clerk[?] deficit on a regular basis, that puts a huge amount of stress on your adrenals. It’s almost invariable and that’s something, again, this exact age bracket is something that we see all of the time. We’re trying to do everything right, trying to eat less, exercise more, to maintain your weight because once you going to perimenopause, it’s very challenging to maintain your weight, and now that turns into its own problem on the back end.

Dr. Davidson: Exactly. I mean I can understand it. She’s 44 years old, she’s hypothyroid, her thyroids underdose. So she probably has to maybe focus a little bit more on vegetables to maintain her weight just because her metabolism might be slow just because of the thyroid, the female hormones, and the adrenals. So honestly, it doesn’t mean Marissa, stop eating vegetables, vegetables are awesome, they have lots of nutrients, lots of minerals, but if and as I said, you are focusing on all food groups, so she is mentioning that it might be maybe, like you said, maybe I’ll just make sure you’re not becoming deficient in the protein or deficient especially and the essential fatty acids.

Dr. Maki: Yeah, right or just fat in general not even essential fatty acids, just a small component, but just fat calories in general, and just calories in general, right? I talk to people all the time to track your calories for a week. See what your average is and I guarantee you, she’s probably 1500 calories or less. With her exercise, four days a week, she needs to be over 2,000 calories a week. That’s really scary.

Dr. Davidson: You mean a day?

Dr. Maki: I’m sorry a day. Yeah, day, and now granted, you don’t have to necessarily be at 2000 calories every day. But basically, your weekly average or your average caloric intake overtime needs to be close to what that maintenance level is, and the more activity you do, the more calories you need to eat. And if you don’t, now, you’re putting a constant stressor on your adrenals that the body can’t really overcome. Literally, in starvation mode on a regular basis. That I think is a big component because she’s doing a lot of things right. I think that is a component that needs to be addressed.

Dr. Davidson: Something maybe to look at there.

Dr. Maki: Yeah. So I think we hash this one out. Hopefully, there’s some good information for Marisa to kind of think about and contemplate. We kind of laid it out and hopefully not we didn’t drawn for too much. But this one is I think challenging, right? It’s how it’s even talked about this as we’re preparing for it. It’s really difficult to try to get someone to sleep better when it seemed the waking up and that very specific time. Like how do you really approach that in an effective way? But as you can see, as we laid out, there’s a food component, there is an activity component, there is an adrenal component, there is a thyroid component, there is a progesterone a component, or a female hormone component. I mean that’s really complicated. That’s extremely complicated to get the net result of I to want to sleep better.

Dr. Davidson: And at the same time, you’ve got to look at it that way. You’ve got to look at it as the body as a whole not compartmentalizing different glands or GI system, your thyroid Endocrinology, everybody compartmentalizes medicine, I got my cardiologist, I got my gynecologist. I’ve got my GI doctor, I mean and that’s great. You got to have a healthcare team, but just like we kind of laid it out. You got to look at it this way.

Dr. Maki: Yeah, right. Now granted, she’s waking the middle of night. She’s having an increase in heart rate. She asks if it’s hormonal or adrenals well in some ways, they’re both hormones.

Dr. Davidson: It’s both.

Dr. Maki: It’s totally both and this is in some ways kind of a classic case one that’s hard to address. But at the same time, it’s kind of simple, and as I said, she’s doing a lot of things right just a couple of tweaks here and there and I guarantee you, her quality of sleep would go from probably C- to a B+ in a relatively short. Sorry, I didn’t mean to cut you off there. Do you have anything else to say we’ve been kind of taught[?]? This has been a little bit of a longer episode than we typically do.

Dr. Davidson: No. I was just saying, any of you listeners listening to this podcast, if you want to learn a little bit more about the ghost, the zombie, and the vampire with the adrenals and sleep because I know we tried to sum it up a little bit, you can always listen to podcast number 69, and I also at the same time wrote a blog on that too where you could go in there and read the article as well. I think it’s adrenal fatigue and sleep or something like that.

Dr. Maki: And I show notes on our website. We do post up the transcription of the podcast on the website and you can actually download actual PDF of the transcription and the dashboard, the analytics, and I know that actually people read the transcription, probably saves them some time, they can just scan through it really fast. Now, we don’t edit the transcription very much. We don’t do too much there. It’s pretty much as we say it for the most part, so, if there’s any typos or things that don’t make any sense, we apologize ahead of time. But again, for people that are quick and like to read and scan and don’t have time to listen to a 45-minute podcast, or if you’re trying to pay attention. Another thing that I know that happens is people are trying to pay attention to the numbers, right? They want to see it in writing when we’re talking about a TSH of this and the free T3 of that and that’s hard to it’s hard to wrap your brain around those numbers unless you see it actually in person or people that I know will actually writing notes down as they’re listening to the podcast, so they can visually see what those numbers look like. So until next time I’m Dr. Maki.

Dr. Davidson: And I’m dr. Davidson.

Dr. Maki: Take care. Bye-bye.

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Do BHRT Dosage Amounts Change Overtime? | PYHP 083

Dr Valorie Davidson and Dr Robert Maki — Wed, 22 Apr 2020 18:32:36 +0000

Maria’s Question:

Hello, I’ve been reading the articles on BHRT, and I have questions. Does the body or will the body develop tolerance to hormones? Whether progesterone, testosterone or estrogens, will I eventually have to increase my dose to get the same effect, progesterone for sleep, estrogen for hot flashes, testosterone for energy and libido… Thank you very much.

Short Answer:

There are many factors that go into a BHRT dosage for a patient. This includes age, gender, lifestyle, stress level, and severity of symptoms. Typically, when we work with a patient, their BHRT dosage will increase over time. A patient does not necessarily develop a tolerance to bioidentical hormones; however, a lower starting dosage may not be effective to manage symptoms and a slight increase may be needed.

PYHP 083 Full Transcript:

Download PYHP 083

Dr. Maki: Hello, everyone. Thank you for joining us for another episode of the progression podcast. I’m Dr. Maki.

Dr. Davidson: And I’m Dr. Davidson.

Dr. Maki: So, we’re going to kind of dive right in. This is another question. This one comes from Maria. Again, looks like she found us on a blog post on how does bioidentical progesterone help. So, Dr. Davidson want to read the question from Maria.

Dr. Davidson: Sure, sure. So, I know we’ve been doing a lot of reader questions lately. Only because we’ve been getting a lot of questions in and I do think that they’re important, but know that we’re going to do a combination on what questions, topics, concerns.

Dr. Maki: Yes, yes. Like I said, we have a kind of a backlog. And these are very specific type questions. And we know, which is why we’re doing them that these kind of answers to these questions are next to impossible to find on the internet, you can’t just type in a question that we get and be able to find that answer. You have to look and look and look and then when it comes to hormone replacement in general, there’s a million different opinions, right? There’s not just one way to do a bioidentical hormone replacement therapy.

You talk to 10 doctors. You’re going to have 10 different opinions, which makes it even more confusing for the patient. Because, well, their doctor does one thing, we say another, another doctor says something else. How does the average person make any sense of any of that, okay? But we have our approach. We have what works for our patients. And a way to when problems arise like on the last episode, when something comes up, knowing how to, which is also an issue that comes up quite a bit. Sometimes doctors do a dose or do a prescription or do a treatment plan, but then something comes up that is not favorable, and they don’t know how to fix it. That’s also why we’re kind of doing this podcast as well, because we end up seeing a lot of those people because they got it, they went to see somebody else, and they just didn’t get the results they wanted and they end up coming to see us. So go ahead. Why don’t you read Maria’s question?

Dr. Davidson: Okay, sure, sure. So, this is from Maria. This was actually an e-mail that she was reading some of our articles or blog posts it says, “Hello, I’ve been reading the articles on BHRT, and I have questions. Does the body or will the body develop tolerance to hormones? Whether progesterone, testosterone or estrogens, will I eventually have to increase my dose to get the same effect, progesterone for sleep, estrogen for hot flashes, testosterone for energy and libido… Thank you very much.”

Dr. Maki: Yes, right, yes. I think that’s a good question. I mean, it’s kind of a broad question but one thing that I do tell women a lot when I speak with them, is I say, “Usually where you start on whatever hormone it is, we’re talking sex hormones, estrogen, progesterone, testosterone, whatever dosage you start at is usually not where you’re going to end up at.”

Dr. Davidson: Exactly. So, I wouldn’t say you’re not going to develop a tolerance just like with caffeine. You drink one cup of coffee really yummy. In a few months or years, you’re into two cups, you’re into three cups, to get the same effect. It’s not like that. You don’t build up a tolerance like that. But with time, like I always say, we’re not statues. We’re not static beings. We’re always changing, whether it’s with the seasons or with time, or with stress. We’re always changing. So, yes, doses do change often and they should change often. You don’t know how many patients have come to see me as a second opinion after being with another doctor, and they haven’t changed their dose for years, for years. And I say that’s because our bodies are always evolving and changing and we’re kind of looking at what end effect we’re trying to get from doing hormone replacement.

Everybody also has a different goal when we’re doing bioidentical hormone replacement. So, to answer Maria straight up is, no, you’re not going to get a tolerance. Your skin adapt, if you’re putting on creams. You’re not going to get some kind of skin adaptation. You’re not going to need more. In some cases of conventional hormone treatment or conventional– when you’re doing very high strong doses, like injections or pellets which are bioidentical, is you can get an adaptation to that because when you give somebody a whole bunch of something they don’t need right away the receptors down regulate and then you don’t get the same effect the next time you do a pellet or an injection so I would say on that. But in terms of creams or capsules, and when you’re working with somebody monitoring their blood work and their symptoms, you’re not going to technically “become adapted”.

Dr. Maki: Yes, right, yes. Certainly, with pellets which it’s kind of died off a little bit. It’s not as popular as it used to be. But for a while there, probably what? Five years ago, maybe a little longer than that, pellet therapy was like this really hot thing, because you don’t have to take anything. You don’t have to rub on any creams. You don’t have to take any pills. You go through a little mini office procedure. It’s not as benign as they kind of claim it to be but you do a little incision on your upper rump area they insert some pellets and then those hormones degrade over time, it usually lasts about three to six months. And we don’t really care for that idea very much for exactly what you just said.

That therapy for women was giving them testosterone, the same thing for men, giving them testosterone. And that’s exactly what happened, you get this huge amount of hormone, right off the bat. And as it slowly degrades that process of kind of flooding the body right away. Every cell in your body has a receptor for all these different hormones we’re referring to. And now that receptor, that’s the physiology term, the receptor basically. When there’s an abundance of a hormone present in the blood, the body’s response to that from being overstimulated is to get rid of those receptors. That’s the process of down regulation. And a lot of the women especially, both women and men, once they’ve gone through a round of pellets, they don’t necessarily feel very good after that. They feel really good for that first three months. And then after that three months they really kind of struggled to get back to where they were.

Dr. Davidson: So, there really is, in some ways, two answers to this question. So, just on the flip side, okay, you think of a female and she’s 48. In perimenopause, maybe drifting into menopause. And yes, we need to do some bioidentical hormones, maybe some progesterone, tiny bit of estrogen maybe, maybe no estrogen, just progesterone and some testosterone. That level of what she needs is a dose at 48 is going to be completely different from as she goes to actual menopause at 51 and a half. So, she’s not become adapted. It’s just the ovaries, rightly so have decided to work less, work less, work less and eventually retire, which they justly deserve having worked so long for so many years.

But doing that replacement, so yes, you’re going to see a change in the dosage, but it’s not necessarily that the receptors are adapting to the dose or I need more because my body, like I said, with caffeine or other sort of substances that you need more to get that similar effect. It’s not like that as you’re transitioning from perimenopause to menopause to post-menopause, but just like Dr. Mackey was talking about. Say a fella, sure when a fellow is 28 years old versus 17 versus 58, their testosterone levels are going to be a little different. But the testosterone levels don’t necessarily go down to zero, which would horrify men. Like it would be with a female when our ovaries decide, “Hey, we’re not going to work anymore. Let’s go into menopause.” So, you do see men with their testosterone lowering over time, but still a 75-year-old fella that’s never taking testosterone therapy is still making some testosterone.

Dr. Maki: Yes, right. I’m so sorry, I didn’t mean to interrupt you there. I thought you were done with your thought. But the difference between men and women is that women stop producing the hormones, men do not stop producing the hormones. So, fundamentally there’s a big difference there. For women, the tolerance, like you said, it’s more about the need, right? Of having an appropriate dose of hormone that helps to ameliorate symptoms. And that, as we’ve talked about, on almost every podcast where we talk about hormone replacement, that dose is specific to the woman. Some can tolerate a lot, some need a lot, right? Because estrogen is what makes a woman a woman. So, it’s not about having too much, it’s about having enough. And that’s something that we do see a lot, is that women are prescribed doses that are always too low, always too low. And then they’re on that dose for sometimes months and years, when if their doctor would just give them a little bit more estrogen or a are a little bit more biased, they probably feel a lot better.

Dr. Davidson: Yes. Unfortunately, sometimes the bioidentical hormones get a little bit of a bad rap. Because they’ll come in and say, “Oh, yes, yes, yes. I took those hormones. I took the bioidentical hormones, and they didn’t do anything for me.” It really was because they’re very gentle. They don’t have a very long half-life. So, you have to make sure that you’re applying them at certain, daily, is that they just didn’t get enough.

Dr. Maki: Yes, right. At that point it comes down to a dosing issue. And that’s on the doctor to know how to dose it properly. You cannot use the same dose for every single woman. That is like BHRT number one. You can start somewhere relatively the same on each patient. But as we’ve said, you’re not going to end at the same dose because some can tolerate, as I said a lot, and some can tolerate very little. And most of them are going to fall in between somewhere.

But every dose that a woman eventually gets to, after a few months or a few years, that dose is specific to her, not a population of millions and millions of women and they all get basically one or two or three doses. That’s ridiculous. That’s cookie-cutter trying to do something that is very specific on a mass scale. That’s why it just doesn’t work when you go see your gynecologist or a doctor that is using conventional hormones because there’s no options. There’s no choice that is customized to the patient. It has to be customized to the patient.

Dr. Davidson: And customize over time. So, like I said, a woman’s hormones at 48 is going to be completely different at 51 or a female that has, they have to have a hysterectomy and have their ovaries taken out. They’re going to go from hormones to no hormones. So, once someone has, let’s say those ovaries either have been removed or they have decided to retire. They’re in full post-menopause, they are not producing any hormones at all. A lot of women will say, “Well, they’re on their bioidentical hormones, and then, hey, it’s time to change them a little bit.” And they’ll say, “Well, why don’t we change them? My ovaries aren’t making any hormones. My ovarian function is gone. Why are you changing my hormones? Shouldn’t it be the same all the time?” And that’s where we come into, hey, we’re individuals, our adrenals affect our how we respond to hormones, our thyroid affects how we respond to hormones, stress, change in season can affect things.

Dr. Maki: Yes, right. Every time we go from winter to spring to summer. There’s always kind of an uptick. Now, we lived in Vegas for 15 years, when it starts to get May, June as the temperature starts to get to 100 degrees, women have an increase just because of the change in seasons, same thing going into winter or going into– in Vegas is kind of like two seasons. You’ve got basically summer and winter where everywhere else in the country they do have certainly four seasons, Vegas is kind of just two, you have four months of summer and the rest of it is kind of the same, which is nice. It’s pleasant.

Dr. Davidson: It’s beautiful.

Dr. Maki: Yes, yes. But at the same time, you see, definitely these kinds of timings of where hot flashes and symptoms start to kind of rear their head. So, of course, their dose needs to be tweaked a little bit. And now, we’re not even talking about, what we’re talking about, basically, in this context and I’m just kind of throwing a wrinkle here. What we’re talking about, for the most part, is what they call static dosing, same dose every day. When a woman is menstruating, even when a man is creating testosterone, which they do up until when man’s in their 80s, they’re still producing testosterone. It’s not in a flat line.

If you graphed out a level of hormone production for a female. And of course, we look at these hormone graphs all the time, kind of ebb and flow, right? You don’t have a consistent level of estrogen all the time. You don’t have a consistent level of progesterone all the time. You have a peak and you have a peak and a peak here and a peak there. When you go into menopause, basically those hormone levels flat line. Right? So, using static dosing is a good way to ameliorate symptoms, because all you’re doing is raising the baseline. Now you have a very relatively low baseline, the adrenals are supposed to kick in and make some hormone. So, all we’re trying to do is just increase that baseline to a point where their symptoms are taken care of.

Now, another strategy that is completely different than static dosing is rhythmic dosing. Now the caveat to rhythmic dosing, is that if a woman still has her uterus, well, of course, we’re talking about women at the time, if a woman still has her uterus and she does rhythmic dosing with estrogen, she’s going to get her period back. In some ways that’s the point of rhythmic dosing. A lot of women that are in their 50s, mid-50s, or whatever, they don’t want to get their period back, so then automatically rhythmic dosing, they’re just not a candidate for so then they become, static dosing only. And that’s the majority, right? Probably 95%, 98% of women, they’re doing hormone replacement or doing some form of static dosing.

Dr. Davidson: And just like rhythmic dosing sounds, you’re changing the hormones over basically a 28-day cycle, which is for females in a perfect world, we have a 28-day cycle, is you change the hormones throughout that 28-day period, that would mimic exactly what your ovaries had been producing when you were cycling. So that’s kind of the premise behind rhythmic dosing. Like Dr. Maki said is pretty much BHRT is static dosing. You take the same dose every day, you never change, you never change. And you don’t want to get a period, you don’t want to get a period with static dosing. That’s not a good idea. But on the flip side, is the rhythmic dosing for a lot of people is the gold standard of hormone replacement. I mean, you were literally mimicking exactly what the ovarian function was doing when those ovaries were, before menopause.

Dr. Maki: Yes. Now, even though you just said that it’s kind of the gold standard that is a little controversial from a dosing perspective.

Dr. Davidson: Truly.

Dr. Maki: Because you’re giving women that are in their 50s and beyond, you’re giving them relatively high doses of estrogen. And that’s where people get uncomfortable, practitioners get uncomfortable with that because they don’t really understand the rationale or why that would be a good idea. All we’re really doing even though the body, the female body goes through this senescence, basically, of the reproductive history. Why not increase that for a while if we can increase that because we have the ability to do that. For women, all the age-related disease that women experience happens basically over the age of 50.

But if we can maintain those hormones for a little bit longer, now we are, essentially, we are reducing risk of diabetes, heart disease, dementia, osteoporosis, and not to mention all the symptoms that come along with menopause, those are going to be ameliorated as well. So, in some ways you and I both really liked the rhythmic dosing. It just some women are, they don’t want to have a period, which I totally understand. They’re just not a candidate for, so now all we’re trying to do is just make sure their symptoms are as manageable as possible.

Dr. Davidson: Oh, exactly. And still doing the static dosing. I have so many patients, probably the majority of my patients on static dosing, that’s what I originally started with, is it is great for anti-aging, it is great for longevity. It’s easy. But, hey, if you were really going to mimic mother nature, doing the rhythmic dosing is where it’s at. But, like you said, a lot of women they’re like, “I’ve had plenty of periods in my life. The last thing I want to do is keep having a period.” I totally get that. You have to change the dose every few days. So, you have to basically, track your cycle, which a lot of women are like, “I’m kind of done with that too. I don’t want to track my cycle on a calendar anymore.” And that’s okay, too. So, of course it depends on the person. And just like we had always talked about all dosings, all BHRT is dose-dependent on the individual, not on the masses.

Dr. Maki: Yes, right. And that’s where the rhythmic dosing I think does. There’s a couple of different stages where you start at the basic. You can increase it a little bit if needed. And then women kind of fall in line with what their body tells us, their body tells. Now, granted, we’re looking at lab work, and we’re monitoring some objective data along that path, but their body will tell us where their estrogen level needs to be. Because I know you always say estrogen is the best hormone in the world. That’s what makes a woman a woman. So, getting that estrogen level, not necessarily being worried about giving her too much but making sure that she has enough, that’s where she’s going to go from surviving really, in menopause.

Just getting to a certain level of functionality to actually thriving in menopause because we’re just perpetuating that menstrual cycle for as long as she wants and now it’s amazing. I talk with patients on a regular basis and people are, in their 60s, 70s, even the 80s. And they’re living these amazing, very active lives, doing tons of things. When you and I were young, I was growing up in Minnesota, and I had– my grandmother was one of 13 children. So, I was around a lot of old people all the time. Auntie Fanny and Auntie Vivi and my grandma, Esther, and senior citizens were 55 years and older, and back then. At 65 they were considered to be old, okay? Now our patients at 65 they’re just getting started sort of, I mean, they’re running companies, they’re busy, they’re traveling, they’re doing things that when we were little people are using canes and walkers and in nursing homes at 65. So, even just in our lifetime, in one generation, it has been pushed back. The people’s level of quality of life has been pushed back, 10 to 15, almost 20 years in some cases which is remarkable.

Dr. Davidson: Oh, it’s awesome. It’s just awesome. So, yes, exactly. So, anything that can kind of help with that, and, with the longevity with the anti-aging, the BHRT as long as it’s, disclaimer, disclaimer, disclaimer, monitored and dosed, right, and all that jazz and you’re the right candidate. It can be absolutely amazing. But to answer Maria, I mean, thank you, Maria for your question is, no you’re not, your body is not going to get adapted to these hormones. But I do encourage you to have them tested, to talk with your practitioner about what’s working for you and what’s not. And if you need to tweak the doses, I love tweaking the doses, just a small little quarter of a milligram to a milligram change can make a huge difference in someone’s sleep because they always say, “Hey, I feel great, but–” But a lot of patients always say, “Well, I feel great, but I, I could feel better, why not?”

Dr. Maki: Yes, right. So, you just take an inventory of what symptoms are going on, what needs to be improved, what’s working well, what’s not, and then you kind of decide from there. So, evolving in a treatment plan for a patient over time really is about the goals that they’re trying to attain, or they’re trying to accomplish. Staying on the same dose forever, in some ways, kind of defeats the purpose. It doesn’t defeat the purpose. I mean, some women are just fine on their same dose consistently. That’s okay. But, there’s always, like you said, six months in the future, our bodies are different or situation is different. Our sleep is different. Our stress is different. Our diets are different, maybe not so much on the diet, people have a lot of tendencies about the diet, but it just means that there’s always room for improvement to some capacity. And for men, because men make testosterone on a regular basis, that’s why the rhythmic dosing is the only way that we do testosterone therapy for them at least most of the time.

So, men get kind of lazy and they don’t follow the protocols so they default to static dosing. But for men, we found that the best way to get them the results they want is to do the rhythmic dosing. So, that wasn’t necessarily intended to be a rhythmic dosing tangent. But based on her question, her question is kind of broad. I do think that it needs to be kind of, thrown out there. As these two completely different philosophies about hormone replacement. You have static dosing versus rhythmic dosing. I think that it’s important for people to understand that there’s even an option. Yes, the rhythmic dosing, most doctors don’t know anything about rhythmic dosing. So, do you have anything else to add about that? I know like I said, I went on a lot about rhythmic dosing.

Dr. Davidson: No, when it comes to bioidentical hormones, we could talk for hours. I love them. They’re great. So, definitely thank you, Maria, for your question. Thank you for everybody listening, all you readers. We appreciate your support.

Dr. Maki: And so, nothing else to add until next time, I’m Dr. Maki.

Dr. Davidson: I’m Dr. Davidson.

Dr. Maki: Take care. Bye-bye.

The post Do BHRT Dosage Amounts Change Overtime? | PYHP 083 appeared first on .

What Are The Side Effects of Biest? | PYHP 082

Dr Valorie Davidson and Dr Robert Maki — Wed, 15 Apr 2020 21:37:32 +0000

Staci’s Question:

Hello, Dr. D, I was on Biest, 80:20 ratio. One mg/mL. I take one click, which is a quarter gram per day. I have been taking that for two and a half months to come about sleep disturbances, low libido, and hot flushes. I also take 100 mg of progesterone capsules at night. After the two and a half months, my breasts were so dense, tender and sore that I had to stop, to get some of the estrogen out of my body. I still get my period intermittently, so I don’t think I’m quite finished going through menopause yet. Should I lower my Biest dose or take it every other day? The hormones do alleviate my symptoms. It’s just that, eventually, it seems to be too strong.

Short Answer:

For a woman, it is a tough situation to be experiencing hot flashes, but still be mensturating at the same time. When a woman is still mensturating, she is not an ideal canidate for bioidentical estrogen. The fact that a woman is have a cycle means that she is still producing enough of her own estrogen, so taking an exogenous source of estrogen can cause some unwanted side effects like breast tenderness or unwanted bleeding. In Staci’s case, taking progesterone alone might be enough to help aleviate some of her symptoms. Also, supplementing with iodine can help to reduce breast tenderness.

PYHP 082 Full Transcript:

Download PYHP 082 Transcript

Dr. Maki: Everyone, thank you for joining of another episode of the progressional podcast. I’m Dr. Maki.

Dr. Davidson: And I’m Dr. Davidson.

Dr. Maki: So we’re back at another episode. Again, if you hear weird noise in the background, we have our co-pilot Bob with us. He’s chewing on a beef cheek and he’s making quit of the noise so, let me apologize for that. Like I said, we used to try to redo this with all the background noise but, we just kind of gave up on it because he always has to be right in our feet where we are, and we are to keep from occupied, is to give him something to chew on so. Hopefully, it’s not too distracting but at the same time when we record these, we always listen to the recordings afterwards and you can hear it back there so hopefully it’s not too terrible.

Dr. Davidson: And he likes to push that beef cheek up against the table desk here and it’s got this metal little prod on the bottom that he just likes to push up against it, so that’s why it’s making all that noise.

Dr. Maki: Yes. He’s trying to get some leverage. It’s not as bad as it probably could be, I guess. But it is connected through the table and the microphones are attached to the table and of course, the frame of the table has to be metal. But anyways-

Dr. Davidson: He could be barking.

Dr. Maki: Anyways, hopefully, it’s not too annoying for you. He’ll probably change positions in a little bit and it’ll go away. So, on this one, we’re going to do another question. We have a kind of a backlog of questions, that come in via email and comments through the website. And it is all time consuming, to be able to answer them one on one. That’s why we decided to do these questions on a podcast so everybody get– we have a lot of questions to answer but then everybody gets the benefit from the answer. So, Dr. Davidson, this one is question from Staci so, why don’t you go ahead and read it.

Dr. Davidson: Sure. This is from Staci, “Hello Dr. D. I was on Biest, 80:20 ratio. One mg/mL. I take one click, which is a quarter gram per day. I have been taking that for two and a half months to come about sleep disturbances, low libido, and hot flushes. I also take 100 mg of progesterone capsules at night. After the two and a half months, my breasts were so dense, tender and sore that I had to stop, to get some of the estrogen out of my body. I still get my period intermittently, so I don’t think I’m quite finished going through menopause yet. Should I lower my Bias dose or take it every other day? The hormones do alleviate my symptoms. It’s just that, eventually it seems to be too strong.”

Dr. Maki: We certainly run into these kinds of situations every once in a while. Now, the interesting thing when she says up to the top she says 80. She didn’t tell us how old she is but we’re assuming based on the rest of her question that she’s probably in her like 40s. I would assume probably somewhere between 47, 48, 49 or it say something like that. Would you agree or just say something different?

Dr. Davidson: Yes. I would say definitely late 40s. Maybe 50 but definitely late 40s.

Dr. Maki: Yes. Sure. So she’s on Bias 80-21 mg/g. She only takes 1 click per day. So, when she refers to the word click that’s referring to a device called the Topi-click. Topi-click, the way I kind of describe it, it’s kind of like a deodorant dispenser that has a little dial on the bottom and you turn it, two clicks and a little cream comes up the top, and then you take that cream and then you rub it into your skin. So, she’s only a typical one gram dosage. We’re kind of discussing this ahead of time making sure that, you and I are on the same page. I want you to break that part down which she’s actually taking.

Dr. Davidson: So, yes. She’s taking the cream, the Bias cream. One mg is very actually not that high, but it does have the 80:20 ratio. Meaning, there’s 80% Estriol and 20% Estradiol. So, if she’s only doing one click which would equal a quart of a gram, one-fourth of a gram of cream, that would be 1/4 of 1mg per mL. She’s technically taking 0.25mg which would equal, which isn’t a lot but still, everybody’s different, 0.2mg of the Estriol so E3, 0.2mg of the Estriol and 0.05mg of the Estradiol.

Now, she does say that this is helping her which is great but one thing is, with the bio-identical hormone it’s not [inaudible]. It’s not one size fits all. Everybody is so different. What might work for one person isn’t gonna work for another person and that’s why it’s definitely you’ve got to work with the individual and also work with the doses because she could just be really sensitive to this Biest

Dr. Maki: Yeah right. She also mentioned that she’s still having her cycle intermittently so, in some ways she’s not exactly a hundred percent candidate because she’s still cycling. Now intermittently, we don’t know if that’s every other month, every 3 months which she had 2 periods on the last year, intermittently means that she’s not having one every 30 days. Her body is still producing some of its own estrogen which you put it in your an external source of estrogen. On top of that, which is your may be conservating. but honestly, looking at when I read this the first time, that’s why we’re gonna talk about it because it seemed a little bit odd that she’s having a such an intense respond from taking such a low amount of hormone.

Dr. Davidson: Like I said, everybody is sensitive, everybody is different. She mentions that eventually, this seems too strong which makes sense because she is cycling a bit. So, when you’re in perimenopause, going in to menopause, there’s just phases like puberty. Puberty is several years long. Just like, perimenopause is several years long which be leads in to menopause which menopause is several years long, unfortunately possibly. We want to minimize that.

Then there’s that post-menopause when thee ovaries have for sure definitely retired. Like the ovaries are no longer functioning because she’s having a cycle every once in a while. The ovaries are doing something. They’re not working full time but they’re working part-time or some, so what’s happening is when her ovaries decide to make some estrogen, this extra estrogen she’s taking exogenously is just making it go up a little bit too high.

What I think in Staci’s case because I have so many different patients and some of them are super sensitive and some of them you have to basically give them so much to make any kind of reaction happen, is I think Staci might be one of those super-sensitive individuals to the Estradiol. I think even though it’s such a small, small amount of Estradiol, I think the Estradiol might be having a contributing factor to this.

Dr. Maki: Like what you said too which is a really good point, that eventually if it comes too strong so I guarantee you that as her breast tenderness increases, her cycle is probably right around the corner. So, those are probably coinciding for the most part at the same time. It is like you said her own production is still there, but now you add up just even a little bit and know it’s kind of putting her over the edge. It’s making her really uncomfortable.

Dr. Davidson: When she’s talking about the estrogen, honestly like I said I do think she’s sensitive to the Estradiol and she is having hot flushes so her estrogen level probably is dropping, because like we said she is probably in her late 40s or maybe at 50. Some women are still having a period but she’s probably not beyond 50 years old.

What I would say is the hot flushes more than likely or probably night sweats, because that’s what typically happens when someone’s going from perimenopause into menopause is they don’t necessarily too many hot flushes during the day necessarily. It really is more about having a hot flushes at night. They might be getting hot and tossing the covers around. There he is. He’s making noise.

Dr. Maki: Sorry, he’s growling at his beef cheek down there.

Dr. Davidson: That darn beef cheek huh. But anyways, so she’s probably having more hot flushes at night, maybe even some night sweats so that’s why she’s taking it once per day and definitely I would have Staci take that, as whenever type of estrogen she is going to take, take it at night to help her with sleep because that would help her sleep and that would help with the night time hot flushes.

Dr. Maki: Right. Like you said, the night sweats that covers your coming on and off and on and off so now, she’s waking up probably multiple times. We had women over the years, they tell us they’re waking up 5, 6, 7 times a night. It’s just like every half an hour or every 45 minutes, they’re waking up. They might get that little window of sleep right in the morning usually between like 5 to 7 o’clock in the morning, right? When they’re getting– when they need to get up for the day, they finally get like an hour of decent sleep and then their alarm goes off and they’re literally completely exhausted.

Dr. Davidson: Definitely with the sleeping and I love, hopefully we’re not jumping around here too much for you but I love the progesterone capsules because they do help you sleep. Like she says, I’m taking a 100mg of progesterone at night that does help with sleep so I like that but just on the side note with the breast tenderness and the soreness, is sometimes too much progesterone can actually cause in some individuals that are sensitive, weight gain and water weight gain especially in the breast tissue.

So, it might even be that her progesterone might be just a little bit too high for her, where a 100mg is pretty much like 80 percent that’s like the most common dose when you’re gonna do progesterone as bio-identical hormone replacement is a 100mg. It could be but that’s just a little bit too much for her.

Dr. Maki: What we don’t know it says progesterone is 100mg but there’s also a possibility that could be Prometrium 100mg and that could easily cause breast tenderness. If it is not bio-identical progesterone sustain release, honestly, if that was the case, let’s just say hypothetically because she didn’t specify that the progesterone was actually Prometrium. You get it from a big box pharmacy and she’s taking such a small amount of the Biest, it’s more related to the Prometrium that it would be in the Biest.

Dr. Davidson: Because Prometrium still technically is, it is progesterone. There’s a lot of fillers in it and it seems to be quite a bit stronger than when you have it compounded from your compounding pharmacy. The Prometrium definitely and there’s only two dosings on Prometrium right now. There’s only a 100mg and 200mg. Some people try to break it in half and reduce it but it’s really just better to have it compounded so you have a clean progesterone capsule.

Like Dr. Maki said, you don’t necessarily want instant release because it goes into your system and it goes right out, where the sustained release on the progesterone taking that at night will stay in your system while you’re sleeping. It raises up the gabet[?], lowers the cortisol, it helps you sleep throughout the night and it doesn’t have that effects so much on the water weight, which our breast tissue is very sensitive to water weight.

Dr. Maki: Yeah right. We’d like to think that it is bio-identical progesterone but the fact that she’s just on such a low dose of the Biest, it just makes me think that progesterone which keeps past up Prometrium gets past off as bio-identical progesterone all the time. Because like you said technically it is, but we don’t prescribe Prometrium very often or hardly ever, because most women they just don’t tolerate it very well. This kind of races that red flag that this could be one of those side effects of women seems to experience.

Dr. Davidson: In Staci’s case, I mean let’s say disclaimer disclaimer disclaimer. If somebody came in with this question, what would you first suggest to do?

Dr. Maki: Well, she’s having some definite symptoms, right? She’s having a very classic perimenopausal transition. She can’t sleep, she’s having some night sweats but now, she’s in kind of a tough spot between having a regular period hot flushes but not being able to tolerate the estrogen. That’s a really tough spot to be. Thank God, we don’t really run into that situation very often and it only happens in rare instances that’s not necessarily the most common.

As we are talking about preparing for this episode, I would want to investigate progesterone for sure, maybe lower the progesterone dose, trying on even going down to 25mg, 50mg somewhere in there and then do a simple titration. When you’re taking the Biest with the progesterone, you want to be careful because if you’re taking estrogen by itself, she’s still intermittently menstruating so the progesterone is very important because if she’s just taking the Biest with no progesterone, it’s going to increase bleeding.

It’s gonna make it in very sporadic, it’s just gonna make it more unpredictable because that will create growth to the urinal[?] lining, which is what we don’t want. As a way to establish tolerance to see how she responds at a lower dose, to see if it alleviates and maybe she can acclimate to a higher amount over the period of a couple of weeks.

Dr. Davidson: Yeah probably 75mg I think would be a good dose for Staci, if she’s doing a very low dose of that estrogen, that would probably eventually, she would probably feel a lot better on that. The 25 like you said working our way up would be really great because that way she can see where she feels the best at. I do think that probably ultimately, I would say she would like 75 to 80mg probably would be the ending dose.

Also to with the Biest honestly, her symptoms are the breast tenderness could be coming from the progesterone but a lot of times, it is from estrogen and it’s usually from Estradiol not from Estriol which is E3, it is from Estradiol (E2) which is the strongest. So, I would even consider taking Estradiol right out of the picture.

Dr. Maki: Just to like straight Estriol cream or a straight E3 cream. I mean, she’s not doing hardly any right now, she’s doing literally based on what she wrote here, this is accurate. She’s doing a quarter of a milligram daily. Our usual starting dose for most women is usually 3 to 5mg but like you said earlier, women are sensitive so you have to take that into consideration and every woman’s dose.

Now I will say, where they start and where they end are two different things. Where they start is different and where they end because eventually she’s gonna need more estrogen just guaranteed because more than likely she’s already having symptoms now. Those symptoms are gonna continue as over the next 6 months to 2 years.

Dr. Davidson: We’re not statues. We’re not static. Our bodies are changing from seasons, time, what hormones. Like you said, we always check people’s blood work, we check with them often to make sure that, “Hey it’s time to change a dose, it’s time to re-adjust this.” Taking into consideration the thyroid and the adrenal. So absolutely yeah, this would be kind of a starting would never be her ending because things never end.

I would definitely, honestly, she would probably be a really good candidate like suggesting to her doctor the prescribe Estriol only. I have several, actually a lot. of patients that do really good on just Estriol which is E3 only and I even have them do it twice a day because you gotta love the bio-identical hormones.

They’re amazing, but truly they don’t have a very long half-life. If you’re gonna put on any kind of bio-identical estrogen whether it’s Estradiol or Estriol, you know Biest, let’s say you put it on 8 o’clock in the morning, really by 8 o’clock, 10 o’clock at night, it’s gonna be pretty much out of your system. So, I would do an Estriol, twice a day.

Dr. Maki: Yeah sure, right. And now again, her symptoms. She’s having some sleep issues, got a low libido, she’s got hot flushes. What we don’t know is anything really about her life situation, right? Is her stress level really high? You would see this kind of symptom picture in someone that has a relatively high-stress level.

So supporting the adrenal function, let’s say she can’t even tolerate any Biest. Let’s say we changed it just to Estriol and she still keeps on having the same situation. Supporting adrenal function is another way to you know kind of help, one help improve the sleep and then that might have an impact on the hot flushes as well.

Dr. Davidson: That’s a great suggestion. In fact, I think we should just run on a little tangent on that. So let’s say that Staci is in her late 40s, okay. Unlike us, late gals[?] in her late 40s were kind of stressed out and a lot going on maybe a little overwhelmed. Think about sleep disturbances, low libido, even hot flushes that can all come from the adrenal gland. I even see that women in their 30s.

Dr. Maki: Right. In some ways, the hole mark of going into perimenopause, there’s a drop in progesterone production, which there’s this pathway if you want to call it the Pregnenolone Steal. When there’s a lot of stress going on, your body is very discretionary scars. What things it’s gonna devote energy to. So the Pregnenolone Steal which in functions medicines kind of a common thing but especially when a woman’s going into perimenopause, her progesterone levels are already dropping anyways, but the body will divert all of those basically steroid-based hormones.

Hormones made from cholesterol which all the sex hormones are, including cortisol. Cortisol is a steroid-based hormone. It will divert all attention towards cortisol, so now you have all these cortisol going around because of life circumstances and not sleeping that compounds the issue and there’s no progesterone or female hormones really to buffer that out. That’s the epitome of perimenopausal symptoms. They’re just miserable because they have all these cortisol all the time.

Dr. Davidson: Exactly. Also threw it out there, female libido is really hard. You guys, you guys, you’re a little bit easier on that libido side but as gals we’re so complicated yet we’re so worth it but we’re so complicated when it comes to sex drive and libido. So, when there’s a lot of cortisol going around, there’s not enough sleep going on, you’re tired during the day, the last thing a gal wants to do is even think about sex, let alone engaging that physical activity. It could even be that, that low libido is coming from adrenal glands.

Dr. Maki: Yeah right. Well, if you think about it from a survival perspective not that we have to worry about that in America but maybe with all the Coronavirus stuff, we’re in the kind of survival mode. Everyone on the daily basis going to work and taking care of your family and doing the million things that women have to do on a daily basis, that does put us in kind of a pseudo fight for flight response.

Those stress hormones do arise and when those stress hormones are elevated consistently and lack of sleep, basically constitutes as a separate stress because now your body is not able to recharge itself, the libido is gonna disappear. Your body is worried about surviving, it’s not worrying about thriving or reproducing at that point. The thoughts of the brain, the desire and that’s same thing holds true for men too.

The more stress men have, their libido runs away for the exact to the same reasons. They just don’t have any thought or they are just nothing there whatsoever. In case, like this if you get a sleep under control, you get the hot flushes which affect the sleep, stress is a tough one. How do you tell someone or how do you– There’s no pill you can give to someone or there’s no supplement or prescription to give to someone to help alleviate their stress.

Dr. Davidson: I think it’s called wine.

Dr. Maki: Yeah right.

Dr. Davidson: No, I’m just kidding. That’s a double-edged sword.

Dr. Maki: Right. That has its own issues. That can certainly alleviate or that can exacerbate the odd life.

Dr. Davidson: And the sleep disturbances.

Dr. Maki: Yeah totally. How many people that we know they get home from work, they have a glass or two of wine, it helps them to shake off the day but now their sleep is completely– It’s gonna blow up all night long because they just can’t tolerate that anymore. So, you’re right. It’s a very much a fine line there between wanting to have some wine at the end of the day or a cocktail or a drink or something but you know there’s some consequences.

Dr. Davidson: Or sugar for that matter too because a lot of times when you’re running on high cortisol, you’re not hungry during the day and then you get home and all the sudden at 7:30 at night, it’s like an extracurricular activity to start eating. It’s not carrots and celery, it’s like where are the carbs, where’s the sugar? That will disrupt your sleep.

Dr. Maki: Yeah right. And then, of course, we’re doing that on a regular basis. In a context of a perimenopausal woman, it’s really– a lot of it it’s not her fault necessarily because her body is changing in a way that she’s not really used to, and that’s what we hear from our patients all the time. I mean, I know you’re kind of in the throws of that yourself.

Dr. Davidson: You’re gonna get it.

Dr. Maki: You can really relate and I could really relate too, because you know we’re just teasing. Nonetheless, a woman’s body at this point her life is going through some very drastic changes and we hear it all the time. Women, they don’t know what’s happening. They go to doctor after doctor. The doctors don’t know what’s happening.

I think we’ve done a fairly good job of understanding what’s going on there and more importantly how to help them. In this case, we would possibly switch to progesterone to bio-identical if it’s Prometrium. Lower the dose. We would maybe switch the Biest from Biest to actually just straight Estriol. Maybe keep the same dosage but then allow her to kind of play around a little bit. Like we said, supporting the adrenal function.

Dr. Davidson: Absolutely. Like you said, the adrenals. I do think Staci talking to your doc about possibly switching to that Estriol only because E3 is very gentle. Estradiol is very strong, I mean Estradiol is amazing hormone but it could be a runaway train if you don’t rain in that Estradiol. So, I really think her symptoms might be combined with a little too much progesterone.

She’s still cycling, so she’s still making some hormones on top and maybe but still not a lot of hormones because she’s not cycling every month, it sounds like. But switching to the Estriol, Estriol being so gentle, won’t have the effect on the breast tissue, it won’t have an effect on weight gain and it won’t have an effect– if anything the Estriol will probably help on that mood, help with those hot flushes but not have the negative effects that you see on the Estradiol.

Dr. Maki: Right. Now another little trick, when it comes to breast tenderness that you can use for at any decade or any point in life for women, is using a little bit of iodine. Whatever reason there’s a lot of iodine receptors on the breast tissue using not a mega dose of iodine. There’s a lot of misinformation about iodine. I have a patient right now and I’ve had a quite of few of them over the last years so that are kind of acutely hyperthyroid.

We use mega doses of iodine. We’re talking in the mg amount kind of dosages. In hyperthyroid cases to basically not shut off that, but to kind of calm it down. Most of the time, people don’t need those mega doses if they are deficient, they just need a slight-small amount. In this case, what would be kind of a dose would you recommend for a case like this?

Dr. Davidson: Iodine, in theory, does help with breast tenderness. Fibrocystic density, iodine is awesome for. Like you said, you got to be careful with it because doing too much iodine can actually– If you read all over the internet they say iodine will make your thyroid go high but it really makes it go low. Some cases it will make it go high. Iodine is kind of interesting one. You gotta be careful with it but if somebody’s having really severe fibrocystic density, doing iodine very low dose would be-

Dr. Maki: Yes, the RDA is 150mcg, which is a very minuscule amount. You’re Japanese right? Your mom’s from Okinawa. So every time we go over to your mom’s house, even here at our house, we’re always consuming some type of soup. Every time we go to your mom, she’s putting her wonderfully, delicious, clam soup in my face that has– if you know anything about Japanese cooking, it has kombu dashi.

So, you have some seaweed in there. It’s made with Bonito flakes which is basically fish flakes. In some ways, that bowl of soup is, I wouldn’t say loaded with iodine, but it has a nutritional source of iodine. In that kind of quantity, very small little incremental amount if you’re having and that kind of soup, that soup base with a dashi, the kombu dashi. Kombu is just a type of seaweed, that is going to give you that very low amount on a consistent basis. The body is very good at absorbing nutrients on that fashion.

Dr. Davidson: The sea vegetables are a great way to get a source of iodine and if your body doesn’t want it, it just shuttles it out. As opposed to taking a supplement of iodine. Like I said, I do think it really helps the fibrocystic density for the breast tissue but if you’re gonna take iodine, I do think doing a blood test. I’ve had plenty of patients that had low iodine. We put them on iodine, do a blood test and it’s too high.

Dr. Maki: I would say probably about a thousand micrograms is a starting point some of between 500mcg to a thousand. Then like you say, doing iodine test just to see where it is. It is no surprise, iodine is a deficiency in America or probably around the world except for people that live that consumes sea vegetables on a regular basis. Kombu, seaweed like that is a great source. Nori, the type of seaweed that you wrapped on a sushi roll, that doesn’t necessarily have a great deal of iodine in it.

Dr. Davidon: But it taste so good.

Dr. Maki: It’s good, yeah. Now great, most people are not gonna go out if you’re interested in something like that, doing a kombu dashi. It’s fantastic. Every time your mom makes me some clam soup, I’m never gonna turn it down. It’s so good.

Dr. Davidson: She loves to feed you.

Dr. Maki: Yeah. So, that’s another little trick. Something you can play around with again, just be careful. Don’t get up too high. There’s some products out there on the market that have 6,10,15, 20, 25mg of iodine. We usually like to go, somewhere between 500 to a thousand micrograms of iodine. Let’s say for example, 25mg is 25,000 micrograms. So be careful with that. Lot of supplements have these mega doses.

What you’re referring to earlier, it’s called Chaikoff effect. Iodine, in some instances, can either turn your thyroid on or turn it off. We’ve seen in those high dosage, that it actually tends to kind of reduce thyroid function. That’s why we use it in hyperthyroid cases not necessarily, at least a mega doses in hyperthyroid cases.

Dr. Davidson: And also, Evening Primrose Oil is really gentle. You can use that even for teenagers, evening primrose oil is great for when those hormones are imbalanced to help with breast tenderness. Actually, Evening primrose oil just in general is great for the breast tissue. Whether you have breast tenderness or you don’t, it’s just really nice for breast tissue for that density. Evening primrose oil usually, disclaimer disclaimer disclaimer, but right around a thousand milligram is a really good dose, 500 to thousand really thousand is the best.

If someone has other issues going on in terms of [inaudible] or other issues, fibroids and whatnot, then I usually bumped that evening primrose oil up to two thousand, but a thousand milligrams is really good for the breast tissue. Also, we use a lot is an Indole-3-carbinol and a DIM, that’s another one, that helps bring down the estrogen metabolize.

It doesn’t help bring down your estrogen but everything that gets processed or delivered turns in to metabolize, it needs to be shuttled out. Reducing metabolize can help with that breast tenderness, that breast density. Usually, with DIM like a hundred milligrams in the Indole-3-carbinol (I3C) is usually around 200mg is a kind of a nice dose daily for– if you feel like those estrogen metabolites are a little too high.

Dr. Maki: We covered that pretty well. One last thing I would say about estrogen and like you said about the metabolites is kind of reflect a little bit about liver function. Making sure there’s no major burden on the liver function that includes the wine we’re talking about, alcohol, that includes coffee. If she’s not sleeping at night, she’s gonna be tired during the day so she might be doing more coffee than normal.

Dr. Davidson: High-fructose corn syrup.

Dr. Maki: Certainly High-fructose corn syrup which causes fatty liver disease. All those things the liver cannot be overburden because it cannot process all those things. Then those metabolites start to shift and build up and it can make the situation like these worse. That’s a lot to talk about. This is a little bit of a longer one than we normally do, but this one is kind of complicated.

On the surface it seems simple but when she kind of dive into it, it’s a– how do you help someone like this when they can’t– They’re having hot flushes. Estrogen is Biest is the best place to start. How do you do that when she can’t tolerate it. I think we passed it up pretty well and hopefully if Staci hears this, I’m sure she will or let her know. Hopefully, this will give her some options that she can investigate and hopefully get some relief.

Dr. Davidson: Absolutely. I can go on and on and on with testing, and when to test and how to test but I think this was perfect and definitely shout out to Staci. Thank you so much for your question. In fact, all of you, thank you so much for listening and for reading and for sending in your concerns and questions, we love it.

Dr. Maki: Until next time, I’m Dr. Maki.

Dr. Davidson: I’m Dr Davidson.

Dr. Maki: Take care. Bye bye.

The post What Are The Side Effects of Biest? | PYHP 082 appeared first on .

What is a Usual Dose of Bioidentical Hormones? | PYHP 081

Dr Valorie Davidson and Dr Robert Maki — Tue, 14 Apr 2020 16:31:03 +0000

Heidi’s Question:

Hi, I’m a 48 year old female who has struggled with PCOS my whole life. I’ve taken 200 milligrams of oral progesterone for several years now. I also take 45 milligrams of Armour Thyroid, and my TSH is 3.87, and my free T3 is 3.22. I’ve had symptoms of: hair loss, dry eyes, vaginal dryness, very low sex drive, and irritability. I just had a saliva test done which revealed very low estradiol levels, and low DHEA along with borderline low testosterone. The practitioner I have, put me on sublingual drops with a dosage of 80/20 ratio of biased being– which is interesting, .8 milligrams of an 80/20 bias, .8 milligrams of testosterone, 25 milligrams of oral DHEA and kept me on my 200 milligrams of oral progesterone. My question is, is this a safe way to administer my Biest and testosterone? Do you agree with the dosing amounts? Any advice would be appreciated. Thank you for your time, Heidi.

Short Answer:

We do not like the idea of taking Biest and testosterone orally. Taking BHRT in a sublingual form is ok because the intention is to avoid the digestive tract and liver. However, for Estrogen and Testosterone, we prefer to use a transdermal cream instead. Also, in this case, the dosing is too low. Her Biest needs to be gradually increased, but with caution in order to prevent any bleeding or spotting.

PYHP 081 Full Transcript:

Download PYHP 081 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: I’m Dr. Davidson.

Dr. Maki: So, we’re going to dive right back in. We have another listener question. Actually, this is a reader question from a post on our website. What is bias? This is from Heidi. Dr. Davidson, why don’t you go ahead and give it a read.

Dr. Davidson: Oh, sure. Sure. So, this is from Heidi. “Hi, I’m a 48 year old female who has struggled with PCOS my whole life. I’ve taken 200 milligrams of oral progesterone for several years now. I also take 45 milligrams of Armour Thyroid, and my TSH is 3.87, and my free T3 is 3.22. I’ve had symptoms of: hair loss, dry eyes, vaginal dryness, very low sex drive and irritability. I just had a saliva test done which revealed very low estradiol levels, and low DHEA along with borderline low testosterone. The practitioner I have, put me on sublingual drops with a dosage of 80/20 ratio of biased being– which is interesting, .8 milligrams of an 80/20 bias, .8 milligrams of testosterone, 25 milligrams of oral DHEA and kept me on my 200 milligrams of oral progesterone. My question is, is this a safe way to administer my Biest and testosterone? Do you agree with the dosing amounts? Any advice would be appreciated. Thank you for your time, Heidi.”

Dr. Maki: So, yes, there’s a lot to dissect there. This is– and I actually responded to her on the website. I asked her a question, is her progesterone, is it Prometrium or is it bioidentical progesterone? She came back to say that it was actually 200 milligrams of Prometrium. She had asked why we don’t– because in my response to her, I said, we don’t typically prescribe or don’t really recommend Prometrium and she was wondering why. So, Dr. Davidson, why don’t you say why you don’t prefer Prometrium?

Dr. Davidson: Well, Prometrium is still technically progesterone, but it’s an instant release, and you can’t– it only comes in a couple of forms, 100 milligrams and 200 milligrams. Hence, she’s on the 200 milligrams. You can’t really move that around and when you’re working with hormones, especially bioidentical hormones, even though we’re all humans, we’re all still so incredibly unique, that it’s not one size fits all. So, that’s where with progesterone, I like to do a sustained release. What stays in your system a little longer, it definitely the sustained release helps with women staying asleep. So, she’s a 48-year old female. She’s maybe had struggled with PCOS. She’s definitely in some kind of perimenopause phase right now. So, she’s probably having trouble sleeping, even though it doesn’t have that on her symptom list but the sustained release helps stay in the system, it helps you stay asleep, and then you can– because I feel like 200 maybe a little high for her, because Heidi had also– because there’s a lot to this that we’re going to break it all down for you. But Heidi had also responded to Dr. Maki saying that she’s still cycling, meaning that she’s still getting her period, meaning that she still has a uterus. So, with that Prometrium being that high, it might be kind of throwing her cycles off a little bit, too.

Dr. Maki: Yes. Maybe either too frequent or too long or kind of increasing– it can do– we talked about on the last podcast and previous ones as well, that progesterone can– especially at 200 milligrams of Prometrium which we tend to find– maybe because of the instant release, we tend to find that it’s a little stronger, women have a harder time tolerating it than the bioidentical oral progesterone.

Dr. Davidson: So, just to kind of back up a little bit. So, Heidi is cycling. So, that means she’s getting a period every– with PCOS, it could be every 28 days, or it could be over 288 days, PCOS, Polycystic Ovarian Syndrome can throw the periods off. But she does say she’s cycling, and she did a saliva test which tested her hormones. Then her estradiol was very low and her DHA was low, and her testosterone was borderline low. Now the DHEA and the testosterone throughout, let’s say, aside from Heidi on a perfect 28-day cycle on a cycling female, DHA and testosterone pretty much stay the same the whole 28 days. Round ovulation that testosterone comes up and that DHEA. But pretty much whatever day you test those hormones, the DHA and the testosterone in that 28-day cycle are going to be relatively pretty consistent. Where the estrogen changes.

When you’re on your period, day one to five, you basically have no estradiol, no estrogen in your system, no progesterone either, because that’s what causes the lining of the uterus to slop off, hence, a period and then the estrogen comes up, estrogen spikes on day 12, in a perfect 28-day cycle, and then comes down slowly until the next period. Progesterone really doesn’t come up in levels in the bloodstream until you hit ovulation. So, typically, you’re going to see levels of progesterone at a good level between day 14 and day 28. So, that’s where her very low level of estradiol, it really depends on when she had her saliva test done, if she did it, because there’s a couple of different saliva tests. You can do an instant saliva test, where I test, one, my saliva all day long, a morning saliva sample, at noon, and afternoon and evening time and then just send it in. Or there’s some saliva tests that you can do that are 28 days that you can follow the pattern of someone’s cycle. It looks like on hers that she just did just a one time saliva test, like a one day test. So, it just really depends on where she is in her cycle to really determine if she has low levels of estradiol.

Dr. Maki: Yes, right. When the history of PCOS too, it’s a little strange or a little bit interesting that her DHA and testosterone are both low on the saliva test. I said back in my comment that I would be interested to see what the– not so much the estradiol level because we could assume at 48 that are estradiol level was probably tapering off, just anyways, even though the fact that she’s still cycling, it’s going to be high enough because she’s still cycling. So, there– she’s still meeting that estrogen threshold. But the fact that her DHA and testosterone are both low on the saliva test, I want to see a blood test just to confirm or double check to see if that’s actually true because giving our 25 milligrams of oral DHEA with a little bit of testosterone, if she got a history of PCOS, I don’t really think those two things are really necessary for her.

Dr. Davidson: Exactly. So, just to back up, she said– Heidi has been struggling with PCOS her whole life. That’s Polycystic Ovarian Syndrome and we have some blog posts. We actually have some podcasts on PCOS if you want to learn a little bit more about it. But one of the hallmarks of PCOS, it’s a huge spectrum of hormones going this way and that way, but one of the main hallmarks is having higher levels of DHEA and testosterone. So, if Heidi is struggling with PCOS, just like Dr. Maki said is, why would her DHEA and testosterone be low or borderline low? So, it makes you think maybe she doesn’t need that because just on a side note, is, DHEA is available over the counter. It’s a dietary supplement. You can go down to GMC, you can go to Whole Foods and you can buy DHEA.

So, one thing that I find with females is 25 milligrams of oral DHEA is a lot of DHEA. But you’re only going to find 25 milligrams pretty much over the counter. There’s 5 and 10 milligrams, sometimes 50 milligram, 15 milligrams, those are a little bit harder to find just running down to Target or running over to Whole Foods to buy it. But I will tell you, 25 milligrams of oral DHEA is high.

Dr. Maki: Yes. Especially for a woman that has a history of PCOS, and one of her symptoms is hair loss. All right, so that’s another reason even besides the PCOS, giving her testosterone and DHEA could be compounding the fact that she’s losing hair, and we don’t really know what her stress level is. Stress level is going to exacerbate that hair loss as well. So, like you, we both– for women, most of the time prescribed usually 5 to 10 milligrams of DHEA, 25 is getting up there. Almost every woman that you give 25 milligrams to, they’re going to have symptoms. Either they’re going to– skin is going break out. They’re going to start growing hair on their chin, around the areola or on the abdomen, or they’re going to start having hair loss issues, almost invariably. It happens more often than it doesn’t.

Dr. Davidson: So, but now, for Heidi’s question, she is doing sublingual drops, that means she’s putting it under her tongue. She’s not taking an oral capsule of estrogen and testosterone combined together. So, with estrogen and testosterone on a female, you never really truly want to take an oral version. There’s a few exceptions with an estrogen with a bias taking it orally as a capsule. But truly, you don’t want to do too– you really don’t want to do oral forms of estrogen and oral forms of testosterone. One, because it’s very difficult to absorb it digestively anyway and two, because it’s very hard on the liver because a liver has to process that. So, definitely doing in a way that you bypass the digestion is the best way to absorb estrogen and testosterone bioidentically. So, doing a sublingual, sublingual is one way. I do find that the sublingual especially the drops and really the troches because you can put these little troches in. You have to let them sit there for like 15 minutes to dissolve, they taste pretty awful. A lot of people get a little hurried with that and end up just swallowing it. So then it becomes, a sublingual turning into an oral. So, you have to be careful with that or we do a transdermal cream.

Dr. Maki: Yes, yes. We prefer to do for both the estrogen and the testosterone but again, the other question that I have, too, is if she’s cycling and what is she taking estrogen for? Now, granted, the dose is less than a milligram, .8 milligrams, that’s fine. But if she’s still cycling, she’s not really a candidate. Maybe she’s having– she didn’t say in her question about having any hot flashes of any sort. So, if she’s not, then that’s a really tough position for woman. If she’s still cycling but having lots of hot flashes, then they’re kind of a candidate because that means her estrogen level is going down. But two things, the DHEA testosterone because of the PCOS, the oral testosterone and the estrogen. Estrogen is not really necessary because she’s still cycling. Of course, the Prometrium, we’re not a fan of that. So, in some ways, if she came to see you and I, we would kind of scrap all of it. We would just kind of start over from scratch.

Dr. Davidson: I would definitely kind of– there’s too many variables going on in here especially with Heidi’s question is I would– and I do consider when you’re working with a female’s hormones is the DHEA and the testosterone are like the frosting. You never start with that first. You got to make the cake first and then you add the little details on top. So, I would definitely keep some of these variables. Because I always– I love math, which is why I love the numbers on this, is you think of things like an equation. If you have all these different variables in Heidi’s equation, you won’t know what the reaction is coming from. So, if you keep the variables very tight, then you know what positive or negative reaction she’s getting from it. So, just like Dr. Maki said is I would take out the bias, I would take out the testosterone, I would take out the DHEA, for now, that’ll be like the frosting on our cake. Probably go back to that progesterone, take into account what was the PCOS, what was the issues with the PCOS she had had her whole life. Was she missing periods? Was she having high androgens? Was she having weight gain? What is the issue with the– was she having a lot of cysts? Hence, the PCOS diagnosis. Then, one thing that we really probably would come back to it the very beginning is looking at that thyroid dose.

Dr. Maki: Yes, absolutely. That’s one of the things I responded back to her, too, that the TSH is 3.87. Now, her free T3 is decent at 3.22. But that TSH, she might– and 45 milligrams of Armour, she might on as not been taking it. We would probably– more than likely would switch it to a compounded thyroid but if we kept her on Armour or some kind of NDT, Natural Desiccated Thyroid. NDT is– there’s a few different kinds. There’s Armour, there’s Westhroid, there’s Nature Thyroid, there’s NP Thyroid, those are all kind of collectively the same type of thing. We probably triple that dose, if not quadruple that dose.

So, she’s on three quarters of a grain, a grain is 60 milligrams. So, she’s on three quarters of a grain. If she came to see me, I probably increased her to two grains with a TSH of 3.87. Now, we don’t necessarily pay attention to the TSH as a standalone test. But when she’s on medication and she– you have a TSH at 3.87, her dose needs to go up. Okay, that number should be closer to one. The reference range that I gave her that we like to go by for the TSH is, let’s say, .7 to 1.3, so it’s either slightly below one or slightly above one. It’s almost at four and she’s actually on medication.

Dr. Davidson: Exactly. I know that Dr. Maki just said a whole bunch of things about her thyroid just now. So, just to break it down. The TSH is the Thyroid-Stimulating Hormone, and there’s a huge reference range on Labcorp Quest, any lab you go to, there’s a huge reference range, it’s like .45 to four and a half for TSH. So, you look at Heidi’s and she’s at 3.87. Her doctor might say, “Hey, your TSH is a normal range. You’re fine, you’re fine, you’re fine,” but she doesn’t feel fine. Because honestly her symptoms: hair loss, dry eyes, irritability, low sex drive, she’s probably having fatigue is could be coming from her thyroid and thyroid is upstream from the female reproductive system.

So, instead of chasing your tale trying to treat these female hormones, go upstream, treat the thyroid first and then go downstream and treat the remaining hormones that need to be balanced. So, just like Dr. Maki said, a TSH of 3.87 we do believe is too high, and the way the TSH works, it works in a negative feedback loop. So if a TSH, thyroid stimulating hormone, which comes from the brain is elevated, that means the thyroid function is low. Hence, if you see a TSH at like, .02 because it’s very, very low, that means someone’s thyroid function is possibly too high. Just like Dr. Maki said is I never rely on a dose of thyroid based on a TSH level. But just to kind of give you a little background, seeing her TSH level at 3.87 being technically what we would consider high, that means her thyroid function is low.

Dr. Maki: Yes, right. So, there’s– what that means is there’s basically a lot of room for improvement to kind of modify and tweak her dose. When it comes to thyroid, you don’t want to do too much too quickly. But I would definitely give her kind of a quick– a fairly initial increase and then probably retest in somewhere between a month to two months, see how she feels and really try to get that TSH down, like you said, down closer to one. The free T3, ironically enough, the free T3 is actually pretty decent at 3.22. What we like to see is a low normal TSH, so again, something around one and a high normal free T3. Her free T3 isn’t bad, but her TSH is high normal and those things need to go in opposite directions.

Dr. Davidson: So, like Dr. Maki said, and of course, I love the numbers. She’s on .75 or 3/4 grain of Armour thyroid, which is 45 milligrams. The thing with Armour thyroid is it’s a desiccated thyroid, it’s natural, it’s from porcine or a pig’s thyroid. It does have the T4 and the T3 component into it. So, that’s what differentiates it from Synthroid or levothyroxine, which is just a T4 only medication. But a, Armour thyroid or any kind of porcine thyroid has a, basically a 4 to 1 ratio of T4 to T3 in it. So it basically 45 milligrams, which is .75 grains that equals 28.5 micrograms of T4, with 6.75 micrograms of T3 in that 45 milligrams.

So, that sounds all in good. But just like Dr. Maki was saying has her free T3 really isn’t too bad? 3.2, I’d love to see it at 3.8. But that’s not– it’s not too bad. It’s not down there at 2.2 or 1.7 where I see them all the time. We don’t know what her free T4 is. So, let’s say we did raise up her Armour thyroid from 45 milligrams to 120 milligrams. Let’s say we raise it up. The unfortunate thing with porcine thyroid, now again, I love porcine thyroid, but the unfortunate thing is when you raise it up, when you raise up the dose, you’re raising up the T4 and the T3 and you can’t balance that because I have some people, they absorb their T4 so great, but it doesn’t convert to T3, so I have to add T3 into their mix. So, that would be one thing I would be concerned about is, “Hey, what’s your free T4 level?” As we’re raising it up, if her free T3 goes up too high, then you have a little disproportionate ratio between the T4 and the T3, if that makes sense.

Dr. Maki: Yes, right. Yes. So, we know that NDT is popular. We do use it all the time. In this case, what would be really simple for– and we’re not giving any medical advice. So, disclaimer there. This is just for educational purposes, so everybody can learn and understand how we– not necessarily how we do it, but just a different perspective. A very simple thing for Heidi to do would be, for her to just add a second pill. So, she goes from 45 to 90. Then in another amount of time, she could add a third pill in the morning. Then she collectively has tripled her dose in the matter of a few weeks to a couple of months based on how she feels, and then we do lab testing on the back end of that. So, she’ll know– the patient always knows when they’re under medicated or over medicated. Okay. The patient always knows at least when they’re over medicated, they know before the doctor does. They know in a lot of cases, they know even regardless of what the lab test show. Okay. If you’re taking medication, you’re tight treating a dose up like that, you start getting anxious, you start getting jittery, you start getting all the symptoms of hyper thyroid, then you know that whenever you’re taking and as long as those symptoms are kind of prolonged, meaning they’re happening on a daily basis, then you know the thyroid dose is too high, and then you have to go back down a little bit. Now granted, that’s a very kind of on the fly kind of way to achieve a thyroid dose, but it’s something that we do quite often and the patient knows when they start to feel better, they actually have the subjective feeling, say, “You know what, my energy is better, my mood is better, my cycle is better. My digestion is better.” All those things because as we know, the thyroid controls literally everything in your body. When the thyroid is functioning properly, then everything else will function at least a little bit better as well.

Dr. Davidson: Exactly. I know a lot of doctors are a little hesitant to do that with thyroid, like, “Hey, let’s raise it up. Let’s increase it up.” Because they’re afraid of putting their patient into “hyperthyroid.” But all of our patients and all of you listeners, you’re very well educated. You know what you’re doing, you know how you feel. Just like with our patients, if they ever felt hyperthyroid, they can get a hold of us in an instant. They don’t– we’re not on– they can get ahold of our assistant, they can get ahold of us. It can be 10 o’clock on a Thursday. So that if we needed to readjust that dose, we can do that very quickly. I think sometimes, it’s a little harder for doc’s when there’s– maybe they have– don’t have the right staff or they’re super busy, and they’re– I hear from patients all the time, they’ll say, “My other doctor, I couldn’t get ahold of him for three weeks, and I was bleeding or I was having these symptoms. That might be something more about their system. But I definitely– we’re not hesitant, but we definitely work very, very closely with our patients in terms of raising up their thyroid.

Dr. Maki: Yes. Because we focus so much on those types of things, the things that we prioritize are bleeding. If woman is on hormones and she’s bleeding, which is normal, it happens all the time. If a woman has her uterus, bleeding is kind of when you’re taking hormone therapy is kind of par for the course, but we want to know about it. So, we want to give specific instructions if that does happen. Then of course, any type of potential thyroid related symptoms: heart palpitations, the anxious, the jittery, insomnia. Now, when we do a compounded thyroid, this would– she would be definitely a candidate, what we typically like to do is compounded sustained release thyroid. Those types of symptoms don’t happen very often. Our job as the practitioners to get the dosing right. Usually, we’re pretty good about that so, we keep them out of that– the hyper thyroid symptoms. But again, as we titrate over the period of a couple of weeks to a couple of months, their subjective response does improve. They will– they tell us that. They say, “Yes, you know what I feel better. I have–” maybe they don’t feel stimulated, like they just drink a big cup of coffee and they’re like buzzing around. But they have a nice level of sustain energy, and they do– subjectively, they do feel kind of better overall.

Dr. Davidson: Exactly. So, hopefully, we’re not beating a dead horse here, but we would definitely first, scale back, kind of reduce down some of the variables in Heidi’s equation. Then look at the thyroid, readjust the thyroid, try to readjust that T4 and that T3 and get that TSH down to basically low normal. Then we kind of go into those hormones. I would probably still keep her on some form of progesterone because if she’s had some type of PCOS her entire life, progesterone is amazing for PCOS. So, we would definitely probably just keep her with that. Maybe readjust the dose, do it is a sustained release. With compound, you can do any milligram you could possibly want. I would say, being a 48-year old female, I mean, I’m going to be 47 pretty soon, so I know what it’s like to be in your late 40’s and [crosstalk] we work with–

Dr. Maki: Did you take your progesterone today?

Dr. Davidson: I don’t take it in the morning. You know that.

Dr. Maki: Yes, of course. You take it at night, of course. I’m teasing you.

Dr. Davidson: But know that you know we’ve also worked with a lot of women of all ages, perimenopause, menopause, PMS, PCOS, so I– if she’s having the vaginal dryness, we want to– we– and the low sex drive, we want to address that the low sex drive can sometimes be about energy, because sometimes when a female is tired, the last thing you want to do is go have sex because you’re tired. So, the thyroid might help a little bit with that. But the vaginal dryness is probably truly hormonal. So, then instead of giving her as a sublingual bias, where that’s just going– where the sublingual goes more into the bloodstream, rather than acutely focusing on the vaginal tissues, we might actually do more of an estriol or an E3 vaginal application to help with that vaginal dryness, and that works so easy.

Dr. Maki: Yes, right. Either a cream or a suppository works very well.

Dr. Davidson: Safe and fast.

Dr. Maki: Yes, yes. So again, we would kind of scrap pretty much the entire thing. So, just to kind of rehash that, okay, so we would do, we would increase her nature thy excuse me, her Armour–

Dr. Davidson: Or switch it to a compound.

Dr. Maki: Or switch it. But she already has the nature thy– the Armour. So, the easiest thing would be to start with that and to increase. If she was open to switching, then that’s great. Get rid of the bias and the testosterone sublingual, get rid of the 25 milligrams of DHEA. Switch from 200 milligrams of Prometrium to probably 100 milligrams of bioidentical oral progesterone, sustained release progesterone.

Dr. Davidson: Or maybe even 125 or 150.

Dr. Maki: Yes, right. Because 200 milligrams of Prometrium compared to 200 milligrams of– that’s actually a good point, 200 milligrams of oral bioidentical progesterone it’s not the same thing. I’m surprised that she can even tolerate the 200 milligrams of Prometrium. That’s a dose that most women really can– they can barely handle the hundred, let alone the 200. Her irritability, so the DHEA, the Prometrium and the testosterone. Now, granted, the irritability part is something that we see all the time. That could be based on those three things. It could have kind of exacerbate some of that irritability and she’s mad at her husband all the time.

Dr. Davidson: Well, maybe he deserves it. Just kidding. But no, exactly. Excuse me. Maybe you could explain a little bit about that, the having high levels of progesterone or Prometrium, taking such a high dose, what kind of symptoms, like why she wouldn’t tolerate it?

Dr. Maki: Yes, right. So, what we hear most often is that’s where the– and she doesn’t claim of any of that. So, maybe she’s not having any of those symptoms. It says she’s been on it for years. So, she’s obviously tolerating it fine. But usually right away, they can’t sleep, they’re anxious, they’re jittery, they’re bloated.

Dr. Davidson: They’re depressed. Having high levels of progesterone can make you really lethargic.

Dr. Maki: Yes. Lethargic and kind of very melancholy, very– kind of go to a little bit of a dark place. We do see that quite often with the Prometrium, which is why we’re just not really fans of it. We just seem–

Dr. Davidson: I see weight gain. Women don’t want to gain weight. We work really hard not to. But definitely with a higher doses, bloating and weight gain.

Dr. Maki: Sure. Yes, yes, yes. So, I hope that is helpful for Heidi, for everyone else, there’s a lot going on there. To be honest, I think there some decent things but, we would kind of scrap– the way that we approach it, we would scrap all of it and start over from scratch. This is where less is more in this case, right, kind of simplifying a couple things, very specifically targeting a couple of key areas. The only thing that we probably not address right off the bat, like you said, is libido. I would imagine there’s probably a stress level component to that. So, as she sleeps better, as the other things kind of take effect, then gradually her sex drive should probably just come back on its own, which you should see. Because if you’re really stressed, let’s say your job is really stressful, your family is stressful, you’re exercising a lot, you got all this stress all the time, you’re not sleeping, your libido is going to disappear. So, if some of that stuff calms down and you’re getting rest, and you’re not over exercising, then the libido will come back naturally, and it won’t be so low on a regular basis.

Dr. Davidson: Exactly. You do have to admit, I’m glad that her practitioner wants to do oral– I’m sorry, wants to do bioidentical hormones. We meet so many doctors that are like, think hormones are horrible or they group them all into Premarin and Prometri– or what does that– pro– the other one they used to use all the time?

Dr. Maki: Prempro?

Dr. Davidson: Prempro. Yes, all that old school stuff. So, it is really nice that there is a practitioner out there that is open to doing bioidentical hormones and the fact, the sublingual, because sometimes they see doctors do oral estrogen and oral testosterone and we get worried about that. So, at least they’re trying to do it by bypassing the digestion, working on– and they’re not afraid of the progesterone, which is great. Hey, hey– and also doing Armour thyroid, so many doctors only want to do Synthroid or they look at you cross-eyed when you want to do something else. So, definitely this practitioner is open to all that. It’s just, like I said, it’s very individualized. We’re all so unique. What might work for one person, might not work for Heidi.

Dr. Maki: Yes. So hopefully, we didn’t talk too fast. Hopefully, you’re writing notes down or– because this one, we did talk a lot of numbers, and it’s kind of hard to keep track of. But hopefully, this gives some insight and we plan on doing more of this kind of questions are– they’re relatively easy for us to talk about. Now, we just been going on for almost a half an hour. It’s easy for us to explain, that way, the person that sends us the question, or the ones that we actually read, they get a very specific answer. But now, everyone else gets to benefit from that answer at the same time, which is why we decided to do these in the first place. So one, it makes it easy for a preparation perspective on our part. We don’t have to prepare a lot because these are the situations we deal with all the time. Now that answer can be shared with, hopefully, hopefully, tens of thousands if not hundreds of thousands of people depending on our download.

Dr. Davidson: Let’s do it.

Dr. Maki: Yes, yes, yes. So, Dr. Davidson, I think we beat this one– we did– we answered this one in every which way we could. Do you have anything else to add?

Dr. Davidson: No, no. Thank you Heidi, for all your information and for your question and for reading and listening, and to all you listeners, thank you so much.

Dr. Maki: All right. Until next time, I’m Dr. Maki.

Dr. Davidson: I’m Dr. Davidson.

Dr. Maki: Take care. Bye-bye.

The post What is a Usual Dose of Bioidentical Hormones? | PYHP 081 appeared first on .

What is a Good Progesterone Dose for PCOS? | PYHP 080

Dr Valorie Davidson and Dr Robert Maki — Thu, 09 Apr 2020 22:34:38 +0000

Sarah’s Question:

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?

Short Answer:

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.

Some other podcasts related to PCOS:

PYHP 063 – What Type of PCOS Do I Have – Classic

PYHP 064 – What Type of PCOS Do I Have – Common

PYHP 065 – What Type of PCOS Do I Have – Concealed

PYHP 066 – Do I Have Adrenal Fatigue or PCOS?

PYHP 080 Full Transcript:

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.

The post What is a Good Progesterone Dose for PCOS? | PYHP 080 appeared first on .

What Should My T3 Free Level Be? | PYHP 079

Dr Valorie Davidson and Dr Robert Maki — Tue, 07 Apr 2020 19:00:15 +0000

Elizabeth’s Question:

I just got my lab results back and they are: TSH, Thyroid-stimulating hormone, is 1.33, Free T4 is 1.64, Free T3 is 2.9, thyroid peroxidase antibodies, that’s for the Hashimoto’s, is 16. My doctor said my Free T4 was a little high so she suggested cutting my levothyroxine, which is a T4 only medication, 50 micrograms in half, which would be 25 micrograms and to come back in a couple of months for labs. Do you think my Free T3 levels are low? I’ve been having terrible issues with my muscles and heart palpitations. –Elizabeth.

Short Answer:

Lowering her dosage is a common reaction, but is not the right one. In this case, we would most likely switch the medication to a compounded, sustained-release combination of T4 and T3. As for the heart palpitations, it is probably not related to her medication because the dose is only 50 mcg. Women in perimenopause and going into menopause will commonly experience heart palpitations and be related to adrenal dysfunction and declining estrogen levels.

PYHP 079 Full Transcript:

Download PYHP 079 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: How are you doing today?

Dr. Davidson: I’m doing great this morning. Thank you. It’s springtime, the birds are singing. The flowers are blooming, the weather’s finally getting to be about 50 degrees, which is good here, which is actually really, really good.

Dr. Maki: Yes, we can’t complain. There’s been less rain, more sun, that’s always fun. The weather’s definitely picking up, now, it’s interesting here in Bellingham where we live. There’s not a lot of difference between– like winter it averaged, this, at least this winter anyway, which I thought was odd. It averaged 40 degrees almost the entire winter which is pretty nice. I’m originally from Minnesota, Wisconsin area and 40 degrees in the wintertime is there wouldn’t be any snow, there wouldn’t even be winter if it was 40 degrees all year. So, we got pretty lucky this winter.

Dr. Davidson: And your sister, my sister-in-law, she still lives in Minnesota. When I send her the– you know, “how warm it is?” I’m like, “Oh, it’s cold. It’s 41.” And she’s like, “That’s t-shirt weather.”

Dr. Maki: Yes, yes yes, she thinks worse, and living in Las Vegas, like we did for so long. We’re getting acclimated certainly to the northwest and I think we’ve transitioned pretty well, but she still thinks we’re wimps when it comes to the weather. I don’t consider that. I think that back there, I think the weather is just a little bit ridiculous. It’s not as bad as it used to be like, I remember being a kid, and it was in January, it was always below zero all the time. Just frigid temperature, it doesn’t seem like it gets that cold anymore like it used to.

Dr. Davidson: I can’t even imagine what that feels like. We only go visit in the summer, by the way.

Dr. Maki: Yes, yes. June through like September it was like the window. And so, the winter, yes, we went back there, I think one time in December. And that was it, we’re not going to do that. No offense for anyone that lives in the Midwest, we totally understand. But at the same time, we are a little bit very sensitive to the cold, to say the least. So, this one, we’re going to do another listener question. This one is from Elizabeth. So why don’t we just dive right in, Dr. Davidson why don’t you go ahead and read her question.

Dr. Davidson: Sure. So, Elizabeth, her question she actually is a podcast listener. So hi, Elizabeth. Thank you for sending your question. It’s really about low levels of T3. So, we have an episode that we did, what number was that?

Dr. Maki: 38.

Dr. Davidson: Episode 38 about “Do You Have Low Levels of T3? So, Elizabeth’s question is I just got my lab results back and they are: TSH, Thyroid-stimulating hormone, is 1.33, Free T4 is 1.64, Free T3 is 2.9, viroid peroxidase antibodies, that’s for the Hashimoto’s, is 16. My doctor said my Free T4 was a little high so she suggested cutting my levothyroxine, which is a T4 only medication, 50 micrograms in half, which would be 25 micrograms and to come back in a couple of months for labs. Do you think my Free T3 levels are low? I’ve been having terrible issues with my muscles and heart palpitations. –Elizabeth.

Dr. Maki: Yes, right. So, that’s a very common response by her doctor, right? To see the Free T3 a little bit high. So, they automatically–

Dr. Davidson: Free T4.

Dr. Maki: I’m sorry, yes. Free T4 to be a little high.

Dr. Davidson: Honestly, it’s not high.

Dr. Maki: Yes, no, no. But to reduce the medication by half at 50 micrograms or even 25, you might as well not even be on anything, right? I mean, that’s not really going to do too much, very conservative, very common, but nonetheless, it’s not going to help the patient feel any better.

Dr. Davidson: And I understand that too. Anytime you have a patient that says they’re having heart palpitations, the first thought is, “Okay, is their thyroid too high?” We’ve got to reduce it down. They’re having palpitations if their heart rate is up if they’re having anxiety or that kind of thing. So, I can understand the doctor feeling a little bit more like, “Okay, well, they’re having these symptoms, maybe it’s the T4, let’s cut it in half and see what happens because with low thyroid, let’s say, we have low thyroid, you’re not going to die, you’re just not going to feel great. So, they’re comfortable doing that, and I understand that but I would say with looking for Elizabeth, that her heart palpitations and terrible issues with the muscles might be something completely different from the thyroid, or maybe only a piece of the puzzle.

Dr. Maki: And with her being on 50 micrograms and having muscle problems and heart palpitations we could definitely assume, at least from our perspective, that the palpitations are coming from something completely different. If a woman’s in perimenopause, menopause, that can cause heart palpitations, stress. So, I look at or we look at heart palpitations as being more of an adrenal issue, as opposed to being strictly a cardiovascular issue. Now, cases like this, a woman has palpitations, that might be one of the first symptoms that she has, or she’s being under someone’s care and they send her to a cardiologist to get those palpitations evaluated. It always comes back normal, they do a stress test, they do all these different cardiology-related testing, comes back with a clean bill of health, but the palpitations keep happening, partially because there’s no treatment for the palpitations. So, when someone’s on thyroid medication of any sort, they get a little freaked out. Even you and I, if someone’s having palpitations that’s something that you can’t ignore. We have to kind of–

Dr. Davidson: Yes. I want to know about it right away. I don’t care if it’s a Saturday at nine o’clock in the morning, I want to know.

Dr. Maki: Yes. But when you know more about the history or the situation or the patient and if they’ve been on a dose for a long time, and all of a sudden, they just randomly start having palpitations, it’s more than likely not. We don’t know how long she’s at the 50 micrograms. But from a dosing perspective, that’s not a very high dose. Her numbers don’t look great. They don’t look terrible, but they don’t look great. So, the likelihood of that causing her palpitations is probably fairly low. It would be nice to know how old Elizabeth was because if she’s the late 40s or early 50s that would tell us what we really need to know when estrogen level starts to drop, those palpitations start to become more prevalent.

Dr. Davidson: Yes, estrogen, low levels of estrogen at the beginning for menopause or perimenopause will cause like little– they feel like little like flip flops like your heart is doing a summersault. And it always seems to happen when you’re laying down at night and everything’s quiet and so it’s scary, but she’s saying she’s having more heart palpitations and problems with her muscles. That would make me think that there’s probably maybe a little bit, like Dr. Maki said, something going on with the adrenals that are affecting her electrolytes and causing her sodium and potassium and magnesium and calcium. So, some of her mineral imbalances to go off a little bit because you think about what is a heart, a heart is a big muscle. So, just like if I don’t drink enough water or my electrolytes are off and I get a terrible Charley horse in my calf or on my foot, that’s a muscle cramp, you can have the same thing in your heart.

Dr. Maki: Yes, right. So, the term when you have a muscle spasm and when you have a– it’s just kind of twitching there a little bit, that’s called a fasciculation. And when that happens in the heart, that is what basically atrial fibrillation is. So, usually, when people have palpitations there’s usually a couple of things that can usually show up, AFib is the most common arrhythmia there is. You see commercials online for blood-thinning medications that help to prevent stroke risk and things of that nature because there is no medication for the arrhythmia itself. So, they kind of redirect and focus more on stroke prevention than actually dealing with the arrhythmia directly because I think there’s a medication called Rythmol, a lot of times they use beta-blockers for AFib, but those don’t tend to really do all that well. And just because our patient base is in this very specific age-range and we see these palpitation things come up all the time. So, in a woman late 40s or early 50s, she’s taking care of the kids, she’s working full time, she’s got stress, stress, stress, she’s not sleeping very well, all of a sudden now these palpitations just come up out of nowhere, as you said earlier, it freaks them out as it should because it’s your heart. Nobody wants your heart to do funny things but the thyroid kind of gets blamed for that when most of the time it has nothing to do with the thyroid.

Dr. Davidson: Yes, so looking at her electrolytes, maybe even supplementing with electrolytes, patients that I’ve had, that have had heart palpitations and muscle cramps is looking at just simple hydration, maybe they’re having hot flashes and it’s making them dehydrated. So, simple hydration and just some minerals and electrolytes can go a long way. So, I would definitely put that on the agenda if we’re looking at somebody like Elizabeth, but looking at her lab work for her thyroid. I agree with Dr. Maki. It’s not great, I mean, her TSH is just fine, the 1.33. Hey, that’s fine. Her free T4, 1.6., I usually like to see it a little bit lower like 1.2 and because our free T3 is low. What’s showing is that T4 is just building up in the system and not converting over to her free T3 hence her free T3 is at 2.9. Now if you look at these typical reference ranges, like we always talk about how ridiculous they are because they’re so huge is a reference range for free T3 is 2.2 to 4.4. So, you look at hers, it’s 2.9. Hey, you’re in range Elizabeth, your free T3 is fine, but it’s not fine, anything under 3.0 I definitely want to look into and anybody on some kind of thyroid medication shouldn’t have a free T3 of under three. So, definitely her T4 is not converting over to her free T3. So, we want to definitely address that by cutting her T4 down in half is probably not going to improve that.

Dr. Maki: Yes, no. It’s not going to make her feel any better. It’s just going to make her numbers look worse. So, in a case like this, usually, when someone comes to us on T4 monotherapy of oxo-levothyroxine Synthroid, we typically switch them to a compounded thyroid in a lot of cases. Because for the same reason, we don’t agree with the T4 monotherapy because the patient doesn’t feel better, their numbers might, their TSH will go down. Instant release T4 which is what T4 monotherapy is, has a very significant impact on lowering the TSH. So, from a very very simplified perspective, if you’re only focusing on the TSH and the medication you’re taking lowers the TSH very easily, then that’s a very easy problem to solve. But of the, what? 30 to 40 million cases of hypothyroid in America, everybody gets the same medication? That’s where it gets a little bit weird, thyroid’s way too complicated for that. There are too many factors and variables that go into thyroid function. We can’t look at one test and provide one medication for 40 million people. It just doesn’t work that well, okay? So, in this case, we would probably switch and increase her dose, right? Switch and increase her dose, and then maybe not right when she’s having the palpitations, deal with the palpitations first, get those under control. Whether that’s through estrogen whether that is BHRT whether that is addressing her adrenals or and mineral status, more than likely a combination of all three of those and then kind of coming back to the thyroid once those palpitations and the muscle issues are under control.

Dr. Davidson: Yes, I absolutely agree as raising up her T3 and trying to get that T4 to convert to T3 because in a beautiful perfect world our free T4 is supposed to convert to free T3 and then we have the active form of thyroid but things just don’t always work that way. And you often see that too in T4 monotherapy, is the T4 just kind of pools and then doesn’t convert over to that free T3 as well as it should. So, if we were to– I would automatically take her off, just like Dr. Maki said, take her off the levothyroxine do a compounded sustained-release T4, T3. Because what the conventional doctor doesn’t want to do and I understand this, is when you think a lot of doctors are afraid of doing T3 therapy and I can understand that because, conventionally, through the big box pharmacies the only prescription for T3 treatment is Cytomel which is, I kind of think, is kind of a dirty medication, it’s instant release so you take– if I took Cytomel it would instantly raise at my T3 way too fast. And that would give me heart palpitations, let alone Elizabeth. So, the last thing her doctor wants to do is give her a medication that’s going to exacerbate her heart palpitations. That’s why we never use of instant release T3, what we tend to use is a sustained-release T3 that just comes in your system very gently, it comes up and doesn’t have the cardiovascular effects. So, if her compounding pharmacies are all over the place, but a lot of doctors are just familiar with the big box pharmacies, and just what Big Pharma is offering. So, if they don’t have access or understand, “Hey, we could do a sustained-release free T3, that would take away the cardiovascular pressure on her system, raise up her T3, she’d probably feel better.” And then, as Dr. Maki said, is let’s look at it as a bigger picture. So, we’re looking at the thyroid, we’re looking at her minerals, we’re looking at her female hormone status and we’re looking at her adrenal glands.

Dr. Maki: Yes, right. I mean there’s this fear when it comes to T3 medication in a conventional setting, everybody is leery of prescribing Cytomel because those cardiovascular side effects are so common. I mean, most people can’t take beyond 10 micrograms, five to 10 micrograms of Cytomel before they start having those symptoms. So that’s why, one, we don’t like to use it. We might use it occasionally here or there. But it’s very rare, specifically for the palpitation issue, but because we’ve been working with women in this age range for so long. This heart palpitation issue comes up all the time and most of these women are very healthy. And they’ve been evaluated, they have lots of doctors on their team. They go through the proper evaluation, and they get a good cardiovascular bill of health that there’s nothing wrong, but they still keep having the palpitations. What are we going to do about those palpitations? So, mineral status, adrenal function and potentially changing the thyroid medication and looking at BHRT, specifically estrogen, that’s a pretty, for lack of a better term, a holistic approach to a problem like that. Now, once she’s going to feel better, and she’s not going to have that side effect on an ongoing issue or an ongoing basis.

Dr. Davidson: And just to also address her lab results here. Her thyroid peroxidase antibody was 16, which every lab’s a little bit different, some of them have been under 32. Some of them say under nine everyone is– she doesn’t have the actual reference range of the 16 like if it’s IUs per milliliter or IUs per deciliter. So, I’m not sure if she would be technically positive for Hashimoto’s or not, because typically, if she were a thyroid peroxidase antibody or they also call it a TPO antibody should be less than nine if it’s an IU over ML. So, this I’m thinking is probably more of the IU over DL or the other one that says less than 32. So, I’d have to probably really see her actual lab work to see if it’s truly Hashimoto’s or not.

Dr. Maki: Yes, right. And with her numbers, I don’t think it really matters too much.

Dr. Davidson: It’s pretty low.

Dr. Maki: Yes, yes, right. So, as you said, it’s probably in the normal range. Or if it isn’t, it just barely outside the normal range and it’s not affecting her other numbers that much.

Dr. Davidson: Yes, we would need the units for that one. The other ones we don’t need the units we already know that we would just need those units for that. But I always do kind of keep an eye on all the Hashimoto’s antibodies like the thyroid peroxidase or also the one that’s not tested as often for Hashimoto is the thyroid globulin antibodies. Those are also part of Hashimoto. So, we always keep an eye on that too. So, with Elizabeth, I’m glad that her doctor is keeping an eye on those.

Dr. Maki: Yes, right, yes. So, we definitely think that her free T3 could be better. But really, the more important issue is the medication was just not going from 50 to 25, both of them I think are somewhat ineffective. Certainly going from 50 to 25 is ineffective, but just the medication itself is ineffective. So, switching her, for some people, NDT, non-desiccated thyroid or natural desiccated thyroid is certainly very popular, that would be a fine option for her. I know there’s some controversy as some of the sourcing and everything from China and all this kind of stuff, that is certainly going to have an impact since the coronavirus stuff has happened, realizing more and more, where some of those raw materials are coming from. Some of them we might not even have known where the raw materials are coming from but now, because everything was on lockdown for so long, we might be able to know where some of those raw materials are coming from.

And it might have further effects as 2020 continues, but palpitations, that’s definitely a scary one, nobody likes to have their heart doing funny things like that. But rest assured, most of the time, just believe that that is usually not your heart, even though your heart’s doing funky stuff, just like I said, a muscle spasm in your thigh or something, that’s what your heart’s doing, it’s not supposed to do that. But it’s usually coming from some other reason than your heart itself and if you are having that issue, please go get it evaluated, you can’t take the risk of not having it evaluated. But usually, that is, we don’t need to get into the heart on this one. But usually, most of those types of arrhythmias are from the atria, okay? And your heart has the atria and the ventricles, arrhythmias that arise from the atria are usually not very serious, the ones that arise from the ventricles, ventricular tachycardia, ventricular fibrillation, those are much more serious. The ones from the atria, they feel like they’re problematic, but they’re not usually that serious. AFib, Aflutter, PVCs and PACs, premature ventricular contractions, premature atrial contractions, those also can show up in your heart can do funny things like that. PVCs, of the four that I just said, the PVCs tend to be maybe the most significant ones to pay attention to, but again, that’s a bigger conversation. But in this context, most of the time, heart palpitations are going to be AFib, very common, and usually, something other than the heart is leading to that. So, Dr. Davidson, do you have anything else to add for this one?

Dr. Davidson: No, no, I’m glad that you did add that in if your heart is doing some interesting things. I mean, it’s always great to have it checked out and honestly I think people need to have a healthcare team, their naturopath, their GP, their cardiologist, it’s good to have there a team put together. But I do think that if she went and got her heart testing, which is great, but most of the time people’s hearts are very strong and very healthy. It’s just more of an outline issue that’s creating that symptom.

Dr. Maki: Yes, right. Yes. So, we’ll talk more about that because that does come up. I wouldn’t say necessary, “unfortunately” but it is something that we deal with and see quite often. So, we’ll talk more specifically about heart palpitations in the future. We do get questions and our own patients are dealing with those things from time to time, so I think this one is good. Any final words?

Dr. Davidson: Nope. Nope. That was great.

Dr. Maki: Okay. Until next time, I’m Dr. Maki.

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

Dr. Maki: Bye now.

The post What Should My T3 Free Level Be? | PYHP 079 appeared first on .

What TSH Level Indicates Hypothyroidism? | PYHP 078

Dr Valorie Davidson and Dr Robert Maki — Thu, 02 Apr 2020 18:14:07 +0000

Lisa’s Question:

I have a free T4 of 1.5, a TSH at 3.09 and I have a free T3 of 2.7. Do these seem like they are within parameters? My ENT says everything is fine with my numbers, and my vitamin D is 26.5.

Short Answer:

This is a good example of a high normal TSH level (3.09), which does raise some concerns. Any time we see a TSH above 2.0 to 2.5, it gets our attention. A high normal TSH level, along with clinical symptoms helpt to determine the best course of action for the patient. We like to see a low normal TSH level and a high normal Free T3 level, preferably greater than 3.2.

PYHP 078 Full Transcript:

Download PYHP 078 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 how are you doing this morning?

Dr. Davidson: I’m doing great. How are you doing?

Dr. Maki: Pretty good. Pretty good. 2020 is moving along.

Dr. Davidson: It sure is.

Dr. Maki: A little bit of a hiccup earlier in the year, but we survived. We’re all making it through. We’re going to continue answering some more questions. This one also is pertaining to thyroid, and this is from Lisa. So, Dr. Davidson, why don’t you to go ahead and read it from Lisa?

Dr. Davidson: Sure. So, Lisa is a podcast listener, hence we’re doing the podcast, but she has a question based on episode 38 which seems like light years away.

Dr. Maki: Yeah, it seems like it was so long ago.

Dr. Davidson: That we did that episode 38. Episode 38 was, Do you have a low free T3 level? So, Lisa’s question is, I have a free T4 of 1.5, a TSH at 3.09 and I have a free T3 of 2.7. Do these seem like they are within parameters? My ENT says everything is fine with my numbers, and my vitamin D is 26.5.

Dr. Maki: Yeah. Right. So, this is in some ways in contrast to Dinette that we talked about. In some ways, almost exactly, the opposite. So here her TSH is already on the high end of normal. 3.0, that’s a little bit of a red flag for us, right? When we talked about Dinette, her number was point– I don’t remember exactly what it was. It was 0.82 or something. So, way on the low end of normal. Now here, her number is on the complete high end of normal. Right away, that automatically puts up some red flags.

Dr. Davidson: Why don’t you reiterate what TSH does and what does it mean when it’s high and when it’s low?

Dr. Maki: Oh, well, why don’t you do that?

Dr. Davidson: Okay, I will. Well, I did that on Dinette, and I will do it with Lisa just for those of you, which I’m sure you already know, because many of our podcast listeners know this stuff forwards and backwards, but if somebody has a high TSH, a thyroid-stimulating hormone, which is a signal that comes from the brain if that TSH is high, that usually indicates that the thyroid function in the body is low. Now, this isn’t 100%. You never want to base someone’s thyroid dose or diagnosis or whatnot on a simple TSH number. But I love to get the input. Any objective data that we can get is better. So, a high thyroid-stimulating hormone definitely jumps out as saying, hey, you know what? That person’s thyroid could be low.

And now, of course, a normal TSH range on pretty much most labs ranges from 0.45 to 4.5. So here, Lisa’s got a TSH almost 3.1, so her ENT is like, “Okay, it’s fine; it’s in range.” But that’s a really broad reference range. 0.45 to four and a half. That’s huge. Anytime we see anybody over 2.5, that’s a serious red flag. That’s like, okay, something’s going on with the thyroid. We’ve got to figure it out. Sometimes even when I see it at one, depending on the symptoms, because we always say is let’s treat the person, not the numbers, but even if you see it over one and then you say, “Okay, well let’s investigate this.” But seeing Lisa’s TSH at like I said, almost 3.1, further warrants some investigation there.

Dr. Maki: Yeah, right. Yeah. Yeah. And then moving onto the free T3. 2.7 again, very common to see it in the twos as opposed to… Instead of it being 2.7, we like to see it at 3.7. Now that’s not necessarily very common, especially as time goes on, the TSH tends to rise, and the free T3 tends to go down. From a clinical perspective, we want the exact opposite to happen. We want that TSH to be nice and low. We want the free T3 to be nice and high because usually that’s where the patient is or the person’s going to feel the best in some respects. So, her numbers raise some flags there.

Dr. Davidson: And I’m glad that her doctor ran a free T3. Most docs won’t. Usually, they’ll do a TSH, and if the TSH is out of range, then they’ll reflex to a free T4. So I’m glad that we have the free T4, the free T3, and the TSH so we can look at them together. So, seeing that TSH up there, almost 3.1, and then that free T3. Now free T3 gets a little bit confusing because they have huge reference ranges for that on labs. So, don’t listen to the reference ranges, they’re just ridiculous. The reference range for free T3 is 2.2 to 4.4, and anybody in that reference range can be “normal.” So, seeing hers at 2.7, anything under 3.0 always triggers me because free T3 is the actual active thyroid hormone.

You can have all the T4 in the world, but if you don’t have enough free T3, then you’re going to have a lot of symptoms of hypothyroid. So, her free T4 at 1.5 is astonishing. Well, 1.5 is amazing. Usually, they have this ridiculous reference range, again for a free T4 is 0.8 to 1.8, but a 1.5 is really good. And those of you that, I’m going to be redundant here, I’m sure you already know this, but the thyroid mainly makes T4, and that travels in the bloodstream, and then with the peripheral tissues, it’ll take that T4 and convert it to free T3. So T4 is a very stable molecule. It’s got a seven-day half-life. It doesn’t have a lot of activity other than it needs to convert to free T3 to have the activity. Now free T3 has a very, very short half-life. It’s 24 hours or something like that. It’s very short, but it’s very active. So, you want to make sure you have enough T4 coming out, converting to T3.

Dr. Maki: Yeah, right. And this is where we get into treatment, and this is why we differ from the conventional mode of treatment, because in this context if her TSH was a little bit higher. Then again, her ENT would prescribe her Synthroid, Levoxyl levothyroxine, which is referred to again, for those of you that know is T4 monotherapy, which we don’t ever prescribe T4 monotherapy because she already has sufficient free T4. Where she’s lacking is in the free T3 and, excuse me, pardon me. Most women in this situation, they have a problem converting their free T3 anyways, and 60% of that conversion from T4 to T3 happens in the liver. Now again, you and I being naturopaths, we always pay attention to the liver. The liver, in Chinese medicine, they refer to it as the General because it does all these different metabolic functions on a daily basis.

If your liver’s overburdened from stress, from alcohol, from caffeine, from toxins in the environment, to metabolic stress, to who knows? Now that conversion capability of converting T4 to T3 is going to be diminished. You’re not going to have as much. And then, of course, as time goes on too, the peripheral tissue, your muscles, and everything else that are supposed to be converting T4 to T3 isn’t going to happen either.

Dr. Davidson: So, whether Lisa is on a T4 monotherapy and that’s why her T4 is 1.5, which is great, or maybe she’s not, and she just makes a really good amount of T4. The problem here, like Dr. Maki, is saying, is that it’s not converting to the free T3. So, there is a problem there.

So I would say, instead of just waiting for that TSH to continue to rise, and that T3 to continue to drop, which will happen if you wait three months, six months, a year, these numbers will be “out of normal range” for these ridiculously vast reference ranges that the labs have, they will be out of range. But do we want Lisa to suffer for the next six months to a year when I guarantee just looking at where her free T3 levels are in that TSH, she’s probably not feeling real great as is.

Dr. Maki: Yeah, right. And we could almost assume, even though, like I said, when it comes to a diagnosis, it can’t always be black and white. And when you see a number of 3.1 for a TSH, that’s pretty much an abnormal number. So, when you talk about these wide reference ranges, that means that those reference ranges need to be narrowed. The lower end, the 0.45 is, I think fine, but the higher end, that 4.5 should be reduced down. I think the American Academy of Clinical Endocrinology recommends that it should be reduced to 2.5.

Now that is a mixed bag because that makes more people potential candidates for medication, but that’s in some ways the wrong kind of medication. It makes more candidates available for T4 monotherapy again, and I don’t think that does anybody any good. But there’s a large number of people, in a case like this where people are being misdiagnosed or underdiagnosed, when their numbers go along with someone that would– So technically, even though her numbers are still normal across the board, we would put her in that subclinical hypothyroid category, particularly because of the TSH and the low normal free T3.

Dr. Davidson: And, if I had a patient that had similar numbers like this, I would put them on some T3, some compounded sustained release T3, because when people think of T3, conventional medicine for T3 is Cytomel, which is just garbage. It’s instant release; it’s hard on the heart and the cardiovascular system. I would never put anybody on Cytomel. Would you? I mean maybe there might maybe–

Dr. Maki: I know there’s a lot of talks online about Cytomel. People take some crazy doses of it. They can’t take it all at once because it will give them cardiovascular symptoms. They’ll start getting palpitations or anxiety or jitteriness. So, people have to take it multiple doses. That’s why we, most of the time, prefer the sustained release because the numbers improve, and it’s much more tolerated over time.

Dr. Davidson: Yeah. You can take it once a day as a sustained release, it doesn’t have that input– impact on the cardiovascular system, and it doesn’t have that impact, like you had just mentioned, about anxiety. And it has that sustainability throughout the whole 24-hour period.

So I would– and she would probably feel so much better just raising that free T3 from 2.7, even to 3.4, would probably be dramatic. But ideally, we like to see that around 3.7 to 4.4 if you’re looking at perfect numbers. But we always say, we want to treat the human, not the numbers. So definitely, like Dr. Maki was saying, Lisa has definitely got a low free T3, a problem with her conversion from T4 to T3, and also, I would diagnose her as hypothyroid with her TSH number.

Dr. Maki: Yeah, right. Yeah. So again, that’s where the controversy is because technically, she is not hyperthyroid because her number is not above four, her TSH is not above 4.5. That is, the diagnostic criteria for someone being hyperthyroid is the TSH only. That’s the only number that you go by for a technical diagnosis.

And we don’t agree 3.1 or 3.09, in our opinion, is close enough. And like you said too, with a TSH of 3.09, she’s going to have multiple symptoms there. So, it’s the doctor’s discretion to treat the patient, not the lab test. In this case, you’re doing both because, more than likely, she does not feel great with a TSH of 3.09.

Dr. Davidson: And, I know we’re talking about free T3, low levels of free T3 and thyroid, but Lisa does mention that her vitamin D is a little bit low, it’s at 26.5. Now the reference ranges again on most labs are ridiculously vast. They’re at 30 to 100, but she is low. She is technically low.

Dr. Maki: Yeah. Right. Yeah. I mean, I lived in the Southwest for 15 years in a very sun abundant environment between Las Vegas and California, and everybody had low normal if not abnormal Vitamin D levels. Now I believe, and there’s probably some research, whatever, but whether the test is wrong, whether we’re testing, or the test is inaccurate, something is going on here.

For people that live in the geographic area, they should have normal, actually high, normal vitamin D levels. For everyone to have low, it’s not– And maybe it is a sunshine problem. I mean, maybe in the desert where we used to live, maybe because people were inside so much in the summertime. But that’s only three months of the year; maybe it is a sunshine problem because everyone’s indoors all the time. I think it’s a more of a sign that there’s some kind of inflammatory and some other hormonal process going on that is dragging that vitamin D level down.

Dr. Davidson: Possibly. But I do think supplementing with vitamin D is a great idea. I love vitamin D. I take it myself. But of course, you don’t want your reference ranges to go too high because vitamin D is technically a hormone, and it’s technically fat-soluble. So, taking too much of a fat-soluble anything can store itself in your body and become toxic. But at 26.5, that probably is a little bit on the low end. Vitamin D is great for bone density. If you’re a female and we’re looking at keeping our bone density good for years and years and years, vitamin D is a must. But, for me, I love vitamin D for the immune system. I think it’s great for keeping the immune system strong without overstimulating it.

Dr. Maki: Right, right. So certainly, with a level of 26.5, you definitely would want to supplement with that. Then, of course, sleep and metabolic status, insulin, cortisol, those types of things, that number should rise from supplementation, and then kind of level off. What is your range? Where do you like to see it? Somewhere between, let’s say 45 and 65, somewhere in that range?

Dr. Davidson: Yeah, I like 55. I think if you can maintain right around 55 to 60, that’s perfect because you’re never going to take too much to end up going over a hundred. I have had patients that take too much vitamin D, and we check their reference ranges, and I’m like, “You’re taking too much vitamin D. It’s 120. We don’t want that chronically.

So usually, if you can keep it around 55, you’re not going to have any trouble going too high or too low unless somebody has any kind of autoimmune condition, especially like MS, I definitely– or any connective tissue autoimmune disease. I love to keep that vitamin D up closer to about 75 because, like I said, it’s great for the immune system, but it doesn’t stimulate it, but it’s just strengthens that immune system. So, I find that it’s good for those autoimmune conditions. But of course, if somebody is having a vitamin D around 75 or 80, I keep a little bit closer tabs a little more frequently to make sure it doesn’t end up cusping over a hundred.

Dr. Maki: Yeah. Right. And then of course with bone density issues, like you mentioned, if someone’s osteoporotic, a dosage of anywhere from 5,000 to 10,000 IUs is not unreasonable, whereas someone that is just trying to maintain a certain level, they might do 2 to 5,000 IUs. Maybe, in this case, she’s pretty low at 26.5, so maybe she’d start out at 5,000 IUs daily for three to six months, retest, see where it comes up to. And then from there, depending on how high it goes, you can determine– Let’s say her number shoots up quite significantly higher on 5,000, then she probably cut back. She could probably maintain at 2000, and the number would stay probably right around your 55 like you mentioned.

Dr. Davidson: Yeah, exactly. Typically, what I find just with the patients that I’ve worked with is that females don’t need more than 5,000. It tends to start to run a little too high once– because it builds up in the system over time. So usually 5,000 is pretty good, keeping it to about 35,000 IUs to maybe about 25 to 35,000 IUs per week, because sometimes I’ll do Monday through Friday with women and then we’ll take off the weekends. But men can do a little bit more, but we still keep an eye on that. But exactly. Once you found that level, then you can just– Everybody’s different. For me, 5,000 works for me. But I have some that take 2,000 and that keeps their levels up there at 65.

Dr. Maki: Yeah. Yeah. So yeah, if you are taking vitamin D, you don’t want to just take it unabated or without any objective information. You want to make sure that you’re at least testing those levels, so you don’t get that– For a short amount of time, having a level a little over a hundred is not a big deal. I’m not even sure. Do you even know what vitamin D toxicity even looks like? I don’t know. I’d have to look it up.

Dr. Davidson: It’s very bad for the kidneys, and it’s not good for the liver. So, it puts huge burdens on there. I’ve only run into people that maybe they came in and we test– they’d been taking it on their own, and it’s about– I think the highest I’ve ever seen was 120. They didn’t, of course, have any beautiful health, perfect health. There wasn’t any issues there, but it was like, “Okay, we’ve got to back off.”

I’ve never really ran into anybody that was taking more than that. But usually, the patients that I have usually start off with not taking vitamin D and then I test it, and then we add it in.

Dr. Maki: Yeah. Right. Right. Right. Right. Now I know, so vitamin D deficiency, as we’re kind of wrapping this one up, vitamin D deficiency is called rickets. That, I don’t think really– I mean I know that nowadays, they talk about all these vitamin deficiencies are starting to come back a little bit because we’re, in some ways, in America and a lot of industrialized nations, we’re overfed, but under– a lot of calories, but our nutrition isn’t as great from a micronutrient perspective, macronutrient meaning carbs, fats, proteins, calories, micronutrients, meaning the vitamins and minerals that we need. And in a processed food world, the micronutrient content is going to always be different.

But that’s the thing about vitamin D is that vitamin D does not really– there’s not a lot of food sources. Natural food sources of vitamin D comes from the sun. So that’s why when you see it low like that in a very sun-abundant environment, it just questions as to why is everybody of all different age ranges coming up at either abnormally low or low normal. I think something else is going on there.

I have some theories, and I have some ideas, and I know there’s probably some other ones out there online as to what that’s all about. But sometimes we do see, and I know you’ve seen it too, you don’t do anything with vitamin D, no supplementation at all, the patient starts to feel better, they’re sleeping better, they’re doing this, and their vitamin D just comes up on its own. I know that you and I both have seen that a few times, which is very interesting.

So anything else to add about Lisa?

Dr. Davidson: No. No. Thank you, Lisa, for listening and also thank you for your question.

Dr. Maki: Yeah, right. I’m not sure what the ENT is going to do, but I would keep looking for more answers or looking for someone that is able to help you because just saying that your numbers are fine, I don’t think is sufficient. I think in your case, I don’t think that those numbers are fine. I think it warrants a little bit more investigation. So, until next time, I’m Dr. Maki.

Dr. Davidson: And I’m Dr. Davidson. Take care.

Dr. Maki: Bye now.

The post What TSH Level Indicates Hypothyroidism? | PYHP 078 appeared first on .

Do I Have Hypothyroidism? | PYHP 077

Dr Valorie Davidson and Dr Robert Maki — Wed, 01 Apr 2020 18:09:50 +0000

Danette’s Question:

Can you determine if I should be considered for hypothyroidism? I have five of the listed symptoms, but my labs fall into “normal ranges” from my lab. Free T4 is 1.1, free T3 is 3.0. TSH, thyroid-stimulating hormone, is .82.

Short Answer:

Many people could be considered to have Subclinical Hypothyroidism. This is when thyroid labs are all within the normal range, but several symptoms are present. In Danette’s case, her labs actually look fairly decent. Her TSH is below 1.0 and her Free T3 is 3.0, but she has many hypothyroid related symptoms. She does not have hypothyroidism, but could easily be in the subclinical category. However, many of the symptoms listed below can be attributed to many other issues including PMS, Perimenopause, Menopause and adrenal dysfunction.

Symptoms of Hypothyroidism: (not a comprehensive list)

fatigue
weight gain or slow metabolism
dry skin
constipation
low mood
heavy periods
heavy irregular periods
brain fog,
hair loss.

PYHP 077 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: I’m Dr. Davidson.

Dr. Maki: So, Dr. Davidson, how are you doing this morning?

Dr. Davidson: I am doing really good. I’m just actually looking at our little dog, Bob. His name is Bob, that we have. He’s what, 15 months old right now? 16 months old? Anyway, I just love to look at him. He’s laying at my feet with his head using, there’s on the desk here, there’s a metal rod and he likes to use that metal rod as his pillow.

Dr. Maki: Yes, yes. So, if you’re wondering, my name is Robert, his name is Bob. My dad’s name was Bob. He always went by Bobby, didn’t go by Robert or Rob. So, he passed away in 2000. But when we got him, he went through a kind of a whole bunch of awful names. Then you just came up with Bob one day like, I think we should name him Bob. I’m like, alright, that’s good. That was my pick in the first place. But you went through a bunch of, I didn’t remember some of that. There are some weird ones.

Dr. Davidson: I won’t tell you but he is a Bob and he’s very cute.

Dr. Maki: We’ve talked about him in some other podcasts, but if you’re interested, he is half Australian Shepherd, a mini Australian shepherd. He’s quarter Border Collie and a quarter Blue Heeler. Needless to say, he’s smart as a whip and he has an unlimited amount of energy, almost to a frustrating point sometimes, but nonetheless, he’s fantastic. So, we’re gonna talk about some listener reader questions. This one is about thyroid, kind of questioning whether someone is hypothyroid or not. This one honestly is something that we get quite often, this is very, in some ways, a little bit of a controversial topic. We’ll get into why that is here in a second. This comes from Danette. Dr. Davidson, once you go ahead and read it.

Dr. Davidson: Sure, sure. So, this question is from Danette and she’s actually a podcast listener. So, she had listened to an episode called, Do you have low levels of T3? So, her question was, from Danette, can you determine if I should be considered for hypothyroidism? I have five of the listed symptoms, but my labs fall into “normal ranges” from my lab. Free T4 is 1.1, free T3 is 3.0. TSH, thyroid-stimulating hormone, is .82. Like, Dr. Maki said, it is a little bit controversial because people always want to be, not necessarily people in general, But there’s always this connotation of being diagnosed, I’ve been diagnosed this, I’m diagnosed this, like this label of being diagnosed. So, if you fall in a certain reference range, then you’re either not diagnosed as hypothyroid. But if you fall just slightly out of that reference range, then you’re technically diagnosed hypothyroid. So, we look at things a little bit more fluidly. Looking at the symptoms, of course, looking at the labs, looking at the person’s lifestyle. So, this is where we’re going to kind of break this down a bit. But just to kind of back up on that episode that we did, the symptoms that we had which Danette is saying that she has five, plus of the listed symptoms. The symptoms we had written down were fatigue, weight gain or slow metabolism, dry skin, constipation, low mood, heavy periods, heavy irregular periods, brain fog, and hair loss.

Dr. Maki: Yes. That’s Episode 38, by the way, if you go back and look. It’s amazing on how long ago that was already that we’re already on, this is what I think 75 or 74, something like that. Now, we’re already almost 40 episodes past that. So, in a situation like this, her labs, again the free T3, the free T4, the TSH, those three tests, at least there is a free T3 level there. Whoever ran her numbers, the free T3 is one that we choose to do all the time. Conventionally, it does not get done very often. Even if it does get done at the patient’s request, most doctors really don’t pay a lot of attention to it. Her TSH is actually perfect. It’s below 1.8. I think is a very good number. The free T3 is a little bit kind of middle of the range, top of the bell curve. But at least it’s in the 3s. It’s not in the 2s. What we don’t know about Danette is how old Danette is. So from her thyroid numbers, she’s technically not hypothyroid. With her symptoms like you say, one of our rules always is to treat the patient first and the lab test second. In medicine, it kind of has reversed a little bit and it’s all always about the numbers and it’s not so much about the clinical presentation as it probably should be, in most cases.

Dr. Davidson: Exactly. So, we’re just looking at the labs and Danette’s probably feeling frustrated with her doctor because they’re telling her she’s normal, but she’s not feeling normal. But like Dr. Maki had said with the reference ranges, and honestly, the reference ranges are really vast that most people when they do their lab work for their thyroid tend to fall in that normal range. But her TSH like he said, the thyroid-stimulating hormone at .82 is actually really good. The usual reference range for a TSH is anywhere between point .45 and 4.5, which is a very big reference range, .45 to 4.5. So, in the way the TSH works, the thyroid-stimulating hormone is a signal from your brain and it monitors overall thyroid status in your body. So, if the thyroid levels go down in your body, that TSH from the brain goes up. So, when you see a high number of TSH, then you think that person’s thyroid is probably low. I’ve had plenty of patients and I’m sure you have too, Dr. Maki, that come in and their TSH is actually down at you know, .45, maybe even a little lower than that, or .75 and they’re like, my TSH is so low is my thyroid low? Actually, I have to tell them, it works in the reverse, which is called a negative feedback. So, if that TSH is low, that means your thyroid levels possibly pretty much are probably on the higher end and vice versa, if that makes sense.

Dr. Maki: Yes, right. Yes. So, it’s kind of the opposite. When the TSH goes up, then your thyroid function is lower. But there’s a lot of controversies out there in the non-conventional world of not really paying a lot of attention to the TSH, which we do agree with. Now, we test the TSH, we want to pay attention with the TSH is because it still provides us some good information. But we don’t necessarily make all of our decisions based on that one test. Conventionally, when people finally come to us, they’ve been to multiple doctors, they might have been to their general practitioner or even an endocrinologist. If that TSH comes back normal, they are not going to do nothing. That’s where we differ with that a little bit, in a lot of cases, because with everything like, you said earlier about being diagnosed. There’s this kind of, I have it or I don’t kind of a concept in medicine. With thyroid, I think thyroid has certain levels of severity. Now, if that TSH, let’s say hers is at 8, you know, it’s 8.2 instead of .82, well then automatically she’d be diagnosed and she put on she’d be put on Synthroid or levothyroxine or Levoxyl, but that’s also a treatment style that we don’t necessarily agree with either. Her numbers, technically she is not hypothyroid but she had a list of five of the plus five plus symptoms on the list that we read off earlier. So, we would put her in a category of subclinical hypothyroid at least potentially anyways, but there’s a whole bunch more information about her lifestyle, her age, her menstrual history, where she is, is she in menopause? Is she not? If she’s in perimenopause or menopause, that could account for all of her symptoms. But if she was, and I believe that she probably isn’t, I would say if she was in menopause, or even close to menopause, her thyroid numbers probably look worse than they do.

Dr. Davidson: Yes. Usually with menopause, that TSH will start to come up and like Dr. Maki said is that we don’t want to fixate on the TSH, we just want to have it in our [inaudible] to be able to put all the pieces of the puzzle together. I do think that Danette’s free T4 at 1.1 is pretty good. I like to see the free T4 right around 1.1, 1.2. You don’t necessarily want to see it too high because a lot of the reference range is vast, .8 to 1.8. Because if your T4 is too high, that means it’s pulling and it’s not converting to the free T3 because the whole goal between free T4 is to have it convert to the active form of thyroid which is the free T3. So, with Danette, her free T3 at 3.0 again, the reference ranges are huge 1.8 to 2.9. Some of them are like 2.2 to 4.4 everybody is, they have all these reference ranges all over the place with these labs. I’m sorry, the typical reference range is 2.2 to 4.4. But anytime you see it around 3 or below, you think that free T3 is low. But that’s where like, Dr. Maki said, we want to treat the individual. We don’t want to treat the numbers. Danette would not feel good if I said okay, your free T3 is low, let’s just throw you on some thyroid, she’d probably feel horrible because her TSH is pretty good. Her free T4 is pretty good. There’s probably something else behind the scenes that’s creating that free T3 to go down. Usually, your first thought is like we had talked about perimenopause, menopause. I’m thinking it probably is a little bit more to do with her adrenal glands.

Dr. Maki: Yes, right. There’s definitely a connection between the adrenals and thyroid function. Depending on what symptom she has there, adrenal issues, stress is going to cause irregularities to the period, it’s certainly going to cause weight gain is going to certainly cause fatigue, dry skin, constipation, even low mood. If you look up anything that relates to hypothyroid, those come up quite often. But there are lots of other things that those could pertain to. They’re classic hypothyroid symptoms, but there are other things that could lead to those as well.

Dr. Davidson: So, granted, this question is one sentence with a couple of lab numbers. But just to kind of really extrapolate a little bit, looking at what she’s saying, I would say out of her symptoms, she probably has fatigue, because of that low T3 level around 3.0 is probably making her tired. She probably is getting weight gain, or she’s stalling and not losing weight. And I would say probably the other ones would be the dry skin, the low mood, and the brain fog. She might be having some hair loss, but usually, that free T3 has to be below 3.0 to really see that hair really fall out a lot because it does when that T3 starts to a dropdown. But I would say definitely she’s probably tired and it’s that metabolism.

Dr. Maki: Yes, right. Yes. With numbers like this, again, with that free T3 being right on the top of the bell curve, so the reference range for free T3 is 2.3. Some labs it goes all the way down to 2.0. Some of it goes down to even like 1.8 and it goes up to 4.2 to 4.4. So the 3.0 would be pretty much at the top of the bell curve. A lot of times, we see that number for women, especially of all different age ranges, we see it in the low 2s. It’ll be 2.3, 2.4, 2.6, 2.7 and as you said, that’s where some of the more predominant hypothyroid symptoms come in. Usually, if that’s the case, what we want to see when we’re managing someone’s thyroid, is we want to see a low normal TSH, a high normal free T3. In some ways, hers is exactly that. She’s got a low normal TSH, I wouldn’t say a high normal free T3, but it’s in a good range. It’s in a relatively good range free T3, as opposed to being in the lower 2s. So then, if let’s say fatigue was one of her symptoms or the weight gain, then you would think more insulin stress, cortisol stress, maybe there are some other things going on there that are making those symptoms manifest on a consistent basis.

Dr. Davidson: Yes. You’ll see that TSH actually drops and then the T3 drops when you see somebody that’s under a tremendous amount of mental or physical stress, like, for example, people that are training for a marathon. When they’re really getting up there in those high mileage numbers, their free T3 will tend to drop a little bit because they’re putting such a tremendous amount of pressure on their bodies that their body is not really understanding. So, it’s trying to conserve energy, and you’ll see the T3 drop and the TSH go down. You see that also when people go on a diet, you know, right? Our typical day, hey, I grew up in the 80s. and 90s, we were told if you wanted to lose a few extra pounds, you just stop eating. Now, we know that’s not right. So, when you try to restrict your calories, the body thinks it’s starving itself. So, what does it want to do? It wants to conserve energy. So, you’ll see the TSH drop and you’ll see the free T3 drop. So, in some respects, like we’ve talked about in the past and Dr. Maki is super passionate about, is Danette may be over-exercising and under-eating.

Dr. Maki: Yes, that’s possible. That may be just because her TSH is below one, but maybe the free T3 would be a little bit lower than that if she was. I wouldn’t expect it to be 3.0 if she was. But when you see more psychological stress, stress at work, stress in the family, financial stress, or they’re approaching menopause, which is a different kind of stress. Now, you start to see that TSH starts to rise, it’s 1.5, then it goes to 2.2, then it goes to 3.2 and it hovers in that upper end of that range, then usually those symptoms are are pretty predominant at that point. So, in this case, if her TSH like I say was 2.5 or higher, even 2.0 or higher, we probably approached this a little bit of a different way. But because her TSH even though that’s not the end all be all as far as thyroid testing. If we put her on medication with these numbers, her TSH would just drop too low of a range, it may not necessarily make her feel any better.

Dr. Davidson: No. So, I had a patient that had this type of profile, definitely like we mentioned looking into the adrenal glands looking into the lifestyle, maybe doing some nutritional supplements to help the T4 convert to T3 and maybe even checking a reverse T3. So, if her T4 is converting to reverse T3 and her reverse T3 is a little bit on the high end, then you know that, hey, we need to do something to get that conversion to go to the free T3, and you can do that. There are lots of different supplements that we use. There are lots of lifestyles. Dr. Maki had even mentioned something about sleeping and cortisol and insulin and glucose. If she’s not sleeping, then her free T3 is going to drop down whether she can’t sleep because her body won’t let her sleep or she can’t sleep because she’s not letting her sleep. So it’d be really looking into a little bit more lifestyle and then after working with her for maybe about six to nine weeks, then we would probably retest, maybe some other adrenal profiles, but then look at this thyroid panel again, to see okay, where’s that T3 now?

Dr. Maki: Yes, right. Yes. Now, again, we don’t know where she is if she’s in perimenopause or menopause. If she’s in menopause, looking at female hormones, definitely it comes into play, even into perimenopause that’s going to have a factor and all those symptoms are going to kind of mimic a hypothyroid-type of situation. So, I think we kind of hashed this one to death, right? I think we beat this one thoroughly. We could probably keep talking about it. I mean, we talk about this stuff all the time. But this one, I think it’s a fairly straightforward case for the most part, but there’s a lot of information that we don’t know, so we’re making some assumptions to be able to… that we would have to know in order to make full clinical decisions about this situation. So, Dr. Davidson, do you have anything else to add about this?

Dr. Davidson: No, no. This was really fun.

Dr. Maki: Okay. Until next time. I’m Dr. Maki.

Dr. Davidosn: I’m Dr. Davidson. Take care.

Dr. Maki: Bye now.

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What Does Biest Mean? | PYHP 076

Dr Valorie Davidson and Dr Robert Maki — Tue, 31 Mar 2020 18:39:13 +0000

Angie’s Questions:

Hi, I’m going to start Biest compounded at 80/20 ratio; 80% estriol, 20% estradiol, 2.5 milligrams once a day, and 100 milligrams compounded slow-release progesterone pill. My doctor and I decided on this amount because I read from a well-known hormone doctor that anything less will not help the heart, the brain, and the bones. Question. Will the cream travel through my body enough to help with those or should it be in a pill form, which I would rather not do since I’m already going to be taking a progesterone pill. I heard that the progesterone pill is a must if you have a uterus, I am in my late 50s and I started menopause later.

Short Answer:

Biest is a very common form of Bioidentical Hormone Replacement Therapy (BHRT). This is often prescribed as a transdermal cream. Biest contains two different forms of estrogen, which is estradiol and estriol. A common starting ratio of Biest is 80/20, which means 80% of estriol and 20% estradiol. A typically starting Biest dose for us is usually 3 mg, but it depends on the severity of menopausal symptoms.

PYHP 076 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 we’re still stuck in quarantine coronavirus. 2020 is upon us still, I think we’re up here in Washington State. Everything’s closed except for banks and grocery stores, gas stations. Bars and restaurants are closed. Of course, hospitals are not, healthcare practices and medical clinics. But hopefully, this will resolve soon. Hopefully, by social distancing we’ll have some positive effects, and we’ll be able to get back to some normalcy fairly soon. In the meantime, we’re going to continue on with the podcast. It does seem a little weird, I’m talking about hormones when all this other stuff is going on but at the same time, we don’t want to focus on that too much. It is what it is. If we all do our part, I think it’ll kind of dissipate, and we’ll minimize some of the collateral damage as much as possible.

Dr. Davidson: Yes, I completely agree. Instead of panic, just try to hope for the best, everybody’s going to be okay. Let’s try to stay home and not infect anybody else. Like Dr. Maki said, we’re in Washington, which there is a lot more cases of deaths here so people are being extra proactive, which I think it’s wonderful that we’re all trying to support the community. I think when this is done, we’ll come together and try to help everybody else that have been impacted financially from this too because that could be very devastating.

Dr. Maki: Yes, completely. Let’s get back to hormones. The last one we talked about Lisa. So, again, some very typical questions. This one, we’re going to talk about Angie. In some ways, we’ve kind of paired these two together from last one to this one, just because it kind of reiterates some of the things that we talked about. Dr. Davidson, why don’t you go ahead and read Angie’s question.

Dr. Davidson: Sure. This question is from Angie. Hi Angie. Angie’s actually a podcast listener. So I appreciate you listening to our podcast and putting out your question because your question is really important, and I love her specificity on this. This is really cool. Angie says, “Hi, I’m going to start Biest compounded at 8020 ratios; 80% estriol, 20% estradiol, 2.5 milligrams once a day, and 100 milligrams compounded slow-release progesterone pill. My doctor and I decided on this amount because I read from a well-known hormone doctor that anything less will not help the heart, the brain and the bones. Question. Will the cream travel through my body enough to help with those or should it be in a pill form, which I would rather not do since I’m already going to be taking a progesterone pill. I heard that the progesterone pill is a must if you have a uterus, I am in my late 50s and I started menopause later.”

Dr. Maki: So, again, similar to Lisa’s but she does provide some very useful information, the 8020 and this time she does give the– which is the ratio of the two hormones the estradiol, the estriol, but she also does give the milligram amount which in the last podcast, Lisa did not provide that milligram amount. So we’re kind of guessing a little bit, assuming a couple of things based on her symptom picture.

Dr. Davidson: Which was fun with Lisa because there’s so many– That’s the cool thing with the compounding hormones is, you can do anything and everything that you could imagine with a patient when you’re using a compounding pharmacy. You can use a quarter of a milligram, a microgram, you can make any changes you want. And so, that’s the cool thing. You can design a hormone dosing profile for a patient based on them individually, as opposed to, as we pretty much know in conventional medicine, it’s one dose fits all. What a 400-pound male dose for antibiotics would be the same if they gave it to me. I’m not 400 pounds.

Dr. Maki: Yes, right. There’s no personalization, there’s no customization. There’s whatever dose the pharmacy has, or what the manufacturer makes, that’s what you get. That’s why this is– and I know you’ve said this before yourself. It’s just as much of a science as it is an art form to know what that particular patient needs based on their symptom picture. Sorry, there’s a little-

Dr. Davidson: A little maniac on the floor.

Dr. Maki: We actually had to redo this episode because we got some new equipment and we have a new setup. Of course, for those of you that have an Aussie out there, he’s always at our feet all the time. And now he’s chewing on a deer antler. It’s kind of banging up against the table a little bit. So if you hear any noise, we apologize.

Dr. Davidson: Sorry, but he’s our little partner in crime, our little Aussie dog.

Dr. Maki: He’s a maniac but he’s cute as they can get. Hopefully that doesn’t carry through. In the past, we do these episodes and he kind of get a little rambunctious and we would stop and rerecord. We’re like, “Ah, who cares? Let’s just let it roll. Just let it run with it.” I think people appreciate that everyone nowadays, not that they never love their dogs that much before, but I think nowadays people are very much open to animals and animals having a big part of our lives anyways.

Dr. Davidson: We love animals. I heard on animal planet, it’s going to be doing a 90-hour marathon of too cute, which is like the cutest show.

Dr. Maki: I’m sure you’re not the only one that likes it.

Dr. Davidson: When that starts I’ll be watching some.

Dr. Maki: So, back to Angie’s questions. She’s right on a bunch of things. The 80/20 is always a good place to start. When a woman’s never been on hormones before, 80/20 ratio is usually the most common or the most typically prescribed hormone ratio. Now the milligram amount, she’s on 2.5 milligrams, which I think is reasonable. I still think it’s kind of low. I usually start myself about three milligrams, maybe even up to five milligrams depending on the severity of their hot flashes.

Dr. Davidson: Yes, or their symptom. There are other symptoms as well. So I would say with Angie, 2.5 milligrams of an 8020 Biest equals 2 milligrams of estriol and 0.5 milligrams of estradiol, which like Dr. Maki said, isn’t a lot. The one thing that does jump out is she’s taking it once a day. So, really, I always say the bio-identical hormones are amazing. They’re awesome. They’re so fantastic. But at the same time, they just don’t have a very long half-life. If you put it on once a day, 16 hours later, I guarantee you there’s not a lot in your system, if any at all, which is why I always advocate to do it twice a day when you’re doing bias. Now, with Angie, she’s taking the progesterone pill once a day as an oral capsule, 100 milligrams, which 100 milligrams is the best dose. I mean, not the best dose but it’s most common doses. She takes that at night but I would say with that her Biest is it’s probably a little too low or she’d want to split up into morning and evening.

Dr. Maki: And even splitting it up. So she split it up two and a half milligrams, it’d be 1.25 in the morning, 1.25 in the evening, she’s barely getting enough hormone there to curtail her symptoms. But like you said, the half-life, it only lasts what you apply in the morning, gets you through the day, what you apply in the evening is going to get you through the night. If she’s only doing it once a day, those blood levels are rising and then dropping back to zero pretty much on a 24-hour basis. She’s almost starting over every time she reapplies her cream.

Dr. Davidson: So, one way if somebody is a little hesitant about increasing up their bio-identical estrogen is, like Dr. Maki said about blood levels, is test the blood levels. It’s really easy to go into the lab and have your blood drawn and then test the levels for the estradiol because that’s the easiest way to test. It’s to actually test a specific estradiol, not total estrogens, that’s not specific enough to give us an idea of how she is absorbing the hormone cream but to do an actual estradiol. And usually, what we would have Angie do is, “Hey, Doc. Start her on her hormones for three weeks up to maybe a couple of months, and then test the blood work.” So she puts on her cream in the morning, and then maybe, 4-6 hours later, do the blood draw so we can see how she is absorbing it and how it’s staying in her system. If she puts it on in the morning without applying her hormone cream, then we’ll know for sure it’ll be zero and it’d be a wasted blood draw. But you definitely always want to test somebody after they’ve had their hormone cream on for about four to six hours.

Dr. Maki: Yes, right. Typically, a menopausal level for an estradiol, we don’t do total estrogens, that’s not really necessary. We do an estradiol level for a menopausal woman that’s going to say less than 30. Some labs will actually give the number but it’s usually going to be less than 30. Our upper limit is trying to get that number somewhere between 75 to 125, but for some women, depending on what their dosage is, it might not even get to 50. But as long as their symptoms are under control, as long as their symptoms are improving, meaning their hot flashes have gone down, their night sweats have decreased, they’re sleeping better, then the blood level isn’t as necessarily as important. We still want to monitor and check it. We want to make sure that it doesn’t go up too high. We’re still always trying to increase it but it’s definitely a good thing to monitor and keep track of.

Dr. Davidson: Angie is also asking about taking her estrogen in a pill form versus a cream form. Now we always do like 99.9%, 99.5% do bias any kind of compounded estrogen as a cream, and that’s because when you take estrogen orally, the liver tends to eat it up, so you don’t really get the dosage as well. And also, that’s pretty much a pretty big burden on the liver to be taking oral estrogen, especially at higher doses. That’s not super healthy for the liver at the same time. So, definitely her doctors’ idea of saying, “Hey, let’s do this as a cream is fantastic.” It’s good that she’s doing a cream and doing a cream does go into the bloodstream. An unbiased cream is going to help the brain, the heart and the bones and the skin and the hair. It’s going to help everything. But her specific question was, is that going to be okay for the heart, the brain, and the bones? Absolutely as a cream it will be, but then here comes in terms of dosage. It might be a little too low that we might want to raise that up a little bit.

Dr. Maki: Right. Again, some similar things to our last episode with Lisa. But she’s right on about the benefits, getting through the bloodstream and besides just the menopausal symptoms, but having those age-related disease benefits on the brain, the bones, and the heart. There’s this connotation when it comes to female hormones that they’re dangerous, but this is the kind of the added benefit helps to maintain some of those things. You’re going to decrease the risk of heart disease, you’re going to decrease the risk of osteoporosis, you’re going to decrease the risk of dementia, because those hormones are helping too. One of the risk of those things go up for women when they go to into menopause. The hormones definitely play a role there, we can extend that a little bit. It’s going to certainly stave off some of those problems, hopefully indefinitely, but at least for a relatively long time, depending on the rest of the lifestyle, which usually in our experience, women that are doing these types of things or lifestyles are already very good to begin with. This just helps to kind of round things out for them.

Dr. Davidson: Exactly. I’d say for Angie that definitely the 100 milligrams compounded slow-release progesterone oral capsule is great. Taking that at night is going to be perfect for helping you stay asleep. Also, the dosage of the bias is good to use as a cream but the dosage might need to be increased or at least split up into morning and evening.

Dr. Maki: Usually, what we’ve noticed over the years is that, where woman starts with her hormone dose isn’t where she’s going to end with our hormone dose. There’s little tweaks that happen. Again, like I said on the last episode, whether it’s stress, whether it’s the time of the year, what’s going on in her life, what happened six months ago, and fast forward six months in the future, her life is totally different in some respects. Some things are very much the same, but her body is different, the time of the year is different, her body does kind of acclimate a little bit to it and estrogen is what makes a woman a woman. So, usually, the more of it, it’s not about having too much necessarily, it’s making sure that the woman has enough. In menopause, when we’re doing static dosing like this, we’ll talk about rhythmic dosing on another episode. But when a woman is doing static dosing, meaning same dose every day, you really can’t give a woman too much. Her body is not getting anywhere close to what she did when she was menstruating. So all we’re trying to do is just raise that baseline up a little bit of those hormones so she’s at least functional, and all those menopausal symptoms are not driving her crazy.

Dr. Davidson: Exactly. And then testing the blood work to make sure because sometimes people can take too much, and then it’s a little high in their bloodstream, and then you just back it down a little bit. But like you said, don’t be too afraid of giving the estrogens as long as it’s the biased, especially an 8020 ratio of estradiol and estriol. So where that estradiol is pretty small in terms of the ratio, whereas a 5050, like we had talked about Lisa on another episode is, sometimes you can go a little bit too high when you’re doing a 5050 ratio. But just to kind of sum it up, I do agree with Dr. Maki, is don’t be hesitant but you can start off low and then work your way up. So maybe with Angie, they’re starting off at 2.5 milligrams once a day. They’ll go to maybe splitting it up to doing it twice a day, then raising it up a little bit more and then having that and maintaining from there.

Dr. Maki: Yes, right. Now, the issue that does come up sometimes, like you said, when you do raise, that’s why her taking the progesterone is very good. Because if you raise that estrogen amount too quickly or too fast, then there can be some spotting or some bleeding issues. But her taking the bio-identical progesterone is very helpful, as we talked about already, that it helps to protect that uterine lining or inhibit the growth uterine lining. Because if you raise that dose high enough on the estrogen side, eventually it would make her bleed to some extent, which we don’t want because that bleeding is going to be unpredictable. That’s also where rhythmic dosing comes into play, which actually encourages a woman to have a period. Now, again, that’s complicated, and we’ll talk about that on another episode. But definitely two and a half milligrams is kind of on the bottom end, and more than likely, she probably feel a little bit better somewhere between, let’s say, 3 to 7 milligrams somewhere in that range. She’s going to find the amount that really eliminates most of her symptoms and she’s feeling really good. So, anything else to add about that Dr. Davidson?

Dr. Davidson: No. Thank you, Angie, for your question. And we’re going to do other questions as part of the format with our podcast. And just like our other episodes we’ve had, we might talk about specific topics and maybe not questions but they’ll all be related around hormones and hormonal health.

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

Dr. Davidson: And I’m Dr. Davidson.

Dr. Maki: Take care. Bye-bye.

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Where Do You Apply Biest Cream? | PYHP 075

Dr Valorie Davidson and Dr Robert Maki — Thu, 26 Mar 2020 20:20:14 +0000

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.

The post Where Do You Apply Biest Cream? | PYHP 075 appeared first on .

What Is A Low Dose of Bioidentical Hormones? | PYHP 073

Dr Valorie Davidson and Dr Robert Maki — Tue, 24 Mar 2020 22:51:02 +0000

Michelle’s Questions: I am 52 years old going through menopause since 48. I had a hysterectomy at age of 36 and kept my ovaries for the hormones. My ovaries are nonfunctional now. I was on Premarin, but when I sought out a specialist for hormone therapy, I was prescribed: Estradiol 0.5 Estriol one milligram, which is technically Bios. It’s the combination of estriol and Estradiol. Estradiol was 0.5 milligrams, Estriol is one milligram. And I am also taking a hundred milligrams of Progesterone.

I take this at night. I’ve had a weight gain of 40 lbs and suffer from anxiety at night since starting menopause. I was prescribed Propranolol, which is technically a blood pressure medication, but it does help with reducing anxiety. But she has prescribed the propranolol for this and it seems to take the edge off. I have poor sleep as well, where I used to sleep very well.

What am I missing? Am I on the right track? I feel deconditioned fatigue and brain fog to mention a few. I feel poorly when I used to be a happy, healthy person. Please help with recommendations. Would testosterone help? My levels were not terrible enough to prescribe.

Answer:

In this episode, we discuss a question we received from Michelle that was started on Premarin but then transitioned to 1.5 mg of Biest cream. Of course, we are not fans of Premarin and would never prescribe this for our patients. However, we do prescribe Biest all of the time. There is very little similarity between Premarin and Biest. When transitioning from a tablet form of estrogen like Premarin to a transdermal cream, the dosing of the Biest needs to be definitely increased. For most women, our starting Biest dose is typically 3 mg to 5 mg.

Full Transcript PYHP 073

Download Transcription PYHP 073

Dr. Maki: Hello everyone. Thank you for joining us for another episode of the progression health podcast. I’m Dr. Maki.

Dr. Davidson: And I’m Dr. Davidson.

Dr. Maki: So just as a warning before we get jumping into the episode, we are in our home office recording this. Our dog is with us as well. He’s always with us. We can’t really go anywhere without him, but he’s laying on the floor with a bone. So, if you hear any strange noises or any banging around, he’s just either repositioning or trying to find another bone. We can’t really go anywhere without him. And he’s happy as long as we’re close by.

Dr. Davidson: In some ways. He’s kind of our first dog, ’cause our other one was a poodle, which they always say once you have a poodle, all the other ones are just dogs. So, he was completely different from this one. He follows us everywhere so if you hear him chewing, he’s chewing on a bone. Thank goodness he doesn’t chew on other things. It’s just his bones.

Dr. Maki: No shoes, no clothes, no furniture. Just bones. So, we’re good, we’re lucky about that. All right, so, now this episode and the next few, we know enough to be dangerous when it comes to SEO and Google and all that kind of stuff. But there was some kind of conspiracy thing about alternative health websites not getting the traffic. We’re not really sure if that was real or not there are some other prominent websites in this space that was kind of commenting on that. There was a recent Google update just a few weeks ago and we’ve noticed that there was a significant drop in our traffic based on what they called Google analytics. For those of you that run websites, you know what Google analytics is. But without doing really anything different, just our normal, we’ve seen a nice little uptick in our traffic and as a result of that, we’ve got a mini flood of questions as of late. As we’re just kinda wrapping up the end of 2019 would be to answer some of those questions we feel some of these questions are very good and as the adage goes, if you have that question, especially on a podcast, there are probably hundreds if not thousands of other people that have a similar question. And because this one and a few of the other ones that we’re going to be doing, we feel like there’s a lot that can be pulled from that. Everybody else can benefit from that question as well. So, Dr. Davidson, once you read the question and we’ll go from there.

Dr. Davidson: Okay, so this question is from Michelle. Her comment is I am fifty-two years old going through menopause since forty-eight. I had a hysterectomy at age thirty-six and kept my ovaries for the hormones. My ovaries are nonfunctional now. I was on Premarin, but when I sought out a specialist for hormone therapy, I was prescribed Estradiol 0.5 Estriol one milligram, which is technically Bios. It’s the combination of estriol and Estradiol. Estradiol was 0.5 milligrams, Estriol is one milligram. And she’s also taking a hundred milligrams of Progesterone. I take this at night. I’ve had a weight gain of forty pounds and suffer from anxiety at night since starting menopause, I was prescribed Propranolol, which is technically a blood pressure medication, but it does help with reducing anxiety. But she has prescribed the propranolol for this and it seems to take the edge off. I have poor sleep as well, where I used to sleep very well. What am I missing? Am I on the right track? I feel deconditioned fatigue and brain fog to mention a few. I feel poorly when I used to be a happy, healthy person. Please help with recommendations. Would testosterone help? My levels were not terrible enough to prescribe.

Dr. Maki: Yes. She’s asking kind of a couple of straight forward questions. I mean am I missing something? We think that she is, we’ll get to that in a second.

Dr. Davidson: Of course. Disclaimer, disclaimer.

Dr. Maki: Yes. And we can’t really give medical advice, but we can certainly offer our opinion. Michelle is certainly not our patient, but we see some issues with this and the testosterone question. Interestingly enough, that’s something that comes up, women are asking about testosterone quite often. And it’s a trend that we see a lot of women come to us after having been on testosterone and we’re not necessarily quite in the same agreement as what other practitioners do. So first and foremost, this issue in general, she’s doing all the right things. At least she thinks she’s doing all the right things. She’s asking, well what else can she be doing cause she’s not feeling any better? And Dr. Davidson, I’m sure you would agree. For the most part, it comes down to a dosing issue.

Dr. Davidson: Exactly. So first off, we want to work with that Estrogen and the Progesterone. The dose is right for her, for her goals, for her symptoms, but she’s wondering, maybe testosterone would be it. And really testosterone, a lot of women do take testosterone, but that’s not the first thing we want to jump into ’cause we always think of when you’re doing the BHRT, the hormone replacement, we want to create a good foundation. Or as I kinda call it, you know, we want to build the cake and then then the testosterone would be like the frosting on the cake. You wouldn’t want to start with that, we want to build it first with that Estrogen and that Progesterone. So, definitely we would change up that dose for that Bios.

Dr. Maki: Yes. And when would you go from a commercial conjugated [inaudible] and the Premarin, an oral hormone and then you switched to Bios. Now granted we love bioidentical hormones. We use it with all of our patients, but going from Premarin to that is kind of taking a step down in dosage or efficacy. Granted other some fewer side effects. And we encourage, we never prescribed Premarin, we never would, never will, never have. However, knowing the transition and like we are talking about as we are preparing for this episode, there’s no really good conversion going from that to that, a common dose of Premarin is like .65 milligrams. You can’t give a woman .65 milligrams of Bios and expect her to feel the same. She’s going to feel probably a lot worse.

Dr. Davidson: I’ve had lots of women, especially maybe about ten years ago, around 2009-2010 when really a lot of people were converting over because of those studies. Showing that Premarin is not healthy for females. I would have women that would come in and of course, their doctors would try to transition into something or nothing. They felt awful. I’ve had women say they, their whole lives have been changed because they’re, they were taken off their Premarin. Now we know that’s not safe. So, that’s the thing is when someone’s on even any other kind of conventional, like even an Estradiol patch, because the Bios or the Estriol and the Estradiol for the BHRT are so gentle is you actually have to start off high on those doses and then work your way down. So, with Michelle coming off of Premarin, we would probably do a much higher dose of the Bios, the Estradiol and the Estriol combination that she’s on, do much higher dose and then over time titrate it down till her body. Cause a lot of times, like Dr. Maki was saying, when you’re taking these oral hormones, they go through your liver and they just eat it up that you can’t convert into something so gentle, so low. So, definitely we would do a higher dose of the Bios and we would for sure do it twice a day.

Dr. Maki: Yeah. Right now we don’t need to get into too much of the liver detoxification pathways, but there’s what they call the cytochrome P450 system, which is this huge crazy kind of network, so to speak, of enzymes that are upregulated when you take Premarin and then when you stop that, those enzymes are still up-regulated. So, your body will, like you say, chew through the BHRT dose relatively quickly. So it’s the simplest solution, they just need more. And 1.5 milligrams of Bios is for you and I is really not even basically a starting dose. That’s a very, very conservative dose. So, the practitioner that prescribed it should know if you’re going from Premarin to Bios, you need to increase that quite significant. Now that increase or the significant increase that you’d go is really based on the person. It’s based on their symptom picture and it’s a little bit of kind of, I wouldn’t call it guesswork on the practitioner side, more based on experience to know that that transition is going to make them feel worse. So, you’re kind of overshooting the mark because let’s be honest, what makes a woman a woman is an estrogen. In a lot of cases, especially in menopause, the more she has, the better she’s gonna feel. And I think that’s what’s going on in this case for sure.

Dr. Davidson: And then like I had mentioned about doing it twice a day cause the BHRT, the bioidentical hormones are so awesome. I mean they’re great, they’re very gentle and they don’t have a very long half-life. So if Michelle is putting on her Bios cream at night, say ten o’clock at night, by the time ten in the morning, noon, one o’clock in the afternoon, it’s pretty much gone. So, that’s why you want to take it twice a day. So, definitely I have people take it at night. So, it helps with the hot flashes, helps with night sweats, helps with cellular turnover, helps them sleep and then you take it during the day. That would probably help a lot with her brain fog. ‘Cause one classic symptom and menopause is, and I’ve had women patients tell me they think they’re having dementia or they want to get checked for Alzheimer’s because they lose their memory and it’s not, and they don’t have dementia, they don’t have Alzheimer’s. Once that estrogen drops in menopause, the recall is hard. They’ll say, “I can’t remember the name of that book. What was that author’s name? Ask me in five minutes, I’ll remember then.” They just feel like they just lost that sharpness. So that’s why doing the Bios, doing the bioidentical hormone estrogen component in the morning. So, morning and evening really help with that brain function.

Dr. Maki: Yes, right. So, from a Bios dosing perspective, what we call a half a gram twice a day. So two clicks twice a day. So, they apply two clicks means that there are more than likely going to be given a toppy click from the pharmacy.

Dr. Davidson: There are so many [inaudible]. There are pumps, there’s so many. There’s jars[?].

Dr. Maki: Yes. I mean there’s a lot of different ways, but typically what we like to use is a simple topic click, two clicks on the bottom of the dispenser. The low cream comes out, they apply it in the morning to their thighs only. We don’t recommend putting it on your forearms or your wrists, anything like that. So, two clicks or half a gram in the morning and then two clicks or half a gram in the evening and whenever you apply in the mornings, going to get you through the day where you apply in the evening is going to get you through the night. And then over time, those blood levels should tend to rise a little bit. They’re not going to surge, they’re not going to go crazy, they’re not gonna go super high. But you should start to see each dose is building on the previous dose. So, now you can hopefully get a sustainable level and now symptoms will start to resolve.

Dr. Davidson: And then like Michelle had mentioned on her comment is she’s taking progesterone a hundred milligrams. I’m assuming that that’s probably separate from the Bios and as a capsule cause that’s pretty common as an oral Progesterone 100 milligrams. Now that in itself we do have women just take once a day. So, taking that at night is great cause Progesterone is very relaxing that if you took it during the day, it could make you sleepy, it can make you tired, feeling a little foggy. I’ve had patients on accident take their Progesterone in the morning and they’re calling me saying they felt like they drink wine or something. That’s cause it’s a little relaxing so, I definitely always taking that progesterone at night. But the progesterone, typically we do it once a day.

Dr. Maki: Yes, right. And as you’re raising the Bios dose or the amount of estrogen, the progesterone capsule, in this situation, we definitely recommend a capsule versus a cream. The Progesterone, not only does it provide some of those other benefits, as you said, it’s fairly relaxing, it can reduce her anxiety at night and we may often go up to even up to 200 milligrams in a situation like this because her sleep isn’t great and she’s still having some nighttime anxiety. So, playing around with that, you have a 100-milligram capsule, it’s easy enough to just to add on a second capsule just to see if you feel any better.

Dr. Davidson: Yes, just like Dr. Maki said, this really is based on the person. You can’t just look at a chart and everybody gets the same cookie-cutter dose. So, looking at what works for her. And we do labs, I do think doing labs are important, checking her estrogen dose, checking her Progesterone dose and then comparing that objective data with her subjective data is perfect, it kind of pulling that together. So, I’d say definitely for Michelle as a start and if she’s worried about raising up her estrogen or her practitioner is unsure, doing a simple blood test to check to see where her levels are at and then you could raise it up, see how she feels, and then do another blood test to see where her levels are at. So, I definitely think coming back to Michelle and her main concern is it really boils down to probably that Bios dose.

Dr. Maki: Yes, I think it needs to be doubled, tripled or, even more, to help her not feel like she’s tired all the time, all this anxiety. She doesn’t mention too much about having any hot flashes or anything like that, but her symptom picture is like super common. These are the complaints that everyone feels. And once you start bumping up that estrogen, we’ll maybe talk about this on another episode, but this is where you also talk about the two types of hormone replacement. You’re doing static dosing, which is what she’s doing, which is what we do most of the time. And the other option is rhythmic dosing, which we do a lot of as well because again, for women and how they feel, it’s really about that estrogen dose in a way to keep them safe but yet give them the amount of estrogen that their body really wants is the difference between static dosing, rhythmic dose. We’ll compare those two on another episode because that is becoming a little more popular, even in the past, static dosing still is by far the most popular because unfortunately, the rhythmic dosing you get your period. But Michelle, she had a hysterectomy at thirty-six. In my opinion, she’s kind of a really good candidate for it because she’s had her hysterectomy already, so, now you don’t have to worry about the bleeding part, which is really the deterrent for most women. They don’t really want to consider rhythmic dosing ’cause the last thing a woman wants in her mid-50s is to get her period back.

Dr. Davidson: Most of the time, yes. I have a handful of women that do want to get a period, but as you said, rhythmic dosing is you do have to change the dose, every several days. So, you have to keep like your calendar and your track and that’s not a hard thing to do. But the static dose, cause you’re doing the same thing every day is a little bit more user friendly. So, that would depend on the person. If I have somebody that’s a little bit more particular on how they like to do things, they were like, oh they’re perfect for the rhythmic and have some that are like, you know what, I’m going to be a little flaky and forgetful. Then we do the static dosing. So, it all really boils down to the individual. And like I said with Michelle, I am actually surprised she didn’t write on here that she wasn’t having night sweats at night ’cause looking at her dose and that she was on Premarin and she’s now 52 and her ovaries aren’t definitely are menopausal. I’m surprised she’s not having hot flashes and night sweats all night.

Dr. Maki: What I hear a lot from women, they say that they’re like hot and cold. The hot covers are coming on and off and on and off and on and off, which is what is waking them up and now their sleep is completely disrupted. I would assume based on what you just said, I would assume that that’s probably happening, but she didn’t write it there, so then, of course, the next day you’re going to be exhausted because every night you try to go to bed, there’s no restoration. It’s just this battle with your body and so, you’re right, I’m surprised that she didn’t mention that, but I would assume that some of those things are probably present. And then, of course, the weight gain, the weight gain, forty pounds. I mean, how many women have we talked to over the years that no matter what they do, their lifestyles really don’t change that much. All of a sudden they just put on a ton of weight like that, which of course is very frustrating because the weight goes on really easy. But getting that weight to come off is sometimes very challenging, very difficult as well.

Dr. Davidson: And that’s definitely a product of the menopause ’cause it’s kind of unusual, if the estrogen is too high, you can gain weight and if the estrogen is too low, you can gain weight. So, you have to really try to get it right in the middle.

Dr. Maki: Yes, we’re trying to recreate what the body normally does when a woman is menstruating. Now she had a hysterectomy. So, more than likely there were either some fibroids in her past or maybe an estrogen dominant kind of a situation, especially at the age of thirty-six. We don’t really have that backstory, but we could probably make some assumptions as to why she had that. So, her cycle might’ve been a little bit more than likely her cycle was a little bit abnormal for a while anyway. So, the one last little comment about the testosterone, once the sleep is better, the estrogen dose has been increased and she has some resolution then would be when you and I would probably consider doing some testosterone once she’s already feeling better, for the most part, significantly feeling better, then it would be a good opportunity to add in some testosterone. Would you agree with that?

Dr. Davidson: Oh absolutely. Like right now, you’d say her estrogen is definitely way low and then you throw in some testosterone who ends up at the top of the hormonal chain, it’s the testosterone. So, the testosterone ends up being dominant. So, then you get these negative side effects ’cause testosterone is a great hormone. All humans have it. Women have less of it than men. But if that testosterone is the dominant hormone running the show, that’s what you’ll see. And women will get irritable, they’ll have hair growth on their face, hair loss on their head, they’ll have acne. And of course, all hormones are steroid. Having too much steroid or steroid testosterone can also cause weight gain.

Dr. Maki: Yes, especially for a woman. Just because that’s not the dominant hormone. So, we like to be a little bit conservative. If she came to us as a new patient, we know we would not put her on testosterone probably for at least a few months, probably ninety days or so, just to make sure that those other bases are covered and then contemplate. And honestly at that point when she’s feeling better, she might not even need or want the testosterone.

Dr. Davidson: She might not even need it.

Dr. Maki: Especially she said her levels were good on a blood test. I would assume that her levels are probably in the mid-twenties the low to mid-twenties something like that.

Dr. Davidson: Well, that’s another issue, right, ’cause the reference ranges for testosterone are huge, on Quest, they’re like two to forty-five, LabCorp, it’s six to fifty-five, so, she could be anywhere on that continuum. But like you said, they weren’t terrible enough to prescribe, hey probably were around twenty.

Dr. Maki: Yes, and honestly, when it comes to a lot of these hormones, especially when a woman is already in menopause when you’re starting the hormones, the levels don’t really mean as much, right? It’s more about once you’re on the hormones and then testing after the fact because if they’re in menopause, you know their hormones are going to be low. Of course, across the board, there’s going to be dysfunction across there because they’re in menopause. It makes more sense to have that objective value or the objective value or objective levels make more sense once they’re already taken hormones. So, you have kind of a baseline and then you have the aftereffects once they’re on them. Because if they stop the hormones, then everything goes right back to basically zero or at least suboptimal because, and then that in conjunction with how they feel, the numbers make more sense once they’re actually doing something or taking something.

Dr. Davidson: Yes, I agree. I mean really with Michelle, she says, “I used to be a happy, healthy person.” She still is a happy, healthy person. It’s just a few little tweaks here and everything would probably feel really good for her because I do love the fact that she stopped the Premarin. That is wonderful. It’s just having that transition, changing up that estrogen a little bit, getting her sleeping better, even just sleeping better will make her metabolism go up and then help her lose weight, just in that regard.

Dr. Maki: And more estrogen plays a big role in helping the sleep. And once that sleep is improved, as I said, then everything kind of trickles off the sleep, her energy comes back or mood comes back or happiness comes back, her weight will start to go down or at least the potential of you can’t sleep or not sleeping well, that’s the number one thing that we try to focus on. If weight loss is your goal, you have to sleep well at night. Otherwise, the weight is almost impossible for that to lose. Your cortisol goes up, your insulin sensitivity goes down, all these things happen when you’re not getting a good night’s rest and then your body is just exposed to all this cortisol all the time. And that’s why a lot of these things are going on. The brain fog, the weight gain, all those things just kind of become a runaway freight train. So, Dr. Davidson, do you have anything else to add about Michelle or do you think that we can call this one a wrap?

Dr. Davidson: No, this is great. And thank you, Michelle, for sending your question. You wouldn’t believe how many women are in the exact same situation that you’re in and they have the same exact question. So, I hope that this helps Michelle, which will also help probably other females out there that have some of the same symptoms or questions.

Dr. Maki: Yes, so, until next time, I’m Dr. Maki.

Dr. Davidson: I’m Dr. Davidson.

Dr. Maki: Take care. Buh-bye.

Dr. Davidson: Bye.

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What Supplements Support Immune System? | PYHP 072

Dr Valorie Davidson and Dr Robert Maki — Thu, 19 Dec 2019 20:25:31 +0000

In this episode, we discuss the immune system and give you specifics to help you during the cold and flu season. Most of us are very busy and don’t really have time to get sick. Below are some simple ideas to help you boost immune function and hopefully protect you during the cold and flu season.

What Supplements Support Immune Function?

Vitamin D: for immune support, we recommend taking 2,000 to 10,000 IU depending on your exact situation. To boost immune function, you could take 5,000 IU’s daily for 1 to 2 weeks and then reduce down to 2,000 IU daily for maintenance. Note: before you starting taking Vitamin D, you should have your level tested.

Vitamin A: for immune support, we recommend taking 25,000 to 100,000 IU depending on your exact situation. To boost immune function, you could take 100,000 IU for 1 week, then reduce down to 75,000 IU for 1 week, reduce again down to 50,000 IU for 1 week and then maintain at 25,000 IU daily. Note: 100,000 IU daily is considered a high dose, so don’t take this amount for too long. A couple of weeks is enough to boost immunity, but not long enough to cause any unwanted side effects.

Larch Arabinogalactan: for immune support, we recommend taking the fiber found in Larch Arabinogalactan, which has been shown to prevent the common cold. To boost immune function, take 2 capsules daily for 1 to 2 weeks. After that, you can reduce to 1 capsule daily for maintenance.

Probiotic (Ther Biotic Complete): for immune support, we recommend taking a probiotic, especially if antibiotics have been taken. Maintaining a healthy microbiome is very important to optimal immune function. Ther Biotic Complete is one of our favorite probiotics. It provides 25 billion organisms per capsule. You can take 1 to 2 capsules daily.

Echinacea Hydrastis and Berberine: for immune support, we recommend taking Echinacea, Hydrastis, and Berberine. Echinacea has a long history of boosting immune function and Hydrastis (Goldenseal), which contains the constituent berberine have anti-microbial properties. EHB is one of our favorite products to boost immune function.

Vitamin C & Zinc: for immune support, this contains vitamin A, vitamin C, vitamin E, selenium and zinc. We have been using this with patients for years as it provides several immune-supporting nutrients.

Elderberry: most of the time, when people get sick, it is typically a virus of some sort. Sambucus or elderberry has a long history of boosting immune function against the common cold.

PYHP 072 Full Transcript:

Download PYHP 072 Full 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, on this episode, we’re going to continue talking about immune function, cold and flu season. Last time, we talked more about prevention, how we segway from adrenals and stress into immune function. This one we’re going to actually give you– this one’s going to be a little bit shorter or just going to give you some things to think about and granted a lot of people understand these or know these things already but we want to just give you some of our favorites.

Dr. Davidson: Just real quickly, we try to really make our sound, sound good for you and not any like weird static or fuzz but if you do hear some noises in the background, our dog is having a great time with his toy.

Dr. Maki: Yeah, yeah. You might have heard that on the last one as well.

Dr. Davidson: That was his bone.

Dr. Maki: Yeah, we’re trying to keep him occupied while we do this.

Dr. Davidson: He’s our little buddy.

Dr. Maki: Yeah. Let’s just dive in. Last one, we talked about diet, minimize sugar, minimize caffeine, minimize alcohol.

Dr. Davidson: Improve your sleep.

Dr. Maki: Lifestyle, improve sleep, lower stress as much as possible. In some ways, kind of try to slide down as much as you can and supporting adrenal function, right? That’s something that we’ve talked about in the last few episodes, that’s how you keep your immune system strong and resilient through the stressors of life. Now this one, we’re going to talk about some actual specifics. Let’s just kind of dive into the nutrients side, so vitamins and minerals, things that you recommend for your patients.

Dr. Davidson: Exactly. I mean, what’s so amazing is now we have access to really good quality supplements that can help with kind of what we talked about last time is, what can we do to prevent getting sick and what can we do if “darn it. I’m already sick right now and what can I do acutely in the moment to reduce the duration, reduce the intensity and the severity” and also, try to not– which ends up happening, not let it progress into something more serious. Of course, we had mention to– I mean, people have kids, people have grand kids, people have nieces“ and nephews and family members and friends and this little kids, they might be little germ machines, granted it’s good for them and their immune system to get sick but they bring that home to us. One thing that I think probably a lot of you have heard of and may know is Vitamin D. I think Vitamin D is great for that immune system, it’s not to preventative. Now, granted Vitamin D isn’t really a vitamin, it’s a hormone.

Dr. Maki: Yeah, it should be called hormone D, not vitamin D. I think there’s a lot of misconception about that but it’s interesting, granted we get most of our Vitamin D from the sun, you know I lived in the South West for almost 15 years and everybody that we would test their Vitamin D on will always be either low below 30 or low and normal in the low 30’s, that shouldn’t happen in a place where there’s constant sunshine at them. Either, people are spending a lot of time indoors, which is probably part of the problem–

Dr. Davidson: Or hopefully wearing sunscreen.

Dr. Maki: Yeah.

Dr. Davidson: That’s my own prerogative.

Dr. Maki: Yeah. Well, we can argue about that. You and I disagree about the sunscreen thing so we’ll save that one for another episode but nonetheless, in a place where there’s sunshine all the time, everyone should have at least the middle of the reference range which is the reference range is 30 to a hundred, at least be at the middle if not high normal when it comes to Vitamin D and everybody is low normal on Vitamin D. I think that we’re either testing a wrong thing, the metabolite or whatever the lab test are set up for or there’s a different mechanism going on there that actually pulls that Vitamin D down whether it’s an inflammatory process or like you say, a hormonal process. I could even see there’s a connection between, let’s say cortisol and low Vitamin D levels.

Dr. Davidson: Yeah. Or just the conversion process. So, you think you’re outside, the sun hits your skin, it converts into Vitamin D1, then it has to go through the liver and the kidneys to convert into Vitamin D2, to Vitamin D3 which is the active form. Sometimes, that gets lost in translation or hormonally or stress-wise or something, I don’t know but reduces that conversion to the active form of Vitamin D3 which is– but then, with wonderful science and technology, we can just take Vitamin D3 or you can stay out of the sun and cover up and wear a little sunscreen but cover up and just take Vitamin D3.

Dr. Maki: Yeah yeah. You’re Asian, right? So you have cultural—

Dr. Davidson: Eye freckle.

Dr. Maki: Yeah. Well, you’re also trying to protect your skin from the sun, which I do agree with trying to protect your skin but I do not agree with the whole sunscreen as a form of protection.

Dr. Davidson: Well, either way, Vitamin D is very good for your immune system. Something I had mentioned on the last podcast was, you don’t want to necessarily take immune stimulating vitamins and herbs and supplements and minerals and what not because if you’re stimulating the immune system but you’re not sick, that’s actually not very healthy but you know, nobody wants to get sick even if it’s for one day. I mean, when you’re sick, you are so humbled by how great you feel when you’re not sick. That actually, Vitamin D isn’t necessarily stimulating the immune system but it’s strengthening the immune system that help prevent you from getting sick and then on the flip side about what’s so amazing about Vitamin D is if you are sick, you can increase up your level of Vitamin D and that will help reduce down that duration and that intensity and that severity. Now, one side thing is, Vitamin D is a hormone and it’s fat soluble which means too much of a good thing isn’t a good thing is they can say “Hey, you can have Vitamin D toxicity.” But you really have to take a lot of Vitamin D for that to happen.

Dr. Maki: Yeah. And most doctors, even conventionally minded doctors nowadays are testing everybody’s Vitamin D. So you are taking Vitamin D or you’re going to take Vitamin D, it’s a good idea to check your levels. We recommend– there’s a couple of different companies that we use but we like to use liquid Vitamin D, not in every case. There are some that are soft gels but liquid Vitamin D usually 1 to 5000 IU’s per drop so 1000 international unit per drop so these bottles, they come with a little eyedropper on the top, and you take 5-10 drops maybe depending on the person, maybe 2 drops, maybe 4 drops, maybe 5 drops, 10 drops, usually on the upper hand and that does a really really nice job of improving lab values. You’ll see it in a matter of a– even a couple of weeks to a few months, that their lab numbers will go from the low 30’s or even abnormal and now they’re 45-65 on a lab range which is actually very nice.

Dr. Davidson: And something that Dr. Maki had mentioned on the last podcast talking more about lifestyle is he had mentioned about the wonderful magic of your gut microbiome and how many– gosh, how many things it can do for a body and probably things we don’t even know about yet but one thing that our gut microbiome does is it’s very involved in the immune system. That’s pretty much where we make a lot of our immunity is from our gut microbiome so a probiotic, I think is a great thing to help kind of strengthen that immune system, not stimulate it but good for preventative.

Dr. Maki: Yeah right. That’s one of those things you could do on a regular basis to maintain that really healthy balance between the good bacteria and the pathogenic bacteria. When that balance is offset, that’s what they called Dysbiosis, that’s why as we’ve mentioned in the last one, that’s why in our opinion, you want to be very very careful with antibiotic use. When I was a teenager, I had a really bad complexion which is the worst time of your life to have a bad complexion when you’re a teenager and you got pimples all over your face. It’s just a really hard thing to deal with and of course, I went to dermatologist after dermatologist and only what they give me is was Retin-A and tetracycline and I think that’s just– knowing what I know now, I just think that it’s just a terrible approach to treat acne but antibiotics, this is also not necessarily a secret or a big surprise but antibiotics are just been over prescribed. Now, you have MRSA and antibiotic resistant bacteria that is going to cause big problems in the future because we overuse them up until this point. In our opinion, you want to use an antibiotic when there’s no other option, okay? So, when you really need it the most when you are in kind of dire straits then take the antibiotic but if you got a stifle or a sneeze or this or that or the typical and flu season, all of those 90+% of them are caused by viruses, the antibiotics are going to do you no good anyways but the things we’re talking about, the Vitamin D and we’ll get in some other ones, those are ways to either bolster your immune system or to acutely bolster it when you really need it. We have lots of options when it comes to that and I think that that is something that gets missed sometimes out there in the conventional world.

Dr. Davidson: Yeah, I think a great probiotic for an adult and even for kids. Like we said, kids are meant to get sick, that’s okay but if we can reduce the severity, I think a probiotic, improving your gut microbiome, working on it is only a benefit to your health. And then another thing that I like to use, I’m going to mess up how you– say it out loud, but it’s also working on that digestive system or that got microbiome is there’s a product that I used that basically it’s kind of like a fiber-like but it’s a little bit more for that preventative, for improving the immune system or strengthening it but not necessarily stimulating it. How would you pronounce the supercalifragilisticexpialidocious?

Dr. Maki: Arabinogalactan?

Dr. Davidson: Arabinogalactan.

Dr. Maki: Yeah, that has been kind of–

Dr. Davidson: Say that 3 times.

Dr. Maki: Yeah right. That’s been kind of used as a long-standing history of being able to enhance immune function and that’s one– like you said, you could use that kind of in some ways prophylactically to give yourself a little surge. Now, when it comes to other herbs like echinacea, everyone’s familiar with echinacea. Echinacea is one of those ones you want to use in a short term basis. You want to use it for that early [inaudible] phase where you’re just kidding, feeling like you’re coming down with something and then use it through the course of it and then you’re done. You don’t want to use something like that over a long period of time because then, like we said on the last episode, when you really need that immune stimulation it’s going to really do much.

Dr. Davidson: Exactly. Echinacea, everybody’s heard of echinacea. Echinacea has been around for a long time mainstream but combining echinacea with Hydrastis, which is goldenseal and berberine which is Oregon grape which grows like crazy around here in the North West is those are really great at stimulating the immune system and you kind of high dose it a little bit and you only do it for about 5 days but that can really shorten the duration and especially the severity of having a virus or a bacterial infection. Now, one thing we’ll put on the show notes because you know, there’s a lot that we’re talking about in terms of nutrients for colds and flus is we’ll put a little list together on the show notes that will have maybe more specifics for the supplementation, for the nutrients, the dosing and all that with disclaimer disclaimer disclaimer but we’ll go into a little bit more about that acute and preventatives so can you see it on paper.

Dr. Maki: Yeah. Now, you mentioned your favorite nutrient which is the Vitamin D and I asked you that question before we actually sort of recording. I asked you, “If you had to pick something for immune function, what would you choose?” and you said Vitamin D. My favorite actually is Vitamin A. I think Vitamin A is a hugely deficient nutrient because if you look at the food source, Vitamin D is different. Vitamin D comes from the sun or at least it’s suppose to, we can debate that, we spend too much time indoors, we’re always in close walls, we’re not getting as much sun as we should, okay fine or like we said, there’s a hormonal inflammatory component to it that exacerbates that but Vitamin A is meant to be a dietary source and if you look at the source of Vitamin A, there’s not very many of them. It’s suppose to come from plant sources as the form of beta carotene. 2 beta carotene molecules create 1 Vitamin A molecule but even that, people’s consumption of colorful fruits and vegetables is probably not as much as it should be so now our Vitamin A levels are actually very low. The reason why that’s important is, as we are talking about in the last episode about the mucus membrane health, our nose, our nasal passage, our respiratory tract, our throat, our GI tract, everything, every wet surface in the body is a mucus membrane. Vitamin A helps to promote what they call IGA or Immunoglobulin A, which is basically our first line of defense on those mucus membranes and Vitamin A specifically helps to improve IGA status on those mucus membrane. Well, my favorite one for that reason is Vitamin A. Vitamin A could be done– like you said, it could be done in maintenance, kind of low dose on a daily basis or it could be done, like you said with the Vitamin D, it can be increased when you really need it if when you come down to something.

Dr. Davidson: And people get worried about Vitamin A also being fat soluble or Vitamin A toxicity but you do have to take a lot of Vitamin A or maybe have some other health conditions where Vitamin A would be toxic, it’s not that likely.

Dr. Maki: Yeah. And we’ve given people in a hundreds of thousands of international unit. They got acne problems, they got immune system problems, they got skin problems. Another little tidbit is the little side note, another thing that Vitamin A is a critically helpful for is polyps. You got polyps anywhere on the body, particularly colon polyps. If you’re 50+, you’re getting your colonoscopy. If you get on the report, if they find polyps, start taking some Vitamin A. Vitamin A also plays a role in what they call Cell Differentiation, meaning when that cell is forming, it needs to differentiate into whatever cell it is and this case, a colon cell. That differentiation process doesn’t happen, it turns into a dysplastic cell and now, you develop a pre-dysplasia or polyp is really in some ways a precancerous type of growth, you can in some ways prevent those with using Vitamin A.

Dr. Davidson: Cool. Also, who hasn’t heard of Vitamin C and Zinc? Of course, those are really great for the immune system but I think sometimes, we forget about it just because it’s so common place. Like hey, you can take Vitamin C everyday, of course you could take too much, you’re going to get a little bit of diarrhea but Vitamin C and Zinc as well, is really good for the immune system.

Dr. Maki: Yeah. If we don’t have to get complicated, like the things we’re talking about are really basic things, Vitamin A, Vitamin D, Vitamin C, Zinc, the little caveat about Zinc, we like to kind of high dose Zinc up to let say a 120mg, a 100-120mg for roughly about 7-10 days at the most and then you want to drop that back down. If you use Zinc too high of a dose for a too long, it’s actually going to have an immune suppressing effect and again, that’s what we don’t want. So, high dose Zinc, like in a form of a Zinc loss and jug a little candy, you can take multiple times a day as a way to get a nice little surge and those work well if people are having, let’s say like a herpes outbreak or even shingles, little bit of L-lysine along with that can be very good to help to mobilize immune function.

Dr. Davidson: One of my other favorites is taking NAC or N-Acetyl Cysteine and you can take that consistently, that’s not necessarily for an acute infection but NAC or N-Acetyl Cysteine converts into glutathione which is a great antioxidant in itself but one thing that glutathione and NAC can do is it helps the lung– the bronchioles, those little hairs, those little velli[?], they’re supposed to be like a little elevator that bring the crude and the crap out of your lungs and you cough it up but some people that might be more at achilles heel is their lungs like maybe they’ve had asthma as a child or they have asthma or their lungs are a little bit more compromised. I have a lot of patients that say when they get a cold, it go straight to their lungs which is not a good thing. So, NCA is a great way to kind of help strengthen that.

Dr. Maki: Yeah, right. Yeah.

Dr. Davidson: And it’s great for the liver too.

Dr. Maki: Yeah. And certainly on that glutathione side, with the list could go on and on, we mentioned echinacea, there’s a elderberry, there’s–

Dr. Davidson: I love Sambucol Elderberry especially for the little kids. Only use it when they’re sick, don’t use it every single day because it is immune stimulating but it actually taste good so then the kids aren’t gagging. You can’t get it in their mouth.

Dr. Maki: Yeah right. Now, when we are at Bastyr, your Dr. Michel, he was one of the founders of Bastyr and he used to say that Dr. Bastyr, who his school was named after, Dr. Bastyr used to use just simple cod liver oil and Vitamin C’s is that, that combination cod liver oil and vitamin c would reduce about 75% of colds and flus for kids. Now, as you said, trying to get kids to take cod liver oil, now they do flavor it well, now they have lemon flavor and orange flavor and strawberry so it doesn’t taste like fish but we’re tackle with this too, I think it’s because of the Omega-3’s, we all need those essential fatty acids but also, cod liver oil is supposed to have it’s own kind of source, it’s contained in the cod liver, you know the cod liver oil of Vitamin D and Vitamin A. I think that’s the reason why you get the immune stimulation of it is because of the Vitamin A content, consistent source and the Vitamin D content over time that helps to bring down and of course just a simple Vitamin C nowadays. One thing to consider when you’re thinking about Vitamin C is you can find the the liposomal forms, okay? That’s basically Vitamin C kind of packaged up in a fat carrier, right? So, you can minimize some of that, meaning that you can get higher doses into the body and you’re not as susceptible to that GI tolerance or what they call bowel tolerance, like you said you’re going to take too much Vitamin C and have some lose stool or something. You can liposomal form and has better absorption and it decreases some of that GI problems that can happen.

Dr. Davidson: And then, one other thing that I don’t want to– like I said, we’ll put a little list together on the show notes to make it little bit easier to understand or to read through and then we’ll have the different products that we really like but definitely the homeoapathy, there’s a guna flu, which is a great homeoapathic little vials that you use for when someone is sick. I actually use it as preventative too, like I might have someone use it when they’re going on an airplane, like I am leaving right now for the airport so i’ll take one vial of the guna flu before I get one the plane and then just weight it out, on maybe on my next flight back home, I would take one. Kids of different ages can use it too. They might use it once a week or if they went to a birthday party with a bunch of sick kids, you can use it once or if you’re actually sick, you can follow the instructions on it and you take it a little bit more frequently and I have seen that it really helps prevent and it will help acutely in homeoapathy, which is so wonderful is it it’s going to work or it’s not. You’re not going to have the side effects that some other things have.

Dr. Maki: And for kids, kids respond extremely well to homeoapathy because their vital forces so strong, they really do respond very well to it. Sometimes, humans like you said, it can be little hit-miss if you have the right remedy or the wrong remedy but kids really really respond well because they’re not as– in some ways, lack of a better turn down is adulterated sort of speak as the adults. Their bodies are– immune systems are so strong and vital. Now, a few other things before we wrap this one up. Hydrotherapy, all right? So, using basically water, moist water and when we are in school, we used to do– just kind of like this thing, we used to call them pit bath. There’s this very particular type of pit moss that was powderized into a little packet, we put it in hot water and basically soak people in there for 20 minutes and that’s a great way of stimulating immune function. Now granted, most people don’t have athletic training tub in their house and if you use the pit moss in there, you’re probably going to stain your tub so it can be little clunky but even taking a hot bath or a hot tub or a shower can be a great way to stimulate immune function, your raising little by using heat like that or sauna, I’m finish. You know, I’m Maki, my last name is Maki so I’m definitely finish origin that are kind of know for taking a sauna. It’s a really great way to increase the internal body temperature, which is exactly what a fever supposed. A fever is supposed to raise to internal body temperature because that mobilizes your immune system and makes it stronger.

Dr. Davidson: Oh yeah. Another old school hydrotherapy is putting on a really cold cold wet towel on little kids back or somebody’s back and then you flip it over and you put a hot towel on it and then you do a cold one and you go back and forth, always end with cold as that will stimulate the immune system as well.

Dr. Maki: Yeah, if you take a hot shower, you’re supposed to rinse in cold which sound awful in the moment. If you take a sauna, you’re always supposed to rinse in the cold shower when you’re done, as a way to kind of close your pores and to kind of get that contrast going. It’s a lot of times, it’s the contrast between the hot and cold that actually does what you wanted to do. And there’s some other little thing that we learn when we are in school, we don’t use them necessarily but there are little tricks–

Dr. Davidson: Recommend them but we don’t have– yeah, we don’t do them on people.

Dr. Maki: Yeah, like what she packed, we used to do a bunch of those things when we’re in school because we are students, we didn’t know anything, we don’t want us to hurt anybody but they let us play with water a lot so we had a lot of fun there and we learned quite a bit. And from when it comes to some serious things like hepsy and HIV and some things we had, just using water, we had water in temperature, we are able to witness some really good results for people. Now, you can go up a force we used to recommend, we haven’t recommend it in a long time but we used to recommend quite a bit B-12 injection for people, especially like you say, when they’re getting ready to fly or a plane, B-12 injections, either on an ongoing basis or prior to or while you’re–

Dr. Davidson: A B-complex?

Dr. Maki: Yeah, while you’re flying and even then from that level, IV’s like what they consider or what they call a Myers Cocktail which is a way to infuse in a– what you call an IV pushed away to get in some nutrients in a very quick way. That can be great way to stimulate immune function when you’re actually sick. We’ll put down some of these specific ideas in the show notes. You can just go to the website and be able to find that information there. Dr. Davidson, do you have anything else to add?

Dr. Davidson: Yeah. Like you said with the show notes, we’re going to put down maybe some specific products that I use– I mean, there’s thousands of products all over that are fantastic but we have some of our little nitty gritties that we love and we’ve noticed worked with our patients and worked on ourselves, worked really well so we’ll have a little bit of a list with that. If you do end up buying it from our website which is fantastic, thank you for being so loyal is you can get the free shipping code which is COLD, C-O-L-D, cold would be our free shipping code.

Dr. Maki: Yeah, and all caps on the COLD. That way, there’s a $9 shipping charge.

Dr. Davidson: Uppercase, all uppercase.

Dr. Maki: Yeah yeah, I’m sorry, not bold but all upper case not lower case. It is case specific so it has to be all capitals, in that way you could save the $9 shipping charge if you do happen to order anything. With that said, Dr. Davidson, anything else? Or are we good for now?

Dr. Davidson: Oh absolutely. Very good.

Dr. Maki: Okay. Well, hopefully this gives you some strategies, hopefully this gives you some things that you can do. Certainly like always, if you have any questions, certainly don’t hesitate to reach out. Otherwise, until next time, I’m Dr. Maki.

Dr. Davidson: And I’m Dr. Davidson.

Dr. Maki: Take care. Bye bye.

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Can You Get Sick From Stress? | PYHP 071

Dr Valorie Davidson and Dr Robert Maki — Tue, 03 Dec 2019 22:44:42 +0000

The holiday season is upon again, which is a great time of year to spend with family and friends. However, it can be a stressful time of year as well. Not to mention, it is also the cold and flu season.

Most of us are too busy and don’t have time to get sick, but that is part of the problem. We push ourselves too hard. Sleep is often never enough, so we open ourselves to illness.

In this episode of the podcast, we discuss the connection between stress, your adrenals, and immune function. Over the years, we have seen it many times with our patients. They are very busy with work, family and just life in general. If an unexpected stressor comes along, they don’t have enough reserves to keep them well. Inevitably, they are laid up in bed with a cold or the flu.

PYHP 071 Full Transcript:

Download PYHP 071 Transcript

Dr. Maki: Hi everyone. Thank you for joining us for another episode of Progress Your Health Podcast. I’m Dr. Maki–

Dr. Davidson: –and I’m Dr. Davidson.

Dr. Maki: So have you noticed the weather’s changing a little bit? It’s getting a little cold.

Dr. Davidson: Oh, absolutely.

Dr. Maki: I think it was like in the 20’s these last couple of days in the morning.

Dr. Davidson: Yeah. I think 30’s because it didn’t completely freeze but when it’s cold here, it usually means that the sun is out which is really pretty. Then with the fall leaves being orange and read, it’s actually been a really beautiful Fall here in Washington.

Dr. Maki: Yeah, you and I went for a hike the other day, we have this called the inner urban trail right behind our house and when we went up to this hike that’s in Bellingham called Fragrance Lake which is a really popular hike. You are telling me about when you went down the trail and all the leaves were on the path and it looks like, kind of, like the yellow brick road from Wizard of Oz.

Dr. Davidson: Yeah, there was a big– kind of like a windy time like a windy night and then the next day when it was really beautiful I went for a walk by myself on that inner ravine trail and nobody had been on there yet. No bikers, no walkers and it was just all these yellow leaves all over and just me that did it. I was like, “I feel like I’m on a brick trail.”

Dr. Maki: Yeah, that’s great.

Dr. Davidson: A yellow brick road.

Dr. Maki: Yeah, yellow brick road. I’m originally from the Midwest Minnesota and there’s a scenic tour, scenic drive you go from Duluth, Minnesota up the, what they call North Shore which is the North Shore of Lake Superior and everyone takes this kind of– I won’t say everyone– but a lot of people take this annual trip to be able to see the change of the leaves and certainly, we never really got a sense of that in Las Vegas when we lived there for so long. But surely, back here in Washington, you can appreciate it cause it’s really–the temperature is dropping which isn’t great. We certainly like warmer temperatures but to see the color of the leaves and everything changing, it’s pretty nice.

Dr. Davidson: Well, I’m not feeling sorry for anybody in Las Vegas ’cause they have great weather right now. I remember October, November were like my favorite months.

Dr. Maki: Yeah. Yeah. I remember when we first moved there, 2004, I actually got a sunburn on Thanksgiving when we’re actually at some park with some friends that you’d met and it was like 75 degrees. I’ve never been– I never had a thanksgiving where it was like 75 degrees and I got a sunburn. That was pretty nice. So having said that, you’re talking about fall and the dropping temperatures, winter is going to be coming fairly soon for a lot of the country. We have the last several episodes, we’ve been talking about adrenal functions so we figured out a really good segue and plus because of the time of the year, we would segue from talking about adrenals into kind of a little bit of a bridge between stress and immune function. Then, of course, the next episode, we’re going to talk about some actual specific things you can do when you are sick or maybe around some people that are sick, how you can protect yourself.

Dr. Davidson: Hey, it’s November, so we’re in the heart of a cold and flu season and this is going to last us ’till probably about January or February. Last year, all the patients I’ve pretty much talked to, they knew somebody or maybe it was themselves that had, you know, there are a lot of viruses coming around. So that’s why we thought we would kind of get a head start on this so we could give you, guys, some good ideas on how to work on your immune system. Keep it nice and strong to prevent actual flu or virus or cold but then at the same time, if you are sick, we can talk a little bit about what you can do acutely to reduce down the symptom, reduce down the severity and reduce down the duration.

Dr. Maki: Yeah, right. Now, I think there’s a kind of a movement in the country to prevent people from getting sick, right? We’re too busy. We’re going, go, go, go all the time. We have a million things to do. People don’t have time to be sick but in some ways, the lack of time to be sick is why people become sick because they’re just stressed all the time. They maybe they don’t sleep that well. They’re pushing themselves to the brink all the time and they kind of allow themselves to get sick. The harder they push, eventually, that is going to catch up with them. I think even from a media standpoint, there’s kind of a push to prevent illness. Now, we talked with patients, patients have, I mean our practices mostly around adults. We don’t do it with a lot of children. Usually, the children that we deal with are the children of the patients that we have, so those situations come up quite a bit. So this episode is kind of really about keeping yourself well as a person, as an adult, as a parent but also things that you can do for your children at the same time. Now, we could probably separate those into two separate things but at the same time, children under the age of 10– kids are meant to be sick. That’s what strengthens their immune systems. We don’t really want to try to prevent them from being sick because I think that over time especially when they really need protection, I think that actually weakens their immune system. So now, when they really need protection, they don’t really have any protection.

Dr. Davidson: Exactly. When you’re little, you’re supposed to get sick. I mean you’re not supposed to get deathly ill but you’re supposed to get a cold, flu here and there. Maybe your fever spikes but then it comes back down really fast. That’s okay. It’s good for their immune system but the take-home part or the flip side of it is those kids come home to us or grandkids come home to us and then we end up catching what they have. That’s what I would run into a lot with patients is, hey, they can take time off of work. They can’t take time and then to be sick so, of course, they’re looking for the quickest, fastest, easiest route to not be sick. So it’s a little bit about, “Hey, your kids are going to bring home some things, what can we do to help prevent that for you?” Then on the flip side, like Dr. Maki was talking about, it really does come down into those adrenals. Those adrenals have a complete correlation or relationship with the immune system. When you’re stressed, your immune system drops, that’s why people get shingles. That’s why people get shingles which would have been if you had chickenpox. That’s why people get Epstein-Barr reactivations is because that immune system is following what’s going on with the adrenal glands.

Dr. Maki: Yeah and you always see those things. You see shingles, you see a herpes outbreak. You see all those kinds of things when people have a major acute stressor. They’re stressed all the time anyway, right? They’re having stress, that just everyday stressors, but then something big comes along and they don’t have enough adrenal reserves in the tank so to speak and now they get some kind of a major infection like that, all still viral related. Those are all still viral infections but the immune system doesn’t have necessarily enough to go around to be able to protect them in the way that is supposed to.

Dr. Davidson: Yeah. So one of the most important things you can do for your adrenal glands, I mean you can’t go run off and live on club med not have or have any stress in your life. You’re going to have some adrenal stress but what you can do is definitely sleep. It’s improving that sleep and making sure you’re getting good quality sleep.

Dr. Maki: Yeah. I am now sure how sensitive microphones are but we’re in our a little studio at our house and our dog is right under our feet. We have an Australian shepherd mix. So, any of you that actually have an Australian shepherd you know that they’d never leave your feet. They’re at your feet all the time and he is actually chewing on a bone. We have this big rug in here trying to help to take down some of the echo. So if you hear a weird noise in the background, it’s our dog chewing on a bone trying to keep him occupied.

Dr. Davidson: Yeah, he is definitely obsessed with bones and chewing. Thank goodness, he only chews on his bones and not anything else in our home or office. But yeah, if you hear kind of like a weird strange noise that’s the dog having a great time with his bone.

Dr. Maki: Yeah. He’s never, even as a– now he’s only a little over 11 months, but even as a puppy, a young puppy, he never chewed up any shoes. I think one pair of my shoes, he chewed off a shoelace and that was it. We got pretty lucky as far as that goes. So back to the immune system, that’s what we thought this was a really good segue talking about adrenals and a little story. When actually, when you and I met at Bastyr, it was pretty intense. It was medical school, right? So it’s a really intense program and I was on the four-year track, you’re on the five-year track. That’s just the way that they do their scheduling and how long it takes to finish. The first two years of the four-year track was pretty intense. You had a huge course load. I was actually working at that time so it was really stressful. In almost every quarter for four years, I would get– we would have finals for an entire week. Finals would be done on a Friday. By Sunday, almost for four years straight, I was sick every time. So then I would spend my short little break before the next quarter started, I’d spent the whole, the first three or four days of it recovering from some kind of a cold. That’s what we see in our patients. We see the same thing. We see a stressor come along. They are fine in the stress of the situation because your cortisol goes up in the short-term so it keeps you surviving, so to speak, but the minute that stressor alleviates, maybe a big deadline at work, you’re doing something and all of a sudden finish the project, you finish the deadline you finish whatever it is, you get that proverbial kind of sigh of relief, that’s when people tend to get sick. You don’t get sick at the moment necessarily, but the longer that stressor goes along, usually on the back end into that is when people really kind of collapse.

Dr. Davidson: Probably for you, which I completely admire you for having taken that course load and working at the number of levels– the number of hours you’re actually working per week but, needless to say, you probably didn’t get much sleep before those finals.

Dr. Maki: Well, you were the good student, right? You were the one that sat in front of the class and took really good notes. So you probably didn’t have to study as hard as I did where I would not take those good notes. I maybe didn’t show up the classes as much as I should and then I will cram before a couple of days before the test. So I was trying to make up for lost time where you are actually, you had better time management than I did. I procrastinated too much. So I made it, I had in some ways, I kind of induced my own stress where you actually had better habits about it than I or you had better study habits than I. I didn’t have very good study habits but nonetheless, from an immune system perspective, every time it was almost like clockwork, I knew it took me a while to make the connection but seriously we would, you know, Friday would come and I’m new by Sunday, I was going to get a cold or something and almost invariably I did. It was too predictable to be a coincidence. It just happened every time.

Dr. Davidson: Yeah. So do not allow yourself– don’t, if you’re going to skimp on anything, don’t skimp on sleep. That’s the most important take-home thing is don’t skimp on the sleep because then as you can see it will create that stress on those adrenals. Then when every stressor over, you crash, and then of course, when you’re under a lot of stress or like Dr. Maki was saying, studying for finals, you might not be eating as well. And probably more shoving in some sugar and caffeine rather than maybe some healthier foods.

Dr. Maki: 100% right. When you’re up all night, the last thing want to do is be eating broccoli and chicken breast, right? You’re eating junk food. You’re pounding caffeine. Nowadays, with the energy drinks, they didn’t have energy drinks back then but now you got Red Bulls and Monsters and all these crazy things that there’s going to have a payback at some point. You’re going to pay for that in some way or some form. Now, it was interesting that when we are preparing for this episode, you said that you were never were really much of a crammer. Like you couldn’t, you put a priority on sleep you could never stay up on doing, quote-unquote, all-nighter like some students do.

Dr. Davidson: Well, you have an amazing memory that you can cram at night and remember it for the test the next day. Not me. I got to read it right. I’d say it out loud, so I know my pattern so I would study early and always spend– you know that’s my personality too.

Dr. Maki: Yeah, sure, right. And the way that I did it is certainly mine as well where I kind of like I said, I kind of induced my own stress or I made it more significant than it needed to be. So again, the point of that little story there is that we do, in some sense, we allow ourselves to get sick and we push, we push, we push. We have a million things to do on a regular basis and we, kind of, run ourselves down. We don’t have enough recuperation on a regular basis and now we have this kind of suppressed immune system. So then we are susceptible to things around us ’cause the things that are around us always around us, right? It’s not a matter of, “Oh, I came in contact with this person that was sick or that person that was sick or in the office or something like that.” It’s whether or not the host, the person or the individual if they are susceptible to what’s around them ’cause those threats are, from an infectious perspective, are always there.

Dr. Davidson: Yeah. So you have to, like, you’re saying, not that we’re trying to blame the human or blame you but at the same time people, it’s okay to get sick here and there. Maybe you might get a sniffle once a year, maybe it’ll last two days but I think the culprit too, is hey, you might be a little bit of a host. You might catch a little bit of this little virus but because you don’t slow down and you push it through and you go to work and you keep doing what you’re doing, that’s when people say, “Yeah, turned into pneumonia or went into my lungs,” because you have to slow down. Granted, nobody likes that person who’s sick come into work.

Dr. Maki: Yeah.

Dr. Davidson: Like come in the office there like, “Why did you come to work?” But of course, we have things to get done and if you don’t get it done that day you’re going to have three times more to do the next day. But really, truly, pushing yourself is going to make it worse.

Dr. Maki: Yeah, right and I think that your body is trying to tell you something. When you’re getting under the weather, you do have to– now granted that we’re not trying to preach here and tell people what to do. We understand that people have a million, even ourselves, we have a thousand things too. You and I can’t afford to be sick but from and immune system perspective especially when we’re young healthy and vital, getting sick is normal. Getting sick is a way that it keeps your immune system primed and ready. That’s why kids when they get under the age of 10, when they get a fever, they get a big fever. But a child can have a fever of 102, 103 and they’re still playing with their blocks and their toys and nowadays is probably their little iPads or their little, the video devices. But they’re still relatively fine.

If an adult has a fever of 102, they are practically bedridden in the fetal position because they feel so horrible. But that child’s immune system is really so vital and so strong. In naturopathic medicine, we call that the Vis; for Latin, it’s called the Vis medicatrix naturae which is, in some ways, it sounds kind of hokey but it’s really a real thing. That healing power of nature and children, their vital force is so strong that, that’s why they respond so well. Their immune system seems like it’s really aggressive but it’s aggressive in the right way. I still, I know that this is a kind of a touchy subject when it comes to fevers but I– and you and I don’t have children, that’s the first disclaimer and the first thing we’ll say. So take our opinion or my opinion with the grain of salt but children that have a fever, leave the fever alone. Don’t necessarily try to suppress that fever but try to convince the parent of that of leaving the fever alone, they think that you should give them children’s Tylenol. Bring the fever down. Bring the fever down. The body, typically, will never– almost in every case– will never go febrile on its own. It’s usually when you intervene with children’s Tylenol or something that actually brings the fever down when the body then overreacts. The fever is a very necessary inflammatory process there to not necessarily kill the virus but to immobilized the immune system. So now the immune system can go attack the virus. So the body has to raise the internal temperature in order to rally the troops, so to speak.

Dr. Maki: Yeah, exactly and then, of course, if you did– granted antibiotics are used for bacteria, bacterial infections intervening with the antibiotics, the immune system doesn’t get to really fight and get rid of that virus. So that’s why you might see adults that get sick a little bit more frequently because they weren’t allowed to get sick as kids. Now, granted like you said when a parent sees her kids sick, that’s breaking their heart and twisting their inside. They want to do something so I totally understand that. So that’s where there is that level of balance.

Dr. Maki: Yeah, right and now, granted and we don’t want to go on to diet tribe or anything like that, again, we don’t have children but there’s always this push for antibiotics and 90% of illness that human beings come down with, most of the time, especially for healthy people is going to be a viral-related problem. Antibiotics do no good for a viral-related issue. They only are intended for bacterial infections and most healthy people are very rarely going to get some kind of a bacterial-related illness. It’s just not going to happen. So taking the antibiotic– now, some things they will prescribe an antibiotic prophylactically as a way to prevent a bacterial infection. But you and I were kind of discussing this before too, taking an antibiotic for a bacterial infection that’s not there, really doesn’t do any good. All it is going to do is wreak havoc on your normal flora and where big talk these days about the microbiome, you want to be very careful. You want to protect that microbiome. The bacteria that’s in your colon and antibiotics given for the kind of the wrong reasons is going to disrupt that flora every single time.

Dr. Davidson: Yeah. Like we had talked about to start with those adrenals. Let’s say you do catch a virus and you keep pushing yourself and you don’t stop, then sometimes that’s when the bacterial infection can piggyback on that viral infection because the host’s immune system is suppressed ’cause they won’t stop. Then there’s a perfect environment for that bacteria to grow in, so that’s were really does come back to that immune system. Of course, I’m sure all of you know, eating broccoli is a lot healthier for you than eating a candy bar. But just try to be mindful about- “What can I do to reduce down those inflammatory foods?” Like the sugar, the alcohol, the caffeine, the coffee and then, of course, the sleeping part. But there are your kids or your grandkids are going to bring home little sniffles and viruses and little bugs. So there are some supplements that you can do to prevent ’cause there’s a little bit of a misnomer there ’cause a lot of people think, “Oh, I’m going to take some echinacea. I want to take these immune-stimulating herbs and vitamins.” You don’t necessarily want to take those things if you’re not sick because if you’re not sick and you’re taking something to stimulate your immune system, that really isn’t a good idea healthwise. Now, if you are sick stimulating the immune system is a great idea. So that’s where I think that preventative part in terms of taking supplements gets lost.

Dr. Maki: Yeah, right. I think that’s where the adrenal connections come in as you don’t want to drain your adrenal tanks too low. You want to keep them, kind of, in some ways thriving so that way, like you said, the host is protected that way. You’re able to keep your guard up so to speak, quote-unquote, and it never gets to that susceptible level and taking something that does enhance immune function. If you take that over a long term basis when you really need it, it doesn’t work. Those types of things which we’ll get into in the next episode, but those things are intended to be used in a short-term fashion. Kind of an acutely in that early window when you just noticed you’re getting– you’re coming down with something or you been around somewhere or if you’ve been really stressed or you have been really burning the midnight oil or something. Then you can target that by taking something for the entire cold and flu season is not really the best approach when you’re trying to, quote-unquote, stimulate immune function.

Dr. Davidson: Exactly. The next podcast after this one, we’re going to talk a little bit more about vitamins and nutrients and herbs and minerals and things that you can take to help prevent but not necessarily stimulate the immune system. So I have kind of the idea on the preventive and then we’re going to talk a little bit more acutely like, “Darn it, I got a sore throat. I’m going to get sick. It’s going to get worse, what can I do right now to reduce the duration?” So we’ll talk a little bit about supplementation in the next podcast but for this one, it’s definitely about sleep, diet, and lifestyle.

Dr. Maki: Yeah. So diet, of course, is always an ongoing evolving thing. The big thing when it comes to– as we are just talking about– studying for finals or working and when your stress level goes up, usually your dietary choices go down, right? Your brain is trying to survive. Your body’s looking for easy sources of sugar, fat, and salt. You’re maybe are not able to– literally– not able to make the healthiest choices at a time when you probably need to make the healthy choices but your brain doesn’t allow you to do that because again, it’s trying to protect you, in a way, but that ultimately a kind of diminishes the health in the long run. So certainly, sugar and I know they’ve done stem studies, in vitro, in vivo so somebody’s research types of terms where sugar actually has a dramatic impact at decreasing white blood cell functions. So white blood cells are, there’s what, five or six different types of white blood cells, macrophages and basophils, and eosinophils all those things of your white blood cells. Their ability to do their work, so to speak, is actually decreased by consuming sugar. So the more sugar you consume, the lower your immune system is.

Dr. Davidson: Then just another completely side note, hey, it’s November and most states it’s getting pretty cold so what do we do? We shut our doors. We shut our windows and we turn up that heat and if you have central heating, when you raise up the heat with central heating it lowers the humidity in your house which then dries out your mucous membranes which when your mucous membranes are dry, that actually–’cause your mucous membranes are supposed to protect you from the outside critters and bugs and viruses and bacteria. But when those mucous membranes are starting to get a little dried out, that actually increases your susceptibility or your kind of being able to get sick. That’s why people tend to get sick it’s because the humidity goes down. So if you can increase the humidity in your house with the humidifier, even here in Washington, it rains all the time but it gets cold. We close our doors and windows and turn up the heat and you can dramatically feel that dryness in the air on your skin, in your hair that goes for those mucous membranes. So some people get humidifiers; other people actually take like water-soluble lubricant and maybe line inside of their nostrils too so that when you’re out in a crowd with a bunch of people that are also going to be sick, it actually helps protect you from getting sick.

Dr. Maki: Yeah, right so every kind of wet surface in your body, your eyes, your nose, your mouth, the GI tract, the anus, the vagina, the urethra, all those little wet surfaces are basically exposed to the outside world. We have protection there that is supposed to prevent us from the viruses and the bacteria and the fungus and the mold and all the different things that are around us. All those things are around us all the time. It’s not like they’re here for different times of the year and they’re not. They’re always there and to be honest, our immune system does a very, very good job especially in the United States where we have such a good quality life. We have running water. We have sewage. We have garbage collection. We live in a very clean environment. So now, the things that happened in other countries where they don’t have those things, infectious diseases still really a big problem. In the United States, infectious disease should not be as big of a problem. Now, I know that it’s becoming a really hot topic these days across the country for a variety of different reasons. But what we’re trying to say is some strategies that you can use on your own to again, keep yourself well. So you can maybe at least minimize, maybe not, you’re not going to not get sick. Maybe that is still inevitable. You and I, even you and I, were supposedly the ones that are you know, have all the knowledge and information, you and I still get sick usually once a year. Once good cold–

Dr. Davidson: Yeah once a year, a tiny cold for about three days that still doesn’t slow you down but at the same time you just don’t want to keep running at the pace that you are. So if you just slow down a little bit, it goes away.

Dr. Maki: Yeah. Yeah. Yeah, and they’re not, they’re inconvenient but for sure. I mean like I said you and I are busy. We have lots of things to do, we cannot really afford to get sick but in some ways, you can kind of reflect back and say, “Man, I was really busy and there is a lot going on then I got sick.” It’s like, of course. But you don’t really look at it or you don’t acknowledge it that way at the moment. It’s always kind after the fact but then our lives tend to be somewhat routine and habit and it recycles itself on an annual basis. Somewhere between the beginning of October and February, it ends up being this annual cycle for people. So in the next episode, we’re going into some more specifics. We’re going to give you some ideas, new trend herb-wise that we’ve seen with our own patients that actually work very well. So, Dr. Davidson, do you have anything else to add for this one?

Dr. Davidson: No. No. This was good.

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

Dr. Davidson: I’m Dr. Davidson.

Dr. Maki: Take care. Bye.

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How Do Adrenals Get Exhausted? Zombie | PYHP 070

Dr Valorie Davidson and Dr Robert Maki — Tue, 29 Oct 2019 21:32:15 +0000

In this episode of the Progress Your Health Podcast, we continue explaining the three main types of Adrenal Fatigue/Dysfunction that we see often. Here is a quick recap:

Vampire (episode 68): High cortisol at night and low cortisol in the morning. Hard to fall asleep and very difficult to wake in the morning. Weight gain and evening carb and sugar cravings. Feel much better in the evening and will refer to themselves as a night person.’
Ghost (episode 69): Cortisol is very low in the afternoon and early evening. This is why they fall asleep so easily, but there is a lot of difficulty staying asleep through the night. The Ghost is broken up into two subtypes: the Ghoul and the Poltergeist.
- Ghoul: The cortisol is low in the afternoon and evening. They fall asleep so easily. But come 2 am the cortisol rises for hours. The cortisol will drop a touch, so they fall back asleep after two hours. But it remains elevated until noontime where the cortisol will dive, along with their energy.
- Poltergeist: The cortisol is low in the afternoon and evening (like the Ghoul). And come 2 am the cortisol rises. But the difference here is the cortisol will rise and fall all night long. That is why these people wake up numerous times in the night. Like the Ghoul, the Poltergeist will have good morning energy but will crash come afternoon.

In this episode, we go on to explain the third type of Adrenal Dysfunction that we have encountered with our patients, the Zombie. The Zombie has low cortisol all day and night. It is not Addison’s disease. But due to the lower levels of cortisol, the Zombie is tired all day and night. They have no trouble falling asleep. They are the people that will easily sleep 8 to 10 or more hours but not feel rested when they wake up.

Zombies report that they could sleep all day long. They have a lot of physical fatigue and cannot exercise. If they tried to exercise, they are wiped out for the rest of the day. And it can take them days to recover after intense exercise. They do crave sugar and carbs. In some ways, it gives them a little short-lived energy to eat sugar, soda, or refined carbohydrates. Not only are they physically tired, but they are also mentally tired and comment that they have a lot of brain fog. It is hard to focus and finish a project, and Zombie’s report that they have no short term memory.

As we mentioned in the podcast, we wanted to give you some tools that can help. Some options that include nutrition, lifestyle, supplementation, and prescription medication that can help a Zombie type Adrenal Dysfunction. Before we answer this, we have to put out the disclaimer: All content found in this blog, including text, images, audio, video, or other formats were created for informational purposes only.

The purpose of this website and blog is to promote consumer/public understanding and general knowledge of various health topics. This content is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Please consult your healthcare provider with any questions or concerns you may have regarding your condition and before undertaking a new health care regimen. Never disregard professional medical advice or delay in seeking it because of something you have read on this website. If your healthcare provider is not interested in discussing your health concern regarding this topic, then it is time to find a new doctor.

Nutritional: The best way nutritionally is to balance your blood sugar and insulin. Cortisol can really disrupt your blood sugar and insulin levels. One of the best ways to do this is to implement a lower carbohydrate diet. That is easier said than done. Trying to restrict your carbs but having intense craving at the same time do not go hand in hand. One helpful trick is to do a ketogenic diet while cycling in carbs in and out on a schedule. We have a manual written that will explain hormones and weight gain/loss. It will also help guide you on a program to balance your blood sugar and insulin levels. If you are interested in downloading our free guide called Keto-Carb-Cycling-Program’ (which abbreviate KCCP), go to progressyourhealth.com/KCCP.

Lifestyle: Reducing stress is probably the most important issue because the adrenals have a hard to time to recover if there are still major stressors present. Also, reducing caffeine consumption can also be helpful. Consuming too much caffeine can make you tired over time. The more caffeine that is consumed, the more tired a person usually feels. Reducing the amount of caffeine consumed on a daily basis can be very hard to do when you are tired, but is necessary to have more energy.

Supplementation: Supplementation can really help the Zombie type of Adrenal Fatigue/Dysfunction. But this is where it gets specific. Because the supplements for the Zombie are different for the other types of Adrenal Dysfunction. With the Zombie, the goal is to raise cortisol during the day and restore a proper circadian rhythm.

Prescriptions: In the case of the Zombie, they are typically the perfect candidate for Hydrocortisone. The commercial version is called Cortef. The adrenals get exhausted due to chronic stress and / or trauma and are not able to recover. By using hydrocortisone, it is possible to begin to restore adrenal function so the person can at least function normally. It can take months if not one to two years depending on the severity of the situation for a person to get back to normal. Once a person is feeling good, then the tapering of the dose begins. Once a person has tapered off hydrocortisone, they usually transition to supplementation consisting of adrenal glandular, herbs and nutrients.

PYHP 070 Full Transcript:

Download PYHP 070 Transcript

Dr. Maki: Hello everyone, thank you for joining us for another episode of the Progress Your Help Podcast. I’m doctor Maki.

Dr. Davidson: And I’m Doctor Davidson.

Dr. Maki: As we said on the last one, today we’re going to talk about the third type of adrenal fatigue, which is what we refer to as the zombie. Hence the name you might be able to understand what the zombie is like. On the last two episodes, the first one we did was a vampire, the second one was the ghost, which is broken up into the ghoul and the poltergeist. If you didn’t fit into any of those two categories, then you’re more than likely the last one left, is the zombie.

Dr. Davidson: Like we have said, these are the three main types of adrenal fatigue or adrenal dysfunction that we’ve seen in our years of practice. There are different hybrids and whatnot, but definitely, I would say these are the three main ones I’ve seen in all patients when we’re working with adrenal fatigue. The vampire, just to recap a bit, has the high cortisol at night, so they’re wide awake and they feel alive, and they feel like themselves. Then, by the time the cortisol goes down, they’ll be able to fall asleep, but is 2:00 AM. Needless to say, come morning time, that cortisol is super low, so vampires are so tired in the morning. Part the afternoon they start to wake up a little bit, but the morning time, they’re the people that every appointment, every place they need to be in the morning, they’re the ones that are late.

Dr. Maki: Yes, absolutely. On the vampire episode, two episodes ago, I talked about when I was in college, I had a really hard time making the eight o’clock class. There is a couple that I had to take at eight o’clock, but if I could pick a class that didn’t start at eight o’clock, I will take class that didn’t start at eight o’clock, because I’ll have an amazingly hard time trying to make it there. The zombie, they would never make it an eight o’clock class. They might not even schedule a class into before noon. They would have a really, really hard time making anything at eight o’clock, maybe even 10 o’clock, for that matter. If not, they’d probably would make it at maybe noon, one, two o’clock, but anything in the morning, they’re not going to make it there.

Dr. Daivdson: Then, the ghost, we broke up into the ghoul and the poltergeist, because the ghoul, instead of roaming the halls, they’re roaming their cell phone in the middle of the night because they wake up for a couple hours in the middle the night, while the poltergeist is little mischievous. These people are waking up multiple times in the night. Both types of ghost, fall asleep super easy, but the poltergeist, they would wake up six times at night. That’s a terrible night’s sleep. The difference between the ghost and the vampire, is the vampire is super tired in the morning, they’re late, they don’t go to their eight o’clock classes, they usually late for work. But the ghost are on time. They’re pretty good in the morning, but the afternoons are when the ghost, they’re just like that, I don’t know if you ever saw that Seinfeld show, with George Costanza, build a desk that he could sleep in the afternoon, those are the ghost. In the afternoon, they want to either take a nap, or drink lots of coffee, or maybe even both.

Dr. Maki: Right. Where the zombie, as you maybe would gather from the other two, the zombie, they’re just tired all the time. They’re just always tired, they never really feel very good, they’re always dragging themselves around. Like I said, they are going to be late for everything, they’re going to be always not very punctual, just because they’re so exhausted on a perpetual basis

Dr. Davidson: Like you said, the zombies are pretty popular -as you said on the last episode- in TV and movies right now, but it’s like that. The zombies, their cortisol is low all the time, they don’t have a spike in cortisol pretty much the entire 24-hour period, so they are tired. They’ll even say, “I could sleep all day, I could sleep all night” they are just tired.

Dr. Maki: Yes. They do actually, sleep pretty well, but they never feel refreshed after sleeping. They could sleep for 10 hours and they wake up and felt like they’ve never slept. They don’t have the sleep trouble that the vampire has, and the ghosts have, they literally can sleep all the time. They wake up at 8 o’clock in the morning, by 10 o’clock they can take a nap, they’re just always tired. One thing that I didn’t mention about the ghosts in the last episode, is that the ghosts it’ll be tired in the afternoon, whatever, but they’re still able to go exercise. A lot of them will exercise multiple times a week, and they say they’re tired -a lot of those people they just need to stop exercising to get some of their energy back-. The zombies, they are way to tired to exercise at all. Even the vampires, just way too tired to exercise, they just can’t do it, they just can not, physically, or mentally, bring themselves do any activity whatsoever. Getting out of bed for the zombie is sometimes hard enough.

Dr. Davidson: And then with the exercise, especially for the zombie, they’re the one that says- Let me back up. The ghost, they’ll go exercise, like you said, Doctor Maki, they probably should back off on some of that exercise and probably help with their cortisol cycle, but they can exercise and they’re the one that says, “After I exercise, I actually feel pretty good” I feel pretty good for about an hour after that. Now, the zombies, if you made them exercise, if they were forced to exercise, they feel horrible after the exercise. It’s like they used up whatever limited reserves of energy they had, and it’s gone.

Dr. Maki: Yes, right. It wipes out the recovery after that because literally, they have no adrenal reserves whatsoever. The recovery from that, it takes them a couple of days, to bounce back. They don’t just wake up the next day feeling fine, they’re even more tired than they were, to begin with, which they are already very tired in the first place and now it just completely wipes them out. Or, if another stressor comes along, they have no more resilience, no more capacity for any other stressor, so an acute stressor that does come along, it really wipes them out, they don’t really have any buffer there, or threshold for extra stress in their lives.

Dr. Davidson: And it’s not Addison. Like I’ve mentioned, yes, their cortisol, it’s being secreted from the adrenal glands, is low. If you did a saliva test, it’d be low in the morning, it’d be low in the afternoon, it’d be low at night, it’s just low all the time. But it doesn’t mean that they have Addison’s disease because that’s completely different.

Dr. Maki: Yes, which is unfortunate because the zombies are really struggling just to function on a normal level. If you do a blood test cortisol, which we don’t ever really do, maybe occasionally, it might be necessary, more so on the Cushing’s side. If you suspect someone’s got Cushing’s disease, you might get a little hint of having an elevated cortisol here or there, they go see an endocrinologist, they’re going to do an ACTH challenge test, but for the zombies, their cortisol might below normal. It’s still going to fall within that normal because the reference range is so big, it’s not really an optimized range at all, so you’re always going to fall into.

If you think about it, like I said before on, I think it was three episodes ago, we talked about adrenal testing. The cutoff to do a morning cortisol is 9 o’clock, at least for a quest I think it’s 9 o’clock in the morning. That means you got to get up, you got to get dressed, you got to take a shower, get dressed, get in your car drive to the lab, and then you get tested before 9 o’clock, of course, your cortisol is going to be in the normal range because you’re awake and you’ve done all those things. Doing a blood test like that really doesn’t tell you much of anything. When it comes to a diagnosis from an endocrinologist or a medical doctor of some sort, they’re like, “No, you’re fine. Your cortisol is normal” but the way that they feel on a day in day out basis is certainly not normal. That’s not a way to function and to be productive on a daily basis

Dr. Davidson: No, and it’s sad. I have patients that come in and they obviously, something is going on, but they’re saying, “All my doctors tell me I’m fine, that I should go see a therapist, or I should be put on some antidepressants” and obviously they’re not fine. But then, when you do the saliva test and they can see, especially with the zombies, like, “Wow, my cortisol is low, no wonder I feel this way”. Don’t beat yourself up, it’s true adrenal fatigue, true adrenal dysfunction. I would say, as I mentioned on the last podcast, the zombies aren’t as common as the vampire, ghosts are second common. A vampire doesn’t turn into a ghost, doesn’t turn into a zombie, you don’t see this kind of progression here, I think it’s just maybe what we’ve been exposed to, how our bodies react, what our predispositions are, but zombies, they’re really tough, some of them can’t even work, which is understandable. They’re the ones that maybe their spouse is picking up a lot of the slack, which you can understand because they’re just so tired.

Dr. Maki: Yes, right. I do think that the vampires can turn into zombies eventually, if it persists for long enough or if another major stressor comes along. I think Hans Selye, back in the ’30s, or ’40s, or ’50s, the doctor that started talking about adrenal issues, there’s the three phases of adrenal fatigue, there’s the alarm phase, an acute stressor. There’s the adaption phase or adaptation phase, and then there’s the exhaustion phase. The zombies are clearly in the exhaustion phase. Most of the other two, the vampires and the ghosts, are in the adaptation phase, that’s where most people are, we’ve seen people in varying degrees of the adaptation phase and the exhaustion phase. Usually in the alarm phase when you’re in the middle of some kind of a stressor, usually people feel fine, it’s usually after what we see most often with adrenal issues, there’s some type of trauma of some sort, mental physical, major stressful event, a death of a family, a divorce some kind of major life upheaval or maybe an assault of some sort or something very traumatic.

Then, six months to two years after that, is when people really fall apart. When that stressor has resolved itself and now you finally relax, is when everybody feels the worst. They don’t really put the two and two together why they feel worse so long after the fact, but in the moment of that stressor, your body does a pretty good job of keeping you in survival mode, you’re just able to get things done and that’s what cortisol does in the short term, but then that regresses and literally that’s where all the symptoms really start to come out of the woodwork and people can’t understand why. They go to their doctor, their doctor doesn’t understand it from to this level and they feel a little bit helpless because they feel so bad, even though whatever happened, they don’t put the two and two together that how they feel now is a result of what happened six months to two years before that.

Dr. Davidson: Yes. Definitely, you think, “I’m fighting the good fight. I’m fighting the war”, the big stressor, you think when it’s over, that you’re supposed to be happy and, “Yes, it’s done, it’s resolved. I’m okay” but you’re not, that’s when you crash. Whether it’s the vampire, the ghost, or the zombie, I think the zombie is definitely more where they have had that really high chronic, chronic stress, or something happened, and then along with chronic stress on top of that, and then they really have this crash. Our goal with the zombie is completely different than it would be with the ghosts. Like Doctor Maki has mentioned on the previous episode, the ghosts, we wouldn’t want to give them a prescription of hydrocortisone, or maybe they might even be too sensitive for the glandular, but for the zombie, we want to raise that cortisol in the morning, raise that cortisol in the afternoon, and then allow it to -of course- stay low in the evening time. So our treatment ideas on working with a zombie is completely different than the other two.

Dr. Maki: Yes. Everybody, they do not. If you have quote unquote “adrenal fatigue”, maybe you’ve been online and you answered a couple of questions to a quiz or something, our point of doing these three episodes is to make you realize that not everyone falls into the same category, therefore, how you address it is going to be completely different. One thing that -I think from a medicine standpoint- can create a zombie, is if you’ve been on long term prednisone use. You got some major inflammatory problem, they use prednisone for all different types of things, from lung issues to GI problems, to potentially life-threatening problems, they’ll put you on prednisone. Prednisone can be a life-saving thing, but, at the same time, they have to taper you down, you can’t just stop it. There’s mid-roll packs, take a week, but then there’s long term prednisone use, where you might be on it for three to six months, and then they taper you down, you go from 60 down, to like one or two milligrams. Then, once you stop the prednisone, nobody bounces back very well from that, the longer you’ve been on it, usually the worse you’re going to feel once you’re off of it. And there’s no alternative necessarily conventionally, they just say, “Okay, you’re” because they can’t start a prednisone at a really high dose and then stop it right away, if you do that, you’d be really ill, potentially it could be very dangerous to do that. That’s why it has to be tapered over time, so your own production starts to come back because that’s what exactly what prednisone does, it basically shuts off your own production. Your body isn’t either was doing it, but it wasn’t doing it to the level of the prednisone, so now they have to taper that dose down to allow your adrenals to start functioning normally. Like I said, that process can take months, but once you’re done with the prednisone, there’s no transition to anything else, that’s where we kind of step in there, and that’s where hydrocortisone, glandulars, a [unintelligible] all those things would be appropriate to help someone bridge the gap. Instead of going from prednisone to nothing, they’re going for prednisone to something, and you’re just stepping them down and rebuilding their adrenal function, which can also take several months to do that. But that’s a way that a zombie can be created, based on whatever medical issue they have going on.

Dr. Davidson: Like we had talked about in that first episode, with the vampire, that they tend to have weight gain, tend to have sugar and carb cravings later in the evening time, when they’re finally feeling awake. I do notice that the zombie does have some sugar and carb cravings as well, I think maybe because it gives them a little source of some energy or a little spark of energy as short-lived as it probably is five to 15 minutes. But would you notice that zombies tend to have a little bit of a sugar tooth or a carb?

Dr. Maki: Sure, yes. Again, if their cortisol output is low, maybe their aldosterone it’s low, they might be having some salt cravings. I think it’s to the person, but whatever they’re craving, whether it’s sugary carbs or salty carbs, don’t think it really matters that much the fact that they have either one of those almost to an exaggerated degree, tells us what we want to know, is that there’s something driving that. You’re right, the brain does a lot of things, it wants caffeine, it wants sugar, it wants sugary carbs, it wants different things as a way to satisfy something in the short term, not realizing, the brain doesn’t realize that those things, over time become fairly detrimental. The body is just trying to survive in the moment and all those things eventually they just become overblown and exaggerated, and it maybe turns into other problems, whatever that might be, whether it’s diabetes or some other chronic problem. Initially, it shows up as being these subtle things that, like I said, can be magnified as the longer that continues.

Dr. Davidson: Well, we came up with these little cutesy names, but adrenal fatigue is not cutesy, it’s serious, it can affect somebody’s quality of life. Just like with the ghosts, and just like with the vampire, we also have some options that can help if you’re a zombie.

Dr. Maki: Yes, right. And give you some ideas and how to approach it, and certainly you’re not going to get that information from your primary care physician, or even an endocrinologist. We understand that we realize that because these are issues that we deal with quite often, and it really, like you said, it really comes down to energy and sleep. How well are you able to do those things, which honestly, if we don’t have enough energy, we’re not sleeping well, it is significantly going to affect our quality of life, and our happiness, and our productivity, and just how good we feel on a day-in-day-out basis. That’s a big deal.

If you go to progressyourhealth.com/podcast you’ll see the show notes there, there’ll be some other information that we really don’t have time to talk about fully on the podcast, but it will give you a synopsis of what we talked about and some ideas that you can consider.

Dr. Davidson: Yes, because there isn’t one pill fits all, or one pill is going to make me better. With the zombie, the ghost, the vampire, it’s all about having a multifactorial. We’re looking at lifestyle, we’re looking at nutrition, we’re looking at exercise, we’re looking at supplementation and possibly prescription medication. If you go into that progressyourhealth.com/zombie, they’ll have the show notes summarizing a little bit about what we talked about here, and then some options that might fit for you, possibly.

Dr. Maki: Yes. We really do understand from a patient perspective, you go to your doctor because you’re tired. If you do fall into the zombie category, there’s really no medications that are commonly prescribed for the zombie, that actually benefit them in any way. You cannot give a zombie a stimulant, like Adderall or something like that, that is just going to make them even more exhausted and cause more problems. A doctor has a really limited options to be able to help someone like this because this level that we’re talking about, they just don’t really understand it on that level. It’s not their fault, just the way the system works, right? You’re tired, you have some symptoms, fatigue is one of those, and all three these have their own levels of fatigue throughout the day, and maybe the night, there’s no medications that really fit for any of them. The things that we use, we’ve used them through based on experience in over the years, and we’re trying to do something fairly specific with them. Like you said, there’s a lot of options outside of medications that people can do on their own to help get you going in the right direction. You have anything else to add for the zombie?

Dr. Davidson: No, this was great.

Dr. Maki: Okay. Until next time. I’m Doctor Maki-

Dr. Davidson: And I’m Doctor Davidson.

Dr. Maki: Take care, bye, bye.

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How Do Adrenals Affect Sleep? Ghost | PYHP 069

Dr Valorie Davidson and Dr Robert Maki — Thu, 24 Oct 2019 22:52:33 +0000

In this episode of the Progress Your Health Podcast, we continue talking about the main types of Adrenal Fatigue that we see. We are certainly not trying to minimize Adrenal Dysfunction but to make it more interesting and easy to understand, we call these main types:

Vampire (episode: 68)
Ghost (this episode 69)
Zombie (episode 70 – next episode)

Adrenal Fatigue or Adrenal Dysfunction (which is what we like to call it) is a real condition that affects millions of people in our country. And the effects can seriously impact a person’s health and quality of life. We have seen different types of Adrenal Dysfunction. These three main types are important to know because a person with a Vampire type of Adrenal Fatigue will have a completely different treatment plan than someone that is a Zombie type.

In this episode, we are to talk about the Ghost type of Adrenal Dysfunction. There are actually two subtypes of the Ghost. We call them, the Ghoul and the Poltergeist.

But first, just to jog your memory. In the last episode, we talked about the Vampire. The Vampire has very low cortisol levels in the morning and elevated levels at night. This causes a lot of morning tiredness, to the point that Vampires are chronically late to anything in the morning. Vampire types also feel more awake at night and cannot fall asleep.

On the other hand, the Ghost type has a different dysfunctional secretion of cortisol from the adrenal glands than the Vampire.

The Ghost will have very low levels of cortisol in the early afternoon that continues until the evening. So you will see the Ghost very tired in the afternoon and evening. These are the people that can fall asleep easily at 8-9 pm. But in the middle of the night, the cortisol levels will rise so they will wake up. It is common for Ghost types to fall asleep hard for four hours and then wake up like it is morning when it is only 2 am.

There are two subtypes of the Ghost:

Ghoul: They will fall asleep easily in the evening but will wake up after about 3-4 hours of sleep. The Ghouls will be awake easily for two hours straight. Ghouls might not be roaming halls, but they certainly are roaming their iPhones. Because they cannot fall back asleep. Then by the time they do fall back asleep, they need to wake up shortly thereafter.
Poltergeist: Fall asleep very easy at night. After about 3-4 hours of deep sleep, they wake up. The difference here from the Ghoul is the Poltergeist can fall back asleep within minutes. But then less than an hour later they wake up again. Just like a mischievous Poltergeist, these poor people will find themselves waking up 4-6 times a night for no reason.

While both the Ghoul and the Poltergeist have a poor night’s sleep, they still wake up in the morning on time. Ghosts easily wake up in the morning. And once they get up and moving, they have pretty good energy. But come afternoon, they crash hard. These are the morning people that get everything done before noon. Because after 12:00 noon, their energy drops, and you can find them drinking coffee or taking a nap.

The difference between a Vampire and a Ghost is the secretion of cortisol in the 24 hours. While both are dysfunctional, they are still different from each other.

Vampire: high nighttime cortisol and low morning. But the cortisol does reduce around 2 am so that the Vampire eventually falls asleep.

Ghost:

Ghoul: The cortisol is low in the afternoon and evening. Which is why they fall asleep so easily. But come 2 am the cortisol rises for hours. The cortisol will drop a touch, so they fall back asleep after two hours. But it remains elevated until noontime where the cortisol will dive, along with their energy.
Poltergeist: The cortisol is low in the afternoon and evening (like the Ghoul). And come 2 am the cortisol rises. But the difference here is the cortisol will rise and fall all night long. That is why these people wake up numerous times in the night. Like the Ghoul the Poltergeist will have good morning energy but will crash come afternoon

I am sure you are asking: How Do I Correct the Cortisol Levels? I have Adrenal Dysfunction Ghost type, what can I do about it?

Before we answer this, we have to put out the disclaimer: All content found in this blog, including text, images, audio, video, or other formats were created for informational purposes only. The purpose of this website and blog is to promote consumer/public understanding and general knowledge of various health topics. This content is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Please consult your healthcare provider with any questions or concerns you may have regarding your condition and before undertaking a new health care regimen. Never disregard professional medical advice or delay in seeking it because of something you have read on this website. If your healthcare provider is not interested in discussing your health concern regarding this topic, then it is time to find a new doctor.

Now that we have the disclaimer out of the way let’s get on with helping the Adrenal Fatigue Ghost type. We are going to break it up into Nutritional, Lifestyle, Supplementation and prescription medication

Lifestyle: There lots of options for good sleep hygiene. More than you will read here. But one of the main points we want to get across is to reduce light as much as you can in the evening. I know that can be difficult because we want to relax and watch a TV show, movie or work on the computer at night. One thing you can do to reduce the blue light burden is to get blue light blocking glasses. And you can get a blue light blocking screen for your computer.

In fact, use the blue light blocking screen for your computer during the day. It will help you sleep better at night. These are easily found online.

Supplementation: Supplementation can really help the Ghost type of Adrenal Fatigue/Dysfunction. But this is where it gets specific. Because the supplements for the Ghost are different for the other types of Adrenal Dysfunction. With the Ghost, the goal is to reduce cortisol during the night and raise cortisol

Cortisol Manager: This is a supplement that has a blend of herbs, nutrients, and vitamins that reduce cortisol levels. Helpful to take at night to reduce cortisol levels while sleeping. Usually, one to two tablets helps.

PharmaGABA: PharmaGABA can actually be digested. While you run of the mill, GABA supplements are very hard to digest. Raising GABA is a great way to drop the cortisol levels. GABA is very relaxing and helpful for reducing angst. By taking this at night can help the Ghost sleep through the night.

PYHP 069 Full Transcript:

Download PYHP 069 Transcript

Dr. Maki: Hello, everyone. Thank you for joining us for another episode of the progressional podcast. I’m Dr. Mackey.

Dr. Davidson: And I’m Dr. Davidson.

Dr. Maki: On this episode, we’re going to continue talking about adrenal fatigue or the types of adrenal fatigue. The last one we talked about the vampire, today we’re gonna talk about the ghost.

Dr. Davidson: So the three types of adrenal fatigue that we’ve mainly seen, so these are kind of where we put these names to it to just sort of be a little bit easier to remember, easier to understand, but we– definitely the three main types we’ve seen are the vampire, the ghost and the zombie. So the previous episode, we talked about the vampire and how the vampire can’t go to sleep at night because their cortisol is elevated, they’re awake, they really can’t go to bed before 2:00 AM, midnight to 2:00 AM. Then in the morning, they’re super tired and they can’t really get going, because their cortisol is so low in the morning. So that’s the vampire. Now, in this episode, we’re going to talk about the ghost and the reason we differentiate this is because the ghost we would treat completely different than we would treat the vampire than treating the zombie. So, with the ghost, they have a little bit of a different diurnal curve or cortisol secretion from the adrenal glands.

Dr. Maki: Yeah. So, the ghost typically doesn’t really have that much trouble in the morning, actually, the early part of the day, they actually do really well. Most of the day, they do very well maybe till what– maybe around noon or so, but then come the evening is when they start having a lot of their problems.

Dr. Davidson: Yeah, the vampire has no trouble falling asleep. They will fall asleep on the couch watching TV. It’s 8:30 at night, they have no trouble falling asleep. The issue with the ghost is they have trouble staying asleep.

Dr. Maki: Yeah, right. Yeah. So, the vampires certainly has we talked with the last one, they get a definite second wind in the evening. They start to wake up, they start to have some energy. Like you said, the ghost can maybe have a little bit of that, a little bit of a second wind that they get maybe after dinner, but they are able to fall asleep maybe while– maybe on the couch or they’re watching a movie or something, they might doze off. Usually, maybe about seven, eight, nine o’clock, which is their– the time that their body’s telling them they should go to bed. If they do go to bed because they’re tired, but now in the next two to four hours they wake up and it’s almost like they go to bed at 10:00, they wake up at midnight and they’re like wide awake.

Dr. Maki: Yes, exactly. So, the ghost will fall asleep hard anywhere from two to four hours, but then they’re up, and then we kind of separated the ghost into two different subtypes. So, we call one the ghoul, and the other one the poltergeists. So the ghoul will fall asleep but nine o’clock easily, ten o’clock easily, but come two, four hours after sleeping really hard they’ll be wide awake, like at seven in the morning, but it’s really only two in the morning. So the ghoul will stay up for easily two hours, so I would say they’re not roaming the halls like a ghoul, they’re instead roaming their iPhones because they’re wide awake, and they can’t go back to sleep. So after about two hours, by the time their cortisol does come down, is then– because what happens is their cortisol is low when they go to sleep, and then it spikes around 2:00 AM or, two to four hours after they’ve fallen asleep, and then it’s up for a while. And by the time the cortisol comes back down, which is generally about an hour and a half to two hours, they’re able to fall back asleep, but by then, they have to wake up for the morning shortly thereafter.

Dr. Maki: Yeah, it’s a lot of them, sometimes the best sleep of the night is that between 4:00 to 6:00 AM. They’ve been awake for a long time. They’re just tossing and turning, like you say, some are looking at their phones, some are reading a book, some are getting up checking their email, some are watching TV trying to get tired again, and then they drift off to sleep right as almost like they just drift off and then their alarm goes off, and they got to get back up again. That usually is the best sleep they get of the entire night and it really maybe only a couple of hours.

Dr. Davidson: Yes, exactly, and then the other one is the poltergeists. So, they’re similar to the ghoul where they fall asleep fairly easily in the evening, nine o’clock easily, fall asleep on the couch watching TV, watching a movie, but then they will also wake up about two to four hours later. So, go to sleep at 10:00, wake up at midnight, but instead of staying up for a couple of hours, their cortisol spikes up and down all night long. So, that’s why we kind of call it like that mischievous poltergeists, because you wake up easily four to six, even more times that at night, you wake up for no reason, then you fall back asleep. Then 40 minutes later, you wake up and then you fall back asleep. They can’t even understand why do I keep getting up all night long for no reason, and then they might get– then by the time the cortisol does drift down, like Dr. Mackey said, it might be five in the morning, and then they’re sleeping hard until 6:30, but then you got to get up, you got to get up for the day.

Dr. Maki: Yeah, right. Yeah. So it can be kind of exhausting. But once they’re awake, the difference between the zombie and the ghost is that even though they didn’t get a lot of sleep, they have enough whatever it is, enough reserve in the tank that they can still be fairly productive in the morning. They don’t need as much caffeine necessarily as the vampire does. They’re not dragging around, they’re actually fairly productive, but that is also somewhat short lived. They’re literally kind of running on fumes to a certain extent, and they’re able to be fairly productive early on, and then it just kind of Peters out a little bit.

Dr. Davidson: Yeah, so for both the ghost– for both subtypes of the ghost, the goal and the poltergeists, they wake up pretty good. Once you get going they say, “Once I get up and get going, take a shower, I’m fine. You know, I’m fine. In fact, there are the people that you could turn morning people because they get everything done before noon because once noon hits, they crash. They always say, “In the afternoon I am so unproductive.” Those are the people that are running, trying to hang out at the coffee maker or they’re taking naps.

Dr. Maki: Yeah. The window that we typically see, two to five o’clock, 1:30 to 4:30, right after lunch, there’s– and their productivity just falls off the cliff for the most part, and they’re really struggling a little bit. But then they kind of are able the way that most people pull themselves out of that is either by carbohydrates or more caffeine, and then that whole cycle just continues day after day, they just kind of keep going that way. But after dinner, and they’re getting ready for bed, that part is really like you say, is relatively simple. It just staying asleep throughout the course of the night, is really challenging. Like I said, for the ghoul or though they’re up for long periods of time or they’re– I mean, we’ve had patients that tell us they’re up five, six times a night if they’re the poltergeist. I mean, they’re just up all night long. And sleep cycles, you know, to go down to stage four sleep, ram and then stage four, it takes about 90 minutes to be able to get down to those restorative levels of sleep. If you’re waking up five or six times a night, you’re probably not getting any of that restorative sleep. So, this kind of perpetuates over time, and they just become more and more exhausted as time goes on.

Dr. Davidson: So, and honestly, I think ghosts are pretty common. We have talked about in the previous episode, I think the vampires are much more common. You see that a lot, and especially in our culture and our lifestyle is people having trouble falling asleep, and then they can’t wake up in the morning. But the ghosts are pretty common too, where especially I think more so for females. I do find men that do have this issue too, but I would say probably more so females have that trouble staying asleep. They say, “I can– my head hits the pillow and I am out, but two hours later, I’m wide awake.” So eventually, that leads into a little bit, of course, sleep debt over time, that inability to be productive and effective in the afternoon, and then they kind of drag a little bit in the evening, get a little second wind but then they fall back, they fall asleep fairly easily. So, if you yourself or you know somebody that says, “You know what? I need to get everything done before noon or one in the afternoon,” they’re definitely probably a type of ghost.

Dr. Maki: So, on the last episode I identified myself when I was in my 20s, college, in my early 20s as a vampire. Now, I have kind of, let’s say, in the last five years or so, I know that I have kind of flipped back and forth between being a ghoul and a poltergeist. Which one do you think you are?

Dr. Davidson: Oh, I’m definitely a ghoul. I mean, I might get up a few times at night, like because I tend to drink a lot of water at night, which I probably shouldn’t. So, of course, you’re gonna have to go to the bathroom. But for the most part, I’m definitely the ghoul, but I’ve gotten a lot better with that because I’ve been that way even as a kid, like I think so.

Dr. Maki: I think they use– I think you’ve always used to be the poltergeist and now you’re the ghoul, right? You’re the one that would wake up five, six times a night, but now it’s transition a little bit, now it’s just for longer periods. I think you went from a poltergeist to being a ghoul now.

Dr. Davidson: Yeah, definitely. But I am getting better, so I’m able to get that sleep for about three hours hard, then wake up and try to get that window from two hours, to an hour, to a half an hour, to getting that smaller window of being up in the middle of the night. But it is like I said, I do think it is common with females and you think, “Well, what they’re productive in the morning and they get up, it can’t be that bad.” But it really is no fun to be up in the middle of the night for an hour plus. With all– I don’t have statistics on this, but with all the patients that I talked to when if they’re a ghoul and they wake up at one in the morning, usually you start and I asked him, “What do you think about? Do you have a repetitive song in your head? Do you have racing thoughts? And most the time it’s thinking about stuff that doesn’t mean anything that seems so much bigger in the middle of the night, and then you wake up in the morning and think, “Why was I stressing over that last night?” Like people will worry in the middle of the night over nothing.

Dr. Maki: Yeah, there’s a sense of anxiousness, right? There’s this– they’re thinking about their to do list, they’re thinking about the day before or they’re thinking about what all the things I gotta get done the next day, and it can be very disruptive. They’re just kind of like you said, they’re almost like in a panic all night long.

Dr. Davidson: Or it’s sort of– Yeah, it’s like I’ll even have a lot of patients, so we’ll think about things that are never gonna happen. There’s not gonna be an earthquake. My tires don’t– aren’t– I’m not gonna get a flat tire. My kids are fine. They’re probably asleep in their beds right now and they’re fine. People will think about things that really you have no control over, that’s not going to happen, but it seems so much more big or enormous in the middle of the night.

Dr. Maki: Yeah, sure. Yeah, definitely a hormonal component that kind of magnifies some of that repetitive thought process. This is happening, literally, this isn’t just like a once a week kind of thing. This is for a lot of these people that we speak with and work with, this is happening on a nightly basis. I mean, that’s a lot to– that’s a heavy burden to carry. It’s almost like you kind of dread sleeping because you have to sleep, right? That’s very important. We put a lot of time and attention towards helping people sleep better, because it’s so foundational, which is why we’re talking about. Because if you don’t sleep well and you have some other issues, those other issues, whether it’s weight, whether it’s a chronic problem, whether it’s how you feel, a lot of that is not going to improve unless your sleep improves.

And conventionally, some of the sleep medications and things like that, those really don’t do any better to improving any of those things. They just kind of create a whole other series of problems. So the way that we help people through these issues is fairly individualized, which is a tough thing to do. You have to do it on a case by case basis, because even what worked for the ghost or the poltergeist, what works for one ghoul is not going to necessarily work for the poltergeist and vice versa. There might be a little bit of– from a treatment perspective, there might be a little trial and error there, because even two ghouls, what works for one doesn’t automatically work for the other.

Dr. Davidson: Yeah, so that’s why we like to differentiate this. So, for example, when we talked about the vampire, our goal is to bring down that cortisol in the evening time, nine, ten o’clock, eleven o’clock at night, and bring up that cortisol in the morning, it’s six, seven eight. Wherewith the ghost, both the ghoul and the poltergeists, it’s completely different. You don’t necessarily want to bring up their– bring down their cortisol in the early evening or the evening time because it’s already low. Our goal is to bring down that cortisol in the middle of the night and then try to keep the cortisol up in the afternoon. So, we actually do a lot of work with ghosts in the afternoon and trying to maintain that cortisol level so that we can get it back into that nice fluidity of cortisol high in the morning, but then it comes down nice at night all night long.

Dr. Maki: Yeah, right. So, either the ghoul or the poltergeist as we talked about in the last one, a vampire could easily be a candidate for hydrocortisone or even a glandulars. The ghost or the ghoul or the poltergeist isn’t probably going to be a candidate for either one of those. They’re going to be too strong. They’re not gonna be able to tolerate them very well, so now automatically, they get tear down a little bit. Like you said, this is a fairly often a female problem very much. So between, let’s say, that perimenopausal, menopausal window, so the female hormones really can have an impact on that as well, too.

Dr. Davidson: Exactly. So, depending, and like I said, I have seen a lot of men that wake up in the middle of the night staring at their phone as well. But it definitely I would say more so you see it with those females, and the 40s and then also menopausal in their 50s also. So working on it from that hormonal component, definitely, like we did with the vampire, nutritional and lifestyle, supplementation and maybe some prescriptions, but the ghost is gonna be completely different.

Dr. Maki: Yeah, right. That’s why over the years, I don’t even know how you really came up with the vampire, the ghost. I don’t know where that inspiration came from, but it even for you and I really sticks. like we talk about people, we talk about particular cases and we’re like, “Oh, are they a vampire or, you know.” So, it becomes a very easy way to recall and way to remember, and way to categorize somebody very simply, as opposed to calling it adrenal take A, B, or C or one, two, or three, or some other subtype that really doesn’t explain it very well. I think these– I think they do a very good job of understanding kind of what’s going on, and how it manifests. Like I said on the last episode as well, when you’re doing any kind of testing with Dutch test or a saliva test, or even blood test, now, those, each one of these categories, they’re testing should look a fairly particular way.

Dr. Davidson: Yeah. So let’s say you did a saliva test for cortisol, and usually with that vampire that morning, one is really low, it’s really low. But what you’ll see with the– and what you’ll see also with the vampire is the evening time isn’t like the cortisol isn’t super high, but it might be high normal, just a little over the edge normal and that’s always your cue that their cortisol is too high in the evening and they’re more of a vampire. Wherewith the ghost, what you’ll see is there morning cortisol is really good because it’s been bouncing around all night or it spiked in the middle of the night. It’s actually pretty good but at night is when it’s really like almost like it’ll be in that low normal to under, and especially the afternoons. The ghosts have much, much lower cortisol levels in the afternoon than the vampires. Now the vampires are tired in the afternoon. They’re better in the afternoon than they were in the morning, but definitely the ghosts are like the afternoon that that’s, I’ve had people tell me, “I could pull over my car and fall asleep on the road.” Like lay on the concrete and sleep, but in the middle of the night they can’t.

Dr. Maki: Yeah, right. That cortisol pattern too, they are, like I said it’s gonna be normal first thing in the morning, right? Then you’ll start to see because you can’t really take a cortisol sample in the middle of the night. Although some doctors will have people do it in the middle of the night, but you’re awake, so it really kind of gives you a skewed result. So you do it up until the evening, maybe ten o’clock, maybe midnight, but you’ll definitely see where it starts to spike. Right when there should be sleeping, you get this rise, there’s cortisol response. So that last sample is where you might see– you get at least an inkling that their cortisol is gonna be spiking. Then it’s gonna be either spiking at that one particular time they’re up for an hour or two or is gonna be bouncing around all night long, and they’re awake four to six times at night.

Dr. Davidson: Now, I know we talked a lot about this and we’re gonna go into the next episode and talk about the zombie. But there definitely are some, like I said, there are some options and that could probably– that can definitely help the ghost. It’s not gonna help all of a sudden. Like I said, if you’re up in the middle of the night for two hours, you’re not all of a sudden gonna sleep all night. We want to make that two hours an hour and a half, an hour, 30 minutes, 15 minutes, so you can minimize that and close that gap, but not with sleeping medications. So, Benadryl and those Advil PMs, those are terrible. They never put– you never– you might be sleeping, but you never get into that deep stage of sleep. Of course, as we get older taking those types of medications, those over the counter sleeping medications, especially are really bad for your memory, long term and short, especially the short term memory, taking those chronically. So, that wouldn’t be an option but definitely we have some options that could help you.

Dr. Maki: Yeah, so again, just like on the last one to get a little bit more information about the ghost, whether you’re a ghoul or a poltergeist is go to progressyourhealth.com/ghost. There’ll be some other information there that kind of help rein this in and give you some ideas on how you can start to improve. And really the goal that we’re trying to get really every adult, every adult, whether they’re the vampire, the ghost, the zombie is for them during the night is preferably for them to wake up just one time. They go to sleep easy at a reasonable time, like I said maybe 10:00, 10:30 at the latest, they’re able to sleep for a good three, four hours. If they do wake up, preferably no restroom break, they’re able to go back to sleep easy, and then sleep for another three, four hours, and now they’re ready to start their day. That seems not perfect, maybe some time, in a lot of cases that’s the best we can hope for. You’d be surprised, maybe you wouldn’t be surprised, but you’d be surprised at how uncommon that actually is. Usually, anybody after the age of 40 does not sleep eight hours straight through, I mean, it just doesn’t happen. But that is normal, but not very common. People need to be able to sleep that way and then which is why we’re talking about this because this becomes a very– it’s almost like as more time goes on, the slower our sleep quality gets, and it becomes a real issue for people.

Dr. Davidson: So if you go to progressyourhealth.com/ghost, they’ll have the show notes, kind of recapping what we talked about in this episode, and then we’ll have some options on there that can make it a little bit easier for you to be able to kind of like I said, close that gap with that sleeping.

Dr. Maki: Yeah, I think this wraps it up. This hopefully gives you an idea. With the next episode, we’re gonna talk about the zombie. Maybe you can understand with all the TV shows lately about zombies, maybe you can understand what that’s our– what we’re already gonna be talking about. So, until next time, I’m Dr. Mackey.

Dr. Davidson: And I’m Dr. Davidson.

Dr. Maki: Take care, bye-bye.

The post How Do Adrenals Affect Sleep? Ghost | PYHP 069 appeared first on .

What Does Adrenal Fatigue Feel Like? – Vampire | PYHP 068

Dr Valorie Davidson and Dr Robert Maki — Thu, 17 Oct 2019 21:00:52 +0000

In our last episode, we talked about Adrenal Fatigue / Adrenal Dysfunction and how to test for it. In the next three episodes, we are going to focus on three main types of Adrenal Dysfunction that we see.

Three main types of Adrenal Fatigue:

The Vampire
The Ghost
The Zombie

Adrenal Fatigue is quite real and can seriously impact someone’s life. We are not trying to make light of the effect that Adrenal Dysfunction can have. But we find by putting some easily remembered descriptions; this medical condition will resonate with people. And it will be more easily understood.

Symptoms of the Vampire:

Cannot wake up in the morning: these are the people that press the snooze button a lot. Often Vampires will have several alarms to help them get up in the morning
They might not be drinking your blood, but will drink a lot of caffeine to get going in the morning. Even with copious amounts of coffee but are still tired.
Morning and daytime brain fog
Weight gain
Sugar and carbohydrate cravings mainly in the late afternoon and evening. They will say their diet is perfect during the first half of the day. But come later in the day and evening time, they cannot control the sugar cravings. Even if they are full from dinner, Vampires still find themselves snacking in the evening.
Fatigue: mental and physical fatigue
Cannot sleep at night. These are the people that will lie in bed for hours, unable to fall asleep. They were so tired in the morning but come evening, wide awake.
Feels more awake in the evening. This type of commonly seen Adrenal Fatigue will get all their chores done in the evening.
More energy at night, especially mental energy. This is when they are getting projects, emails done.

The adrenal glands secrete cortisol in a diurnal curve. In a perfect world, you will see the cortisol being highest in the morning and will slowly decline, being lowest at night.

With the Vampires, you will see what is called a reverse diurnal curve.’ With very low cortisol levels in the morning, it makes it very difficult to wake up in the morning. The cortisol can continue to stay reduced in the afternoon, also causing afternoon fatigue.

Come evening time, cortisol levels rise. This makes it difficult to fall asleep. The rise in cortisol in the evening can disrupt insulin and blood sugar. This can cause sugar and carb cravings, which are almost impossible to resist.

I am sure you are asking: How Do I Correct Cortisol Levels in a Vampire? I have Adrenal Dysfunction Vampire type, what can I do about it?

Now that we have the disclaimer out of the way let’s get on with helping the Adrenal Fatigue Vampire type. We are going to break it up into Nutritional, Lifestyle, Supplementation and prescription medication

Nutrition: The best way nutritionally is to balance your blood sugar and insulin. Cortisol can really disrupt your blood sugar and insulin levels. One of the best ways to do this is to implement a lower carbohydrate diet. That is easier said than done. Trying to restrict your carbs but having intense craving at the same time do not go hand in hand. One helpful trick is to do a ketogenic diet while cycling in carbs in and out on a schedule. We have a manual written that will explain hormones and weight gain/loss. It will also help guide you on a program to balance your blood sugar and insulin levels. If you are interested in downloading our free guide is called Keto-Carb-Cycling-Program’ (which abbreviate KCCP), go to progressyourhealth.com/kccp.

Lifestyle: There lots of options for good sleep hygiene. More than you will read here. But one of the main points we want to get across is to reduce light as much as you can in the evening. I know that it can be difficult because we want to relax and watch a TV show, movie or work on the computer at night. One thing you can do to reduce the blue light burden is to get blue light blocking glasses. And you can get a blue light blocking screen for your computer. Use the blue light blocking screen for your computer during the day. It will help you sleep better at night. These are easily found online.

Supplementation: Supplementation can be incredibly important for Adrenal Dysfunction Vampire type. But this is where what works for the Vampire will not work for other types of Adrenal Fatigue.

You can find all these products on our website. As a Progress Your Health podcast listener, use the free shipping code: VAMPIRE to get free shipping.

Nutrients:

Cortico-B5-B6: by Metagenics. This formula contains Vitamin C and B5 (Pantothenic Acid), which both have an affinity for the adrenal glands and helps with the production of cortisol.

Herbs:

We love using licorice solid root extract to help raise cortisol levels for the Vampire. Licorice increases the half-life of cortisol. So it helps to keep cortisol levels in the blood around longer. But if you have high blood pressure, do not take licorice. As it can raise the blood pressure. Commonly in Adrenal Fatigue, there is low blood pressure so the licorice can help with this. But in the cases of high blood pressure, do not take.

Licorice Solid Root Extract: by Wise Woman Herbals: ½ teaspoon in the morning for the Vampire Type Adrenal Fatigue. Optional 1/8th teaspoon in early afternoon or lunchtime for energy.

Glandulars: Using an adrenal glandular can be really helpful for the Vampire. Cortisol is made from the adrenal cortex. Taking a glandular with adrenal cortex can help upregulate low cortisol levels in the morning.

We really like using a product by Thorne called Adrenal Cortex: two capsules in the morning to help with energy. With an optional capsule early afternoon to help with energy. By helping the energy and adrenals in the morning can help drop the cortisol at night for sleep.

I’m vegetarian/vegan and do not want to take anything that has animal product, let alone an animal organ’: There are Non-glandular Supplementation (no animal products) that the Vampire can take if they do not want an animal product.

Adrenal Response: by Innate Response, Formulas has no glandular and can help the Vampire with morning energy. Take two tablets in the morning. Optional one tablet in the early afternoon for energy.

As mentioned above, as being a Progress Your Health Podcast listener, use the code: VAMPIRE for free shipping.

Prescriptions:

Hydrocortisone: (Cortef) Hydrocortisone raises cortisol levels. Cortisol itself doesn’t exist outside of the body. Taking hydrocortisone orally will convert into cortisol in the body. The Vampire has low levels of cortisol in the morning. By prescribing hydrocortisone in the morning, it will help raise the cortisol levels. Raising cortisol levels in the morning will help the adrenals drop the cortisol in the evening to help with sleep. We like using a low dose of sustained-release hydrocortisone. That way, you can take one capsule of hydrocortisone in the morning and not have to take any later in the day.

PYHP 068 Full Transcript:

Download PYHP 068 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. Dr. Davidson.

Dr. Maki: So, we are rapidly approaching fall here in the Pacific Northwest. The leaves are changing. The leaves are falling off of the trees and changing colors and you can definitely tell that the temperature is dropping a little bit. The mornings are a little bit brisk. So, this is a blog post that you wrote actually, I don’t know what, probably almost a year ago this time. The three types of adrenal fatigue so we thought it’s appropriate considering Halloween. This actually is going to probably post it like a right around Halloween and we thought that it would be kind of– it would be congruent with the time of the year.

Dr. Davidson: Yes, because the three types of adrenal fatigue. Now with adrenal fatigue or adrenal dysfunction which is what we really like to call it, that we’ve seen, there are so many different types. The three main types that we’ve seen over the course of being in practice since what, 2003 to 2004, is we’ve called– we’ve named them, the vampire, the ghost, and the zombie. So, that’s why Dr. Maki was saying it would seem appropriate because we’re coming around Halloween because we have given them these names. Now, we definitely don’t want to make a light of adrenal fatigue because adrenal fatigue, adrenal dysfunction is serious. It’s real and it can cause a lot of symptoms for people, affect their quality life. But in some regards, it’s easier to help you understand it if we can kind of have some fun names to go along with it.

Dr. Maki: Yeah, it’s a little more memorable than calling it some kind of medical term and in honesty, for adrenal fatigue as we talked about on the last couple of episodes, that’s not a real diagnosis. Some people certainly, in our view of the world, in our view of medicine and physiology and our experience working with people, as you just said, we feel that it’s a completely illegitimate diagnosis. Conventionally, not so much and that’s as we’ve talked about it a few different times, this huge divide between having low adrenal function which is Addison’s disease and too much adrenal function which is Cushing’s disease. There is really nothing in between and we just find that to be very silly because cortisol, as we’ve talked about, which is our primary stress hormone which is also important in blood sugar balancing, how can that not have an impact on the way we look and feel on a day-to-day basis?

Dr. Davidson: Exactly. So, as we talked about with testing, the previous episode prior to this one, is we talked about testing for adrenal fatigue or adrenal dysfunction. We talked a lot about, like Dr. Maki said, cortisol and the way cortisol is secreted in a diurnal curve of a 24-hour period. Now, the reason we separated into types is because if one person falls into the vampire type of adrenal fatigue, their options on what would we do to help correct that, help manage that, would be completely different than somebody that fell into the zombie type.

Dr. Maki: Yeah, right. And maybe there might be a little bit more similarity between the zombie and the vampire, which we’ll get into on the next two episodes. But certainly, the difference between the ghost and the zombie or the ghost and the vampire, that’s where you would approach those situations completely differently. So, just like PCOS, there’s three different types of PCOS. We’ve kind of classified it just to simplify, now we’ve came up with these interesting monikers for the three types of the most common or let say it that way, the most common types of adrenal fatigue. Now, remember there’s probably subsets and more subsets and we can keep dividing, everyone might not follow into each one of these three. There might be– and we’ll talk about the ghost on the next episode. There’s actually two types of ghost and we’ll talk about that as well.

But this helps to at least in your mind, you should be able to– if you are dealing with fatigue issues or you think you have an adrenal problem, you should be able to identify with at least one of the three to some extent. That’s our goal or our hope from these three podcasts.

I think it’s a very memorable way for people to kind of conceptualized. Then if you’re going to do testing, right, if you’re going to do either blood test, looking up pregnenolone, DHA testosterone or if you’re going to do a saliva test from ZRT labs or maybe even a Dutch test, each one of these categories or each one of these types is going to have a certain, their test is going to look a certain way. You can almost predict that based on which profile you fall into.

Dr. Davidson: Yeah, just for example like we were talking about the cortisol secretion from the adrenal glands. So, in a perfect world, which we know we don’t live in a perfect world, but in that perfect Utopian world is that cortisol is high in the morning so you’re bright-eyed bushy-tailed and then that slowly comes down over time, over the day and then it comes down at night so that we can go to sleep and stay asleep all night. So, this is the three types that we see where that cortisol dysfunction or that secretion of cortisol from the adrenal glands gets dysfunctional and you’ll see the cortisol come in. Like for example, the vampire, you’ll see the high cortisol at night and then a low cortisol in the morning.

Dr. Maki: Yeah, right. And I think that right there, that diurnal curve you’re talking about, so the cortisol helps us maintain our circadian rhythm. We wake up with the sun, we go to bed with the moon and that is, we’re not meant to be nocturnal mammals, right? We are very much regulated by a light-dark cycle. However, we’ve all probably known somebody in our lifetime that falls into that night owl category, hence the night owl and the vampire kind of the same thing. I know back in my 20s when I was going to college and working or whatever, I used to have some trouble sleeping like a lot and I was definitely a vampire for sure, 100%.

Dr. Davidson: Because that’s what you would see is that vampire can not go to sleep at night. I mean a lot of them, they’ll say, “I’m wide awake, staring at the ceiling, why lay in bed staring at the ceiling? I might as well get up and do things.” A lot of times the vampires just cannot go to sleep, fall asleep before 2:00 a.m.

Dr. Maki: Yeah, right. And you’ll notice that with the vampires, they are the ones that tend to be shift workers or working the graveyard shift. I used to work actually at a hospital in college. I used to be a cardiac monitor technician in a hospital in Duluth Minnesota and I used to work graveyard. They couldn’t get anybody to work graveyard shift. Everybody hated the graveyard shift. It was boring but I’ve had sleep trouble anyways. I would try to go to bed at a reasonable time and I’d be up, like you said, for hours. So, I used to, not volunteer but I would work night shift a lot just because it was easier just to stay awake than trying to sleep when I couldn’t sleep. Since now, we’ve been in practice for over 15 years, we’ve seen lots of people that fall into that vampire category.

Dr. Davidson: Yeah, same thing and then, of course, come morning time, so the thing with the vampires is like we mentioned that cortisol’s high at night so you’re actually bright-eyed bushy-tailed at night, so they’re awake. By the time they do fall asleep and that cortisol drops, it’s almost impossible to wake up in the morning.

Dr. Maki: Yeah, right. Yeah, so if you have a traditional 9 to 5 kind of a job, you have to get up, you maybe went to bed somewhere between midnight to two in the morning. You have to get up early. The vampires are the ones that just no matter what, they can not get out of bed. I remember back when I was going to college at that time, I would have such a hard time making it to my 8:00 class. Like I could not do it. I had to drive across town and go over the bridge and it was kind of far and long ways away and I’ve hardly ever made it to that on time to the 8:00 class. It was so difficult. But now, it’s interesting. Now 20 years later, 25 years later, my sleep patterns are completely different than they were when I was in my 20s.

Dr. Davidson: Yeah, so you can’t beat yourself up and I actually have a lot of patients who bring in maybe a family member or something and say, “Why can’t they wake up in the morning?” I even have some patients that set alarms around their bedroom because they will without even consciously be aware, turn off their first alarm and go back to sleep and forgot they even turned it off which is why they have to have one across the room and they have to have one on the other side of the room. Their pressing snooze and it’s not, in some ways, you can’t say, “Oh, well, why can’t you just wake up?” It really has to do with that adrenal dysfunction. In some ways, you don’t want to point a finger and make them feel shameful about it because it’s that biology that’s at work here.

Dr. Maki: Yeah, right. And especially if your cortisol’s been up all night long, right? Which in this particular subset, your cortisol is low all day and then evening time is when they finally start to feel alive. It might be 7:00, 8:00, 9:00, and all of a sudden, they’re finally awake and now it’s really hard to turn that off because now the cortisol is peaking when they should be sleeping. Then of course, when it comes for them to wake up again in the morning, their cortisol is plummeting. That right there I think is probably the most common of the three, to some extent. There’s subtle vampires and then there’s some kind of really obvious vampires. I think most people, what we just said, hard time waking up and difficult time going to bed. I think that affects– I don’t have any real statistics because I don’t think anyone really pays attention to. But I would imagine that that’s probably affects a third if not more of the population. Everybody has that problem.

Dr. Davidson: Then, like you had mentioned, they, like you said, they’re awake at night. Like patients will tell me, “I feel really good at night. I don’t want to go to bed. I want to you know, this is the first time all day long that I actually felt like a normal human being. I want to stay up and enjoy my time,” especially when everybody else in the house might be asleep. They want to enjoy their time. Vampires are the people that are doing laundry at 10:00 at night and ordered– checking their emails and writing and being creative because they actually feel alive at night. But come morning time, they are sucking down the coffee, drinking the caffeine.

Dr. Maki: Yeah, they need that, the caffeine boost just to keep going. Now caffeine as we have said, probably in another podcast in the past, caffeine’s kind of have a double-edged sword because too much caffeine consumption kind of just magnifies that adrenal dysfunction because now you’re using a central nervous stimulant that raises your catecholamines, your epinephrine, norepinephrine dopamine, but then also raises your cortisol. So, you’re doing that kind of an artificial way so that the more caffeine you drink, the usually the more tired you’re going to become eventually.

Dr. Davidson: Also with vampires, you see waking. It’s very common to have waking that they can’t really– in some ways attribute to, because I’ll have patients with this kind of reverse diurnal curve of a cortisol mostly say, “I’m great in the morning. I don’t even eat anything in the morning. I’m not hungry for lunch. I can have a salad for lunch. I have no cravings. But come late afternoon or even at especially evening time, after dinner they’re full but they have the sugar cravings.

Dr. Maki: Yeah, right. Carb and sugar cravings. Whether it’s salty carbs or sugary carbs, it’s like they– and it’s also in the floodgates open and they just can’t stop eating. I mean, maybe not with that much of lack of self-control but there’s a certain component that where they just– their appetite, they kind of they wake up, their appetite wakes up, their body kind of sense, “Hey, if you’re going to be awake then you need to find some food”. Partially, because they have been hungry all day and now, this the first time they’ve actually had an appetite and their body is kind of– their body and their mind is kind of making it up for lost time in some respects.

Dr. Davidson: Like you had mentioned, cortisol has a direct effect on glucose which also has a direct effect on insulin.

Dr. Maki: Yeah, right. And that we talked about that in other episodes, right? So, all the time, the more impact that we have, that’s why stress sometimes, I don’t know how many people– I just talked to someone last week that was going through a really stressful time. Of course, her cortisol is elevated and she was hardly eating or drinking anything, right, during out the day and she gained like 30 pounds over the course of a few months. But she knows that there was many nights where she didn’t eat anything. Like she has to remember if she ate anything or not but she still gain some weight because of the impact of that very powerful hormone has on other hormones that contribute to fat storage. So, when you’re in that stressful moment like that your cortisol goes up, it really kind of shuts off your appetite temporarily but then it comes back with a vengeance later.

Dr. Davidson: Like we had said, of course, if you’re not getting enough sleep at night, you’re going to be tired in the morning. But with the vampires and with the way this cortisol secretion is, it’s different. It’s not just that they’re tired like, “Oh, I didn’t get enough sleep last night, I’m tired.” Sure, we all have a night like that or day like that where we didn’t get a lot of sleep last night, but with the vampires, they are physically and they’re mentally tired especially in that morning and that afternoon. Like even mentally tired trying to fill cognitive or being able to do their work or their emails or meetings. They will say, “I feel like I’ve got like a towel over my head or I just can’t think. I can’t see. It’s just not enough processing.”

Dr. Maki: Yeah, right. So, if you’re like trying to go to work and trying to do your job and it’s going to be really a struggle to even use them fairly basic mundane tasks if your brains not working the way that it supposed to. Then like you say, then comes 7, 8, 9, 10:00 o’clock, all of a sudden there– it’s like they got this little surge, literally, they have this surge of energy because their cortisol is finally rising and they feel like– I don’t know how many people had said, “Yeah, come 10:00 o’clock and I feel alive”. They finally feel fairly good but it’s just not necessarily conducive to the typical 9 to 5, Monday through Friday works schedule that so many people have. Vampires don’t fit into that type of schedule very well.

Dr. Davidson: No, I mean you got to get the kids to school. You got to do things in the morning. Morning comes early. There’s a lot of vampires out there that are just– that’s why the coffee comes in because you got to have a crutch because you got to get through the day but at the same time, it is a little bit like a credit card where you’re borrowing the energy and you got to pay it back later. So, one thing with the vampires, these people think, “Well, what do I do now or why did this happen?” It does happen from chronic stress over time that kind of degrades that diurnal curve or that secretion of the cortisol. But there definitely are options to be able to help people kind of readjust this.

Dr. Maki: Yeah. Now, granted, I think this happened because we live in a very artificial world, right? There’s lots of stimulus coming out us all the time. TV and computers and I mean even more now than there ever used to be but for the last hundred years basically since– this might sound weird, but really since the invention of the light bulb, which was that Thomas Edison invented the light bulb, what, a hundred years ago, hundred and some years ago? Maybe at the turn of the century, and now we’re able to control the light in our environment where before it was all sun and the moon. I mean, we’ve all been camping before and you go camping, you will have a campfire, no external stimulus, people get tired relatively, really. You’re going in the woods for a week, your insomnia, your vampire status is going to slowly dwindle because now there is not this ambient light that’s going to affect your hormones drastically over time.

Dr. Davidson: It’s easy to say, “Turn off your light or turn off your TV or turn off your phone a couple of hours before going to bed.” That can be really difficult, but there are other options that you can do as well. You don’t all have to go camping and then come back to reset.

Dr. Maki: Yeah, right. I mean that like I said, that’s kind of an extreme example. That’s not really practical that you’re going to go in the woods for a week at a time. That just to– that’s what we’re kind of design for, as that kind of environment, and the world we live in now which is normal to us, as our current society, but hormonally, it doesn’t match with our biology very well and I think that the vampires tend to be kind of the sensitive ones, right? They are the ones that the external stimulus that’s coming at us are the ones that are really affected by that and which is why they end up that way because they’re just maybe genetically predisposed to respond in those ways. Then you throw some others, pressures on top of that and it really just puts a lot of pressure on that, on that circadian rhythm in that as you said, that diurnal curve.

Dr. Davidson: Yeah, definitely that degraded curve is exacerbated over time. So, one thing with vampires that we want to do is we want to try to bring down that cortisol at night to help them fall asleep so then also bring up the cortisol in the morning without coffee. We want to do in a way we were basically sort of helping those adrenal glands be able to get back to that circadian rhythm of bringing up that cortisol earlier. Somebody that can’t wake up before 10:00, you can’t all of a sudden overnight, help them wake up at 6:00. It’s a progression of, “Hey, 10:00 and then we work for– let’s get you wake up at 9:00. Let’s work at 8:30,” and then we work away back. Same with sleeping, if you can’t go to bed until 2:00 in the morning, we don’t try to make them go to bed the next day at 10:00. It’s just not going to happen. You’re just slowly resetting that over time and there’s definitely ways to do that. Lifestyle, like Dr. Maki had talked about. Nutrition-wise and definitely exercise-wise, there’s supplementation. There’s even prescriptions you can use to kind of help change this diurnal curve of the cortisol or the degraded curve.

Dr. Maki: Yeah and we were looking at someone’s adrenal status and granted it’s kind of a grey area because there’s no actual diagnosis. These things that we’re talking about are just kind of fun little terms that we had kind of developed for us to be able to compartmentalize and we can spot them in a second. We ask a couple of questions like, “Oh, yeah, you’re the vampire. Opp, you’re the ghost. Opp, you’re the zombie”. So, it helps us kind of help categorize. We’re hoping it’ll do the same thing for you. But then what that translates to is how we are going to be able to help them? When it comes to adrenal function, there’s basically like 5 tiers of treatment options here. Like you said, there is a prescription option which should be like hydrocortisone.

Then there’s glandulars, adrenal glandulars which can be very helpful but some people don’t tolerate them very well just like the hydrocortisone. Then you get into the herbs and then the next your down would be vitamins and minerals and then lifestyle and diet lifestyle. So, those different tiers kind of help depending on which category they fall into. The severity of their symptoms help to determine where on that tier. Now, you might combine a couple of those tiers together. You might notice the vampire for sure is potentially an easy candidate for hydrocortisone. Maybe a low dose, maybe morning and noon, something like that. But maybe someone, maybe that isn’t initiated or tried and maybe they can’t tolerate. So that now, as a practitioner, it gives us an idea where their adrenal status really is, right? So now, we can look at those other tiers and adjust accordingly depending on how they respond.

Dr. Davidson: Exactly. One thing when we’re looking at this, so we’re going to go onto the next episode with the ghost and then the next episode after that, we’ll talk about the zombie. It’s not a progression. It’s not like a vampire turns into a ghost which turns into a zombie. Like Dr. Maki said, the vampires, they might be predisposed that way. I think honestly, I think the zombies are the more sensitive ones. They’re the ones that are less common but they’re the ones that have more of a tremendous effect on their quality of life and their health with the way their cortisol is being secreted. So, but you don’t– you know, one doesn’t turn into another but you can see over time like Dr. Maki said, he was a vampire in the past and working on lifestyle and nutrition and supplementation able to kind of reverse that and change that. So, one thing we have kind of talked about is, you might resonate with this and say, “Oh my gosh, you know what? I think I’m a vampire. It’s not my fault that I can’t get up and get the kids to school because my cortisol just isn’t coming up.” It really isn’t your fault but we had talked about maybe having some options that might be able to help you.

Dr. Maki: Yeah, right. Really when you’re trying to– especially for these vampires, you’re trying to bring the cortisol down at night but a really good way to do that is to raise it in the morning. So again, this is, like I said, the vampire I think is probably one of the more common ones that we see you often. So, if you want to go to the show notes, right, so an easy way to find us, we’ll have a few more resources on the show notes for this episode. Go to progressyourhealth.com/vampire. The show notes will be there. There’ll be some other information that we didn’t share in this podcast but it’ll help give you some ideas as far as what can be done to kind of get you going in the right direction.

Dr. Davidson: Yes. So, progressyourhealth.com/vampire, we’ll have a short little description of what we talked about on this episode and then also below that we’ll have a little bit of some options with disclaimer, disclaimer, disclaimer, educational purposes about whatever, whatever, but it will have some options that you might be able to help facilitate right now to be able to help you go to sleep a little earlier, wake up a little earlier like you feel like people tell me, “I just want to feel like myself. I want to feel like a normal human being at 9:00 o’clock in the morning and not have to fake it.”

Dr. Maki: Yeah, right. And like you said too, that process, you can’t expect to have huge change. Like if you’re having a really hard time waking up by 8:00 in the morning or 6:00 in the morning or whatever it is, don’t expect you’re going to change that by a few hours. You just start working on 15, 20 minutes, a half an hour at a time and then of course over a three-month period or a little bit shorter or a little bit longer, now you’re going to be able to start making a lot of progress and then be able to re-establish a proper diurnal curve. Your cortisol rises in the morning like it’s supposed to between 5:00 and 8:00 in the morning and then it’s going to start to go down in the evening, appropriate time. We would like most of our patients to be in bed preferably sleeping right around 10:00. There’s one hour window, 9:30 to 10:30, that’s kind of your goal window. So, you’re still able to get a few hours of sleep prior to midnight, that’s really important, and then have enough hours of sleep before you wake up for the day, the following morning. That can be a challenge. We work with people of all different age ranges and they all have their sleep challenges as we have been talking about. It’s really difficult in our very artificial world. So, Dr. Davidson, do you have anything else to add?

Dr. Davidson: No, this is great.

Dr. Maki: Okay. So, on the next episode, we’re going to talk about the the ghost which has a couple of subsets. We’ll get into that, in the next one but until next time, I’m Dr. Maki.

Dr. Davidson: I’m Dr. Davidson.

Dr. Maki: Take care. Bye-bye.

The post What Does Adrenal Fatigue Feel Like? – Vampire | PYHP 068 appeared first on .

How to Test Adrenal Function? | PYHP 067

Dr Valorie Davidson and Dr Robert Maki — Mon, 14 Oct 2019 19:27:34 +0000

In our last episode we talked about the differences between PCOS and Adrenal Dysfunction, which is often called Adrenal Fatigue. Adrenal Fatigue or Adrenal Dysfunction is not a ICD10 diagnosis. There is an actual ICD10 billable code called: unspecified adrenocortical insufficiency (E27.40). But there is controversy in using this code for patients. It is technically meant for conditions where the adrenal glands do not produce enough steroid hormones such as cortisol and aldosterone. You might be saying, but this sounds exactly like Adrenal Fatigue/Dysfunction! Most people with Adrenal Dysfunction have normal labs, so their doctor cannot code for Adrenocortical Insufficiency (E27.4). And because their labs and testing look normal people are told they are fine and dismissed.

In this episode, we are going to talk about the testing for Adrenal Dysfunction. There are some testing that can show Adrenal Dysfunction such as saliva and urine testing. But most conventional docs are mainly familiar with blood testing. Typical blood testing for adrenals usually will show that a person doesn’t have adrenal dysfunction, when in reality, they do.

We are going to talk about the different methods for testing Adrenal Dysfunction.

Let’s start by talking about the most common testing method that most docs use, blood testing.

Adrenal Blood Testing:

Cortisol: Blood testing for cortisol is not accurate. Most, if not all people with Adrenal Dysfunction will test normal for cortisol blood testing. The reference ranges are vast and a blood test is only done once or twice in one day. And when you have a needle coming to stab you, automatically the body raises the stress hormones. So cortisol can be falsely elevated in a blood test.

DHEA: DHEA is secreted mainly from the adrenal glands. In adrenal dysfunction, you will see lower levels of DHEA. DHEA reference ranges are vast and everyone falls in normal when doing a DHEA total blood test. But a DHEA-sulfate blood test is fairly accurate for evaluating levels of DHEA in the body. But again, those lab reference ranges are still pretty broad. But in general, terms, if the DHEA is low or low normal range then you can start to consider that a person has Adrenal Dysfunction.

Testosterone: DHEA is secreted mainly from the adrenal glands and will convert to testosterone for females. In adrenal dysfunction, you will see lower levels of testosterone in women because of the reduced DHEA levels. In men with adrenal dysfunction, you will also see lower levels of total testosterone. Testosterone reference ranges are very vast. Quest has a reference of 2-45 for females and for males the reference range is 250-1100 ng/dL. These are pretty big reference ranges. But if someone has a low normal testosterone level you can consider that person has Adrenal Dysfunction.

Pregnenolone: Pregnenolone is secreted from the adrenal glands and there is a small amount made in the spinal cord and brain making it very neuroprotective. Pregnenolone is accurate as a blood test. But like DHEA and Testosterone, the reference ranges for pregnenolone is huge. For Labcorp the reference range is anything less than 150 is normal and Quest has a range is 22-237 ng/dL. Usually, any level under 80 will be considered for Adrenal Dysfunction.

Saliva test:

Saliva tests are much more accurate for cortisol than a simple blood test. Doing a series of 3-4 specimen samples of saliva throughout the day can really reflect the cortisol diurnal curve.

There are four samples of saliva taken. Morning, noon, afternoon late evening. Often in Adrenal Dysfunction, you will see low cortisol in the morning and elevated cortisol at night. It is much more accurate to see this in a salivary test.

There are several companies that do saliva testing. We have used ZRT and Diagnos-techs mostly with patients on testing adrenals using saliva.

DUTCH test:

This leads us to the next testing, A DUTCH test. A DUTCH test is a urine test. It is one of the most comprehensive hormone tests and adrenal testing available. It can check all the hormones with urine testing. And there is an add on or extended test that can also check the cortisol diurnal curve accurately.

If you are interested in getting tests done for Adrenal Dysfunction, we have all the testing available for purchase from our store. Because you are a Progress Your Health podcast listener, use the codePYH67 for 20% off.

PYHP 067 Full Transcript:

Download PYHP 067 Transcript

Dr. Maki: Hello, everyone. Thanks 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, in this episode, we’re going to continue our series on adrenals. The last one, we talked about the kind of transitioning from concealed type of PCOS to adrenal fatigue, or if you would like to use the term adrenal dysfunction. This one we’re going to talk about testing.

Dr. Davidson: Sorry, I’m a little distracted. If any of you hear like a little like chomping noise throughout the entire episode, I apologize. We have our dog with us because we always bring him to our office, and he’s going to town on this bone.

Dr. Maki: Yeah, he’s sitting at our feet enjoying a bone of some sort.

Dr. Davidson: It won’t be a bone much longer, I think it’s gonna be eaten.

Dr. Maki: Yeah.

Dr. Davidson: But yes, we’re going to talk about–we’re going to continue talking about adrenal fatigue or as we like to call it more adrenal dysfunction. One of the main things that, you know, we’ve been dealing with adrenal fatigue, adrenal dysfunction for years, I mean, since we started practice in 2003, 2004. But what we’ve always run up against and even now in 2019, is you know, patients aren’t really technically being diagnosed with adrenal fatigue, because technically, it’s not a diagnosis.

Dr. Maki: Yeah, right. We touched on this in the last episode too; how cortisol is such a major hormone, you know, like you said, we can’t live without it. Our body– we wouldn’t survive without that major hormone. But yet, when it comes to a diagnosis, there’s these two rare things. What was the one– What was the diagnosis, the ICD 10 code that you actually found? What was the name of that?

Dr. Davidson: Well, throughout the years, I’ve always been looking for some kind of ICD–you know, ICD-10 code to be able to diagnose, you know, there’s Dr. Maki will talk a little bit about Addison’s and Cushing’s disease, but there is one that has been around not that long called an Unspecified Adrenal Cortical Insufficiency. Now, that is also a little bit vague, and a lot of doctors don’t use it because the whole kind of controversy behind it is the diagnosis is meant for people, you know, patients that don’t produce enough cortisol and aldosterone or cortisol or aldosterone. And you might say, “Hey, that sounds just like adrenal fatigue, adrenal dysfunction.” But everybody that does the typical normal lab testing that their conventional doctors do always come out in the normal range. So, they can’t diagnose them with that E27.4 ICD-10 diagnosis code because their labs look normal when in reality, we know you know, that they’re not normal; that they have adrenal dysfunction. But they’re told that they’re normal, they’re dismissed and sent on their way.

Dr. Maki: Yeah, right. S, that’s really a kind of a drawback from doing a Blood Cortisol test. And most functional medicine doctors are aware that. Most functional doctors do not test cortisol through blood precisely for that reason because everybody, as you said, is going to fall within that reference range. And it’s a fairly wide reference range. You might be low normal, but technically, if the numbers low normal, using that objective information for that for– to be able to build that diagnosis code, you wouldn’t be able to do it if the number– if the cortisol level comes back within that reference range, you wouldn’t be able to use that, that diagnosis code. So, it really leaves doctors and patients with really no other options. That’s why a lot of people that we work with, they don’t really have a diagnosis. They have this kind of pseudo functional medicine ideas or concepts or theories that are not an actual real diagnosis.

Dr. Davidson: And that’s a good, you know, kind of segue into, you know, blood testing. So typically, when you’re looking at testing for any diagnosis for any condition is, “Hey, let’s do some lab testing. Let’s do some blood testing.” That’s what pretty much most conventional doctors will do. And Dr. Maki’s right, if you do a cortisol blood test, everybody– I would say probably most, if not all, of the people with adrenal dysfunction, come back with a normal Blood Cortisol level on that test. And of course, you know, we had talked about the diurnal curve of cortisol, the adrenals secrete cortisol; high in the morning, it comes down slowly with time, and then it’s very low at night so that we can go back to sleep. So, when you’re doing a blood test, it’s just one second, one minute of your day. Let’s say you go in at 10:00 in the morning, it’s not– and the reference ranges are huge, everybody just falls in those normal reference ranges. And some doctors trying to be a little bit more progressive might have somebody go in at 8:00 o’clock in the morning and then go back at 4:00 in the afternoon. But they’re still gonna– nine times out of 10, you know, if not 10 times out of 10, fall in that normal range.

Dr. Maki: Yeah, because the range is so wide. So, everybody falls within that range. When you do a morning cortisol, you have to be at the lab by 9:00 o’clock. But when you’re trying to assess someone’s adrenal function– so, think about it, you got to get up, you got to shower, you got to put in your clothes, you got to drive to the lab, and have to be there before 9:00 o’clock, depending on what time you woke up. Of course, your cortisol is going to be a little bit higher by the time you get there. So, because you’re awake and you’re moving and you’re driving your car, you know, on your way to the lab, it may still below normal, but it’s more than likely can still be a normal test.

Dr. Davidson: And you think, you’re sitting in the lab, you have a needle coming at your arm to be stabbed. No matter how calm and cool and collected you are, your cortisol levels are still going to spike up a little bit as a stress response to a needle coming to stab you in the arm. That’s why I’m– on a side note, a lot of times when you run someone’s fasting glucose, it might be high normal or a little over the edge normal. And that’s usually because I’ll ask them, “Hey, how was that draw?” And they’ll say, “Oh, it was awful. They had to poke me twice. And they were moving the needle around. And I had this huge bruise.” And I’ll say, “Yeah, no wonder, you know, your cortisol went up, and that automatically mobilizes glucose. So, that’s why your glucose is a little bit over the edge normal.” So, definitely blood testing and with cortisol to determine cortisol levels for adrenal dysfunction is a no go.

Dr. Maki: Yeah. And that’s even why like coffee is not, you’re not really supposed to drink coffee in the morning because coffee raises cortisol. Cortisol will have an effect on your blood sugar, and it can throw off pretty much everything: throw off your blood sugar and throw up your cholesterol control of all those numbers. So, you know, that’s why they usually only recommend water in the morning because you’re already going to get a skewed result. But based on we just talked about, the needle driving to the, you know– If you’re driving they’re before 9:00 o’clock, you’re probably going to be stuck in at least a little bit of traffic or some kind of rush hour. Those are all kind of stressful things that’s going to give you an artificially inflated number anyways, so back to your point, then everyone’s going to have a normal number. Now, I’ve seen over the course of the years, I’ve never seen a low cortisol on a blood. Have you ever seen a low one?

Dr. Davidson: I’ve seen. Definitely seen low normal, but not actually out of their huge humongous vast reference ranges. But I have seen high.

Dr. Maki: Yeah. I’ve seen a few high. They were kind of borderline like Cushing’s, like the patients didn’t end up having to have Cushing’s because again, Cushing’s is a fairly rare problem. But they were definitely, you know, high– an elevated number that was, you know, certainly got our attention for sure.

Dr. Davidson: And also too LCM high if people are on certain medications, of course.

Dr. Maki: Yeah.

Dr. Davidson: You know, steroids, prednisone, that kind of thing.

Dr. Maki: Yeah. Right. Right. Right. And that wouldn’t– that doesn’t really– I mean that doesn’t really count.

Dr. Davidson: No.

Dr. Maki: Because like you said, they’re on such a, you know, powerful medication. But there are a couple of ways that you can infer what’s happening with the adrenals, right? And especially for women, you know, somewhat for men, but really for women, that gives a little glimpse, you know, because we’re going to do blood work anyways because we’re looking at thyroid, we’re looking at some other inflammatory markers, we’re looking at insulin, we’re looking at a few other things. So, it just makes some sense to look at these adrenal hormones at the same time.

Dr. Davidson: Exactly. So, we’ll go into some other testing. But let’s continue talking about some of the common blood testing that you can do for the adrenals. Like we said, we kind of, you know, put cortisol, blood testing to the side, but you can also test for DHEA which– DHEA is a hormone that’s secreted from the adrenal glands. So, that’s another blood test that you can do trying to infer or look for that adrenal dysfunction.

Dr. Maki: Yeah, right. Another one that we both do quite often is pregnenolone. Now all of those hormones are, you know, technically would be classified as steroid hormones because they’re all made from cholesterol. So, cholesterol– if you go down the little steroids tree and a lot of these labs and you know, different things will have these little pathways; cholesterol then gets turned into pregnenolone. Pregnenolone gets turned to DHEA, and then DHEA will branch into the other sex hormones: estrogen, progesterone, testosterone, including cortisol. Alright, so they’re all fairly similar with their cholesterol backbone. And as we just said, testing directly for cortisol doesn’t really tell you a lot. But testing for the other ones can tell you quite a bit.

Dr. Davidson: Exactly. So, with the DHEA, you don’t want to test blood levels of DHEA total because usually has such a broad number is we like to– if you’re going to do a blood test is do the DHEA sulfate, which is a metabolite of DHEA. But it’s a little bit more specific or accurate in evaluating the levels of DHEA in the body. Now, DHEA in men is– it’s an androgen. Men have more DHEA than us females. And also we have more DHEA when we’re younger, and it slowly goes down with time. So, that’s why it’s a little bit of a double-edged sword because the lab reference ranges are pretty broad even for DHEA sulfate.

Dr. Maki: Yeah, right. It’ll range for a woman in her 20’s, it’ll range anywhere from 40 to 300, 350, something like that. And then as the decades go on that, you know, that the bottom number– the bottom end of the reference range stays pretty consistent with the top in the range, but the time a woman’s in her you know, 50’s or 60’s, I think it goes up down to like 188. I mean, it goes pretty low. So, it drops, you know, quite a bit over about a 30-year period.

Dr. Davidson: But you can pretty much on generalize terms. To tell you is, you know, a DHEA sulfate that’s under 100 are on that, you know, that low end of normal range, you definitely should consider that that person has adrenal dysfunction. So, if you’re seeing that DHEA sulfate on that low normal range, regardless of the age, you’re going to have to infer like, “Hey, we need to look into this adrenal dysfunction”, because that’s typically what you will see.

Dr. Maki: Yeah, right. Yeah. So, even for us, we’d like to see a DHEA sulfate for women at least at 100. And now granted, as we talk about PCOS in the last series that we did, we don’t want that number to be too high. Somewhere between, let’s say, 125– would you say 125 to 175 would be kind of appropriate. Once you get above 175, that’s kind of where you start getting into that PCOS range.

Dr. Davidson: Yeah, over 180 you start– They could be having a, you know, sensitivity to those androgens or to the DHEA. And then, you know, as we’re gonna talk now about the testosterone because testosterone isn’t an adrenal hormone, but for– especially for females, is DHEA converts into testosterone. So, when you see that DHEA sulfate, you know, over 180 you know that that could also be converting into testosterone and creating high levels of testosterone. But like we were saying, in adrenal dysfunction, you’re going to see the DHEA sulfate on that low end of normal.

Dr. Maki: Yeah, right. Yeah, the DHEA is going to be, you know, less than 100, less than 75. In some cases, it’s going to be less than 50. And then, of course, you would almost expect the testosterone to follow suit, and the testosterone is going to be probably more than likely, like in the single digits can be less than 10. That is definitely an indication that that person, whoever that person is, has had, you know, chronic stress, you know, for quite a long time to make those numbers to be so low.

Dr. Davidson: Yes. So, you know, we– You know, I know, it seems like we’re talking a lot about the ladies, but you know, we see a lot of ladies as our patients, but– So, you will see in the females with adrenal dysfunction, their DHEA sulfate is low, their testosterone, you know, low normal, and then that testosterone as a blood test as well for the females, you will see that on the low normal range too. Now, the Quest to reference range for testosterone is 2 to 45. What is it, nanograms per deciliter. It’s huge. I mean, you could be at 2 and you can be at 45. And that’s normal. But typically, with adrenal dysfunction for females, you’ll see that that number somewhere, you know, anywhere below 15. Usually, if you see it below 15, you know, 8,9,7– I’ve seen 3, that’s definitely pointing to some kind of adrenal dysfunction that you want to look into. Now men, because men have adrenal fatigue, adrenal dysfunction as well, I mean, just as much as females do, is the reference range for testosterone in men is 250 to like 1100 nanograms per deciliter. That’s huge, 250 to 1100.

Dr. Maki: Yeah, right. Now, if you’re a man, you know, and your testosterone is 8 or 900, you’re gonna feel pretty good. If your testosterone is 250 or 251 in the normal range, you’re going to feel a little bit different than– Again, there needs to be – and this is what we work with, there needs to be kind of a– you take the patient’s case or their situation into consideration, you look at the numbers. And honestly, if there’s a clinical presentation, and those numbers are low normal, even though they’re still normal, that is, you know, that’s a positive test right there.

Dr. Davidson: Exactly. See, a male, if, with adrenal dysfunction, you will definitely see their testosterone down at 250. I’ve even seen men, which– like I said, that a vast reference range of men at 100, 180 for their testosterone. So, that and even in young men, you know, they’re 45, 48, 53, they’re, you know, they’re young that they should have a testosterone of at least, you know, 500 or 600. So, definitely– Fellas, if your testosterone testing low and you’re not sure why or low normal, definitely we want to work on the adrenals, not just the testosterone.

Dr. Maki: Yeah, right. Yeah. And now granted, we do obviously, a hormone replacement for men. We do prescribe testosterone quite often. But we do have somewhat of an age limit. Like we’re not going to give a 20-year-old or 25-year-old, we’re not going to give them testosterone, we’re not even probably going to give an early 30-year-old testosterone. Some situations where that might applies that they’ve already been given testosterone by another doctor, which does happen, we do a little bit of a different way that can hack–actually help restore their testosterone rhythm. But almost in all those cases of men, whether they’re in their 20’s, 30’s, 40’s or beyond, if they have low testosterone or low normal testosterone, usually their stress level’s really high. Right? So, the cortisol is just a testosterone killer, you know, for men, and it just pulls their numbers down so significantly. You know, so in some ways, you’re right, a low normal testosterone for a male or a female is a really good indication that they have been under stress for a long time. You can even look at the labs; you don’t even have to hear anything from them. You just look at your lab and say, “Oh, yeah, this person’s really stressed out.” And then usually you ask them, and they’re like, “Oh, yeah, it’s been– it’s been a rough couple of years”, or you know, something and they confirm that your suspicions were right based on what the numbers say.

Dr. Davidson: Now, Dr. Maki had mentioned earlier about pregnenolone. And pregnenolone is a hormone that comes from the adrenal glands. There’s also a little bit made in the spinal cord and the brain which is why pregnenolone is so amazingly like neuroprotective. It’s great for memory. It’s what helps you learn things. When you’re, you know, your kids, you know, when you’re 20, you have such high levels of pregnenolone which is why you remember everything. You don’t even have to take notes in a meeting. But you will definitely see with pregnenolone, with adrenal dysfunction, it drops. Pregnenolone probably is more – I’ve noticed over the years, more sensitive to the adrenal stress or as Dr. Maki was mentioning, you know, lifestyle, external stress that’s putting stress on those adrenal, you’ll see that pregnenolone plummet. And I’ll see it plummet in all ages. I’ve seen girls in their early 20’s. And it’s nothing because of something, you know, something bad that had happened, or you know, you’ll see, you know, somebody in their 40’s and it’s like it, you know, what, eight. Now, this is another little bit of a– as again, we’re going to test pregnenolone in the blood, which is very accurate doing it blood wise, the reference range, you’ve got to take into consideration because even for Quest, the reference ranges, 22 to 237 nanograms per deciliter. That’s huge, 22 to 237. Lab Corp doesn’t really have a reference range. They just say anything less than 150 is normal. But we will tell you, anybody that has a pregnenolone level of under 80 is definitely going to be considered for adrenal dysfunction. I always kind of make 80 sort of my creme de la creme number that we’re working towards to bring their pregnenolone up to.

Dr. Maki: Yeah, right. Yeah. And those are– DHEA sulfate I think has been done for a long time. Pregnenolone isn’t done– it’s never done in primary care settings. It’s never done by endocrinologists. Certainly, you know, functional medicine minded doctors are certainly going to test a pregnenolone. But this is a very simple way between those three tests: the testosterone, the pregnenolone, the DHEA. It gives you a little glimpse of what’s going on. Now, we’re gonna go into– if we do need more information, right? If there’s something going on, or they’re not responding to our initial treatment or something, or there’s just something weird going on with their symptom picture, then we might actually go into a little bit more adrenal– specifically, more adrenal testing.

Dr. Davidson: Yes, honestly, the saliva testing for adrenal dysfunction in particular for cortisol is so accurate and so amazing. So, we’re talking about the blood tests because that’s what generally everybody in this country has access to. They have access to their primary care, who has access to doing, you know, send you over to Quest. So, we’re giving you some background or some insight into saying, “Hey, you know what, I don’t have the availability to do a saliva test, which you’re going to talk about, or urine test, which we’re going to talk about, I only have the availability to do a blood test.” So, we’re kind of giving you a little background on that. But definitely, if you have the option for– and we’re suspicious of having adrenal fatigue/adrenal dysfunction is you– doing a saliva test is going to tell you everything you need to know about your cortisol.

Dr. Maki: Yeah, right. It gives a really good baseline. You know, granted, now, if someone comes in, you can just tell by asking some questions where it, kind of, where they are, but the saliva test– And the reason why the saliva test is different one, now granted, like you said, it’s a different expenses, it’s a little more complicated. Where the lab test, the blood testing is just all done in one shot. Makes it really easy, really simple. It’s convenient. And a lot of times covered by insurance. So, like you said, people have access to it. The saliva testing is done at home, right? So, you can’t go to your doctor and request them to do a test because they won’t know what they’re– they won’t really know what you’re talking about. So, you get a test into your home, you provide four samples over the course of the day and evening, so, morning, noon, afternoon, evening. Usually, evening is probably close to bedtime. And then when you get the report back wherein your– when the practitioner gets to report back, there’ll be a little graph that shows up on the report. And it’s very easy to see where your cortisol is mapped out compared to what the reference ranges, and we see them kind of all over the place. Sometimes they’re like a flat line, sometimes it’s– Again, most people low in the morning, you’re tired, can’t get out of bed, and it starts peaking in the evening which is why people can’t fall asleep. That’s probably one of the most common.

Dr. Davidson: And well, like Dr. Maki said, you can talk to someone, you can get their symptoms. We kind of already know that they probably have that reverse diurnal curve with cortisol. But when somebody can see that on paper, it can be pretty powerful. I mean, people will cry saying, you know, “My doctor’s think I’m crazy.” You know, “They say I’m normal but I’m like–” you know, look at your cortisol. No wonder you can’t wake up in the morning. And no wonder you can’t go to sleep at night. You know, it can’t, you know, having that objective data can be really powerful.

Dr. Maki: Yeah, right. And it does give a certain level of severity, like, you said, how significant is the dysfunction. And then for, you know, from a practitioner perspective, it helps us to kind of determine what the treatments going to be. Because when you’re talking adrenals, everyone is going to get the same treatment, right? You’re talking all the way from prescriptions, like hydrocortisone, down to lifestyle and, you know, nutrients like vitamins and minerals. And there’s a few things in between, you know, having that extra little bit of information, whether it’s a blood test and/or the saliva test or we’re to talk about the Dutch test here in a second, having a little bit of extra information is going to help the practitioner be able to make those decisions. And now hopefully getting that person back to a functional state fairly soon.

Dr. Davidson: And saliva tests have been around for a really long time. And they’ve come a long way since we’ve been in practice, you know, not even that long. Since 2003, you know, you’ve seen the saliva tests really change. There’s two companies– there’s lots of companies that do it, but there’s two companies that we like the best; Diagnostics, we’ve used for years, they’ve been around, oh my gosh, since the ’90s, doing saliva testing for cortisol? I want to say, yeah.

Dr. Maki: I think the late ’80s, I think. I think they are already– yeah, late ’80s.

Dr. Davidson: Yeah, they are the leaders in that. And like I said, the saliva testing really has changed even over the last decade. And ZRT is another lab that’s been around, I guess, longer now. I still think of them as being new, but they’re probably more like what? 12 years?

Dr. Maki: I think is probably even longer than that. But yeah, and they’re both, you know, Pacific Northwest companies. So, Diagnostics is in Tukwila, or Kent, which is basically South Seattle. And ZRT is in Oregon, you know, so that’s great.

Dr. Davidson: Yeah, they’re great companies to use and work with.

Dr. Maki: Yeah, so those are– I think ZRT is probably a little more popular as far as what the public or what people are aware of. But both of them, you’re still going to get a four saliva sample, you know, it’s going to give you that. That’s why doing a blood test at 9:00 o’clock in the morning, that one blood draw, that’s why that is not necessarily the best way to do it. Because you’re literally, you know, for whatever it takes the time for that blood to go into that vial, that’s really the only information you have over the course of the entire day. And that diurnal curve; cortisol basically helps us regulate our circadian rhythms, so supposed to be high in the morning, supposed to be low at night. So, it’s going to rise and fall over the course of that, you know, light-dark cycle. Doing one blood test isn’t going to tell you that. It’s just not going to give you really any useful information. Not to mention, like we said earlier, everyone’s going to come back within the normal range anyways. So, what does that tell you?

Dr. Davidson: Exactly. So, the saliva tests will look– We like the saliva test for the cortisol. It will do DHEA and insulin and you know, testosterone saliva. I kind of prefer doing the blood test for that just because I’ve always done that. So, I do compare it to the blood test for the DHEA sulfate, the testosterone. Pregnenolone isn’t on a saliva test yet, so I’m sure it will be soon, but it isn’t. So, it’s having both of those, you know, the DHEA sulfate, the testosterone, the pregnenolone, blood wise, and then doing the saliva test for the cortisol is really comprehensive. But if you want to get really like ultra comprehensive is doing what’s been out for the last couple of years, is doing a dried urine test called a Dutch test. Now, that’s probably one of the most comprehensive hormone and adrenal testing that you can probably find, even now.

Dr. Maki: Yeah, right. Yeah, I think it’s good because it gives you a metabolite. It shows you where things are converting and where things are, you know, kind of really the metabolites that never get tested, the [inaudible(23:32)], and all the things in between, and, you know, cortisol, free cortisol, cortisone, there’s a lot of–

Dr. Davidson: The estrogen metabolites that– yeah.

Dr. Maki: Yeah.

Dr. Davidson: Those are really cool to look at on that urine test that you can’t get, you definitely can’t do that on a blood test. I know they haven’t done that yet on a saliva test. But on the urine test, you can definitely see those estrogen metabolites which we could go on and on and on. But those are really important especially for females that might be at risk for breast cancer. So, it gives us a little bit of an idea. So, the Dutch test is super cool.

Dr. Maki: Yeah. So, you’re looking at the androgens, so DHEA, testosterone, all those metabolites. You’re looking at the stress hormones. So, cortisol, cortisone, and all those metabolites. You can’t do progesterone through the Dutch test. So, you look at a couple of specific progesterone metabolites. And then of course, like you said, about the estrogen. So, you really get a wealth of information that you can’t get through a traditional– a typical blood test. So, that definitely from an adrenal perspective, that is really valuable. There’s a lot of really good information there that, you know, that can really help someone kind of get going in the right direction.

Dr. Davidson: Yep. And you don’t have to do a blood draw, you just collect your urine. And it does have the cortisol diurnal curve on there too. So, if you kind of want, you know, the Full Monty, a Dutch test will provide that. But like I said, I still like to get that pregnenolone with the blood definitely. And then, you know, a couple other things just to match up, you know, just to match things up. And then of course, like Dr. Maki said, is most importantly, is getting your subjective information on what your symptoms and what your lifestyle and what’s going on with you and put it all together.

Dr. Maki: Now, we do run into situations a lot. We do sell direct to, you know, the public, we do sell lab testing just because we want people to be able to have access. And we come across situations all the time where people’s doctors, they just refuse to run certain tests. They just will not. So, we’ll be working with the patient. Patient wants– we’re of course, not covered by insurance. They want to go back to their doctor to have their labs covered by insurance. We give them a list of labs to be requested. And the doctors won’t right now– We understand why doctors don’t want to do that, they’re doing labs for some other doctor, I understand that part. But there still needs to– the information still needs to be gathered, you know, so we provide to our patients. We provide them cash pricing on labs; both blood testing and functional testing labs. So, the ZRT in the diagnostics and the Dutch testing, we provide that direct because we want people to be able to get access to the information. We don’t want it to be kind of held hostage necessarily. Because nowadays, there’s enough information out there. If you have those things, you can kind of help yourself in some respects. And that’s why we’re doing these podcasts is to be able to educate and to help people to be able to do just that. Kind of take responsibility and take control. And in some ways, in this day and age, you know, back in the ’50s, the doctor was the center of the healthcare team. Right now, it has to be the person or the patient has to be the center of the health healthcare team. And they have to kind of direct people the way they want. Otherwise, things don’t really get done. There’s just too many people. And you know, healthcare has changed quite a bit since then. So, you have to kind of be your own advocate. And we’re trying to enable people to be as much of their own advocate as possible.

Dr. Davidson: Yeah. We want to make this available to you. So, if you might not have the availability to do a DHEA sulfate test or a pregnenolone which, you know, it’s kind of like I think the unsung hero of the adrenals but isn’t tested very often from your conventional doctor, if you don’t have access to that or, you know, you want to do a saliva test because you’re sure your cortisol is low in the morning or the Dutch test is really amazing. “Hey, I want the Full Monty”, is we know we have that available for you because you’re one of our Progress Your Health Podcast listeners.

Dr. Maki: Yeah. So, if you’d like to, you can always go to our website progressyourhealth.com, click on the shop to go to our online store. You can use the code PYHP promotion.

Dr. Davidson: 67

Dr. Maki: Yeah, PYHP67. So, that is progressyourhealthpodcast67. So, PYHP to get a 20% discount on adrenal lab testing. Now, we do pretty much all types of lab testing. And we can even put together a custom panel. If there’s something that you want that we don’t have listed on our website. So, you can just reach out, either send an email or give us a phone call. Our assistant Erica will take care of whatever details, questions you might have and fill in any details that we didn’t talk about on this podcast.

Dr. Davidson: And the reason the code is PYHP67, is this is our 67th podcast which I’m kind of stunned because we were talking about yesterday, I was like, “Oh, I’m still kind of nervous when it comes to podcasting.” You know, like we’ve done 66 of them. I’m like, “No, we haven’t.”

Dr. Maki: This is 66, 67.

Dr. Davidson: I should be more comfortable. But I’m getting there.

Dr. Maki: Yeah, no, this is PYHP67, 20% discount on adrenal testing. And we’re going to continue this series where we have the next three coming up, we’re going to talk about the– it’s getting close to Halloween. We did this before, but we’re going to do it again just because it’s appropriate based on this series and the time of the year. So, we’re going to talk about the three types of– it’s not really adrenal fatigue, but that’s kind of what we call it. So, the three types of adrenal fatigue that we see. That will be the next three episodes.

Dr. Davidson: And like he’s mentioning about Halloween, the three types that we see, that we talked about a lot is the vampire, the ghost, and the zombie. So, when you listen to those, you can see if maybe you fit into one of those types.

Dr. Maki: Yeah, right. So, I think this wraps up the adrenal testing for now. Dr. Davidson anything else to add?

Dr. Davidson: Nope. We’ll see you at the next podcast.

Dr. Maki: Alright. Until next time, I’m Dr. Maki.

Dr. Davidson: And I’m Dr. Davidson.

Dr. Maki: Take care. Bye-bye.

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Do I Have Adrenal Fatigue or PCOS? | PYHP 066

Dr Valorie Davidson and Dr Robert Maki — Thu, 03 Oct 2019 22:16:04 +0000

In our last series of episodes, we talked about polycystic ovarian syndrome (PCOS).

We have categorized PCOS into three types:

Classic
Common
Concealed

Classic has the majority of all the symptomatology that pertains to PCOS.

Common has some but not all of the symptoms of PCOS.

Concealed PCOS is often missed. What we have found is that the Concealed type of PCOS has a lot of properties and similarities with adrenal fatigue.

In this episode, we are going to talk about the similarities between PCOS, and especially the Concealed type and Adrenal Fatigue. We are also going to explain the differences between PCOS and Adrenal Fatigue.

Let’s differentiate between Concealed PCOS, Adrenal Fatigue:

Concealed PCOS:

As mentioned, the Concealed type of PCOS is not often picked up on. It is often mistaken for Adrenal Fatigue/Dysfunction. These are the women that have been to many doctors looking for answers. Their symptoms seem to develop or get worse when they hit their late 30’s to early ’40s. Because at this time, the female hormones can be changing due to perimenopause, and the body cannot maintain balance, so the PCOS and Adrenal Fatigue symptoms start manifesting. This is what you typically see in a

Concealed PCOS Symptoms:

May have a child, so it looks like there are no fertility issues
Regular periods but might be more painful and cramping with terrible PMS
Anxiety and fatigue: feeling wired and tired at the same time
Irritability
Thin Hair
Slender until mid 30’s to early ’40s. Then it feels like they gain weight overnight. Especially in the belly area. No matter what they do, eating less/exercise more, the weight doesn’t budge.

What is Adrenal Fatigue?

This name can be misleading. We actually like the terminology, Adrenal Dysfunction. Because it is the dysfunctional activity of the adrenal glands that creates all the symptoms associated with Adrenal Fatigue.

Let’s explain a little more about Adrenal Dysfunction. Like we mentioned earlier, the adrenal glands are not fatigued per se. They are healthy tissue and healthy glands. It is the hormonal secretion and function of the adrenals glands which are degraded or dysfunctional. We have all heard about cortisol. Cortisol is essential for life. But secreted inappropriately, can cause a lot of symptoms, specifically ones of Adrenal Dysfunction. Cortisol is supposed to be highest in the morning and then will slowly drop and will be very low at night. This allows us to be awake in the morning and daytime, but able to sleep at night. In Adrenal Dysfunction, you will see what is called a Reverse Diurnal Curve of cortisol. Meaning the cortisol is low in the morning and can be especially low in the afternoon. This causes morning tiredness and afternoon crashes in energy. Then the cortisol will rise at night, causing one with Adrenal Dysfunction unable to sleep.

In Adrenal Dysfunction, you will also see some of the other hormones released from the adrenal glands to be off. For example, you will see low pregnenolone and low DHEA in Adrenal dysfunction. With resulting low levels of Testosterone in the body due to the drop in adrenal hormones.

Why would one confuse PCOS with Adrenal Fatigue?

It is easy to understand how one would be confused whether they have Concealed PCOS or Adrenal Dysfunction.

Some of the common overlapping symptoms are:

Fatigue
Weight gain and having an extremely difficult time losing weight
Brain fog
Menstrual irregularities
Trouble sleeping
Mood issues

But there are differences. And it is common to have both. Many people with hormonal imbalances such as hypothyroid, Hashimotos, Perimenopause, and more can have Adrenal Dysfunction at the same time. But In this case, it is important to differentiate between PCOS and Adrenal Dysfunction. As the treatment plan can differ between the two of them. You will see a lot of overlapping of the symptoms of PCOS and Adrenal Dysfunction. But the hormonal imbalance can be different between the two. That can cause an increase in symptoms if you try to treat the Concealed PCOS as you would Adrenal Fatigue and vice versa. Let us further explain this.

With typical Adrenal Dysfunction, you will see lower levels of some of the adrenal hormones. In the next episode, we will go over testing and diagnosis of Adrenal Dysfunction.

But this is what you would typically see:

Low pregnenolone
Low DHEA-sulfate
Low Testosterone
Disrupted diurnal curve of cortisol: low in the morning and rises at night

With the Concealed type of PCOS, you will see a bit of a different picture:

Low pregnenolone
High normal or just over the edge of normal range of DHEA-sulfate
Moderate to high normal levels of testosterone.
Disrupted diurnal curve of cortisol: low in the morning and rises at night

In Adrenal Dysfunction, you might try to raise DHEA, Pregnenolone, and Testosterone. A lot of docs will give patients with Adrenal Dysfunction supplementation and prescriptions of DHEA, Pregnenolone, and Testosterone. You can see this would not be a good idea in the Concealed type of PCOS. That would only raise their levels of DHEA and Testosterone, making their symptoms worse.

While there are many of the same symptoms in PCOS and Adrenal Dysfunction, there are differences, which is why it is important to differentiate the two.

We have a free hormone video series on PCOS, Perimenopause, Menopause, and Hypothyroid.

In both PCOS and Adrenal Dysfunction there is weight gain and a very difficult time losing weight. We also have a free weight loss guide that can help: Keto-Carb-Cycling Program (KCCP) that you can download at progressyourhealth/kccp.com.

PYHP 066 Full Transcript:

Download 066 Full 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: I’m Dr. Davidson.

Dr. Maki: So in this episode, we’re going to transition from going– from talking about PCOS specifically the concealed type in transitioning into talking about adrenals, and comparing the two of those because sometimes they kind of get misconstrued. Sometimes people think they have PCOS when it’s really not and vice versa.

Dr. Davidson: Exactly. So with PCOS Polycystic Ovarian Syndrome in the past episodes we broke it down into the three types that we typically see in our practice over options 2004. Is we have the classic PCOS which has pretty much all the symptoms you can’t miss it. The common which has some of them can be missed but most often you can find it. Then the concealed which honestly the concealed PCOS is missed a lot. You see people going from doctor to doctor trying to find answers and that’s where we get people coming into us saying, I think I have adrenal fatigue or do I have PCOS? I don’t know. PCOS or adrenal fatigue they’re not really sure and of course, Dr. Maki and I were talking about this little earlier this morning is you can have adrenal fatigue and Hashimoto’s. You can have adrenal fatigue in PCOS.

You can have adrenal fatigue in menopause. Adrenal fatigue isn’t by itself. They can go concurrently but one of the main aspects in differentiating whether is that concealed type of PCOS or adrenal fatigue is sometimes a treatment plans for both of those are completely different. So you wouldn’t necessarily want to treat somebody with the concealed PCOS as your typical adrenal fatigue because you can actually exacerbate the symptoms. So just to back up, let’s talk a little bit about what the concealed PCOS is, for those of you that might not have listened to the previous podcast.

Dr. Maki: Right, right, right. We say it on the last one too. We don’t necessarily agree with the term PCOS for the concealed type but it does have some of the characteristics both in symptom and lab testing. The reason why it gets missed so often is because it’s not like the classic, right. It doesn’t have all the textbook diagnosis that it’ll show up. But there are some subtleties to it which is if what you’re looking for, both on how the patient presents. With the lab show, it starts to kind of paint that PCOS kind of picture. We’re just trying how to kind of differentiate to see which one of anyone listing out there, which one you fall into. Now it’s certainly possible if you have the classic or the common that you could have. I just said you could have both of them but you’re not going to necessarily have adrenal dysfunction and concealed PCOS not necessarily at the same edge probably more than like we going to be one or the other or a component of one on the other.

Dr. Davidson: Yes, so that way– sure you can treat both of it but we’ll get into it a little bit more on why you want to– you wouldn’t want to just automatically treat somebody with the concealed PCOS or Polycystic Ovarian Syndrome with just your typical adrenal fatigue treatments. We’ll get into that a little bit. But the concealed type mainly you know people– the women seem to do pretty well. They do pretty well as teenagers and in their 20’s and like we talked about in the last episode, the concealed PCOS is a little but more like adrenal fatigue driven. Where it’s almost like they’ve been under a lot of stress and they’re maybe predisposed to PCOS but it’s not manifesting but you put a tremendous amount of physical or mental stress on thus female and then you’ll see that concealed PCOS start to rear its head right around their late 30’s and early 40’s. Because on our 40’s or early 40’s, I’m maybe more in my mid to late-ish 40’s. But we all know that those hormones changed.

When you’re 40’s your hormones are changing, late 30’s your hormones are changing, so as those female hormones are changing then the body can’t maintain or buffer some of the symptoms and so you see these– that’s where we get these women therein they’re late 30’s and they’re saying, “You know what I think I have PCOS but I never was told that.” They might even have a child because typically in PCOS there’s fertility issues but, this woman might have a child, they might even have regular periods or maybe missing a period here and there. So it looks a little bit like PCOS because they’ll have the thin hair, they’ll have the irritability, they’ll have the weight gain, they might they’ll have the terrible PMS but not completely like you would see in a classic PCOS.

Dr. Maki: Yes right. Honestly, we might be kind of splitting hairs a little bit, trying to differentiate between adrenal dysfunction. You and I like the term adrenal dysfunction more than we like to term adrenal fatigue. But adrenal fatigue is kind of like this implied umbrella term for adrenal issues but it doesn’t always manifest as your adrenals are just exhausted. I think from an endocrinology perspective, you go to an endocrinologist they’re going to reluctantly test your adrenals. They might do an ACTH test which is a brain hormone. They might do a blood cortisol test which is, we don’t prefer them. We’ll talk about that on the next episode. We’re going to talk about some testing. Everyone falls within a normal range on those. We’re looking at some– literally looking up some diagnosis codes and really there is nothing. There’s two ends of the spectrum. You have Cushing’s which is an overproduction of cortisol which would be a hyper cortical. You have Addison’s disease which is really true a diagnosable adrenal insufficiency. Those are both fairly rare problems and then there’s nothing else in between.

So adrenal dysfunction and adrenal fatigue everything that we’re talking about is kind of like this limbo-land. I know you talked about pre-menopause is being this limbo-land of hormones but really adrenals are there’s these huge expands between two end of the spectrum and nothing in between. Now, maybe what we’re talking about is concealed PCOS type is part of the middle ground there somewhere. Adrenal dysfunction is a middle ground in there somewhere where people are being categorized a little bit better so we can understand what’s going on, then hormonally. Then you and I is the practitioner, other practitioners are able to help them, feel better and function normally on daily day basis.

Dr. Davidson: Yes. We’ve been treating patients with adrenal fatigue for years and over time we both have talked about this endlessly that is not– you know the word adrenal fatigue just really isn’t the right term because it’s not that the adrenals are necessarily fatigued like they’re so tired and they need to go on vacation or something. But that’s really more–

Dr. Maki: Although everyone probably does need a little more of vacation. As you said earlier about all the stress they have, they probably do need a vacation.

Dr. Davidson: Let’s all go in vacation. Let’s make it a plan.

Dr. Maki: Yes right.

Dr. Davidson: All of us together now. But no truly it’s more of a dysfunction. Your adrenal glands are healthy, they’re not dying. You don’t have adrenal glands, you wouldn’t be alive. But the adrenal glands are healthy tissue it’s just there output of hormonal production is dysfunctional. That can be do to internal or external circumstances over time, chronic stress. So that’s why we like to call it adrenal dysfunction. Like Dr. Maki was talking about– you know, yes you go to your endocrinologist and tell me you have adrenal fatigue, they’ll just look at you cross-eyed and say stop paying out on Google which sort of you know [chuckles] which is totally dismissing somebody.

Dr. Maki: Yes right. Like all the stuff that we talked about when it comes to the adrenals like it just make believe. Like people don’t have symptoms that are really– now granted, this why this so unusual from a doctor’s perspective like cortisol and your adrenal glands plays huge role in how we look and feel on a day to day basis, right. Everything really at the end of the day comes down to our response to our environment and the adrenal glands and the brain of course, you know, that’s what they call the HPA Axis, the Hypothalamic Pituitary Adrenal Axis. How the brain the adrenals are connected and how it basically interprets the world around you.

Now, you can’t tell me that that is– now I think you and I were kind of speculating. Maybe this doesn’t get talked about a lot because there’s really no medications that you can give for this type of dysfunction, right? So then it’s just gets ignored. Now that’s probably why there’s no ICD 10 insurance building codes for this because there’s no treatment for it. So then they just kind of brush it off and make you seem like a crazy when in reality it’s just a little bit of ignorance. Endocrinology in our opinion really has evolved very much in the last 70 years.

I think that in a functional medicine space, this is where you and I often don’t really need an actual diagnosis, right? We can look at someone’s symptom picture, maybe get some functional testing. We’ll talk more about that on the next episode. That helps us kind of point in a particular direction and then differentiating between these different things that we’re talking about that are not real diagnosis, right. I can see why from a person’s perspective, going your doctor, you don’t feel very good, you don’t feel like yourself. You go to your doctor, he’s supposed to help you and they make you almost feel worst because there– it’s almost like they blame it on you when it’s really their lack of knowledge that because they don’t even consider that these things are even real problems.

Dr. Davidson: But like I said, your adrenal glands with adrenal dysfunction are healthy. They see a healthy person, you know, a lot of endocrinologists deal with a lot of very unhealthy people with diabetes type 2 or diabetes type 1. So it’s just– it is kind of a flood system and I’m sure all of you listening, understand, health care really has so many limitations and it’s such a flood system. But with adrenal dysfunction, we absolutely 100% believe in it and like we we’re going to go into the testing on the next episode but it really is partly what’s about hormones that the adrenals are secreting. So for example the adrenals, we all know secretes cortisol. But cortisol is secreted in a diurnal fashion over the day. So it’s highest in the morning, it starts to come down and then it slows it at night so you can go to sleep. What you see in adrenal dysfunction is the cortisol is low in the morning and then you do see the cortisol come up at night. That’s pretty classic for most people with adrenals dysfunction. But you also see that with that concealed type of PCOS. Actually with pretty much all 3 types of PCOS because of the burden on the hormones is you see that adrenal dysfunction can kind of manifest that way as well.

Dr. Maki: Yes right. What you’re talking about that what it’s called the reverse diurnal occur, right. You supposed to be high in the morning between 5 o’clock in the morning. Supposed to be low at night, usually between midnight and 2 in the morning. How many people that we deal with on a regular basis are having a really hard time waking up and they can’t go to sleep or they can’t stay asleep all night. That is kind of your classic representation, your classic manifestation that there’s a little a bit of adrenal problem going on. Now, is that diagnosable? I mean how many people have sleep issues across the country? Probably tens of millions of people are having sleep issues and your adrenals don’t really get talked about much in that conversation. You and I believe that it is the cornerstone of those issues. That’s why with every patient that we deal with, we take sleep as a really high priority because that’s the only way those adrenals are going to begin to rebounds themselves.

Dr. Davidson: Yes. So definitely with PCOS and adrenal dysfunction, you see that sleep issue. They’re tired in the morning, they can’t sleep at night. Like I’ve mentioned earlier there’s weight gain with really tough time losing weight. You see the fatigue, you see the irritability, you see the– there can definitely be menstrual irregularities, the brain fog, the mood issues. So now you’re saying well it almost sounds like PCOS and adrenal fatigue are the same things. But that’s where there’s a little bit of a catch. So yes, the diurnal curve of that cortisol is degraded in both concealed types of PCOS and with adrenal dysfunction. But one thing that we noticed with those PCOS women especially the concealed type, is they do have a little high normal or just over the edge of normal of those androgens. So you’ll see the testosterone a little bit high normal. You’ll see that DHEA a little bit high normal, if not a little bit high. Now typically with adrenal fatigue, because DHEA is secreted mainly from the adrenal glands with adrenal fatigue, adrenal dysfunction is you will see typically low DHEA levels, low testosterone, low, low normal testosterone levels that you wouldn’t necessarily see in that concealed type of PCOS.

Dr. Maki: Yes right. So really, as what we are talking about this, right. They really the distinction comes down. To maybe not necessary how the patient or the person manifest but your clinical presentation is just really about the lab testing. That’s why for pretty much all women from their teens to their 60’s we are testing their DHA prenatal testosterone because you can’t sometimes– for what you just said, you can’t predict what are those numbers are going to be high or low. You might think and I’ve seen– I know we both seen this many times. The one that you think their DHA is going to be really high or high normal, it’s like 75, right. Their testosterone you might think that it would– should be really low, and now it’s– that’s also 75. It doesn’t always match what their presentation is until you look at those labs and you see, what kind of what’s going on. Of course your better idea.

Dr. Davidson: Which like we mentioned we’re going to talk about the labs in the next episode but just to kind of make a little more clear, you know this– you know years ago, I was noticing– you know, I’d have a patient come in to see me and they have adrenal– they say I have adrenal fatigue. They’ve been to numerous doctors and they’re still looking for help. What we would see is these patients would say, “Well I was at– I was being treated for adrenal fatigue from my– from this other doctor and they gave me testosterone and I felt horrible.

But they told me I needed it or they gave me DHEA and I broke out like crazy and felt terrible.” So that’s what it kind of lead to this little bit of distinction because then I say well, of course, they’re not taking that testosterone or DHEA anymore. As I would test their levels and they actually had kind of high normal. So then over time we kind of figured out, well, sure this person might have aspects of adrenal dysfunction but they have that concealed type of PCOS. That’s never picked up by a practitioner so you give this person that has high normal DHEA, high normal testosterone and you give them more. Of course, they’re going to feel horrible. So that was kind of why my kind of basis for doing this podcast today because, sure, we’re splitting hairs that seems like the same. PCOS concealed seems just like adrenal dysfunction but in some ways, you want to be careful about the treatment because you could make somebody worse by giving them those androgens then not doing the testing.

Dr. Maki: Yes and really the– we are maybe splitting hairs a little bit but it’s something that we have noticed and really like you said in that 30, mid 30’s to mid 40’s range, honestly we could call it perimenopause at the same time. So there’s kind of three things happening there that as the female hormones, there estrogen, progesterone are starting to change, of then all of a sudden you get this surge of the androgen to DHA in the testosterone. We see that quite often. They’re the ones that like you said they go to the anti-aging clinic or another type of hormone clinic and they usually end up doing worse because they– you can’t give them estrogen yet because they’re still menstruating, right. So of course doctors are prescribing them way too much testosterone. They usually do– they don’t perform very well that way. Testosterone in our opinion for women is kind of like the icing on the cake. You don’t start with testosterone, you don’t start with DHEA, you kind of end with those because those are really powerful hormones and those are really not the hormones that make women, women. Those are hormones that are– they are very powerful but you have to be kind of careful and delicate with them to have the response that you want.

Dr. Davidson: Exactly. So with this podcast, we wanted to just sort to differentiate a little bit because that is probably one of the top questions we get is, do I have adrenal fatigue? Or do I have PCOS? My gynecologist says I have PCOS but I don’t think I do and they don’t know what adrenal fatigue is. So people are confused and sure you can have a little bit to both but we just want to kind of differentiate that sometimes that treatment might be different. So you want to test it but like Dr. Maki said is usually when comes in and you can get the symptoms, you can also get their past history, you can pretty much pick up like you know what? I think they might be a concealed PCOS. Let’s treat this just a little bit differently than you would a typical adrenal dysfunction patient. But in both respects which is really important and probably the top number question is they want to lose weight. Again, it’s almost like with both. With adrenal dysfunction and especially with the concealed PCOS, it’s like, I have the women come in, I was fine to my 20’s, I was great 30’s and then all of a sudden I have a belly. I’ve never had a belly in my whole life and where did this belly come from. It’s almost like they gained 12 pounds overnight.

Dr. Maki: Yes right. We are now going to get into the cortisol physiology but again that’s usually where their stress level is the highest and for whatever reason the body just the size that it wants to– when it’s cortisol driven it wants to redistribute weight around the midsection. Usually, that’s why it starts happening in the 40’s is when those female hormones are usually declined a little bit. They tend to act as buffers or this very powerful insulin cortisol hormones that like you said earlier, we can’t live without them. Those are such a major part of our physiology that they kind of– in some ways kind of run a mock a little bit when you don’t have the female hormones or the male hormones on the counterpart to balance that out.

Dr. Davidson: Yes. So just on a side note because we’re very much into hormonal weight loss is we do have a guide that we’ve created. A free weight loss guide called the Keto Carb Cycling Programmer. We like to abbreviate it as KCCP and you might’ve heard about it on other podcasts because we want to give it to everybody. So if you’re interested in it, we use it a lot with people with adrenal dysfunction and especially with PCOS because the way it’s modified is to kind of help with that– because it’s all that hormonal leaking. It’s not like, these women that come to see me with the concealed type of PCOS, they’re not eating ice cream and junk food of anything and they’re doing the opposite to that and they’re not seeing any changes. So if you’re interested in the KCCP, you can download it at progressyourhealth.com/kccp

Dr. Maki: Yes just progressyourhealth.com/kccp, just a simple enter your name and email and you’ll get access to it right away. The keto part I will say about it. The keto part is optional. You don’t have to go into keto and some people do fine with keto, some people do terrible with keto. Keto really is more about having a little bit more of a lower carb phase. But it doesn’t have to actually be keto. The carb cycling part is intentionally raising calories on a strategic basis. The strategic basis is based on your stress levels, based on your activity level, how much exercise you’re doing that dictates how frequently you raise your calories and then it just kind of add some flows overtime. We kind of designed it specifically for these types of situation, right.

Women that are at this point in their life they cannot do what they used to do on their 20’s, right. It does not work anymore of just eating less and exercising more. That when you’re 25, but once you get beyond the age of 35 and have had a few kids, that no longer works. You have to take a little bit of a different strategy and that the big mistake that we see all the time is that, everyone is under-eating overtime for far too long. Honestly based on what we’re talking about adrenal dysfunction increase more of that and it almost this like a self-fulfilling prophecy kind of creates exactly what everybody’s trying to fix. So there’s a section in there about calories. That’s important you don’t have to count calories but you need to be calorie aware. It’s kind of designed that way based on exactly our patient population that hopefully get you going in the right direction. So, Dr. Davidson do you have anything else to add about the difference between concealed PCOS which is our own creation, right. That’s something that we came up with on our own, you’re not going to find that online any works that from us and adrenal dysfunction. You have anything else to add about them?

Dr. Davidson: No, you’re right. I mean a lot of doctors have their own types of they’ve seen and that’s great. It’s just this is kind of the types that we’ve been broken it down to as we’ve commonly seen because for example, I’ll treat a classic PCOS case completely different than a common or as we talked about here with that concealed. So, no. This was great.

Dr. Maki: Yes, all right. Till next time I’m Dr. Maki.

Dr. Davidson: I’m Dr. Davidson.

Dr. Maki: Take care. Bye-bye.

Dr. Davidson: Bye.

The post Do I Have Adrenal Fatigue or PCOS? | PYHP 066 appeared first on .

What Type of PCOS Do I Have? Concealed | PYHP 065

Dr Valorie Davidson and Dr Robert Maki — Fri, 27 Sep 2019 18:15:34 +0000

In this episode, we are going to continue talking about the Types of PCOS that we have seen. As we have said, (repetitively) PCOS is not a one size fits all. There are some women that have most of the symptoms to just a few. We have three types that we have seen in treating patients since 2004. It is important to have this distinction when it comes to health goals and treatment plans. Doctors that routinely treat PCOS will tell you there are different types. They might have their types that they have seen. But in our experience, these are three types that we have seen most regularly.

The three types of PCOS

Classic
Common
Concealed

Concealed: This type of PCOS is never picked up on. These are the women that have gone to many doctors looking for answers. This is because they have just a small few of the symptoms but not enough to point to PCOS. But they do have a hormone imbalance, and when you break it down, it is a type of PCOS. It seems to get worse when a Concealed Type hits perimenopause or late 30’s to early 40’s. The female hormones are changing, and the body cannot maintain.

This is typically what you will see in the Concealed-Type:

May have a child, so it looks like there are no fertility issues
Really irritable–all the time, and way worse before their period
Yes, they have regular periods but the worst PMS
Anxiety –it seems that they have a lot of low-grade anxiety all the time.
Hair is thin
Slender until they hit mid to late 30’s to early 40’s. This is when they gain weight, especially in the stomach. No matter what they do, they cannot lose weight. Even with severe caloric restriction and lots of crazy exercise, there is no real budge to the weight.
Carbohydrate cravings especially for sugar
All these symptoms of the Concealed are blown off as genetics or lifestyle. I have had so many patients with Concealed PCOS say that their previous doctors did not believe that they had a healthy lifestyle.

This is what their blood work typically looks like:

LH : FSH ratio : the LH is higher than the FSH just a little. There is no 2:1 ratio like you see in the Classic-Types.
High normal testosterone or just over the edge of normal testosterone. Let me explain again those ridiculous reference ranges for testosterone blood labs. Most labs have the reference range for testosterone to be 2-45, which is a very wide range. Those with Concealed PCOS will have a testosterone at 35-55. The average levels of testosterone for women regardless of age or menstrual status is about 25, so the Concealed are higher than the average.
Low progesterone
High normal DHEA-sulfate
Lower thyroid function but not hypothyroid
- Low normal FreeT3
- Normal FreeT4
- Normal TSH

If you would like more information, visit our website: progressyourhealth.com

We have a free hormone video series on PCOS, Perimenopause, Menopause, and Hypothyroid.

Thank you for being part of our Progress Your Health community

PYHP 065 Full Transcript:

Download PYHP 065 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 on this episode, this is the last of our five-part series. Today we’re going to talk about the concealed type of PCOS. The last one we talked about the common type, the one before that we talked about the classic type. This one, you know, the concealed definitely is the most confusing in some respects.

Dr. Davidson: It is. It’s a little bit more vague. So we have, you know, since being in practice and working with, you know, hormonal imbalance and whatnot with PCOS we found three different types. Of course, the classic that we talked about, that’s easy to spot. They’ve got it all. They both got the full gamut. Now the classic really isn’t that common even though everybody knows about all the common symptoms or the classic symptoms of PCOS with that classic type. And then we have the common, which is what we mostly see, which should be diagnosed easily but isn’t because they don’t have all those classic symptoms. So it’s kind of like a watered down version of classic. So the common type is a watered down version of the classic type of PCOS.

But the concealed is where it gets a little more, like I said, vague or a little bit more tricky because it’s, I wouldn’t say it’s a watered down type of common, but it’s a little bit different because you still have some of the symptoms, but it’s not picked up on, like for example, these women that have the concealed type of PCOS have gone to doctor and doctor and doctor looking for answers, but never finding them. Their symptoms are blown off as, “Oh, it’s just your lifestyle.” Or maybe that’s your family genetics, but it still doesn’t mean that they’re getting any better. Now, they might not have the huge risk factors that you see in the classic like diabetes type two in high blood pressure but you still, they still have these symptoms that are going to affect their quality of life.

Dr. Maki: Yeah. So one of the things that, no, granted, this is not an every single woman, but one thing that you may give you a clue as to the concealed type is they’re going to have really, really bad PMS you know, on a monthly basis, cycle after cycle. It’s almost like each they are almost dread when their cycles is coming because they’re at 7-10 days before they’re going to be, before they actually menstruate, where all the symptoms that are possible are just going to be exacerbated for these type of people.

Dr. Davidson: Yeah. So everybody says with that classic type of PCOS, they miss their periods. In common types they might miss their periods every once in awhile, but in the concealed PCOS, they’re getting a period every month. They’re getting a period every single month since they started puberty. But they have that terrible PMS. And so in fact, some women will say, like, Dr. Mackey, you know, it’s 10 days before my period, and I tell them, that’s like 1/3 of your life sometimes happier life, you know, half of the month you’re going to feel terrible. So that’s probably one of the few things that doctors, unfortunately, they think PMS is not going to kill you, so they just blow you off. But PMS not feeling good for 50% of your month is a terrible feeling.

Dr. Maki: Yeah. Right. And I mean, again, this is why we deal with these kinds of issues because, you know, you’re right. I mean, we talk to women all the time. They’ll have two good, sometimes they’ll have one good week, which is usually the week they menstruate, they might have two good weeks and two bad weeks or one okay week, one bad week two bad weeks you know, I mean, you’re right. That’s a lot of time where you’re not feeling your best. And just to accept that, like there’s no options for that. I think it can be a little bit demoralizing. I mean, you know, and that’s not necessarily the person’s fault or the patient’s fault that’s on the doctor not having any ability or any way to be able to help them effectively.

Dr. Davidson: Exactly. So that’s one of the things that we’re so into is balancing the hormones for that quality of life. I mean, a concealed PCOS woman is healthy, you know, she’s healthy, her blood work is going to come back amazing. And the doctor’s going to say, you have, you are so healthy, but they’re going to say, well, I don’t feel like it. I feel terrible because like I said, they go doctor to doctor looking for answers because they have terrible PMS. Their periods might even be really bad, really heavy. These are the women that might get an ablation. You know, the uterine lining burned off because their periods are so heavy and uncomfortable. Now all it does is it corrects periods, but it does nothing for the other, you know, the other symptoms, because not only will you have terrible PMS, but the whole month long and these women are irritable, they’re anxious and they’re mentally tired.

Dr. Maki: Yeah, right? Yeah. They’re just– Now, granted we’re going to talk about stress in a minute, but they’re just, you know, kind of drained both physically and mentally because you know, they have probably a lot going on in their lives, right? They have work, they have kids, they have a family, they have all these different things and this is the one that conceal type, which we use kind of, I just kind of glossed over there. They may actually have a child already you know, where the classic type is probably not going to have a child just because that’d be very, you know, that’d be very challenging for a classic type to have a pregnancy relatively fairly easy. This one would have a child or I’ve had, you know pregnancy and therefore that infertility part kind of gets, you know, kind of just gets missed, they kind of declassifies them because they’ve already had a pregnancy.

Dr. Davidson: But it, and also to these concealed types, we don’t normally see them cause they were going doctor to doctor. They walk into our office right around their mid thirties, you know, to their early forties. And that’s because usually they can, they can buffer it, they can blow off the symptoms. You know, in their twenties and early thirties. They just have to work really hard. But by the time they hit their mid thirties, they’re so mentally exhausted, they’re not feeling good. They’re irritable. That’s when they start to gain weight. So everyone thinks, Oh, PCOS you’re going to have weight gain. Yes, you do have weight gain and PCOS, but with the concealed type, it doesn’t start to manifest until you hit about your mid thirties.

And that’s when they say, Oh my gosh, I put on 12 pounds overnight and I have no idea how to get rid of it. In fact, I’m eating less and exercising more and it’s even creeping up a little bit more. So you’ll see that weight gain and when you break it down, like I said, it almost seems like, you know, so different from the classic PCOS. The concealed type does have that, those higher levels of androgens, just like the common, they’ll have kind of high normal DHEA sulfate. They’ll have high normal testosterone, which you wouldn’t expect in someone that had been cause typically cause we consider the concealed type, not necessarily genetic but more, I guess you could say like adrenal derived PCOS.

Dr. Maki: Yeah, right. They have, usually they have, they’ve either had or have lots of stress whatever kind of stress that might be. And it and for whatever reason, as those female hormones, like you said, once they get into their mid thirties to mid forties, those female hormones are declining a little bit. So now they’re more responsive to the cortisol and some of the insulin issues that you might see in the other two usually happens via the, you know, the cortisol route. In some ways if you have a cortisol problem, you have an insulin problem. If you have an insulin problem, you have a cortisol problem. So they both kind of feed off each other a little bit. This one is more on the cortisol side that creates issues based on that, you know, based on other hormone problems, based on the cortisol. Oh, how would you say it? The cortisol dysfunction.

Dr. Davidson: Exactly. So it’s almost like a delayed PCOS that starts to manifest in their mid thirties, but then it just gets blown off because they might have a child and Hey, you’re getting older, you know, or your lifestyle. But it is, it’s like a delayed you know, a delayed common PCOS that starts in their mid thirties now, like Dr. Maki said, is they, you know, having stress, you know, a lot of stress chronically is not great for our adrenal glands. You know, our bodies are meant to run from a bear and then get away and then be happy, not, you know, 15 seconds of, you know, intense stress, not 15 years of intense stress or 15 months of intense stress. So you see in these women, they’ve had a lot of stress. Their cortisol goes up and then when they hit their mid thirties, their female hormones start to change a little bit so it can’t buffer those higher levels of androgens, like the DHEA sulfate or the DHEA in particular the testosterone, so that starts to come to a head then because of the high levels of cortisol for so long, then you see the insulin start to come up.

So that’s where you’ll see those delayed symptoms. They will have had the terrible PMS probably their whole life, but once it hits 35, it gets really bad and almost feels like it’s permanent PMS. So they have that anxiety, they have the irritability, they go up, maybe you know two sizes in there, you know, when their dress size or their pants size. Like for example, I have a patient and she’s that classic concealed PCOS, you know, she’s in her early forties and she’s very, you know, very good willpower. She works very hard during the week, but on the weekends all she does is lay in bed all day and she tells me how tired she is that she just binge watches Netflix Saturday and Sunday so she can get ready for Monday through Friday and she’s so tired. But I tell her you go to pilates a couple of times a week.

If you had to help me pack up these books in this bookcase and this desk, you could help me do it. You have the physical energy. She doesn’t have the mental energy. Her female hormones are starting to dip. She’s went from, you know, a size four to a size seven so she or her size seven pants are fairly comfortable but that, she’s never been more than a size four. So we see that her hair starting to fall out, you know, she’s not necessarily breaking out in having acne, but looking at her blood work, you would think after all the stress of all the years that she has had to deal with, that her adrenal glands, her adrenal hormones would be low, you think the DHEA sulfate would be low, but in anything it’s high normal. Her testosterone is high normal, which you know it, which is unusual. So she has that delayed or that concealed PCOS and in some respects people say, well you know, she’s fine, just blow it off. But no, we want to address that but we might not address it exactly like that classic type.

Dr. Maki: Yeah. Right. Cause you just start throwing female hormones at them, right? You know, they’re just not–

Dr. Davidson: She will feel awful.

Dr. Maki: Yeah, they’re not– Those are the ones that, Oh as we are talking before we actually started recording, we were talking about that. They are the ones that they take birth control and they just feel worse, you know, or we try to give them progesterone. They might not tolerate it very well you know, and now granted some of the symptoms that the concealed type, that’s why the name the descriptor PCOS doesn’t really fit this one. Okay. But it’s not exactly PMS. It’s not exactly perimenopause in some ways it’s kind of a transition between the two of those. So concealed PCOS really doesn’t fit all that well, but the other two don’t really fit either, cause they’re, you know, they’re different than PMS. It’s different than just straight perimenopause.

Dr. Davidson: But you do see that higher normal androgen status, but it never affected them. They might’ve had a lot of stress and you know, tear it maybe not the greatest periods. You know, PMS, you know, was yucky in their twenties and early thirties, but they at least had that mental energy. They’re at least able to get through everything. And then they, it’s like they hit a wall in their mid-thirties and early forties. I hit a wall, I’m done. And that’s when you look at that picture and you see, hey that insulin is starting to come up. You know, in their 20s these concealed do not have high levels of insulin.

Like you would see in a classic or even moderate elevated levels of fasting insulin in their blood, like a common, but once they hit 35, 40 you’re like, you know what, they’re eating less or exercising more and their insulin is coming up to a nine why would it, you know, why would it be that? So you see it delayed, the insulin is coming up, you know their androgen status is up, but their blood pressure is low, or like, you know, that classic type, they have high blood pressure. If anything, the concealed PCOS, their blood pressure is low because it really is coming from, there might be a predisposition, but then you put all that adrenal stress on there and then that’s when it manifests. Now this is kind of a form of adrenal fatigue or adrenal dysfunction, but in adrenal fatigue you see low DHEA sulfate.

Dr. Maki: Yeah, right? Yeah, yeah. Someone’s got a, and that’s why again, we, that’s why we’re looking at DHEA and women all the time DHEA sulfate, because these are the exact ones that when you hear their story and they tell you what’s going on, if you didn’t look at their blood work ahead of time, you would expect them, like you said, you expect their DHEA level DHEA sulfate to be less than a hundred, maybe even less than 75. It might be somewhere between let’s say 25 to 65 or something like that. But here it is, it comes back and now it’s, you know, 195 to 185. It’s, you know, it’s 175. It’s almost exactly the opposite of what you would expect it to be. Same thing with the testosterone. You might expect their testosterone to be in the single digits in here. Their testosterone is high normal.

Dr. Davidson: So treating these women with let’s say we didn’t let say somebody didn’t know they have this concealed type of PCOS and they of course know that, Hey, I got to work on my adrenals and they work on their adrenals. Maybe take some adrenal supplementation, they’re going to do better, they’re going to do better. But when you’re looking at this concealed type of PCOS, you want to focus on those androgens and in some respect trying to balance out the higher level of androgens. So if you could get them down just a little bit, like for example, that one patient I was talking about, her testosterone level is 41, the reference range request is two to 45 and what’s LabCorp? Like nine to 49 or something. So hers was 41 that’s a pretty good level of testosterone. That was one of those things that kind of jumped out at me.

And then she says she’s anxious all the time. She’s irritable, her patience is short, she’s mentally exhausted. So we want to try to bring, if we could bring that testosterone down to about 32, 30 just by 10 points, that would help tremendously. So there are lots of ways we can do that. But like, but you know, so that’s why I really love working with the concealed PCOS because you want to focus, you have a particular treatment plan that goes along with what would ideally you would work with, with PCOS that gets missed because doctors will be like, hey, let’s put you on antidepressants. Maybe you get a great functional medicine doctor that might not pick this part up but want to work on the adrenals, they’ll get better, but they won’t do great.

Dr. Maki: Yeah. Right. And that’s why we’re talking about this one and the other ones are fairly obvious, you know, even the common type, you know, especially nowadays with the internet and symptoms and you know, symptom quizzes and you know, conditioned quizzes and things like that, people can usually figure those things out fairly easy. This is the one that even for us sometimes becomes a little confusing because it doesn’t fit into the name of it for one concealed PCOS. You would never classify this one exactly as PCOS. It’s just like you said, those high androgens and some of the other things that are similar to the other 2 the classic and the common type. So we understand that the name might not be perfect, but it’s not exactly PMS. It’s not exactly perimenopause. It’s kind of a, in some ways it’s almost like a hybrid between the two of those but because of those high normal androgens, we can sort of attach it to the common and the classic and it makes, at least in our brains, it makes sense to do that.

Dr. Davidson: Exactly. And you do see, we kind of call it like I guess adrenal derived PCOS because it is coming from the adrenals as opposed to the female reproductive hormones. But at the same time, the reason why we broke it down this way. And the reason why I love working with women that have that concealed PCOS is we’re still doing some of the same things that you would do with the classic and the common. And then you just interject a little bit with the adrenals at the same time and they do great. You know, it’s like you’re coming at it with the, you know, the right treatment plan as opposed to, you know, a shotgun and hopefully, I hit the target. This is where, okay, we’re streamlining it. We know exactly what we need to change. We have our objective data, we have our subjective data and we have it really more of kind of like a sharpshooter on what we want to get done.

Dr. Maki: Yeah. Right. As opposed to taking a prescription or supplementation or something for kind of broad strokes. This is a, you know, there’s enough information there to be able to pinpoint and then hopefully there’s an improvement on some of those numbers, like you said, lowering a testosterone from 41 to 32, which may seem very subtle and not really, you know, like that’s really going to do that much. But you know, testosterone for women is a very powerful hormone, getting some kind of a change at least that way you know that you’re going in the right direction. And usually there is a, at least some level of clinical improvement, they’re going to feel better in some respects.

Dr. Davidson: Yeah. Working on that cortisol, working on the insulin. So you’re kind of coming at it from a few different angles, but really, you know, it really gets it right on that bullseye. So I do think, you know what, you know, like we always say PCOS is a spectrum of this, of symptoms. It’s a spectrum. You might have all the symptoms, you might have some of the symptoms you might have very just a little bit. So, that’s why you wanted to break it up because everybody is a little bit different.

Dr. Maki: Yeah. So hopefully this gives you some insight certainly this one, the concealed type is really the most confusing and this is the one also, conventionally, you’re not going to get a diagnosis of PCOS with these types of symptoms, even if you have the high normal DHA and androgens because again, conventionally, if the numbers are normal, then you don’t have something. Okay? That’s why you have to, you know, understand and look at the subtleties. And this one really is a lot about how they present a lot about their subjective symptoms, their emotional state, their, you know, their mood, all those things. And then a little tiny little little pieces of objective information in their labs that kind of points you in that direction. And as like you said, it’s enough to help you focus on, you know, working on those adrenals and they usually you know, they respond fairly well that way.

Dr. Davidson: Yeah. Cause you don’t necessarily see the lower thyroid function like you do in the classic and the common, but they will have low levels of T3. Their T4 is great, their TSH is fantastic, but they have low normal to low levels of T3. That’s pretty common with the concealed, that LH FSH ratio we talked about in the previous episodes, the luteinizing hormone to the follicles demining hormone ratio. You don’t see the LH as high as the FSH like you do in the classic of course. And even the common has a little bit higher LH to FSH.

You might not see this here but or it might be just a touch or doing the blood work over time. You notice that LH tends to trend a little higher than the FSH for this person because we have patients that we’ve had for, you know, 15 years and I have in, which is awesome. I have 15 years of blood work that I look at to see how are things changing because I always tell them we want things to get better, you know? Right? As we’re getting older we want things to get better. So it’s great to have all that objective data to watch that through. But like Dr. Maki said, the concealed is very slight at, you know, almost like slight of hand. It’s not picked up on that easy, but you can put it together. So that is, you know why we wanted to talk about this on the podcast.

Dr. Maki: Yeah, well in some ways it’s not going to be picked up on because it’s not really a true diagnosis, you know? So it’s in some ways it’s kind of like a hybrid diagnosis that we’ve come up with over the years because it doesn’t fit into the any of the other categories. So again, like I said a few minutes ago, it’s maybe not the best name. I think the concealed is a great name, concealed PCOS, but just the fact that we’re categorizing it in pieces the only real reason why we’re doing that is because of those high normal androgens.

That’s the commonality between the other two types. In some ways this one is its own situation or its own syndrome or problem, but because those lab values tend to be somewhat similar and how they present, like some of their symptoms tend to be somewhat similar. That’s why we decided to include it into the PCOS umbrella anyways, so. Hopefully that shed some light, hopefully you’ve identified if you’re listening to where you are on that, on the three different types, I’m sure that that was fairly easy to do based on what we talked about, you’re probably resonating with one of the three types. If you would like more information, you can visit our website progressyourhealth.com. You can enter your email right there on the homepage. There is a free hormone video course there we go through similar profiles. We have a PCOS profile, we have a hyperthyroid profile. We have a perimenopause and a menopause profile where we talk about actual patients, not, you know, we saved their identity. We don’t talk, you know, we don’t give their any identity away, but we have, you know, a fictitious names and a very specific profile for each one of those. So if you’re interested, you can download that. Just enter your email, you get direct access right away. Dr. Davidson, do you have anything to add to the concealed type?

Dr. Davidson: No, no, no. This was great. Thank you.

Dr. Maki: Yep. Until next time, I’m Dr. Maki.

Dr. Davidson: I’m Dr. Davidson.

Dr. Maki: Take care. Bye bye.

Dr. Davidson: Bye now.

The post What Type of PCOS Do I Have? Concealed | PYHP 065 appeared first on .

What Type of PCOS Do I Have? Common | PYHP 064

Dr Valorie Davidson and Dr Robert Maki — Fri, 27 Sep 2019 02:40:04 +0000

In this episode, we continue talking about PCOS. As mentioned in the previous episode, we have seen three main types of PCOS. PCOS is more of a spectrum of symptoms. Some women have most of the symptoms of PCOS and others just a few. The varying degree of hormonal imbalances will help mold the three types of PCOS that we have seen. Many doctors that treat PCOS all can agree that there are different types of PCOS.

The three types that we have found with PCOS are:

Classic
Common
Concealed

In this episode, we are going to talk about the Common-Type of PCOS. In the previous episode, we spoke about the Classic type. And in the next episode, we will go over the Concealed Type.

The reason that we want to differentiate the Types of PCOS is because, in each type, there are different health goals, health consequences, and multiple treatment plans.

Common PCOS: This is the most common type of PCOS seen. The Common-types should be diagnosed fairly easily. But because they do not fall into the Classic presentation, they may get missed in diagnosis.

Symptoms that a PCOS Common-type will present with:

Easy weight gain in the middle, the stomach, and the hips and thighs
Thinning hair
Irritable easily
Some cystic acne on the chin and jaw area
Trouble getting pregnant but is usually successful with fertility options or IVF
May get random cysts on or in the ovaries. But there is no string of pearls or multiple ovarian cysts.
May miss a period occasionally. Common-types are not regular in their periods. But they may get a period every month for five months then miss two. Or have very long cycles up to 45 days. Or they may have a period every other month. Common-types again, are not regular, but they do not miss multiple months like the Classic Types PCOS.

Typical lab work for a PCOS Common Type:

LH is double the FSH
There is high normal to just slightly over the normal level of testosterone
High normal DHEA-sulfate
Insulin is in the normal range but may show up in the teens or anywhere above 9.
Normal glucose
Estradiol can be high, showing Estrogen-dominance or be normal ranges
Low progesterone
Low thyroid function

If you would like more information, visit our website: Progressyourhealth.com

We have a free hormone video series on PCOS, Perimenopause, Menopause, and Hypothyroid.

Thank you for being part of our Progress Your Health community

PYHP 064 Full Transcript:

Download PYHP 064 Transcript

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

Dr. Davidson: And I’m Dr. Davidson.

Dr. Maki: So, the last episode we talked about our one of the three different types, we talked about the classic type of PCOS. Which is if you looked up again in a gynecological textbook would be, you know, that’s what the classic type is. All the different lab values, all the different clinical symptoms. That one is an easy diagnosis, but it doesn’t happen that often. That’s not necessarily “as common as you think it would be”. Today, we’re going to actually talk about what we feel is the common type. This one also should be diagnosed fairly easily but is often not.

Dr. Davidson: So, since we’ve been treating patients since 2004, we do all sorts of treatment for hormones and hormone imbalance. But in particular, with PCOS, we found three different types. The classic, which we just talked about in the previous episode or our previous podcast. There’s the common and then the concealed. So in this podcast, like Dr. Maki said is we’re going to talk about the common PCOS that we see. Which, as he mentioned, it should be diagnosed fairly easily, but because they don’t have all the classic symptoms, they tend to fall through the cracks and get misdiagnosed.

Dr. Maki: Yeah. It might take them a while to either getting a diagnosis, but because it’s not the classic textbook definition, that’s why it gets a little confusing and probably even a little frustrating because it takes a while for that to get teased out.

Dr. Davidson: Yeah. These women with the common PCOS, these women, they don’t have the string of pearls. When you do a transvaginal ultrasound, they don’t have all the cysts on the ovaries. Now, everyone is from our females, we might get a follicular or common cyst that’s normal. We don’t even know we have them. But with the common PCOS is they don’t have that string of pearls. They might get an ovarian cyst or complex or hemorrhagic cyst where it bursts and it’s painful and they might get that once every few years, but it’s not enough to point to PCOS. So that’s why women will just get like, “Oh look, you’ve got an assist. You don’t have that string of pearls.” And so they get blown off and they might even because, hey us ladies, we’re online. If we don’t feel well, we’re trying to find out what’s going on. So they might go to their gynecologist and say, “I think I have PCOS.” And they just get blown off because they don’t have those ovarian cysts.

Dr. Maki: Yeah. Right. Now granted, some of the things they might have of course from a clinical presentation, they certainly can have the weight gain, especially on the middle, now granted that it’s not enough just on that side. You might have some hair issues. Again, some of the irritability, some of the anxiety, certainly some of the acne problems might tend to show up and one that needs to be considered if there is any, as we talked about in the last few episodes if there’s trouble getting pregnant.

Dr. Davidson: Exactly. So, with the common PCOS, they might not have that string of pearls of all those cysts on the ovaries, but they will still have some of the hormonal imbalances creating less ovulation or reduced ovulation. But at the same time, the women with the common PCOS usually can get pregnant pretty easily if they do some type of fertility intervention like Clomid or IVF easy, so they definitely can get pregnant, but there are going to have reduced ovulation which would be reduced fertility, which isn’t quite like the classic where their fertility is pretty, very reduced that that’s definitely something that we hone in on if that’s one of their goals.

Dr. Maki: Yeah. Right. So, the trouble getting pregnant sometimes might even be like their number one complaint. Like they’ve been trying and trying. No one’s really been able to quite figure it out. I don’t really have a relationship with a fertility doctor specifically, but I don’t think they really addressed the PCOS portion of it at all. They might give them Metformin or something along those lines, but taking up a very kind of specific approach to the PCOS, they really don’t do. That’s the void or that’s the gap in the treatment of PCOS that we’re trying to feel and help people. So, now if they do have to resort to IVF or fertility treatment, they’re going to have much more success.

Dr. Davidson: And I think it’s because those reference ranges because we did a previous podcast on PCOS testing and diagnosis is those reference ranges. A lot of time that the common PCOS types will fall in the normal range. They might be the high normal, but it’s not enough to flag a doc to say, “Hey, you know what? Let’s look at this a little bit or put the picture together and look at it a little more comprehensively.” Because with the common types you will see, high normal androgens. So their DHEA sulfate might be high normal, their testosterone might be high normal. It might not be out of the range, but it’s enough to say, “Hey, you know what? That’s kind of a little bit high normal.” And then you put together that subjective information. Like you, Dr. Mackey had mentioned the acne, the common types will get cystic acne on the chin and the jaw, maybe not enough to go running off to Accutane but enough to say, “You know what? This kind of irritating.” So you put that together and say, “Hey, you know what? These androgens are, if they’re affecting the skin, if those high normal androgens are affecting the hair with the hair loss, it’s going to affect other things too.” Like you had mentioned with the ovulation and the fertility.

Dr. Maki: Yeah. Right. If you’re starting to get some of those and like you said, it might be very subtle, right. But some of those hirsutism type symptoms are going to start to show up and it might just be for the common type, as far as hair growth, it might just be a couple of little dark coarse hairs here or they’re, not enough to really pay attention. You might be irritating, you pluck it out with a tweezers. It might not be that necessarily that upsetting. It’s not that big of a deal. But it’s one of those little pieces to the puzzle that helps determine what’s going on.

Dr. Davidson: And like Dr. Mackey had mentioned, there is easy waking. It’s probably more vanity pounds. So that weight gain isn’t putting a tremendous pressure on the heart or on the glucose or anything like that. So it’s we’re on the liver, but it is enough to say, “Hey, these common types they’re really trying to maintain their weight, but it’s really easy to gain, especially you’ll see it in the middle, like the stomach maybe a little bit with the hips and the thighs, but definitely the stomach first and then the hips and the thighs.”

Dr. Maki: Yeah. Now, I know you talked the last time you talked about the FSH/LH ratio, wherein the classic type that total ratio is going to be there for sure, right there. LH is going to be 2 to 1 times are pretty close to–

Dr. Davidson: Or more.

Dr. Maki: Or more to the FSH level. Where do you typically see it in the common type?

Dr. Davidson: So, you definitely see that luteinizing hormone, the LH higher than the FSH. That’s one thing that triggers you that this is a common but not a classic. Is it might not be quite that 2 to 1 ratio. So like in a classic, you’ll see an LH at 14 and FSH at 7 and LH at 21 and an FSH at 7. So you know, that LH is 2 or more times higher than the FSH in a classic type, but in a common type, you’ll see it just a little bit like the, you know, that LH might be 10 and then the FSH might be 6. So it’s not quite double, but it’s enough to say, “Hey, that luteinizing hormone is higher than the FSH.” Granted with the cycle, the LH and the FSH do change. So you don’t want to base anything on one minute of one moment of your day on a blood test.

You want to collect these tests together and put the information, but you will see that LH a little higher than FSH were typically over the course of a, you know, I want to say a perfect 28-day cycle. Is the FSH and LH really should be even, they should be pretty much even Steven. So when you see that LH continuously a little bit higher than the FSH, that’s another piece of the puzzle for us.

Dr. Maki: Yeah. Right. So, on the lipid profile you might see maybe a total cholesterol will be normal, but now their triglycerides will be high normal or maybe right around that hundred and 50 mark. Now, I would like to see triglycerides really about 75, over half of the reference range.

Dr. Davidson: 100 or low, 100 or below.

Dr. Maki: If not even lower that in some ways the lower the triglycerides, the better. But they might not have anything else. But they might have that triglyceride level starting to creep up. The correlation between insulin and triglycerides is a fairly good correlation. So you can assume that’s why we pay attention to triglycerides because as their triglyceride level increases, we can assume that their insulin-resistant level is also increasing at the same time.

Dr. Davidson: So as we talked about on the last one, the classic, their insulin is high, and they had these ridiculous reference ranges through the labs, which is sad, but they’re like reference range up to 20 is normal for insulin. Anything over 9 or 10 is high. So with somebody with a classic, they’re easily going to be close to 20 maybe even over the range in the 20’s for the insulin fasting insulin levels, blood levels. But for the common, you’ll see it a little bit higher than you would think their dietary is. Like Dr. Maki had mentioned, hey, their triglycerides might be a little high normal, but the dietary and lifestyle doesn’t really seem to be the marker for that. And sure, there might be some genetics, family genetics for cholesterol, but then you look at the insulin and you think, you know what, they’re not eating a lot of carbohydrates or sugars are really working very hard with their diet, but their insulin is like 9 to 13, you know, 12 that’s another, like I said, a piece of the puzzle, another flag to put that together.

Dr. Maki: Yeah, right, exactly. It doesn’t come across as being overtly insulin resistant. It’s not a 25 or higher. But like you said 9 to 13, and I was thinking like 7 to 12. You know, where you’re kind of paying attention certainly when it’s in the double digits, maybe not 7, 8 or 9, but certainly when that insulin the fasting insulin gets to be in the double digits, 10, 11, 12, 13 that is where you get an idea. And usually, at that point when that fasting insulin is in the double digits, those others thing are going to start to look worse than they should.

Dr. Davidson: So it’s kind of like, we talked about the classic and they have it all. The common is just like one step below. So they’re going to have a little higher levels of insulin. They’re going to have a little higher normal levels of the androgens. They’re going to have a lot of the same symptoms but not quite as extreme as the classic. So it’s definitely like, right in the middle there and you will notice that they do have the lower progesterone so, but they still might be able to get pregnant, especially with some intervention. But they do have the lower progesterone, but they are cycling pretty much. They have irregular periods. So the common PCOS types do have a regular period, but they’re not so avert as a classic that it jumps out. So they might have five periods in a row and then miss one, they might have longer cycles, like up to 45 days. And then the next one is 33 days. So it’s, they’re irregular. But there, like I said, it’s not enough to really stand out.

Dr. Maki: Yeah. Right. Well, like you said, in the classic type, they probably don’t have hardly, maybe on a yearly basis they might have 2 or 3 periods a year. You know where this one, they might just miss a couple over the course of an entire year. They’re not going to have 12, but they might have 9 or 10, just enough to kind of throw things off. And like you said, based on those longer cycles, it might even end up being in a 12 month calendar year, might even end up being like more like 9. Those cycles are a little bit longer.

Dr. Davidson: Yeah. And they’ll say, “Hey, I’ve been always that way, that’s my normal to have longer cycles or to have 2, 3, then miss one or half 5 and then miss one, they’ll say, that’s my normal.” But to me we’re all different and we’re all unique and that’s okay. It’s still another bit of information that we can put away and put it all together when we’re coming up with our treatment plan. Because when you’re looking at the classic, I mean, first thing you’re thinking, we going to make sure this blood pressure isn’t going to go crazy. We want to make sure they don’t develop diabetes type 2 or if they already do have it, that we want to try to minimize that as much as possible. There’s some definitely some health consequences to having classic PCOS. But it’s the same thing with common. Is there going to be at a little bit more risk for diabetes type 2 overtime? They’re going to be at a little bit more risk for continuously gaining weight every year. They’re going to have risks too. So we definitely want to put that all together so we can figure out, well, how can we balance these hormones so we can get the best effective plan to get them feeling good now, but also preventative for the future.

Dr. Maki: Yeah. Right. Which again as we’ve talked about a couple of times, they cannot be done with just a prescription and needs to be a multifactorial approach, a diet, lifestyle, sleep. Sleep is critically important in all three of these types. Stress level is critically important. All three of these types. And we see people all the time, they have really high stress in their lives and they don’t sleep very well. In some ways, you could say that is the reason why their hormones are the way they are just because of all of that alone. Not to mention every other factor in America that leads to these hormonal issues.

Dr. Davidson: One other thing that you do see with actually all three types honestly, is that lower thyroid function or someone with classic might have complete hypothyroidism. You will see with that common type that they do have lower thyroid function. So we always want to address that as well because it’s pulling in, like we talked about on the previous episode is, hey, we’re pulling in the adrenals, we’re pulling in the thyroid function, we’re pulling in working on that insulin and glucose and cortisol kind of, I guess that interaction, we want to be upstream and then work on those female hormones downstream.

Dr. Maki: Yeah. And you know, conventionally thyroid is also one of those really controversial things. If your numbers, if your TSH is normal, 0.45 to 4.5, they’re not going to address it whatsoever. But in cases like this, it has to be addressed in at least somehow. So that TSH comes down, that free T3 goes up. That’s the clinical response that we usually want to see. So if someone has a low normal TSH and a higher normal free T3 that’s always a good place.

Dr. Davidson: Perfect. Yeah, exactly.

Dr. Maki: So, I think we’ve done a fairly good job of kind of differentiating between into this one is just a little bit more subtle than the classic type. Maybe in some ways, maybe a lot more subtle. Which is why it is not as diagnosed as often as it should be. The next episode we are going to talk about what we call the concealed type as we mentioned. And this one they’ve kind of struggled for a long time. They go to a lot of doctors and they have a hard time ever getting any real answers.

If you’d like more information about our hormonal approach, you can visit our website progressyourhealth.com. There, right on the homepage you can enter your email and get access to our free hormone video course. There we go through 4 specific profiles, PCOS, hyperthyroid, perimenopause, menopause, and we have some names and actually based on real patients that we kind of go through that kind of help paint a picture of what these different problems look like.

Dr. Davidson: Exactly and it’s free. So absolutely free to download, just enter your email and we’ll send it over to you. But just kind of a take-home message with this episode is the common type PCOS, there are enough flags that it will attract attention. There’s enough to say, “Hey, you know what? The symptoms with the high androgen symptoms and some of that blood work, that LH to FSH, that insulin looking fasting insulin looking a little odd.” There are definitely some red flags. So that way we can help that person and we can develop a treatment plan. It’s to concealed that those flags are so quiet that really have to kind of delve in a little deeper to pull that out.

Dr. Maki: Yeah. Right. So, we’re going to discuss that on the next one. So for this one, any last thing to add, I think we did a good job on the common type. Do you have anything else to add?

Dr. Davidson: No, this is great.

Dr. Maki: Okay. Until next time. I’m Dr. Maki.

Dr. Davidson: And I’m Dr. Davidson.

Dr. Maki: Take care. Bye Bye.

The post What Type of PCOS Do I Have? Common | PYHP 064 appeared first on .

What Type of PCOS Do I Have? Classic | PYHP 063

Dr Valorie Davidson and Dr Robert Maki — Wed, 25 Sep 2019 23:22:43 +0000

There are three main types of PCOS that we have seen treating patients since 2004. As you have heard from the past podcasts, PCOS is a spectrum of symptoms. It is a spectrum of symptoms coming from a set of hormonal imbalances. Every woman with PCOS might have some to all to a few of the symptoms of PCOS. That is because there might be varying degrees of hormonal imbalances.

While there might be some disagreement, there are three types that we have encountered the most. And each of these three have different goals and treatment plans.

These are the main types we have seen in treating patients with PCOS. As I mentioned before, PCOS is a spectrum. There can be some women that have all the symptoms to others that have just a few. This is a key concept for treatment. Someone with many symptoms is going to have a completely different treatment plan than someone that has some of the symptoms.

The three types that we commonly see, we have named: CLASSIC, COMMON, and CONCEALED.

Classic PCOS: Honestly, this is not seen that often. A Classic-PCOS, you will see all of the symptoms.

Dark facial hair
Chronic cystic acne.
Thin hair, especially the top of the head and temples
Weight gain–being it is super easy to gain weight and what feels like, impossible to lose
High blood pressure
High cholesterol
High blood sugar
High insulin: leading to insulin resistance and possibly diabetes, if not already diabetic.
Irritability
Terrible carb cravings, especially for sugar.
Miss multiple periods for consecutive months in a row. They might get maybe two periods a year.
These are the women that have many cysts in and on their ovaries. They have the Classic’ string of pearls visualized on a transvaginal ultrasound.
Infertility

You will see the full gamete of the blood work readings:

LH to FSH ratio is 2:1 or even more
High levels of testosterone: well above the normal levels. You can see the testosterone anywhere up to 90 or more
No progesterone levels
Normal levels of estradiol and sometimes there can be higher levels such as Estrogen-Dominance from the conversion of testosterone to estradiol.
High DHEA-sulfate
High insulin, high teens to well over 20
High blood sugar and Hemoglobin A1c
Hypothyroid/low thyroid function

We have a free hormone video series on PCOS, Perimenopause, Menopause, and Hypothyroid.

Thank you for being part of our Progress Your Health community

PYHP 063 Full Transcript:

Download PYHP 063

Dr. Maki: Hello everyone. Thank you for joining us for another episode of The Progress Your Health Podcast. I’m Dr. Maki.

Dr. Davidson: I’m Dr. Davidson.

Dr. Maki: So on this episode we’re going to continue our series on PCOS. The first two we did on the– basically, what is PCOS. The last one was on the diagnosis of PCOS, looking at some of the lab values. This one is going to be the first one of the next three, looking at the different types of PCOS.

Dr. Davidson: So, we’ve been dealing with patients since 2004 with PCOS. We’ve actually found that as a lot of other practitioners have as well is that PCOS isn’t just either you have it or you don’t. It’s almost like a spectrum of symptoms where some women might have all of the symptoms. Some women might have just a few of the symptoms. So, what we’ve seen since 2004 is kind of three different types of PCOS that we want to break that down and tell you a little bit about because these different types are going to have different symptoms, different health goals and different treatment plans.

Dr. Maki: Yes. Right. The conventional approach oh, with a lot of the things that we do with patients is that the conventional approach really isn’t really all that great. Metformin, a couple of other prescription–

Dr. Davidson: Birth control pills.

Dr. Maki: Yes. Right. None of that really helps them get any better. It has to be– now granted, we might use some prescription. Some of those might be part of the different treatment plans. But there needs to be more to it than just Metformin or birth control pills that’s not going to really solve anything. I think that’s where some people that have– some women that are struggling with PCOS, they get a little frustrated because those conventional approaches really– there’s a lot to be desired with them because it really doesn’t solve much of anything.

Dr. Davidson: Exactly. Actually if you go online and on the famous Google is you’ll see that there are a lot of doctors or practitioners that talk about PCOS. There might be other types that they develop, too. So, these three that we’ve come up with are the ones that we typically have seen. So, we’re just going to break that down in a three part series for you.

Dr. Maki: Yes. The point of that whether you– have you done some– now granted, if you think you have PCOS or you know you have PCOS you probably done lots of research. So you might have seen that there’s other types. The point of it is whether it’s our types or someone else’s types, the point is that we all feel that there are multiple types of PCOS. Again, usually from a symptom picture and a diagnosis perspective, there is a spectrum from low to moderate risk or severity to a high level of severity. We’re going to– hopefully get that across over the next three episodes.

Dr. Davidson: So, the three types that we have seen is we call them classic, common and concealed.

Dr. Maki: Yes. Right. So, the classic is kind of the name would emulate is this is– if you’re going to look in a textbook, a gynecological textbook and you’re going to look up PCOS, these are the things that you would expect to see in there.

Dr. Davidson: Then we have the common which is, I guess, you could say like medium and then the concealed which really isn’t found that often. So, we’re going to break these three types up into three different podcasts so that we can really kind of hash it out a bit.

Dr. Maki: Yes. Right. So, the classic in some ways, you could say is, like I said, if you looked up in a gynecological textbook, that’s what would be in that textbook. They would have many– maybe not all, but they’d have many of the symptoms listed there. Once that we talked about a couple of episodes ago. So, they might have– on an ultrasound, they might have the string of pearls or multiple cysts. They might have the facial hair in areas where they don’t want which is also called Hirsutism. They might be struggling with an acne issue.

Dr. Davidson: Those of course, if you’ve been listening to the previous podcast or coming from a lot of having those higher androgens. Honestly, the classic, like if you looked it up in a dictionary and you have all these, the classic symptoms. But it’s not that common. Honestly, we don’t see classic PCOS that often. But that’s what a lot of the doctors are saying is PCOS, so that’s why a lot of people get missed. But they do. They have the full monty of symptoms when it comes– for the classic PCOS. Like you said the dark hair, the dark facial hair. But unfortunately, they’re losing it on their head and they’re growing it elsewhere. They have the cystic acne. Definitely, probably the weight gain is probably the worst for the classic.

Dr. Maki: Yes. Right. They might have a weight range somewhere between, let’s say, 175 to 225. They also are the ones that have the absolute hardest time trying to get that weight to come off. A lot of them– a lot of women that have the classic types are, a very disciplined there. It’s not a matter of you know, sometimes they know that when it comes to weight issues there’s this stigma or prejudice or whatever it is. But they, a lot of times are working the hardest, to try to get their weight to change. It’s almost like no matter what they do, the scale doesn’t change at all.

Dr. Davidson: Yes. So easy to gain and so impossible to lose. Granted, because of the levels of hormones being imbalanced, there are a lot of cravings. I mean, don’t get me wrong, there are a lot of sugar cravings and carb cravings but like you said, the classic PCOS women, they are disciplined and they are working so hard and I can understand where it’s frustrating to have such trouble losing the weightiness, so easy to gain when you’re looking at your friend next to you and they’re eating pizza and ice cream.

Dr. Maki: Yes. Now some of that is the approach that people take, right? Some of them, they are trying to eat less, exercise more. So, they’re going on a diet and exercising a lot. We’re going to talk about that more in subsequent episodes because if for that, for the classic type PCOS, that eat less, exercise more approach could actually make the entire situation worse. So, you have to be a little bit careful and you have to know what is best depending on some of these variables. You certainly might see, very classically, high blood pressure, high cholesterol, high blood sugar and maybe even high insulin. Right off the bat, that kind of paints that picture, that very specific PCOS picture.

Dr. Davidson: Yes. That’s that triad that we mentioned earlier in the previous podcast is that cholesterol, the triglycerides are elevated, the blood sugar could be elevated and then you’ll also see that high insulin which leads to insulin resistance and also is a risk of course for diabetes type 2, if they don’t already have diabetes type 2. Because it’s pretty common for the classic PCOS women to eventually get diabetes type 2.

Dr. Maki: Sure. Yes. Now, they might not get diabetes in their 20’s because they’re only in their 20’s. But as time goes on and that problem continues and progresses and progresses and progresses and the person becomes more insulin resistant, then it eventually develops into a problem like that. So, part of it in the beginning is age kind of protecting you. Your body just hasn’t really quite become that dysfunctional yet. Which is why sometimes diagnosis isn’t really made early on. But as that is left to continue, it just gets worse and worse over time. When it’s that hormonal problem like that in American society is very, very much kind of a hormonal nightmare sometimes. They just kind of tend to get worse and worse and worse as time goes on.

Dr. Davidson: Exactly. They’re always, “Hey, we’ll fix it when it’s broken.” We’re, “No. We want to prevent it.” We see this in someone in their 20’s, we want to prevent that diabetes type 2. Then just like Dr. Maki had mentioned, if you’d did a transvaginal ultrasound, looking at the ovaries, you’ll see that classic string of pearls which are really all these little cysts that have developed, which then on the flip side, if you’re making that classic string of pearls of that that chronic cystic, polycystic as they call it PCOS, Polycystic Ovarian Syndrome, that’s going to reduce if not make your ovulation to zero, which then creates that infertility.

Dr. Maki: Yes. Right. That underlying piece is the part that needs to be somewhat focused on. So, that way eventually pregnancy is a possibility. I know that these are– I think– not I think, but PCOS, this classic type is probably the number one reason for infertility. That’s why we’re talking about this as well because even the common and the concealed type can certainly play a role into that. If you’re struggling on the fertility side, this might be the reason why. So, that can be very one, very frustrating. But also very important to help someone to be able to achieve that goal of getting pregnant, staying pregnant and having a baby.

Dr. Davidson: Yes. Balancing those hormones because typically with the classic PCOS, these women will miss periods for three months, six months. They might get two periods a year. They are the ones that are continuously missing periods.

Dr. Maki: Now, there might be some other– a mood related things going on. Certainly a high level of irritability. Now, that’s a very subjective thing. But certainly it’s an emotion, if you want to call irritability an emotion, something that we hear a lot from patients that they’re– just the littlest things. They have a short temper. They have a short fuse. Small things tend to set them off. We see that in some of the other female hormone related things. But certainly in PCOS, there’s– irritability is one that we get a lot of feedback on.

Dr. Davidson: Yes. You think high estrogens, high testosterone, they’re going to feel testy. They’re going to feel irritable. But at the same time, we also see which isn’t shown so much in the list of symptoms, if you look it up on the web is always with the classic PCOS women is we always see anxiety. I don’t– either it’s– because I do think higher levels of insulin can create anxiety, having higher levels of androgen, having low levels of progesterone really contributes to anxiety. But there is a lot of kind of that anxiousness or they’re feeling really wound up.

Dr. Maki: Yes. Definitely, I think those two are very common. You did mention, of course, which again is kind of where part of that cycle continues. They have terrible sugar and carb cravings, that can kind of continue to all the things we just mentioned, kind of exacerbate all of them over time. It’s not a matter of– honestly, again, part of that stigma and the prejudice that happens sometimes is not a matter of they don’t have any willpower. Their hormones are kind of driving some of that behavior. So, then it kind of disempowers them. It makes him feel bad about their self. Really it’s just their hormones that are driving a lot of that behavior.

Dr. Davidson: Like Dr. Maki is saying, willpower, they have lots of willpower. But biology will always overpower. I guess, overpower willpower. But truly, that biology will always win in the long term. But you can balance those hormones. That’s the whole goal is to rebalance those hormones whether you’re doing it, partly with medication or supplementation or changing their dietary or lifestyle. Change that. So then, when you change that biology, then it makes it easier to make the changes that you want to.

Dr. Maki: Yes. Right. With a such a complicated issue as PCOS, all the different types of PCOS, all those things you just mentioned, that multifactorial approach is the point, right? All those things have to be addressed. The lifestyle, the diet, the supplementation, possibly prescriptions, all those things have to be looked at. That’s how we create treatment plans around those types of things because you can’t just take Metformin or birth control pills and expect these kinds of complicated issues to be able to either be reversed or improved or whatever the case might be.

Dr. Davidson: Exactly. When you do the bloodwork with a classic presentation here is you see– like we had talked about in the previous podcast, all those labs and testing that we talked about, they have it all. They definitely have it all. That LH, FSH ratio, the luteinizing hormone to follicles stimulating hormone ratio, you’ll see that two to one. Their LH might be at 14 and their FSH is at seven or their LH is at 20 and their FSH is at 10. You see that classic two to one ratio. With the testosterone levels like we had talked about before is they definitely have well above normal levels of testosterone. They’re anywhere 45 to 90, maybe even more.

Dr. Maki: Yes. Right. I’ve seen plenty of testosterone levels in the– the high 90’s to even over 100. I’ve seen DHA levels in the 500 range before. Those are– I wouldn’t say, like you said, I wouldn’t call them necessarily that common to see numbers quite that high. But they can certainly get up there fairly easily. Usually when they have those type of androgen numbers, like you said, those other tests, the triglycerides, the fasting insulins, the cholesterol, all those things are going to also be abnormal as well. So, when you look at the entire blood panel, it’s going to really point you in one particular direction fairly easily.

Dr. Davidson: Exactly. You’ll see the low to no progesterone levels. Then one thing that we love to test on all women, not just PCOS, but all women is checking for the thyroid function. You always see hypothyroid or low thyroid function in that classic type. So, it’s really important to keep an eye on their thyroid all the time.

Dr. Maki: Yes. Right. Granted, thyroid is not a female hormone. But as we talked about on the last episode, thyroid function– improving thyroid function has a dramatic impact on the female cycle. So, you can use a different hormone to have an impact on the female hormones and that can be– we kind of look at them as you have your primary metabolic hormones, the hormones your body can’t live without, right? You have your insulin, your cortisol, your thyroid. There’s a few other ones. But those are the ones that most people know. Then you have your secondary hormones, which are the female hormones and some other ones. Usually in most instances, the primary metabolic hormones always influence the secondary sex hormones. But not necessarily so much the other direction. Sometimes, like you said, you’re giving a woman some estrogen, you’re giving her some progesterone. Maybe a little– men giving them some testosterone. But it’s usually the influence of those primary metabolic hormones having the impact on the female hormones. That’s why PCOS, as we’ve been talking, it’s really an insulin issue but it manifests as a female hormone problem. That’s why it gets– that’s why the treatment aspect of it gets kind of convoluted or is just really ineffective because they’re focusing on the wrong part.

Dr. Davidson: Exactly. So kind of think of it, like the thyroid and the adrenal glands are upstream from the female reproductive hormones. So, instead of chasing your tail with trying to correct these female reproductive hormones, you definitely want to go upstream, balance those hormones first and then later, I kind of call, like the reproductive hormones kind of like the frosting on the cake. You got to correct that thyroid. You got to work on those adrenal glands, so then you’ll have your base. You have your cake and then you can add a little– the frosting on top with balancing up that estrogen, raising up that progesterone. But definitely always working upstream is where we want to start.

Dr. Maki: Yes. Now, the thyroid part is fairly easy to implement whether we’re doing supplementation or prescription. But the insulin, the cortisol, that’s the hard part. That is the really the essence of not just PCOS but a lot of conditions are, we could blame them on insulin and cortisol dysfunction. But there really isn’t a lot of– there’s– one, there’s no prescriptions for them specifically that manipulate them in a good way. Metformin, as we talked about, that has an impact on insulin sensitivity. But even that falls short very quickly, even in diabetes treatment. It works but it doesn’t– I think Metformin in general is a fairly– I think it’s a good medication. I think– we prescribe it ourselves. But I think when you just focus on that one thing, I think that’s where– there’s lot to be desired with that. There’s so much more of that that can and should be done to help a patient like this.

Dr. Davidson: So, while I mentioned, you don’t see the classic, a full Monty here are the classic PCOS that often. But when you do, I really think that they are underserved because there really isn’t a good conventional treatment model for them. Which is why we’re so passionate about it.

Dr. Maki: Yes. That’s why we treat the things we treat because we’ve seen, over the years, people come to us for these types of reasons or these types of complaints. Our job is to help our patients achieve whatever it is they’re trying to achieve. Whether it’s weight loss, whether it’s pregnancy, whether it’s just to feel better, all those things and they’ve already been down that conventional route and they just haven’t gotten anywhere. Whether they haven’t gotten a diagnosis or not. So now, it’s our turn to step in there and hopefully get things turned in the right direction. So, if you’d like more information about us and our approach, you can visit our website progressyourhealth.com.

You can enter in an email. You can actually get access to our free hormone video course, where we go through a few of these profiles. One on PCOS, one on hypothyroid. I think there’s another one on perimenopause and menopause. It’s Dr. Davidson on videos, so you get a chance to see and listen to her, have some very good information, things that you might have either heard before but kind of condense down into a very easily digestible way. The videos are relatively pretty short but packed full of good information.

Dr. Davidson: Now, I’m blushing. Yes, you get to see me on the video, talking away. But it’s a good course. We’re proud of it. Definitely go to the website and you can download it. It’s free. But for this podcast, we talked about the classic PCOS. For the next two, we’re going to talk about the two types which is common and concealed.

Dr. Maki: Yes. So, I think that wraps up this one. The next episode we’re going to talk about the common PCOS. Common and classic might seem fairly similar. But we’ll kind of hash those out and hopefully you’ll have a better understanding of the difference between the two. So for this one, I’m Dr. Maki.

Dr. Davidson: I’m Dr. Davidson.

Dr. Maki: Take care. Bye-bye.

Dr. Davidson: Bye.

The post What Type of PCOS Do I Have? Classic | PYHP 063 appeared first on .

What Tests to Diagnose PCOS? | PYHP 062

Dr Valorie Davidson and Dr Robert Maki — Thu, 19 Sep 2019 21:59:19 +0000

PCOS Testing and Diagnosis: In this episode, we talk about the testing and labs for a diagnosis for PCOS. These testing and labs are also a good way to monitor PCOS.

Ultrasound: Checking for multiple cysts on or in the ovaries. It is still very common to have PCOS but have not cysts ( string of pearls ).

LH: FSH ratio:

2:1 or more

DHEA-S:

DHEA-sulfate is the best way to test for DHEA levels in the blood.
DHEA-sulfate is a metabolite of DHEA and is much more accurate to determine DHEA levels than a total DHEA level.
DHEA levels are highest when we are young, around 25 years old. And will slowly decline with age. It is considered an androgen.
The reference ranges for DHEA-Sulfate are very vast and are based on age. For example, a woman that is 35 years old gets her blood drawn for DHEA-sulfate. The reference ranges for a typical lab is 23-266 mcg/dL.
For a female that has PCOS around 35 years of age, you will see the DHEA-sulfate at 200 or above.
Commonly PCOS, the DHEA-s will show over 200 mcg/dL.

Testosterone:

The reference ranges for testosterone labs are huge.
Quest has a reference range of 2-45 ng/dL.
LabCorp has a reference range of 8-48 ng/dL.
Testosterone levels at 35 or higher

Estrogen

Three circulating estrogens: Estrone, Estradiol, Estriol

Vast reference typical reference ranges for most labs:

Follicular Phase 19-144pg/mL
Mid-Cycle 64-357
Luteal Phase 56-214
Postmenopausal
These are large reference ranges and do not tell you a lot.
In PCOS the estrogen levels do not fall much and may actually be elevated.

Progesterone:

It is very common to have low levels of progesterone in PCOS.
Ignore the typical lab reference ranges, which are huge:
Follicular Phase<1.0ng/mL
Luteal Phase2.6-21.5ng/mL
Postmenopausal<0.5ng/mL
Let’s say you are having regular periods and have your blood work done between days 16-25.
If the less than 1 ng/mL then that woman is not ovulating and we need to work on the progesterone levels. As it is common to have low progesterone in PCOS.
If the progesterone is 4-8 ng/mL, then that means that woman is making some progesterone. But the levels are not optimal
If the progesterone is over 8 and even in the teens, that is perfect, and there is ovulation and proper levels of progesterone.
If you are not having regular periods and your progesterone levels are less than 3ng/mL. Or you have had a uterine ablation or hysterectomy. Go ahead and check the progesterone any day. Then recheck the progesterone in 2-3 weeks to compare the levels. If the levels are <1.0ng/mL, then you have low progesterone

The Triad risk for Diabetes:

High insulin: Most labs have it at 2-19.6 IU/mL. Anything over 9 is higher insulin.
High triglycerides: In PCOS, you will see the triglycerides over 150 mg/dL reference range.
High glucose: ref range is 65-99. May be normal or over the edge of normal.
Risk for IR (Insulin Resistance) and Diabetes type two.
HOMA-IR: this is a test to check for and measure IR (Insulin-Resistance).
- Fasting insulin x fasting glucose / 405 = IR
- Example fasting insulin of 12 and glucose of 99
  - 12 x 99 = 1188
  - 1188 (divided by) / 405 = 2.933 (severe IR)
- The reference ranges are:
  - <1.0 is very good/ideal insulin sensitivity (no IR)
  - >1.9 is mild IR
  - >2.9 is severe IR

Hemoglobin A1C:

Over 5.7%

Cortisol:

Salivary test
Urine test: DUTCH testing
Both tests show the diurnal curve of released cortisol. In PCOS you will often see low cortisol in the morning and high at night.

Thyroid function is lowered:

TSH: high normal or high (reference range is .45-4.5 mIu/L)
FreeT4 is low normal (reference range is .8-1.8 ng/dL)
Free T3 is low (reference range is 2.0-4.4 pg/mL)

If you have questions, leave a comment or send an email to help@progressyourhealth.com. Also, download our free hormone video series on PCOS, Perimenopause, Menopause, and Hypothyroid.

Thank you for being part of our Progress Your Health community

PYHP 062 Full Transcript:

Download PYHP 062 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 on this episode, we’re gonna continue our series, our PCOS series. Today, we’re gonna talk about lab testing and diagnosis. So, Dr. Davidson, why don’t we kind of just dive right in and get started?

Dr. Davidson: Yeah, absolutely. So, last time we talked about what PCOS is and described it. This one, we’re going to talk about testing and diagnosis. And of course, when you’re thinking about Polycystic Ovarian Syndrome, you’re thinking about cysts on the ovaries. So one of the first tests or testing that a doc would do with D and transvaginal ultrasound to actually look at your ovaries to see if you’ve got cysts.

Dr. Maki: Yeah, right. So maybe someone’s experiencing some pain. Maybe literally they could have a ruptured cyst. We’ve had lots of stories over the years where patients are having a lot of discomfort. They go to the gynecologist and they do an ultrasound. And sure enough, they find cysts or like we talked about in the last episode, they go in to do the ultrasound and there is no cysts which can easily happen as well too.

Dr. Davidson: Yes. So one definitive diagnosis when you’re looking for PCOS is, if you go and do a transvaginal ultrasound and you see a string of pearls, a bunch of cysts that looks literally like a string of pearls on the ovaries, then you can pretty much say 100 percent that person has PCOS. Now, like we said on the other podcast, women with PCOS don’t normally have cysts. It’s actually not as common as you think. In fact, actually having a follicular cyst or a simple cyst is quite normal for us females. But in PCOS with women, you might not even see those cysts. But definitely, first thing off is you wanna get a transvaginal ultrasound.

Dr. Maki: Right, yeah. And that’s obviously a very conventional approach to do the ultrasound. That’s usually the first step in this process. And then there might be some follow-up bloodwork that comes in on the backside. We kind of do it in the opposite direction. We always do the bloodwork first. And depending on that bloodwork, we may or may not do the ultrasound. We may not have to do the ultrasound. They might have had that in the past. But we’re always kind of on the lookout, so to speak, for PCOS diagnosis anyways.

Dr. Davidson: That’s why we wanted to do this podcast on the diagnosis is because a lot of times women aren’t getting what we think would be the proper testing to check for PCOS, ’cause one of my most favorite tests to check for PCOS is to do a blood test on the Follicle Stimulating Hormone, which is abbreviated FSH (Follicle Stimulating Hormone) along with the Luteinizing Hormone, abbreviated LH.

You do what’s called a ratio. So an FSH to an LH ratio in women with PCOS will have that LH (The Luteinizing Hormone) usually double or more to that FSH, which definitely points you in the direction of PCOS. So like for example, you run an LH in a woman’s LH is 14 and her FSH is seven. That’s a 2 to 1 ratio. So that definitely makes you say, Hey, we need to go look at the PCOS and do some more testing too, and also get their subjective information as well .

Dr. Maki: Yeah, right. And I think FSH and LH levels are done routinely by a gynecologist or a primary care doctors, but I don’t think they necessarily know a lot of times what those numbers even really mean.

Dr. Davidson: Exactly, or they might only do an FSH and not the LH. And the FSH is a great test. It tells you, like if I were in perimenopause or going into menopause, it’s a great way to tell you where you’re at in terms of that transition. But for PCOS, you’ve gotta have that LH in there. And then do, you know, the math is easy and sometimes it might be that the LH might be 20 and the FSH is five. So anything two to one or more for that LH to FSH ratio is really what you’re looking at with that. And one of the main reasons behind that is because with PCOS, like we talked about, is one hallmark is those high levels of androgens.

Dr. Maki: Right. Yeah. So the first androgen that you would expect almost in most PCOS cases, but sometimes it is elevated, sometimes as normal is DHEA or we like to test for DHEA sulfate.

Dr. Davidson: DHEA sulfate is probably a little bit more accurate or specific when you’re looking at levels of DHEA for a female. Doing a total DHEA doesn’t give you a whole lot ’cause pretty much everybody kind of falls into the same level. Now, I got to say, on the flip side, these reference ranges which we’re going to go through with you are huge and vast and it’s hard to differentiate. So, for example, DHEA sulfate has a very big reference range. So, of course, DHEA comes from our adrenal glands, its highest when we’re young, you know, like 20, 25 and then it comes down with time.

So when you’re 90, your DHEA is gonna be considerably lower than when you were 25. But for example, let’s say a female is 35 years old and we want to check her DHEA sulfate because we’re considering that her DHEA might be a little elevated pointing to PCOS. The reference range for a DHEA sulfate for a 35-year-old female is 23 to 266 micrograms per deciliter. 23 to 266 is a huge reference range.

Dr. Maki: Yeah. Right. Yeah. So we do DHEA sulfate pretty much on every menstruating woman and even non-menstruating women because as we said on the last ones, sometimes you don’t know whether that number is going to be high or low. If that number is let’s say in the low 20s or the low 30s or anything even below 100. But then you go all the way up to the high 200s, that woman is going to feel in some ways completely different on one end of that spectrum to the other.

Dr. Davidson: So for the sake of looking at the lab reference values, you can pretty much say, let’s say a 35 year old female considering PCOS, if that DHEA sulfate is 200 or more, then you definitely want to delve into looking more into that PCOS diagnosis ’cause typically if you might see it at 150, 177, over 200, you start saying, you know what, if you’re not taking DHEA as a supplement and you’re DHEA is over 200, even if you’re in your 30 to 45, you’re checking them. Even 30 to 45, if it’s over 200, then that’s gonna strike a little flag saying, Hey, you know what, that’s looking like it’s kind of a little bit on that high end . Then, of course, you’d want to jump into the testosterone.

Dr. Maki: Yeah, right. And there might be, especially if some of those physical characteristics start to show up. There is some acne, there’s some hair growth in unwanted places. And then you look at a number like the DHEA sulfate that’s high normal, certainly that is going to be a red flag. Testosterone Reference Range for testosterone for a woman, it doesn’t really change much but 2 to 45, 8 to 48, depending on which lab you’re using. Again it’s a huge range but when that number- where would you say, when you start to suspect- when the number is in the, maybe the mid-30s.

Dr. Davidson: Exactly. So like you were saying, Quest has a reference range of 2 to 45 nanograms per deciliter. That’s huge. 2 to 45 in LabCorp is at 8 to 48 and I think some other labs might have it up to 55 depending on the age.

But whenever you see that testosterone over 35, that’s gonna spark a little interest in you and say, Hey, you know what, this has a little higher to high normal values of testosterone, which is an androgen like the DHEA, that’s gonna make you want to look and into that PCOS diagnosis. So one thing I didn’t mention earlier is one beautiful thing about DHEA, because it’s really a great hormone, is DHEA can convert to testosterone for us ladies. So it’s a way for us to be able to get our testosterone levels. So if you do see that higher normal or high level of DHEA, you can pretty much assume that it’s converting into testosterone. Then you check the testosterone and if it’s over 35, you know that you definitely wanna look at that PCOS diagnosis.

Now, there are plenty of women with actual, you can see it right off the bat that PCOS and their DHEA is well over 200 and their testosterone is like 90. It’s double the reference range. But those of you that might get missed with the PCOS is definitely looked at that high to normal Testosterone as well.

Dr. Maki: Yeah, right. Yeah. So hypothetically, you go in, you get an ultrasound. There’s no cysts. You get a DHEA that’s high. Normally get a testosterone is high normal. But they’re all you have a negative ultrasound, high normal. Well, at that point, what can you diagnose? You can’t diagnose anything at that point because everything’s in the reference range. That’s why when something is approaching there, especially if there’s clinical presentation, then you can assume that that is an actual diagnosis.

Dr. Davidson: Exactly. You wanna put that clinical presentation together along with what their health goals are or how they’re feeling. You know, Hey, I’m gaining weight and my hair’s falling out or I’m considering, you know, possibly pregnancy, but I haven’t been able to get pregnant . Why? It could be part of this kind of this diagnosis of PCOS. Now, later in the series of PCOS, we’re gonna go into the different types that we see and why some people get missed and why some people don’t get missed.

Dr. Maki: Right. So, of course, we’re talking a female hormone issue. So, of course, estrogen has to be part of that conversation. Some doctors don’t even test estrogen levels that they might do a total estrogen. We prefer almost invariably to do an estro dial level.

Dr. Davidson: And again, if you look at the typical reference ranges, they are huge. They’re looking at stuff they called the follicular phase, which would be day one to day 11, 19 to 144 picograms per milliliter. And then mid cycle, which would be your typical ovulation, would be 64 to 357. That is a huge reference range. Not to mention the Ludio phase, which is supposed to be post-ovulation is vast as well. But what we do find in PCOS is that the estrogen levels don’t necessarily drop. They have the higher levels of the androgens, but they still have levels of estrogen as well.

Dr. Maki: Yeah, right, and one thing that you would see often in a PCOS patient, if they’re not having a regular period, then you know something is not really quite right with their estrogen. If they’re having a regular period, then you can make some assumptions about estrogen levels if they’re cycling every single month. Again, it’s part of the complication of PCOS. Those androgen start to get to be a little bit too high and now the normal female rhythm starts to get thrown off.

Dr. Davidson: Exactly, which leads you to the other most important female reproductive hormone which is progesterone. Now classically in PCOS and pretty much all the types which we’ll go over the next couple of podcasts or the next podcast is progesterone is low. That’s pretty much another hallmark that usually gets missed. Like everyone thinks PCOS, high androgens, high testosterone. But really another hallmark is the low progesterone.

Dr. Maki: Yeah. Right, and that could create a having a low progesterone and we use progesterone the time with patients as a way to help them feel better, but also to kind of change a little bit of the hormonal signalling that’s happening as well. So why don’t we run through kind of where their progesterone levels would be?

Dr. Davidson: Now, if there are plenty of women that have PCOS that have a period every single month. And if they do, that’s great. It’s really easy to test their progesterone levels. You want to check it between day 16 and day 35, 28 to 35, depending on how long their cycles are, ’cause sometimes in PCOS, women can have a little bit longer cycles. But anywhere from day 16 to their next period is a great time to check for progesterone. But again, on that flip side, there’s a lot of women with PCOS that don’t have regular periods. They might miss six months. They might miss three months. They might miss every other month. And then they’re also women with PCOS that have had their uterus taken out. They have had an ablation because they had such heavy periods. So they had a uterine ablation to diminish that. That makes it a little bit more tricky in determining what their progesterone levels are.

Dr. Maki: Yeah, because you don’t have the landmark of the periods. So how do you decide what day they’re on? So usually we recommend in the beginning, when you don’t have a day to start with, right? You don’t have a way to keep track of it month by month, then you just pick a random day, go any time. It doesn’t matter. And then we can test it shortly thereafter and then see the difference between those numbers and maybe get some kind of a conclusion from that. Or maybe the number is pretty much the same thing, which would be common in a patient with PCOS anyways.

Dr. Davidson: So for example, let’s say, Hey, I’m missing periods or I had an ablation, so I don’t know when my period would be coming , is I’d say go get your blood work done right now. And if the progesterone shows up at less than 1 or less than 0.5 nanograms per milliliter, you think, okay, that level is low. Then we wait about two weeks, maybe three, and we retest it because then you’ll see, Hey, look, that progesterone rose up because that’s what’s supposed to happen in a typical cycle . And a woman that has had a hysterectomy or they they’ve had an ablation, they’re still gonna be cycling. You just can’t follow it in terms of the period. So, we do that first one of that progesterone, then maybe two, three weeks later, we check the progesterone level again. If it’s still less than 1 or less than 0.5 nanograms per milliliter, then you’re then you can definitively say, “Hey, you’ve got low levels of progesterone.”

Dr. Maki: Yeah, right. And for a woman that is cycling or doesn’t have a uterus, you can’t really give them estrogen, right? They’re not really a candidate. But for women of all the different age ranges, giving them progesterone can be very beneficial in how they feel. Not to mention that the clinical benefit of adding a hormone in like that ’cause, like you said, especially in a case like this, they have usually more progesterone deficiency than estrogen dominance, so to speak.

Dr. Davidson: Exactly like you said, adding in some progesterone. There’s also lots of supplements and herbs that can help modify and balance that and work with your progesterone as well. So that’s looking at kind of what when people think of PCOS, they’re thinking the hormones, the progesterone, the androgens. But there are other hormones that are just as affected in PCOS than these female hormones or the testosterone of the DHEA in particular, which Dr. Mackey loves to talk about, which we all do, is the insulin levels. In PCOS, you’ll see the higher levels of insulin.

Dr. Maki: Now we get a little frustrated or at least I get a little frustrated because a lot of doctors don’t even test insulin levels or a fasting insulin. We test them just like the DHEA and testosterone. Specifically, for this reason, we want to see a fasting insulin, because if that number is greater than 10 on a fasting insulin, we can make some assumptions, especially if we know if we couple that with these other numbers. Now, it paints a very specific story, even though that story might not be completely a classic representation. Things are starting to lean in a particular direction. So ideally, a fasting insulin should be less than five. Less than seven would be appropriate once it gets into those double digits. And the higher it is now, you can feel pretty confident that is really kind of the underlying mechanism that is driving all those female hormone issues and the high androgens.

Dr. Davidson: And we kind of call it the triad. So what you’ll see is you’ll see higher levels of insulin, and granted the insulin reference range is huge. It’s like 2 to 19 or 2 to 20 IUs per milliliter and reference in labs. Ignore that. Like Dr. Maki said, ideally anything under 5, 5 to 7. Anything over 9 to 10, then you know they have higher levels of insulin. But the triad we talk about is higher levels of insulin, high triglycerides, which is part of a cholesterol panel and then possibly high glucose.

Dr. Maki: Yeah. Right. So a normal glucose level, again, fasting glucose levels can be a little bit misleading. Just because that number is under 100 doesn’t make it ideal. I think a good like a really ideal range for a human is probably right around 85, 83 to 87, something like that when you start to get into the mid-90s and above. Now you can assume that there some other issues going on there. And I would say the 85 range is normal, not very common. An American with a blood sugar of 95 and above I think is very common but not normal. And that is something that that I think happens an awful lot. We just take these numbers in the high 90s as being in the normal reference range. But I think it’s telling a story that it’s leading to a problem or that problem already exists.

Dr. Davidson: Exactly. So if you have high normal glucose, higher levels of insulin, especially over 9 or 10, and then the triglycerides, like I said, which is on it, cholesterol panel, ideally you want your triglycerides 150 or below. If you see those triglycerides right around 150 or higher, then you’re looking at that triad which the consequence is insulin resistance and diabetes type 2. That’s the risk factor there. There’s another kind of interesting equation that I want to let Dr. Mackey kind of explain, which gives you an idea what your actual insulin resistance status is.

Dr. Maki: Yeah, it’s basically just an insulin-resistant calculation. And this, again, as we talked about last time, this is kind of like the underpinning or the underlying reason as to where the PCOS comes from, and it’s called the HOMA-IRs or H-O-M-A, and it’s literally just a calculation. So you take insulin, multiply it by glucose and then you divide that by 4 or 5. So a typical insulin that we would see would be, let’s say, somewhere between 7 to 12. You know, the higher the number, the worse it is. A fasting glucose would be somewhere in the let’s say the 90 somewhere. You multiply the insulin times the glucose, you divide that by 4 or 5 and that gives you a score that gives you a number usually in the lower digits, 1 or less is optimal, right? That means that that person is insulin sensitive, meaning their body is responding to insulin very well. Once that number gets to be like 1.9 and above, maybe 2.0 and above, they have kind of mild early-stage or kind of mild to moderate insulin resistance. Once that number is above 3, then you can determine that they probably have significant level of insulin resistance. And more than likely, like you just said, Dr. Davidson, that their triglycerides are gonna be elevated. They’re gonna have probably baby cysts on their ovaries, their testosterone DHEA is going to at least be high normal, it’s really going to paint that picture and that HOMA-IRs or something that you can track over time as well, because if you there are improving and they’re becoming more insulin sensitive now that HOMA-IRs score is going to actually start coming down?

Dr. Davidson: Yes. So you’d be able to see that as you’re going along with the treatment or with your health goals. So, I know that’s a little complicated. I’ll definitely put that HOMA-IR into the show notes so that you can read it and see the calculation and see the equation. And I’ll put an example on there too so that perhaps if you have your levels or you’re going to have your levels tested, you can have this equation to be able to check your IR score. So and then, of course, that the next one, which I’m sure a lot of people already know about, is your hemoglobin A1 C.

Dr. Maki: Yeah, and that one has gotten to be very popular over the last several years. If you’re a non-diabetic, that number can be a little bit confusing. But it should be, I remember when you and I first started the practice a long time ago, anything under 6 was considered to be normal. And now the reference range is already down. Some labs it goes down to like 5.6. So they’ve really kind of tightened up that reference range. They are using that number to be kind of a diagnostic number. So if that number is elevated, now, though, your doctor might tell you that you’re pre-diabetic. Pre-diabetic and insulin resistance in some ways is kind of the same thing. At least that’s the way we view it. But I think it’s a little bit unfair if your number is 5.6, 5.7, 5.8 and your doctor says you’re pre-diabetic. You can’t base it solely on that one test. You gotta have a little bit more information on the things we’re talking about, a higher normal glucose, a high fasting insulin, elevated triglycerides to really see if someone is either insulin resistant and or pre-diabetic, which in our mind is kind of the same thing.

Dr. Davidson: I absolutely agree but I still love the hemoglobin A1 C tests. So anything over 5.7 percent, you’re gonna have to put this picture together, put all the data together to say, hey, this is really pointing in that – definitely that insulin resistance, which is part of that PCOS picture. And then, of course, cortisol. Everybody loves talking about cortisol. Cortisol is a hugely important hormone in our body. But at the same time, too much of a good thing isn’t a good thing.

Dr. Maki: Yeah, right. And testing cortisol for a normal, relatively healthy person, testing it through blood is really not the best way to do it. Honestly, that’s why we do. The other reason why we do DHEA sulfate a lot because you can infer a little bit about cortisol through DHEA and doing blood work, the DHEA is easier to do or more accurate than doing the cortisol. So the best way if you want to assess cortisol, the best way to do that would either be a saliva test, which usually to provide for samples morning, noon afternoon and night. That can be all but time-consuming. Usually that is an out of pocket expense because most insurance companies do not cover salivary testing. The newer tests that a lot of people are aware of nowadays is also doing a Dutch test, which is a dried urine test, kind of a newer technology.

Dr. Davidson: But like Dr. Maki is mentioning is cortisol is secreted in a diurnal curve. So it’s supposed to be highest in the mornings or bright-eyed, bushy-tailed, and then it comes down at night. And truly, the saliva or the urine test is the best way to accurately see what your diurnal curve is of cortisol. Now, usually with PCOS, what you’ll see is that cortisol is low in the morning, which is why it’s tired and hard to get going. And then you’ll see that cortisol come up at night, which is why the food cravings come in and it’s very hard to go to sleep at night. So it’s a really good test, not just for PCOS but also just in general with checking the adrenal glands.

Dr. Maki: Yeah, I think that that gets missed an awful lot. In conventional medicine when it comes to cortisol, the only things they really consider to look at whether you have Cushing’s disease, which is an excess of cortisol or if you have Addison’s disease, which is an insufficiency of cortisol. But those two are on the extreme ends of the spectrum. I definitely think there is a subclinical Cushing’s, there’s a subclinical Addison’s that no one really ever talks about. It’s almost like they just kind of blow it off. And I think that is a huge, especially in PCOS. This plays a very big role in in the development, the progression of PCOS over time.

Dr. Davidson: And then another test that kind of gets missed with PCOS because everyone’s focusing on the reproductive hormones and the androgens is the thyroid function. Pretty much I’d say 95 percent of all PCOS women that we deal with have some type of lowered thyroid function. Now, do they have thyroid disease? No. But they’re still have some that hypothyroid or Hashimoto’s in conjunction. But you do see that thyroid function tends to drop with PCOS.

Dr. Maki: Yeah. Right, and we could maybe even make the, as we’re talking about the insulin and the insulin resistance, there’s definitely a connection between insulin sensitivity and thyroid issues. So as they become more insulin sensitive, their thyroid numbers are going to improve over time. But we see all the time. We see these high normal TSH numbers. We see low, normal 3T3 numbers. And if pregnancy is part of what they’re trying to accomplish, approaching and improving thyroid function is necessary in their success.

Dr. Davidson: Exactly and it doesn’t mean you have to go out and throw them on a bunch of thyroid medication, which some people that does qualify for. But there’s lots of things you can do with PCOS to help raise up that thyroid function, because having a lower thyroid function almost like compounds that PCOS symptoms, because lower thyroid is going to reduce your metabolism, is going to make your hair fall out more. It’s gonna make you tired. And then you’ve got this, and then like Dr. Mackey was saying, with fertility and, with, gosh, with pregnancy and even when thyroid is low, especially that low T3 or even a low normal T3 can really set people up also for miscarriages, it increases the risk of miscarriage.

Dr. Maki: Yeah. Right. So thyroid, even though it’s not a female hormone, it is one of those major metabolic hormones just like insulin and cortisol that can have a huge impact on their on their eventual success. So before we forget, if you would like more information about PCOS and a few other very common female hormones, you can visit our website progressyourhealth.com. Right on the home page, you can enter your email to get access to our short free hormone video series. We go through PCOS, we go through a hypothyroid, you go through menopause, peri-menopause. We have some profiles there about what those things look like. Very good. You just enter your email, you get direct access to it right away.

Dr. Davidson: Absolutely. And then I’m on the video. So you get to see me up close and personal.[chuckles] But with the show notes, I’ll definitely write these up and also put down the typical reference ranges. And then what we’re looking at, too because, like Dr. Maki was saying with the thyroid, the TSH, I’ll have the reference ranges on there and the T4 the T3 so you can look at where, if you’re looking at your own T3 and you see it at 2.2, you know, you’ve got lower T3 function. So I’ll put that all together for you.

Dr. Maki: Yeah. So I think we cover what we wanted to cover for this one. The next couple of episodes, we’re going to actually talk about the different types of PCOS. There’s not just one or we at least we don’t think there is. It’s not a matter whether you have it or not. It’s kind of where you fit in the continuum or the spectrum of PCOS. So do you have anything else to add for this one, Dr. Davidson?

Dr. Davidson: No. This was great.

Dr. Maki: Okay. Alright. Until next time. I’m Dr. Maki.

Dr. Davidson: I’m Dr. Davidson. Take care. Bye-bye.

Thank you for listening to the Progress Your Health Podcast. If you like what you’ve heard on this podcast, please give us a positive review on iTunes.

This allows us to spread our message, grow our audience and help more people around the world. For more information, visit our website at progressyourhealth.com.

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What Does PCOS Look Like? | PYHP 061

Dr Valorie Davidson and Dr Robert Maki — Wed, 18 Sep 2019 19:30:15 +0000

In this episode of the Progress Your Health Podcast, we are going to talk about PCOS. I know our last podcast was, PCOS, Questions to Ask your Doctor. We are still going strong on our PCOS information. But we are going to do things a little different than we have. We are going to do a five-part podcast series about PCOS.

What PCOS Looks Like: What is it? (this podcast)
How PCOS Can Be Detected: Testing and Diagnosis for PCOS
Which Type of PCOS Am I?: Classic
Which Type of PCOS Am I?: Common
Which Type of PCOS Am I?: Concealed

PCOS stands for Polycystic Ovarian Syndrome. It is not a disease but considered a syndrome. From the name, polycystic ovarian syndrome, it is easy to assume there are multiple cysts on the ovaries. But in fact, many women with PCOS do not have multiple cysts or any ovarian cysts. As a general statement, in PCOS, there are hormonal imbalances that can cause unwanted symptoms and conditions. That is why we consider it more of a spectrum as some women can have nearly most of the criteria of PCOS and other just a few symptoms.

What are the Hormonal Imbalances present in PCOS?

In PCOS, one of the hallmarks are elevated levels of androgens: testosterone and DHEA. A lot of time these can range from high normal to over the reference lab values.
DHEA: comes from the adrenal glands
Testosterone is from conversion from DHEA, ovaries and other peripheral tissues
Progesterone levels from the ovaries are low to none
Thyroid function can be low
Elevated insulin
Cortisol diurnal release is degraded.

Common PCOS Symptoms:

Multiple Ovarian Cysts:

Just like the name states: Polycystic ovarian syndrome, there can be multiple cysts on the ovaries.
It is normal and common to get small follicular cysts during our cycle.
But in PCOS there can be actual cysts that stay on the ovaries almost indefinitely.
While as the name states, polycystic. Many women with PCOS do not have cysts on their ovaries.

Period issues:

Irregular or lack of a period.
In PCOS, there can be missed periods. Some women might miss a period or two in a year. And others can miss their period for up to six months or more. But of course, the goal is to balance the hormones, so the cycle is regulated and not painful or heavy.

Infertility:

Some women that have PCOS can have reduced ovulation to no ovulation, impacting their fertility. This is always a big concern when a woman gets the diagnosis of PCOS.

Weight gain:

Most complained about and frustrating symptoms of PCOS. It is very easy to gain weight. Women can have the best diet and exercise regime and still notice that they are gaining weight. Also, because of the easy weight gain, it can be very hard to try and lose with PCOS.

Acne:

Cystic and deep
Located more on the chin and jawline area
Neck and back as well.
Specifically, due to the elevated levels of testosterone and DHEA.

High Blood Pressure:

This can be a combination of the adrenals and elevated insulin. Not everyone has high blood pressure with PCOS. Remember, PCOS is a spectrum of symptoms. But blood pressure is important to consider and monitor when looking at PCOS.

Irritability:

Higher levels of testosterone and DHEA can make you, testy (no pun intended). But the combination of hormonal imbalances such as lower progesterone, higher insulin, cortisol disruptions can really cause a short fuse.

Hair loss:

The higher levels of testosterone and DHEA without the buffering effect of the progesterone. Will cause androgen derived’ hair loss. You usually will see it in the temples and top of the head.

Hair growth:

While the hair on the head can thin and fall out in PCOS, and there can be hair growth elsewhere.
Face, upper lip, and chin.
Under the chin and neck
Chest and belly

Now, remember, we are humans. And humans grow hair. It is perfectly normal to have hair growth on your body. I have a couple of chin hairs that pluck every so often. And my ethnic background means I shave my legs pretty often. But in PCOS the hair growth is a little more descript. Also called hirsutism is to a higher degree. The hair is dark and coarse, and there is more of it on the body. This is usually attributed to the higher levels of testosterone and DHEA.

Thank you for being a part of our Progress Your Health Community! Stay tuned for the next episode of our five-part series on PCOS: How PCOS Can Be Detected.

The post What Does PCOS Look Like? | PYHP 061 appeared first on .

Questions to Ask Your Doctor About PCOS | PYHP 060

Dr Valorie Davidson and Dr Robert Maki — Tue, 17 Sep 2019 19:12:32 +0000

In this episode of the Progress Your Health Podcast, we want to discuss questions you might want to ask your doctor when it comes to PCOS.

PCOS stands for Polycystic Ovarian Syndrome. The name can be misleading. Polycystic means, having multiple cysts on or in your ovaries. While this can be true, many women with PCOS do not have any ovarian cysts. PCOS is a collection of hormonal imbalances that may result in cysts and other unwanted symptoms.

During this episode, we talk about the diagnosis, symptoms, and questions to ask your doctor regarding PCOS. We explain that PCOS is more of a spectrum of symptoms as some women can have all the symptoms and others a few.

This is why it is important to have clear communication with your doctor on how:

PCOS is affecting your life.
What your health goals are with PCOS.
The proper treatment to help with PCOS.

Before we move on, let’s understand the basics with PCOS. The common symptoms that are associated with PCOS:

Common PCOS Symptoms:

Cysts: if you have not had an ultrasound, request that your doctor order you transvaginal ultrasound. As mentioned earlier, many women with PCOS do not have cysts on the ovaries. But if there is any thought that you might have PCOS, then you do want to have a transvaginal ultrasound. This will give us information on the size of the uterus and ovaries. If you have any growths or cysts. It will even check the thickness of the lining of your uterus.

Missing, Irregular Periods: It is very common in PCOS to miss periods for multiple months. Some women miss one month a year, and others can miss up to six months at a time. It is also common to have cycles that range from 25 days to 45 days.

Weight gain: Weight gain is one of the most common frustrations with PCOS. It is very easy to gain and hard to lose. Even with strict caloric restriction and a lot of exercise, women with PCOS will be frustrated because they cannot lose weight.

Hair loss: It is common in PCOS to have hair loss. Particularly on the top of the head and temples can appear to be especially thin.

Hair growth on the face and other areas of the body (except for the head): While it might be easy to lose hair on the head. In PCOS there can be hair growth on other areas of the body. Most commonly, the upper lip, chin and jaw, chest and pubic area before the belly button. We are human, and humans grow hair on our bodies. But in PCOS it might seem a bit more extreme.

Irritable: It is common to feel irritable not warranted for the situation in PCOS.

Lack of Conceiving, Fertility issues: PCOS is one of the top causes of infertility. There tends to be a lack of ovulation in PCOS. But there are many women with PCOS that have children. But there is a link between fertility and PCOS.

Elevated Blood Pressure: Some women with PCOS will have essential hypertension. Or elevated blood pressure that doesn’t seem to have a cause. So if you have PCOS, make sure to check your blood pressure regularly. These are some of the most common symptoms.

Other issues that can be part of PCOS are:

Increased Risk of Diabetes: Women with PCOS do have a higher risk of developing Diabetes Type Two. This is due to the higher levels of insulin, triglycerides, and glucose that can be seen with PCOS.
Increased Levels of Insulin: We could go on for hours about insulin and its effect on weight gain and blood sugar and risk for developing Diabetes Type Two. But the key concept here is, in PCOS it is common to have higher levels of insulin in the bloodstream.
Increases Levels of Triglycerides: Triglycerides are part of a lipid/cholesterol panel.

A typical basic lipid panel includes:

Total cholesterol
LDL (low-density lipoproteins)
VLDL (very low-density lipoproteins)
Triglycerides.

It is more common to see higher levels of triglycerides in PCOS.

Let’s say you meet with your doctor and he/she/doc tells you that you:

You might have PCOS
You have PCOS

If this is the case, you are going to have a lot of thoughts and questions running through your head. From What is PCOS? to How is this going to affect my health? to How will this affect my fertility? and even Oh my gosh, that explains why I am feeling this way! .

We wanted to form a list of the most important questions to ask your doctor if you are looking at a PCOS diagnosis.

Questions to Ask Your Doctor About PCOS:

Why do you think I have PCOS?

Is from my symptoms?
Does my blood lab testing show I have PCOS?

What treatment can help my symptoms of PCOS?

Conventional treatments?
Nutritional advice?
Lifestyle changes or modifications?
Dietary supplements that can help?

How do I lose weight with PCOS?

Is there a better way to lose weight when you have PCOS?
What kind of exercise is the best for PCOS weight loss?

Should I concerned about my ability to conceive and fertility?

Will PCOS affect my fertility?
Should I see a fertility specialist?

What About My Thyroid Function?

Have you tested my thyroid function?
Can you run a full thyroid function panel? (we will get to what those tests are later in this episode)

What is my risk of developing Type 2 Diabetes?

Do I have Insulin Resistance?
What can I do to minimize my risk for Diabetes Type Two

Now your Doc may not have all the answers to these questions. And don’t expect them to have all the answers, as docs cannot be the jack-of-all-trades’. But it is good to have a discussion so your doc can refer you to the proper specialist(s).

Unfortunately, there are not a lot of helpful conventional treatments for PCOS. Most often, the common treatment is birth control pills, which we all know have numerous side effects.

Common Conventional Treatments for PCOS:

Birth Control Pills:

If you have PCOS than your gynecologist, GP, PCP will most likely offer your birth control pills. This will regulate the periods. And because birth control pills have an effect on testosterone levels, it can reduce breakouts and acne. But not everyone is a candidate for birth control pills. And many women have cannot tolerate birth control pills. Honestly, they are a band-aid that when you stop taking them. You are back to square one. This is especially true with conceiving. PCOS has an effect on ovulation and is one of the top causes for infertility. If a woman is trying to work on getting pregnant, then birth control pills are the farthest from her solution.

Metformin:

Metformin is actually a really good medication for insulin resistance and blood sugars. It is common in PCOS to have elevated levels of insulin and glucose. So metformin can be helpful. But not all women with PCOS have high glucose or insulin.

Spironolactone:

Spironolactone originally was used for heart conditions and blood pressure. Now it is very common to help reduce testosterone levels. It can be helpful for reducing the elevated levels of testosterone in PCOS.

By reducing testosterone, this can help with hair loss, acne, and mood. It can help periods, as well. If you take too much spironolactone for some women, it can cause spotting or frequent periods/short cycles. Also, it is a diuretic, so it can make you dehydrated. Also, you have to be careful with taking certain medications or supplements. Or ingest too much potassium. It is recommended to have your blood tested regularly, especially for potassium levels.

Blood testing for PCOS:

You don’t want to rely on symptoms alone to diagnose PCOS. It is important to have lab work that can support the diagnosis of PCOS. As you recall, PCOS is a spectrum of symptoms and hormone imbalances. Not all women with PCOS have the same symptoms or hormone levels. It is important to have labs to see what hormones are not balanced to be able to put together a proper treatment plan.

Below we are going to explain the proper lab testing for PCOS.

FSH: LH Ratio Blood Test
FSH = Follicle Stimulating Hormone
LH = Luteinizing Hormone

Both FSH and LH are secreted by the pituitary in response to ovarian function. In PCOS the LH is at least 2x or more higher than the FSH. For example, an FSH of 4 and an LH of 8 would warrant looking into PCOS. Or if the FSH were 4 and the LH was 19, that would show that PCOS is a strong possibility.

Androgens Are High on a Blood Test:

Testosterone and DHEA are androgens. Meaning men have higher levels of these hormones. The best way to test for DHEA is to do a DHEA-sulfate test as that is more accurate and specific.

Testosterone: Quest has a reference range of 2-45 ng/dL. And LabCorp has a reference range of 8-48 ng/dL. In PCOS you will see high normal to high out of range levels of testosterone.

DHEA-Sulfate: Common lab reference ranges are pretty vast for DHEA-S.

For example, a woman that is 35-years old gets her blood drawn for DHEA-sulfate. The reference range for a 35-year-old female is 23-266 mcg/dL. Usually, in PCOS, you will see high normal levels well over 200 mcg/dL.

Estrogen (Estradiol) Blood Test:

Estrogen levels are usually pretty normal in PCOS. But you sometimes see an elevation in estrogen, which can lead to Estrogen-Dominance. Because of this, it is important to test for Estradiol. Which Estradiol is much more specific than Total Estrogens

Progesterone Blood Test:

Without going into too much detail. It is important to note that progesterone is secreted from the ovary after ovulation. So in a perfect-28-day cycle, you will see progesterone levels rise starting at day 14, will peak at day 21 and then slowly decline until day 28.

Under the best circumstances, it is ideal to test progesterone after day 14, usually day 16 – 25. But in PCOS, many women are not getting regular periods. Making it hard to test progesterone. But regardless of where they are in their cycle. I always have women test their progesterone. Because in PCOS, it is common to see low to no levels of progesterone.

Cholesterol Lipid Panel:

A cholesterol basic panel includes:

Total Cholesterol: less than 200 mg/dL
LDL <100 mg/dL
HDL >50 mg/dL
Triglycerides <150 mg/dL

As mentioned earlier is common to see triglycerides higher than 150 mg/dL in PCOS.

Insulin:

A fasting insulin on a typical lab reference range is huge. Quest’s reference range is 2-19.6uIU/mL. And Labcorp range is 2.6-24.9uIU/mL. Anyone that is fasting should not have an insulin blood level over 12. Ideally, an insulin level should be under 5 for optimal ranges. Five to twelve is moderate, and anything over 12 is high insulin. Having higher levels of blood fasting insulin will put you at risk for developing Insulin Resistance and Diabetes Type Two.

Glucose:

Fasting glucose should be 99 mg/dL or less. A glucose test alone is not sufficient for PCOS. while you want to make sure that the glucose is not too high. Often in PCOS, the glucose is normal or just over the edge of normal. But insulin and triglycerides are very high.

Hemoglobin A1c

A hemoglobin A1c is more specific for looking for Diabetes risk compared to a single fasting glucose reading. It is also a good marker to monitor the treatment of Diabetes. This is a good test to look for the potential risk for Diabetes Type Two in PCOS. Or if a woman with PCOS already has Diabetes Type Two, the Hemoglobin A1c is a good marker to monitor her treatment.

Cortisol:

Doing a cortisol saliva test is a good evaluation of Adrenal Dysfunction/Fatigue. The hormonal imbalances in PCOS make a woman more at risk for Adrenal Dysfunction/Fatigue. Blood testing for cortisol is as accurate as a saliva test.

Thyroid function: TSH, FreeT3, FreeT4:

Testing a TSH alone is not enough for monitoring thyroid function. Because of the hormonal imbalances in PCOS, it is common to see the thyroid function low. This can contribute and exacerbate the PCOS symptoms. Symptoms such as easy weight gain, hair loss, and extreme fatigue. For an accurate reading of thyroid function, you want to make sure to also get the FreeT4 and FreeT3.

You might not have all the symptoms of PCOS. But the ones that you do, you should ask your doctor for help.

There are supplement, dietary, lifestyle, and prescription options for PCOS. Again your doctor may not have all the answers. But he or she can refer to you specialists that can help you in these areas. If your doc just offers you birth control pills and tells you to go on a diet. That is not helpful, and then you may want to consider seeing another practitioner.

If you have PCOS, after listening/reading this, you might have a lot of questions. If you have questions about the best dietary program to follow for PCOS, download our KCCP (Keto-Carb-Cycling-Program).

PYHP Episode 060 Full Transcription:

Download Episode 060 Transcript

Dr. Maki: Hello everyone, thank you for joining us for another episode of the Progressional podcast, I’m Dr. Maki.

Dr. Davidson: And I’m Dr. Davidson.

Dr. Maki: On today’s episode we’re going to talk about something that we actually see and deal with on a quite consistent basis. Today we’re going to talk about PCOS.

Dr. Davidson: Which PCOS stands for “Polycystic ovarian syndrome”, which is a little bit misleading, because not everybody with PCOS has polycystic ovaries, but we’re definitely going to get into that later in the podcast, but mainly with this specific one we’re going to talk to you about is questions to ask your doctor if you think or you’ve been diagnosed with PCOS.

Dr. Maki: Yes, now, granted, PCOS has been around for a long time. I think it used to be called Levenstein something, named by a couple of doctors like 50 years ago so, PCOS has been around for a long time. It’s a syndrome, not a disease, we can kind of debate that, but it usually has some hallmarks as to the syndrome, which is usually just a collection of symptoms.

We think it even goes a little further than that, and we think that a lot of women sometimes if they don’t meet the exact definition of PCOS, they get kind of missed and lost in the shuffle sometimes, and maybe don’t get a proper diagnosis a lot earlier than they should.

Dr. Davidson: Exactly, and then, on the other side of the coin there, is a lot of women have been told they have PCOS but they don’t necessarily have it because their doctors are just basing it on their symptoms.

That’s where we wanted to kind of talk to you a little bit today about. What to ask your doctors, what to request and what you might be looking for if you think or you’ve been diagnosed with PCOS.

Dr. Maki: Yes, right. Now, I think it’s estimated that PCOS is the number one reason for fertility issues, so I think it’s estimated about 10 to 15% of the reproductive age population has PCOS. Oh, I think the number is quite a bit higher than that because that’s based on some conventional diagnostic parameters and I think that it goes a little bit beyond that in a lot of cases. We’re going to talk about that on a couple of future episodes.

So, why don’t we start off, what you and I see all the time? We end up in– a lot of times, not all the time, but a lot of times we end up diagnosing someone of having PCOS, or what we would call maybe even “PCOS-like”. Something that would have all the characteristics of PCOS but they’ve never been officially diagnosed with PCOS.

Dr. Davidson: Exactly so, let’s go over the symptoms. Now, we’re going to go over kind of the main symptoms here. Now, it doesn’t mean that if you have PCOS you have to have all of the symptoms, which is why we call it kind of like a spectrum or a syndrome, because you might have one, you might have all the symptoms, you could have anywhere in between, so I think that’s where women tend to get missed when we’re looking at PCOS.

Like I had mentioned to begin with, polycystic ovarian syndrome is you can have a bunch of cysts on or in your ovaries.

Dr. Davidson: Yes, so, that’s the obvious, just based on the name. Usually in order to have a cyst problem, there’s going to be some pain, especially around ovulation, it might be a very significant pain. Then, of course, you go to the gynecologist, they’re going to request a transvaginal ultrasound, and there may or may not be cysts present on the ovaries.

Dr. Davidson: Yes, so, if you think you have PCOS, or you’ve been diagnosed with PCOS and you haven’t had a transvaginal ultrasound, then request your doctor to do one, because you do want to find out if you have cysts or if you have multiple cysts.

Now, one thing, even though they call it “PCOS”, polycystic ovarian syndrome, a lot of women with PCOS don’t have cysts. In fact, there are more women with PCOS that don’t have cysts than women that do, but traditionally, as this has been around for many, many years, is what they call “the string of pearls”.

They do a transvaginal ultrasound, they look at the ovaries, and it really does look like there’s like, really pretty round pearls in the in the ovary. You will see that sometimes, but honestly, most of the time, you’re not going to see that.

Dr. Maki: Yes, right and as the name implies, polycystic ovarian syndrome, if you don’t have any existing ovaries, then you’re not going to fit into that conventional diagnostic criteria, because that’s– and believe me, the ultrasound, the transvaginal sound is usually the more common step to this process.

If that comes back unremarkable or there’s nothing present, then you’re kind of back to the drawing board trying to figure some things out.

Dr. Davidson: Another common symptom is missing periods. A lot of doctors will tell you have PCOS just by you telling them, “Well, I’ve missed periods for six months and no, I’m not pregnant”.

They just based that on their criteria as PCOS, but it is common with PCOS to miss anywhere between two to six months at a time with your periods, or one every other month, or some women with PCOS have regular periods.

Dr. Davidson: Right, right. That’s something that we see quite often, and also, maybe an obvious situation at that point, if they haven’t had a regular cycle, that would be the first thing that you and I would think of for sure, right?

Then we can go from there, and maybe do some blood work. If they haven’t had that transvaginal ultrasound, that would be the time to order it for sure.

Dr. Davidson: Now, granted, not all women want to have a period every month, and when you have PCOS, when you do have a period they can be pretty painful. When we see a patient and we’re like, “You know what? We’re going to get those periods regular”, they actually look at me horrified because they’re like, “I don’t want to have a horrible period every month”, but that’s where we balance the hormones to try to encourage that period to become more regular.

In fact, I had a– you probably remember her, my roommate in college. She had PCOS, but she was one that wasn’t quite overt, like, she didn’t have all the classic symptoms. She would miss her period for months, and I remember buying her pregnancy tests because I’m like, “Girl, if you miss your period, we got to check to make sure you’re not pregnant”.

We would do that all the time because she would miss three or four months in a row, but feel fine. Feel fine until she got that horrible period on the fifth month. It is something to definitely look into with PCOS is those missed periods.

Dr. Maki: Yes, now, some of the other things that definitely show up, certainly acne or complexion problems. That can certainly be on the list. Other things that are classified is hirsutism so, unconventional or unwanted hair growth in places that women don’t typically want it, especially if it’s on the face. You could even have it around the nipple area, even on the abdomen below the belly button.

Those are areas where men typically grow hair, women typically are not supposed to grow hair in those areas and that’s usually driven by an excessive amount of androgen production. We’ll get into that in a second.

Dr. Davidson: Yes, it’s unfortunate because there’s hair loss on the head, hair thinning particularly in the temples and the top of the head, but then, unfortunately, then it’s growing elsewhere. Now, we’re humans, humans grow hair and everybody’s different, so having a couple of hairs around the areola on your breast is totally normal, but if you are having PCOS-driven hair growth, it definitely looks like there’s more.

Dr. Maki: Right, right, right. No woman of any age– we deal with a lot of women that are having hair issues, either losing it or growing it, but no woman wants to be having either hair growth or hair loss issues so, that certainly becomes a priority. Of course, the skin issues, right?

That can become problematic as well. Probably the most common one that we hear a lot of, of course, is that weight gain, and also underpinned by the stubbornness to be able to lose that weight, right? We talk with a lot of women, and they’re working really hard and their weights not budging. They’re having a really, really hard time trying to have any weight loss success.

Dr. Davidson: Yes, we call it “unexplained weight gain”, because they gain it really fast and it’s so hard to lose. Now, a lot of times they’ll say, “Oh, let’s go on a diet and let’s just stop eating and exercise a whole bunch”. In PCOS that’s not going to do the trick here. You might lose a pound or two, but really it’s all about that hormonal imbalance.

Dr. Maki: Yes, right, yes, and we’ll talk more about the weight gain side of it. I think with any doctor that deals with women on a regular basis, especially if they deal with any kind of weight loss, they would say that the PCOS patients are definitely the most stubborn when it comes– not them as people, but trying to help them lose weight, that becomes a very stubborn process, because of what that PCOS is, it’s a very significant hormonal issue.

Like you said, going on a diet and exercising a bunch doesn’t always sometimes that actually makes the problem worse, which we’ll talk about later on future episodes. Another thing that goes along with the weight gain, we’ll talk about some labs here in a second, but another thing that we both see quite often is elevated blood pressure.

Dr. Davidson: Exactly, elevated blood pressure or borderline or moderate blood pressure, which you wouldn’t typically expect, but then of course, you definitely want to address that and make sure you bring the blood pressure down, but that’s one key characteristic is, they’ll come in and say, “Yes, I have this moderate blood pressure issue, but I’m on blood pressure medication, so it’s controlled”.

You want to take that into consideration, but like I said, on the flip side, there’s a lot of women that have PCOS that don’t have high blood pressure. In fact, they have low blood pressure. So, it’s definitely taking the collection of symptoms and putting them together before you throw out a diagnosis.

Dr. Maki: Yes, especially if a woman is in her 20s or 30s. She probably shouldn’t have hypertension in her 20s or 30s, and if her blood pressure is even borderline in her 20s or 30s, that is the same mechanism that creates the PCOS, which is an insulin-resistant issue, is the same reason why the blood pressure goes up.

Now, we’ll talk more about blood pressure and insulin and how that’s connected, but it has to do with what they call “The Renin-Aldosterone System”, and water retention, and increasing blood volume, it’s pretty complicated. But again, when you see elevated blood pressure in that kind of atypical person, it’s a clue that they might have a PCOS problem.

Dr. Davidson: Now, you mentioned insulin, now, I don’t want to bore everybody and put everybody to sleep, but insulin is one– I wouldn’t say it’s a symptom, because usually symptoms or something that you notice and you feel, but you can have elevated insulin, which then that can lead to weight gain in PCOS, but that can also lead to a risk factor or an increased risk factor for insulin resistance, pre-diabetes and eventually diabetes type 2, depending on the person.

Dr. Maki: Right, right, and that’s where it gets complicated, right? Because on the surface this is viewed as is a female hormone problem, but it’s a little more complicated than just estrogen, progesterone. Once that insulin level gets a little bit out of control, now it starts having an impact on the androgens– DHEA and testosterone, and that’s where all the symptoms manifest on the surface.

Whether it’s weight, whether it’s the hair growth that we talked about, or the big one we mentioned early on, is the fertility issues. This is the number one reason for women to have fertility problems, and you and I are not fertility doctors, but I don’t think fertility doctors necessarily work on the PCOS part.

Their job is to try to help women get pregnant, but they kind of ignore the PCOS, and if you don’t really deal with or take care of the PCOS part, getting pregnant it’s going to be a lot more challenging, a lot more difficult.

Dr. Davidson: Exactly, I mean, that’s their job. Fertility experts are working on having you make a baby, but at the same time, the reason there could be an issue in not conceiving is because of PCOS. Now, that’s what also I’m gonna say again, a lot of doctors will diagnose you as PCOS if you haven’t gotten pregnant in six months to a year.

They’ll say, “Oh, but you got PCOS”, without doing any diagnostics, without looking at any other symptoms. It’s just, “We’ve been trying, I haven’t gotten pregnant, it’s been ten months”, so that’s immediately what they tend to jump into, and then they jump into all the fertility meds are referring you to a specialist.

Do know, with PCOS there is a lack of ovulation, which can, of course, reduce down your possibility for conceiving, and that’s a big deal with a lot of women, is, “Yes, I’ve got PCOS, but I’m looking at possibly in the future having children” so, it’s definitely something you want to work on hormonally.

Dr. Maki: Yes, right. Definitely for couples that are trying to get pregnant and they’re not able to, that’s a really, really big deal, because there’s this pressure, there’s a finite amount of time, there’s this sense of urgency, and we always want with our patients we want everyone to be as successful as possible.

And again, sometimes the conventional approach kind of misses some of those bigger things, and that can greatly increase someone’s chances of conceiving and maintaining that pregnancy. Why don’t we go into–

Dr. Davidson: You forgot one of the most important common symptoms.

Dr. Maki: Which is what?

Dr. Davidson: Well, you talked about the high androgens, which are the testosterone and the DHEA, so you think having high testosterone is going to make you testy. Irritability is huge and PCOS, in fact, sometimes that’s the only complaint that women are really concerned about, is they can’t stand their mood.

Dr. Maki: That you’re right, yes, yes. Irritable for sure, it’s just kind of not angry necessarily but could be. Certainly have episodes of anger or rage, but just irritable at the littlest things. They just don’t have a tolerance for– now, granted, that also accounts for some other female hormone issues, but you’re definitely right, for PCOS that probably would be close to the top of the list.

Dr. Davidson: Yes, irritability, being annoyed at things that possibly don’t warrant that level of being annoyed at.

Dr. Maki: Yes. Now, granted, that maybe just personality, that might not necessarily be a hormonal problem, but a lot of times in the people that we deal with, it ends up definitely being hormonal problem. It gets better, right? Your mood lightens up, there’s a reduction to some of that irritableness on a regular basis, if that’s even a word. Then women tend to mellow out a little bit, which is good for them and for everyone else around them.

Dr. Davidson: Exactly so, now, we kind of went over the symptoms here with PCOS or some of the most classic ones. Like, I said, to have PCOS doesn’t mean that you have all of them, but you can have some of them. The next part, I think, especially when you’re talking to your doctor and your doctor says, “Hey, you have PCOS”, is to find out, well, of course, “Are you basing my PCOS diagnosis on just my symptoms or also on some lab tests?” We want to go over some of the proper lab tests that you can do for PCOS and how to interpret them.

Dr. Maki: Yes, right. Honestly, we deal with hormonal problems all the time, that’s pretty much what we do. For any menstruating-age woman, we’re always running these exact same tests, and when we’re preparing for this episode beforehand, we kind of realize, without realizing it, is that a lot of times, even if you go see a gynecologist, these tests might not be run until way later.

They’re not necessarily part of initial workup, unless you’re going to see someone that actually specializes in PCOS, which I don’t know if gynecologists specialize in PCOS necessarily, our primary care doctors. Certainly functional medicine-minded doctors that deal with women’s health issues, it’s going to be at the top of their list or at least on their list, because this is a relatively pretty common problem.

If it’s 10 to 15%, I think the number is, of the female population– I think the percentage is even higher than that, that’s going to equate to millions of millions of women across the country that are dealing with this, and not to mention around the world that have this kind of a problem.

Dr. Davidson: For me one of my favorite tests to do– granted, it’s a blood test, is to do the FSH to LH ratio. The FSH stands for “follicle stimulating hormone”, follicle-stimulating hormone, and the LH stands for “luteinizing hormone”, and they’re not really hormones but they’re, as they say, stimulating hormones that are coming from your pituitary, and they’re monitoring the overall hormonal activity in the body.

Don’t fall asleep here, I know I’m saying a lot here, but to back up, I do an FSH and an LH. Commonly your gynecologist will run an FSH. It tells you where you are, quote-unquote, “anywhere near menopause, anywhere near perimenopause or nowhere near either”, but a lot of times they don’t run the LH, and what you find in PCOS is the LH, the luteinizing hormone, is at least double or more than the FSH.

For example, I do FSH and LH, and my LH is 16 and my FSH is eight. That weren’t looking into a possible diagnosis for PCOS, granted, taking all the factors into consideration, or even in LH that’s 32 and their FSH is seven, then that LH is really high, or in LH at 12 and the FSH is at six. You’re seeing this pattern of the LH being double or more than that FSH, and that really does point to looking into PCOS.

Dr. Maki: Yes, right, and that ratio certainly does play out. Now, the next one, of course, we’ve already mentioned, but this is maybe more of the classic or the conventional, which is DHEA sulfate, not just plain DHEA, but DHEA sulfates or DHEA-S, which is just a metabolite of DHEA, and then of course testosterone.

Both of those numbers can be either both elevated, they both can be high-normal and still have the same situation. It may come back normal, within the reference range, but it might be on the high end of those reference ranges, but yet all the physical symptoms are still present. You combine that with the ratio you’re just talking about, and now it kind of paints a lot of a different picture.

Let’s go through the reference ranges for those two. For a woman, testosterone, two to 45, right? What would be a number on that testosterone where you start to maybe suspect that they’re on that spectrum?

Dr. Davidson: Right around 35 and higher. Granted, two to 45 is a huge reference range and it’s kind of pathetic that a female could be at 3 and be normal and could be at 40 and be normal for their testosterone, so yes, like you said, take into consideration the symptoms, but when you see 35 or more, you start thinking, “okay, this person has a little bit elevated testosterone compared to the rest of the population”, that we want to look at that PCOS.

I see a lot of teenage girls and their reference ranges are different pediatric, but they might be at like 30 or 35. I definitely, on teenage girl, when I see that, we want to jump into it and look at a little bit of PCOS, so we can work on that now rather than later when they’re older.

Dr. Maki: Yes, because of what PCOS is, the fact that it is what we would consider to be a metabolic hormone issue, a primary metabolic hormone problem, it tends to get worse over time. In the early stages, as a girl as in her teens or early 20s, by the time she’s 30 or 35, that problem has gotten way worse, because the time that she has gone through and life she’s living, and the stressors and all the different things, that hormonal issue tends to compound on itself.

The more time that goes by, in some ways, the harder it is for that problem to be resolved down the road.

Dr. Davidson: And the DHEA, which is an androgen, DHEA comes from our adrenal glands, mainly, and its job is to convert into testosterone, so it’s another way that we make testosterone is by way of DHEA, so you definitely want to check the DHA but, as Dr. Maki said, we want to check the DHEA sulfate because that’s a metabolite of DHA and it is a little more specific to understand if someone has elevated levels of DHA. Now, I’m getting the reference ranges like testosterone are huge, DHA is highest when we were young and that does down with time as we get older, so you want to take that into consideration but normally you will see with PCOS a high normal DHA sulfate, if not over the edge of normal.

Dr. Maki: Yes. So let’s say, a DHA reference range for a 25-year-old woman is probably 40 to 280, something like that, again, kind of just a ridiculous reference range. But rerun these numbers on pretty much all aged women because DHA sulfate also is a really good way to get an idea of what their adrenal status is because DHA is made in the adrenal glands and sometimes, depending on the woman, depending on the situation, you might think that it’s going to be an elevated number or high normal number and then it’s really low. You might see a number for a woman that you would expect it to be maybe 250 plus and it ends up being less than 100, but for PCOS that number is going to be definitely above the reference range or at least high normal so we like to see it for most age women somewhere between, would you say, 125 to 175?

Dr. Davidson: It does depend on the female but usually right around 150 because sometimes when it does get a little bit higher, you do notice acne. People always think of acne being caused by testosterone. I find DHEA causes way more acne than testosterone ever does. In fact, I’ve had plenty of patients that I’ll tell them, “Here, you need to take 5 mg of DHEA, maybe 10 mg, because we need to work on your adrenals.” They go home, or they go to Whole Foods, or they go and take their husband’s DHEA and it’s 25 or 50mg and when they come back to see me their face is covered in pimples, it’s really common, because DHEA will cause acne.

Dr. Maki: And then you do their follow-up blood tests and their DHEA is like 400. So for a menstruating woman that really wouldn’t be a good idea, that could easily kind of shut your period off because that’s what we’re talking about. If you’re supplementing for a menstruating woman you want to be a little careful with those androgens, for a woman that is no longer menstruating, she’s in menopause or has had a hysterectomy, you can get away with a little bit of a higher DHEA level and in some ways that can be very beneficial. But those cosmetic issues it can exacerbate the hair loss, it can exacerbate the hair growth and it can definitely, like you say, kind of aggravate the skin a little bit and no women wants any of those things.

Dr. Davidson: And especially if you have PCOS and you’re making more DHEA, so it’s not like, “I can stop taking my supplement, my skin clears up.” They’re making too much DHEA, they’re making in there, having the cystic acne which tends to be on the chin, in the jawline, that’s probably more specific where they get that acne, then they don’t know what to do. There are definitely options but that DHEA it’s a fine line.

Dr. Maki: Yes. Now, this is a female hormone issue so, of course, it would make sense to consider doing estradiol or estrogen, usually in the form of estradiol. We don’t do total estrogen. We don’t really find that to be a very useful test at all and then, of course, if I had to pick between the two of those I’d say probably more progesterone than estradiol. But the day of the month you’re not cycling then it’s really not important to do because that kind of tells us already if you’re not having a regular cycle, if you haven’t had a period in six months we already know your estrogen levels on the low end because, otherwise, you had a cycle already. But the day of the month if you are having a regular cycle either day 12, which is the peak of estrogen, or day 21 which is the peak of progesterone, we prefer day 21, but either one of those or at least close to those days would be beneficial to know because then that will also dictate the FSH and LH numbers as well too.

Dr. Davidson: Yes. So you don’t want to just do one of these tests. I’m a doc and I’m testing you for PCOS, I’m not just going to run the testosterone and that’d be it, you have to have the whole gamut. As I said, a lot of women with PCOS might miss a few months or their periods are irregular and they’re missing one month, three months, six months, you still want to do that progesterone because progesterone comes up only if you ovulate pretty much so, if you’re not ovulating, then you’re not can be making progesterone so, you do want to do that progesterone but at the same time you want to pair it with that FSH and LH at the same time, and then do the DHA sulfate with the testosterone. It’s not like one’s better than the other, you really want to have the whole picture.

Dr. Maki: Yes. Now, we’re not really big fans of cholesterol in the classic sense of statin drugs and lipid management. However, the cholesterol profile can be very helpful when you’re looking at some of these things and definitely, probably the number that we think is the most important of that profile is your triglyceride level. A reference range is anything less than 150, we prefer them to be less than 75 so the lower, the better. But the reason why the triglycerides are significant is because they’re directly correlated to insulin status, so the more triglycerides you have we can infer that your insulin is a little bit about auto whack and that’s really kind of the underlying issue of the PCOS in the first place.

Dr. Davidson: I kind of call it the triad. With PCOS you’ll see high triglycerides, you’ll see the elevated insulin and eventually, you’ll see the elevated glucose, so those hence the triad, the three. Those are the three main players that you’re looking at, especially when you’re looking at insulin resistance or that risk for diabetes type 2.

Dr. Maki: Yes, right. As that insulin tends to become more dysfunctional or imbalanced than your testosterone, it will eventually rise at some point. But that might not be the first step in that process, there are other things that are going on there and that’s why. If you just look at the DHEA or the testosterone, one or the other, you might miss some of these other clues that are giving you an idea of what’s going on, because you and I both know that, of all the pages we’ve dealt with over the years, even PCOS, every other hormonal problem for that matter, it never shows up with the exact way that the textbooks tell you, right? just never. You can see ten people that have a diagnosis of PCOS, you look at their lab work and you’ll see ten different sets of laps, they’re always different, some will have a high testosterone, some will have a high DHEA, some will have both of them elevated, some of them will have normal triglycerides, another person won’t so, piecing those little things together and they tell you a little bit of a story about what’s going on with that particular patient.

Dr. Davidson: Exactly, not only is the labs helpful in, quote-unquote, diagnosing PCOS, but it’s also helpful in having to treat PCOS. I had one teenage patient the other week and her testosterone is actually pretty low, it’s down there at 19, but her insulin is so high, it’s up there at 22.6, so that’s where we’ve got to focus on that insulin. And you’ll see that in other patients where that’s reversed, their insulin was a little bit lower, maybe about 9 or 8 but then their testosterone is up at 55, so you got to take that patient and treat them differently than the other one. This is definitely more of individualized medicine but you want to have this data so that when you help treat them, of course, the proofs in the pudding, they feel better but then you run the lab work again to see if you’ve had any changes with that objective values.

Dr. Maki: Yes, because month-to-month minus, let’s say, a woman that is not having appear at all since she gets period back, that’s great, but there might not be a lot of changes month-to-month for a while. The woman might not be experiencing anything and they get a little frustrated or they might get a little bit demotivated, they get upset because their bodies are not changing as quickly as they want to but now, you look at that objective information and say, “Your insulin is gone from 22.5, now it’s gone down to 15.5, it’s gotten down to 14.” Or preferably it’s less and where we want to see insulin is less than 5. Another example of a ridiculous reference range when it goes from 2 to 20 on a reference range and we think as other doctors like us think that that number ideally should be less than 5 on a consistent basis. And really the insulin, as we talked about, the confusing part most doctors won’t even run a fasting insulin, conventionally, if you’re part of regular insurance-based medicine, they will not even run your insulin level unless you ask and if you ask them to do, what they’ll say, “That’s not necessary.”

Dr. Davidson: But there’s a lot of people that have good relationships with their primary care physicians that they may run it, so it’s good that you know this so you can go to your doctor and tell them, “I really want this run.”

Dr. Maki: Yes, right. Even you and myself, we tend to get a little stuck in our ways, we try to be as progressive as possible and always trying to expand, grow our expertise, and help our patients, but at the same time doctors in general get a little bit habituated to what they do and the way medicine is done, it doesn’t evolve very much so you definitely have to be an advocate for yourself. We think these are important because these are the things that we see all the time and you need to see all of this collective information to be able to make the right decisions for your patients.

Dr. Davidson: Exactly. One really important thing, if you’ve been diagnosed, or you think you have PCOS, or you’ve been told you have PCOS, is you want to ask your doctor about your thyroid function because thyroid and PCOS go together very hand in hand. When the PCOS hormones are a little bit not balanced well, that testosterone is up, the DHA sulfates up, that progesterone is really super low and then the insulin is elevated, that can put a huge burden on the thyroid and then it reduces the function of the thyroid which then you’re down the rabbit’s hole with a whole bunch of other symptoms, or the low thyroid can actually exacerbate a lot of the PCOS symptoms.

Dr. Maki: And one of the best ways to have an impact on the female cycle is via the thyroid, especially when it comes to fertility. I mean, if pregnancy is what your ultimate goal is, and for a lot of women it certainly is, then the thyroid function has to be not just normal. You can’t look at a TSH and see someone’s thyroid is fine when it’s 2, 2.5, or 3.2, those numbers really need to be optimized because it will greatly increase their likelihood of getting pregnant.

Dr. Davidson: So the best test, we think, to really have a quick look at that thyroid function is to do the TSH, the thyroid-stimulating hormone, just like the follicle-stimulating hormone. It’s a stimulating hormone that comes from the brain and it monitors your overall thyroid level in your body. Like Dr. Maki said, you never want to base someone’s thyroid function or someone’s thyroid medication dose on a simple TSH test but, a TSH is important to have along with a free t4 and a free t3. Free hormones mean that they’re bioavailable, that they’re ready for use, so you don’t want to do the total t4 and the total t3, is just not specific enough. Just like the total DHEA or total estrogens, it’s not specific enough, you want to get more specific so to really test that thyroid function, TSH, free t4 and free t3.

Dr. Maki: We could probably throw on there, to be honest, just to be thorough, we could throw on the Hashimoto antibodies especially if fertility problems are present, that’s a really common reason. Literally 70% of hypothyroid cases are Hashimoto type so we could easily put those on, especially if it’s a screening test and you haven’t necessarily been told before whether you have Hashimoto’s or not, it should be definitely evaluated.

Dr. Davidson: Of course, probably one of the most important things to ask your doctor if you’ve been diagnosed with PCOS is, “What are some healthy options to help with my symptoms? What are some good treatment plans?”

Dr. Maki: Now, that’s kind of a loaded question because unfortunately, and this is part of the reason why we’re doing this, we know how the conventional system works and what they do. I mean, honestly, most of the time its birth control pills and/or maybe metformin. Metformin is a diabetes medication that is for the most part supposed to help with insulin sensitivity, which in theory makes a lot of sense, but not necessarily enough to completely change that situation.

Dr. Davidson: Yes, it’s not, “One pill fits all.” It’s really more of looking at it from a full approach, you want to look at the supplementation, you want to look at the dietary, you want to look at the lifestyle and then possible prescription options for PCOS. As Dr. Maki said, metformin can be a great medication for the particular individual when you’re also implementing it with other dietary or lifestyle. So, as Dr. Maki said, if a doctor tells you, “Here are some birth control pills and go on a diet.” That’s probably not the best option you want, not that they’re not trying to help but and not that primary care physician should be the jack-of-all-trades because they’re really not, but at least be able to help you find a specialist, or a nutritionist, or functional medicine doctors so that we can all work together as your healthcare team.

Dr. Maki: Right. Now, the other part of that is, like you said, you can’t just take a couple of medications. Now, one that we do actually use quite a bit for a situation like this is spironolactone. Spironolactone actually is a diuretic as a class of drug but it can actually have a really good impact on lowering testosterone levels which can help that situation in the short term. We both wouldn’t necessarily agree that it’s going to be a long term treatment by any means, and it’s usually for the most part fairly well tolerated and it can get those testosterone levels down fairly quickly while you’re working on the other things, lifestyle and supplementation things at the same time.

Dr. Davidson: Exactly, because we work with a lot of women with PCOS, especially with getting pregnant, and once they get pregnant they wouldn’t want to be on their spironolactone or whatnot, then we make a whole new treatment plan once they’re pregnant to work with the pregnancy. So, I guess, it really does come down to just work everybody as an individual, we’re a unique individual so where you are on that spectrum of PCOS is going to determine and what your goals are is going to determine where we’re going to work with.

Dr. Maki: Right. Now, one thing I do see a lot, especially when it comes to the weight side, we’re going to talk a little bit more about this in some other episodes coming up about weight in general but, I do see a lot of women that have PCOS or, at least on the spectrum of PCOS, it’s not an all-or-nothing, kind of a syndrome, there’s definitely a low moderate and a high level of severity of PCOS which we’ll definitely be talking more about that later. But I do see a lot of women that are doing the classic eating less and exercising more, you kind of alluded to earlier, so they’re going on a diet, starving themselves and exercising a lot, and sometimes with PCOS that can actually make the situation worse. It can drive up those hormones, it can exacerbate the whole situation. It is not about as they say, “No pain, no gain.” It’s about take more of a gentle approach and understanding how the hormones are affecting you and now you’re able to follow a strategy that is, one you’re going to be fairly easier for you to manage your overtime and then, hopefully, you’re going to get better results without having to necessarily work so hard on a week to week basis.

Dr. Davidson: Exactly. We have another podcast that talks about exercise and weight loss and whatnot, also definitely lots of blogs and articles about that as well, but we really just want to help you a little bit with what questions to ask your doctor because, a lot of people have lots of doctors all over the country that, sometimes, they get lost in a fold and they don’t really know what to really ask a doctor. Like I always say, write a list of your questions before you walk in because the second you get into that office, you’re going to blank, so write a list ask, “Does my blood testing reflect your diagnosis of PCOS?”, “What symptoms are you referring to that would be part of my PCOS?”, “What are some healthy options and treatment? And if you don’t quite know, which is fine, you have somebody can refer me to that can help me with my diet, with my supplements, with my lifestyle, with my exercise?”, “What possible prescriptions can I take and are they going to be safe? Are they going to be effective?” And then, most important, like I said, the thyroid function is huge with the PCOS and for a lot of women, the fertility is huge for them, too.

Dr. Maki: This is a complicated issue, there are lots of nuances to it, there is not really one way to treat someone. Like you said, it definitely takes a lot of an individualized approach [inaudible], there are some common things there and it tends to be similar from one person to the next but definitely it needs to be more than just take a couple of prescriptions and off you go, there are more tools than just that. Hopefully, this is giving everybody some insights if you are dealing with this or you are thinking you may have an issue or if you have really been diagnosed yet just know that it is not black or white either, it’s not just what you have and you don’t, there are definitely some shades, some absolute shades of gray there, and that’s the point that we are trying to get across, is for you to understand that are shades of gray and you might be on that spectrum somewhere and it gives you, at least, some more insight and you can advocate for yourself. Dr. Davidson, do you have anything else to add?

Dr. Davidson: No, no, this was really great. I hope it helped everybody, and if you have any questions, please, please, reach out.

Dr. Maki: Alright. Until the next time. I’m Dr. Maki.

Dr. Davidson: And I’m Dr. Davidson.

Dr. Maki: Take care, bye-bye.

Dr. Davidson: Bye.

The post Questions to Ask Your Doctor About PCOS | PYHP 060 appeared first on .

Perimenopause, Why Am I Gaining Weight? | PYHP 059

Dr Valorie Davidson and Dr Robert Maki — Thu, 05 Sep 2019 18:58:40 +0000

This is one of the top concerns of women in Perimenopause. Perimenopause usually occurs in women between the ages of the late ’30s to late ’40s. An important note here is, Perimenopause is not Menopause. And while both Perimenopause and Menopause may have some of the same symptoms. There are also many differences between the two. It is of value to know this because treating and working with Perimenopause can be quite different from Menopause. The hormone changes in Perimenopause can cause a lot of unwanted symptoms. If you are interested in more in-depth information, and healthy options to deal with Perimenopause, check out our course, The Perimenopause Masterclass.

But for this podcast, we focused on the unexpected, unearned weight gain that can happen in Perimenopause. In Perimenopause, it is common to hear women complain of feeling like they have gained 10-20 pounds almost overnight. They are stumped because they are unsure of where his added weight came from. We have many patients exclaim that they have not changed their diet or exercise routine, yet keep putting on weight. And this weight gain is almost always focused in the stomach and waistline. I cannot tell you how many patients I have had that say, they have never had a belly before. And now they have grown a gut for no reason. Well, there is a reason, it’s your hormones.

What do women do when they start gaining weight?

Common response to weight gain is to eat less and exercise more. Bluntly put, this is the wrong response. There might be an initial drop in weight when you restrict your food and jump on the treadmill. But more often than not, in Perimenopause, restricting your calories and increasing your exercise will either result in no weight loss or even more weight gain.

But this is what we have always been taught.

Less calories in + exercise(calories out) = weight loss.

Well, maybe in your 20’s this might work. This will not work in your 40’s. There is nothing more frustrating than to workout like crazy, eat like a rabbit, and not lose weight. Not to mention this not a realistic way of living. When you start to eat like a normal human, you will gain the weight back plus more at a rapid pace.

Why doesn’t eating less and exercising more in Perimenopause not work?

It is about the cortisol-glucose-insulin love triangle. Yes, it is like an awful drama that results in the fatty belly that you never had.

When you do intense cardiovascular exercise, it will raise your cortisol. When cortisol rises, it will mobilize glucose. When glucose rises, then your pancreas will release insulin. Insulin is a fat-storing-hormone in the body.

This is really the real deal. You are doing some crazy intense, cardio exercise. This will cause your adrenals to increase cortisol. The cortisol will then mobilize glucose from your large muscles, such as your gluteus (bum) and quadriceps (thighs). The increase in glucose will cause your pancreas to pump out insulin. The insulin opens the door cell and allows glucose to enter. Now the glucose that is mobilized from your muscles gets turned into fat. That is why in Perimenopause, you will see a change in body distribution. The thighs and bum shrink and the belly grows.

If I can’t do cardio exercise, what do I do?

Resistance training and building muscle is the best thing you can do for your metabolism. No, cardio will not build muscle. By working on resistance training builds muscle but not increase your cortisol or insulin. Hence, building muscle will blocks that cortisol-glucose-insulin response that cardio can cause. The result is less belly-fat.

Another awesome form of exercise is walking. I know, Dr. Maki says that walking is not really exercise. But that is where we beg to differ. Walking is great for the adrenals. It is not stressing the adrenal by releasing a bunch of cortisol and glucose. It is great for bone density and all the muscles in the body. Not to mention, walking is very relaxing and is a great way to focus on yourself for a moment as opposed to focusing on all the commitments and demands made of you.

If I can’t starve myself to lose weight, what can I do?

Eat more. Don’t freak out, eating more calories will increase your metabolism, reduce cravings, balance your blood sugar, and help your hormone imbalance in Perimenopause.

You need to eat more. What? If I eat more, won’t I gain weight? No, in fact, eating less can slow your metabolism and make you gain weight. That doesn’t mean, lets hit up Crispy Creme and mow down on donuts. But eating more by balancing your macronutrients, such as protein, complex carbohydrates, and healthy fats. There are so many diets, weight loss plans, food options for healthy eating. I know the vast information on the many diet plans out there can be overwhelming. We do feel that balancing your macros and incorporating a ketogenic diet with carbohydrate cycling with intermittent fasting is a great way to lose weight in Perimenopause. I know that the last sentence was a mouthful.

We have written a program that is realistic to follow to help with Perimenopausal weight gain. We call it the Keto-Carb-Cycling-Program (KCCP) and it is a free download on our website and included in the Perimenopause Masterclass. This will give you so much more information on what hormones are involved with weight gain and weight loss. There is also a program to follow to help you lose weight in a healthy manner.

Sleep!

Yes, sleep is super important for your weight. A lack of sleep is the best way to gain weight, especially belly fat. Unfortunately, in Perimenopause, you can have a really difficult time staying asleep. This is also one of the most common complaints of Perimenopause. No trouble falling asleep, but a horrible time staying asleep. This lack of rested sleep, not only makes in Perimenopause tired during the day but will help cause the gut. One of the first things we address in Perimenopause is sleep. Not with sleeping meds or habit-forming medications. But address with nutritional, lifestyle and supplementation components to help you stay asleep in Perimenopause.

I know we talked about a lot of information here. Perimenopause can really disrupt your hormonal balance causing a lot of unwanted symptoms. In this podcast, we only addressed the weight gain associated with Perimenopause. If you have more interest, please check out our Perimenopause Masterclass for more options and information. Hope you enjoyed the podcast!

PYHP 059 Full Transcript:

Download PYHP 059 Transript

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 in this episode today, we are going to talk about weight gain, you know- weight loss. But specifically in women that are in perimenopause.

Dr. Davidson: So perimenopause, of course, as it sounds is right before menopause. But it’s actually a really underserved, I guess, age demographic. Because perimenopause can be anywhere from your late 30’s to your late 40’s, because typically menopause is supposed to be in a perfect world at 51 and a half, so a lot of women can deal with these perimenopausal symptoms, one of them being in particular which is probably the number one complaint in perimenopause, is the weight gain. Women say they feel like they gained 10 to 15 pounds almost like overnight.

Dr. Maki: Yes, right. They’re just- life is the same. They’re still just kind of doing their thing. And before they know it, they get this weight particularly around the midsection`, right? Women don’t typically develop spare tire necessarily, and also they have this weight that they can’t get rid of. And regardless of what they do to try to lose the weight, the weight just keeps- either it doesn’t budge, doesn’t go down, or the weight just keeps going up over time.

Dr. Davidson: And of course, people try to chuck it up to say, “Hey, you’re getting older. This is supposed to happen.” Well no. It’s not supposed to happen and why did it all of a sudden happen? Because I’ll have women- and this is so true, will say they have never had a belly even when they were pregnant. Afterward, they have never had a belly and now they literally have this belly fat that they don’t know where it came from because the diet hasn’t changed, the exercise regime hasn’t changed. If anything, I have women in perimenopause that try to do the opposite way, which we’ll get into. And be very strict with dietary and exercise. And if anything, it doesn’t go away or they gain even more.

Dr. Maki: Yes, now. The reason why we’re going to talk about this is that this is of course, a very common issue that women are having. But a lot of times, the strategy that people are employing to lose the weight actually ends up making the situation worse. And this is something that we see all the time, so we felt like it was a good idea to deal with it contrary and from our observation of what we see people are doing to try to lose that weight, in some ways they’re doubling down. But they’re doubling down in a way that actually makes them end up gaining more weight in the long run.

Dr. Davidson: Exactly. And we get it. Putting on weight when you didn’t even earn it is not fun, and a lot of women- these perimenopausal women are super healthy. It’s not like the way it is causing them ill health, but they might go to their doctor, they go to their GP, gynecologist, they don’t have any answers for them. They’ll say, “Oh, you’re just getting older. Your blood work looks great.” But it’s not fun to feel like you’re gaining 5 pounds every few months. Then all of a sudden, who knows when is that going to stop. It’s kind of terrifying sometimes when you feel like you have nothing to stop it. So of course, when you think about gaining weight, what do we all learn since we were kids, was just stop eating.

Dr. Maki: Yes, right. The proverbial eat less and exercise more–

Dr. Davidson: Which is terrible advice.

Dr. Maki: Which really- the take-home message for today is that eat less, exercise more idea really does not work. Okay? Because that is the approach that almost all of our patients come to us, utilizing that strategy trying to lose weight. It worked when you were 25, right? It certainly- and you can eat just a little bit less, exercise a little bit more, and your body will respond appropriately. But once you get to quote and quote, literally perimenopause, there are some physiologic changes that are happening- inevitable physiologic changes. Your body is producing less of very particular hormones that buffer the stress that we all would agree, more than likely, that we have more stress in our mid 40’s than we did when we’re 25. But we don’t have the hormones to buffer that stress. So now that, the things that we are doing as we talked about in the last episode, the things that make us not sleep very well, kind of get magnified a little bit, and now our bodies just don’t really- are not as resilient as they used to be.

Dr. Davidson: Exactly. And it really is about those stress hormones having an impact because you don’t have some of the reproductive hormones that you did when you were on your 20’s. And granted, sure, there’s a lot of different kinds of stressors when you’re in your 40’s than you did when you’re in your 20’s, but, you know? I have a lot of women in their mid to late 40’s and they’ll say, “I don’t know what’s wrong with me, because my life is actually better now than it was 15 years ago when the kids were young and I had to work full time and I was getting a divorce. My life is so much better now, but I feel so much worse.”

Dr. Maki: Yes, right. Yes. Some of that maybe, a little bit, as we’re talking about, a little self-induced. Not that they create their own stress, but their ability to handle the stress is so much less. So they feel more stressed or more overwhelmed and that’s because of the inevitable hormonal decline, particularly in the beginning of this process. Like you said, late 30’s to early 40’s is when you start losing some progesterone.

Dr. Davidson: Yes. So really, not to get into too much physiology here so you don’t get super bored, is when we make estrogen and progesterone- we’re females. We make estrogen and progesterone. Men do too, but we make a lot of it. But we cycle it, which is why you get a period every ideally 28 days or whatnot. But the progesterone is what drops first when you hit perimenopause. So everybody knows about menopause. Menopause, the ovaries have decided to retire, they justly deserve have got to retire. They’re not making any more estrogen and progesterone, but in perimenopause, it’s a little bit different. Because you’re still cycling, if you have a uterus, you’re still having a period. But you’re just not making as much progesterone if anything, a lot of times, the progesterone is almost non-existent in perimenopause.

So as Dr. Maki said, having changes in those hormones doesn’t allow you to buffer some of those stress hormones, so things seem like they’re way more chaotic than they might be. Because I have a lot of women that say, “I don’t know why I don’t feel well given the circumstances really aren’t that big a deal.”

Dr. Maki: Yes, right. Now, we’re not blowing people off like a lot of times women go to their gynecologist, to their primary care, or whatever. They get blown off a lot, right? Because those doctors, unfortunately just don’t have the tools to be able to help them effectively. So in some ways, and we’ve heard this from a lot of patients, they kind of blame it on the patient like it’s the patient’s fault. Right? Or on paper, on a lab test, because that doctor does not know how to interpret the lab test, then there’s nothing wrong with them. Because they don’t class- perimenopause, unfortunately, is not a disease, right? It’s this limbo land, as you always call, the limbo land of hormones where women- there are millions of women across the country that are in this demographic. But really, there are very few practitioners that know how to effectively help them.

Dr. Davidson: Exactly. And especially with the weight gain, when you look at people, there are some not so great weight loss medications out there that you wouldn’t want to take. But who are the women that are taking them? The women in perimenopause. Because that’s when they feel like they don’t have any control over their metabolism and how to stop this weight gain. So like we alluded on, we said the worst advice in the world is what we learned when we were kids which was you can’t under-eat and you can’t over-exercise. Because that’s just going to exacerbate that whole hormonal cascade of particularly- one hormone in particular, is that cortisol, or as we always call it, kind of the cortisol insulin interaction.

Dr. Maki: Yes, right. Cortisol is where that a midsection, the muffin top, the spare tire, the belly fat that nobody wants to develop, it’s happening because of cortisol. Your body literally is redistributing fat, and it’s all happening because of the stress response. Now if you take that eat less, exercise more approach, and we talk to women all the time, they’re trying to exercise three to six times a week, but yet their bodies are not changing at all. If some cases and this is an observation or reflection for a lot of you listening, if you’re exercising multiple times a week and your weight has not changed in the last 90 days, then you need to reevaluate your exercise strategy. All right? If your weight is not budging based on your dietary and your exercise regimen, if it’s not changed at all, then you need to reevaluate. Because- or if during that same time frame, if your weight has gone up during that same time frame, so you’re technically eating at a deficit and expending a bunch of energy on a weekly basis, your energy balance is completely off. You’re just exacerbating this cortisol response and really in a sense, you’re making the problem worse.

Dr. Davidson: Exactly. Now there’s lots of hormones and you’ve probably had Googled them, read them and heard about them. With leptin and ghrelin and as we’re talking about insulin and cortisol. So not to bore you with the physiology, but we really feel like when you’re doing that intense cardiovascular exercise so frequently, is will raise up your cortisol. And of course, what does cortisol do?

Dr. Maki: Cortisol- by category, cortisol is classified as what they call a glucocorticoid. Gluco meaning glucose or blood sugar. Cortocoid meaning, cortical steroid, because it’s

made from cholesterol. All hormones that are made from cholesterol, which is cortisol and all the sex hormones are made from cholesterol. That’s what makes it a cortical steroid. Its job in the body literally is to raise blood sugar. Okay? As we’ve talked about on another episode, you go to exercise trying to lose body fat, right? And you go to exercise, your cortisol goes up because your brain thinks that you’re starving to death and running from a tiger. Now, as a result of your cortisol goes up, it tells your liver as you mentioned a minute ago, gluconeogenesis- I think that was maybe, you mentioned gluconeogenesis in the last episode.

Gluconeogenesis is where your liver makes blood sugar, and as a response to the rise in blood sugar, now your pancreas has to release some insulin. But now, you’re in a situation where you don’t really need any of that extra energy, so now your body has to do something with it, and now it redistributes that blood sugar and stores it as fat around the midsection.

Dr. Davidson: And the same thing happens with stress. One thing with estrogen and the progesterone, when the progesterone drops in perimenopause, the estrogen really doesn’t drop a lot. But it can drop a little bit. Actually you’ll see in a lot of women’s- one month it drops, the other month it goes through the roof. It can- estrogen is the best hormone in the entire world, but she can be like a runaway train. So when you don’t have the progesterone reining that negative effect of estrogen, that can actually exacerbate feeling moody. So you feel irritable, you feel moody, and then you get stressed out really easy, which again when you get stressed out, what does that do? It raises up your cortisol.

Dr. Maki: And if you think about it in our late 30’s to early 50’s, that’s when we have real responsibility. We have jobs, we have families, we have mortgages, we have taxes. We have all the things that make us stressed in America. When we’re 25, we have all the hormonal capacity to handle lots of stress. We don’t really have stress. I mean we do, but not nearly compared to what it is to have the adult responsibilities. And then in order to try to lose weight, we stress ourselves out even more. And then as we’ve been talking about in perimenopause, sleep quality becomes affected as well. That’s why we said in the last episode and we reiterate it here, that your number one thing, to try to lose weight is improving your sleep quality. Whenever we work with a new patient, our first month is devoted to really get them sleeping better. Because if you’re not sleeping well at night, losing weight is going to be next to impossible.

Dr. Davidson: Which is a huge issue in perimenopause, is having trouble staying asleep. Either you’re waking up multiple times in the night, or you’re waking up for a good solid hour to two hours in the middle of the night, and by the time you can fall back asleep, it’s timed to actually get up for the day. So that is probably number one. And that again is about that cortisol. Because the cortisol’s coming up in the evening and then it’s staying down to low during the day, which is why you’re trouble staying asleep at night but then also feeling tired the next day.

Dr. Maki: Yes, right. So that kind of cycle just really starts to ingrain itself and the body gets really good at what it’s forced to do all the time. So, when you’re always trying to push and push and push and push and keep going and keep going and keep going all the time, the brain just gets used to that. So these patterns kind of get stuck. I know you wrote an article before about adrenal issues and you talked about the vampire, right? The proverbial night owl, the one that stays up too late, can’t get up in the morning, that’s a very classic example of this flipped cortisol curve. We’re not born that way, right? These things just kind of develop. Now, we might all have this [inaudible], we might have hot tendencies. Some people are morning people, some people are night people. But because of society, because of what we talked about last time about electric devices and lights and computers and TV’s, these things become- they just become our own patterns and we develop into them. That doesn’t mean that they’re normal, they’re not necessarily normal. We are supposed to follow a very classic circadian rhythm, we rise with the sun and go to sleep when the sun goes down. But we see these circadian rhythm problems all over the place. Everybody has them to some degree or another.

Dr. Davidson: So in perimenopause, not having those, especially the progesterone to be able to buffer that extra cortisol, that’s where that weight comes on. And it’s not a lot, it’s usually about 10 to 20 pounds. Usually the average is around 12-15, depending on the stature of the female. And it’s not unhealthy, it really is vanity pounds, your health is good, blood sugar’s good, liver function, electrolytes, all that is good. That’s why your doctor will say you’re super healthy, it’s just age. But it’s not age, it’s really your hormones.

So for example, with the cortisol, another thing we talked about is stress will make you fat. That’s why when you’re young, you have those female hormones to buffer it, but when you’re in your mid 40’s, you don’t. So you get a stressful email, yucky phone call from somebody you don’t like or some kind of stressful event happens. But it’s not necessarily a tiger chasing you down wanting to eat you. You just get some bad news, but that automatically raises up your cortisol and your catecholamines, which then, what does that do? Your body thinks you need to run away from whatever predator has assault- trying to assault you. So in that moment, that cortisol raises up, you make some glucose, the pancreas secretes some insulin, and then it takes that glucose and shuttles it into a fat cell because you didn’t run like the wind. You sat in front of your computer or chatted on the phone with that stressor.

Dr. Maki: Yes, right. So in some ways, your body is trying to save you by giving you a whole bunch of immediate energy. But there’s no energy expenditure so now your body has to deal with that somehow. And then that whole cycle continues. So, not sleeping and a lot of stress, that’s kind of a mute point that we all know. Stress causes some weight gain. But the way that people try to remedy that, their first inclination is to go exercise, all the time. I don’t know how many times I’ve encouraged women as they are trying to lose weight, in the process of it, or have failed at trying to lose weight, and they’re just so frustrated. I tell them literally, take a month off. No exercise for a month. They all get nervous, they all get a little bit panicked, because they think they’re going to gain even more weight. And I usually notice, or what I’ve notice is that they do actually gain a little bit of weight as a result of not exercising because they’ve also been under eating in that same process. That’s the number one thing that I see, is women are trying to exercise four to six times a week literally but they are under-eating in some cases by over a thousand calories a day.

So when you have this opposite end, you’re expending a bunch of energy but you are not taking in enough, that alone will raise your cortisol and that again, this whole energy balance process is literally out of balance. And it just makes sure, literally, the fat loss process by under-eating basically shuts itself off. Your body can not burn any more fat. So this is the part a lot of people have a hard time with. You actually have to eat more food in order to keep the weight loss process moving in the right direction.

Dr. Davidson: And I know it sounds- everybody gets a little wide-eyed when you say, “Oh, you need to stop exercising and eat more.” They’re like, “Well, that’s what got me here in the first place. Isn’t it?” Like, no. No, no, no. But at the same time, we don’t- we like to exercise. I mean, exercise is good for the human body. But it’s trying to back off on that intense cardiovascular exercise that raises up your cortisol.

Dr. Maki: Yes. Not only- granted, and you’re right, we’re not complaining about exercise. And general exercise has a myriad of benefits, so don’t take this the wrong way that all exercise is bad. Intense cardiovascular exercise actually also, when that cortisol rises, it actually breaks down your muscle tissue. We want an activity that encourages the preservation of muscle tissue. The more muscle you have, it raises up your metabolic rate. The higher your metabolic rate is, the more you’re going to burn fat at rest. And particularly, we end up burning a lot of fat while we’re sleeping. If we’re not sleeping, we’re not burning any fat. And now, the whole process continues in the wrong direction.

That’s why we always say that sleep is the number one point of that process because now that means your cortisol and insulin which are the two major players in that process, your cortisol and insulin are going to be in a proper balance, and it’s not going to be a runaway freight train. Partially, you have to be a little bit more- and honestly, this is probably good. Because women in America these days are- there’s a lot of expectations for women these days, right? There’s a lot on your plate, a lot of responsibility. There’s no glory in it necessarily, there’s no recognition for it, you have a lot on your plate, we’re just trying to say, “You know what? Be a little gentler on yourself. And don’t try to physically and mentally push yourself so hard all the time because you’ll get the wrong results in the long run.”

Dr. Davidson: Exactly. And one- like you were mentioning about the muscle masses, when we do hit our 40’s and later, it’s harder to preserve the muscle mass. So doing exercise like resistance training or doing some more weight, maybe not doing the running instead of doing some hiking. Something that’s going to help you build muscle is actually better in perimenopause than I think, any kind of exercise.

Dr. Maki: Yes. I would agree. Like I said, if you’re exercising a lot and you’re not sleeping well, then cut back on the exercise. Maybe do more yoga or some more lower intensity. Certainly, weight training so you can preserve some muscle mass. Maybe even gain some muscle. A lot of women I talk to, I want them to change their perspective. Instead of trying to actively lose weight, because if you’re trying to literally fix your problem areas by losing a little bit of weight around the midsection, or a little bit from your here, there, wherever, and you’re trying to lose, let’s say less than 20 pounds, that perimenopausal 20 pounds that you gained, trying to eat less and exercise more to lose that 20 pounds is literally next to impossible.

Anybody if you just change your approach a little bit and focus more on trying to build muscle, not in a bodybuilder sense that you’re becoming big and bulky, but just about your approach. So you’re not too much of a deficit, you’re doing more weight training, not as much cardio. You’re focusing on strength versus how many calories you’re burning, and I promise you in that process you will become leaner and leaner and leaner as time goes on. Because now you’re forcing your muscles to adapt. You’re raising your metabolic rate, you’re preserving your metabolic rate. Now, your body in some ways kind of burning hotter all the time, not figuratively like a hot flush, but facetiously so that where your body can actually utilize the extra energy. And now you’re going to become leaner and leaner as time goes on. So now that translates not the weight on the scale per se, but your body composition, so your percent body fat, your lean muscle mass, all those things are your- literally, weight might not change much. But your body composition could change quite a bit. That I think is a big deal. That’s how our focus should be changing over time.

Dr. Davidson: And to build muscle, we need that energy. So instead of cutting back on calories, we actually want to increase up your calories. But this would be a good point to talk about wor-. Because a lot of women ask me, “Well, what am I supposed to do? There’s paleo, there’s keto, there’s vegan, carbs with no fat-,” I can’t remember what the name of that one is. There’s this diet, they don’t know what to do which I totally get it because there’s so many different things out there. So this would be a good point and maybe finesse a little bit of that.

Dr. Maki: Yes, right. So we wrote a weight loss guide called the Keto Carb cycling program. Keto’s very popular. However, as we are talking about, one of the biggest mistakes that people make on Keto is they under eat. So they’re eliminating a whole macronutrient, carbohydrates- now granted, we do like the idea of low carb in Keto. But again, Keto is meant to be low carb, it is not meant to be low carb and low calorie. The low-calorie part is what gets everybody in trouble. Because literally, your calories are dropping anywhere from 500 to a thousand calories a day. And the body is extremely sensitive to that drop of calories over time.

Dr. Davidson: Exactly. And another part is you don’t want to be afraid of carbohydrates. People get scared of, “I eat those carbs, I’m going to gain weight.” It’s not really about the carbohydrates, of course, it’s about the type of carbohydrates. A complex carbohydrate is a whole lot different than a processed refined carbohydrate. But I don’t think we necessarily have to be afraid of carbohydrates, because if you cut your carbs down too low, that’s actually terrible for our thyroid function, it’s terrible for our female hormones, and it’s not conducive long term. So doing some kind of re-feed or as we say, we did with our KCCP, was doing a little bit of some carb cycling actually is beneficial.

Dr. Maki: Yes, right. And really, the attempt of the KCCP when we wrote it was to, in some ways protect women from themselves, right? Because that’s our patient base. And we see this mistake, we’ve seen these for years. So the Keto Carb Cycling is if you’re going to do low carbo or Keto, do it for short little increments, but then as you just said, make sure you’re adding in those starchy carbohydrates back in. The potatoes, the sweet potatoes, the yams, maybe some rice. You’re Japanese, we eat rice all the time. Maybe some quinoa, some legumes, or some beans. And all the other starchy vegetables. That’s a big difference than eating processed refined carbohydrates. That’s really what low carb is to you and I is really just eliminating the processed refined carbohydrates. That’s really what low carbo is to us.

So low carbo is relatively, literally, it is a relative term. Keto is usually when you drop your carbs on a daily basis less than 30 grams a day. That’s what a ketogenic diet is. But low carb could be anything less than 125 grams of carbs a day. Technically, I think less than 50 grams of carbs is considered to be a very low carbohydrate diet. The average American probably consumes 200-300 grams of carbohydrates a day. Now, granted if that comes from whole food sources, that’s great. That’s really, at the end of the day, whether you’re doing paleo or low-carb or vegetarian or vegan or whatever diet you want to choose if you’re focusing on whole foods- and that eating to your own level of appetite. Because when everything is in sync and you’re sleeping well, then your brain, your adipose tissue, your fat cells, and your liver, should all be able to sing in harmony so to speak so that where your body regulates itself.

If you’re not sleeping then something is off and then now, there are other signals are going to be distorted and now that energy balance is going to be wrong and now your brain isn’t going to be able to quite regulate things well, and you’re going to keep gaining weight.

Dr. Davidson: So I know that’s a lot to throw at you. But if you’re interested in the Keto Carb Cycling Program, or as we abbreviated it, KCCP, is we have an- I think we might have it in the website. I know we have it in our perimenopause masterclasses, a pdf for women to follow. But, is it on the website?

Dr. Maki: We had it up there on a like a content library then I had it set up kind of wrong, whatever. So people couldn’t download it. I don’t know. I kind of screwed it up. So, if you go to- we’ll make it available if you just go to progressyourhealth.com/KCCP, then you’d be able to download it there. Because it is good. It’s really good information. There is a section on there about calories and how to figure out where your calories are. Because like I said, everyone that I talked to, literally is under-eating anywhere from 500 to a 1000 calories a day. The average for a woman is anywhere between, let’s say maintenance calories, is anywhere from let’s say- depending on the size and the age and all that stuff, height and weight. On average, a woman’s maintenance level calorie should be anywhere from let’s say 2,000 to about 2,500 calories.

Dr. Davidson: Isn’t that wild? It works, but I know for a lot of us women, we get wide-eyed and “What? 2,000 calories?” But it does work. You’ve got to eat more.

Dr. Maki: Yes, right. And especially if you’re exercising a lot. If you’re going to a boot camp class or the spin class or this and that and you’re eating less than 1,500, you’re creating too big of a deficit and that throws off your energy balance, and literally the fat loss process basically stops. So you can not lose anymore weight. That’s why when you’re engaging in your process, whatever that is that you’re doing, you lose weight for three months and that plateaus, the plateau is a sign that your body is starving to death, and now it goes in a compensation mode, and it becomes very difficult for you from that point forward. That’s where you should actually eat more food which a lot of people do. They end up eating less food and exercising more to compensate, they’re just magnifying the problem.

And now, granted, this is not an exact science- is weight loss or losing weight, is it a calorie issue or a hormone issue? Well, I think it’s both. I don’t think you can separate one from the other because they both come into play. But eating enough food, that’s where the paradigm shift. We just think if we just eat less food, we’ll be fine. But in reality that is the wrong long term strategy. So every program in the country is always focused on the short term weight loss. Losing weight in the first six months. But every one of them is an attempt that restricting your calories. So in the KCCP, that’s why we encourage people to re-feed on a regular basis, every week, every other week, add in some of those starchy carbohydrates because that’s going to raise up your calories and it’s going to tell your leptin levels, your thyroid and all those things to maintain that you’re not starving to death and running from a tiger, and now the fat loss process can continue. It’s complicated, it’s really, really, complicated but it is not impossible.

Dr. Davidson: No, no. And we do have in that write up a little bit about all the different hormones that contribute to weight loss or weight gain like you mentioned, the leptin. We have the [inaudible] in there, the relin, the insulin, the cortisol and all that jazz, and the hormones on there. So it would be good because I do feel like people want to know what to do and have a little bit of structure which I think we all need. But we also want to learn at the same time and figure out why am I doing this. Like I mentioned, doing hardcore Keto for long periods of time will lower your thyroid function. In the KCCP, we go into a little bit with intermittent fasting, because intermittent fasting is very hot right now. Is intermittent fasting good for you? Good for other people? It can be, it just depends.

Dr. Maki: Yes. A lot of people, they interpret intermittent fasting which really at the end of the day is just a way to manipulate your calories. So even if you’re doing intermittent fasting, you can’t just eat dinner every day and think you’re doing intermittent fasting. You still have to re-feed yourself. Otherwise, you fall into the same trap of lowering your calories too much and that’s why you see plateaus in people’s weight loss journeys. Or their body just goes the other direction and now they just start overeating again, because that’s what the body’s designed to do. That’s why we’re not- our rational brains are not smarter than what the body does. The body is way too smart for that. It is designed for that food scarcity environment so it wants to protect it in every chance that it can.

Now, one other thing before we run out of time, another thing I’d like to say, is when you’re using the scale at home to track your weight loss, that is literally- and all of us know that when you’re looking at the scale trying to see if we’re progressing the right way or not, it is enough to drive you crazy. The scale goes up and down, and up and down, and up and down. If you looked at the scale every single day, some of you we know that you don’t even step on the scale because it’s too much of an emotional trigger for you to be stepping on the scale. But if you did, let’s say for 30 days or for 6 months, every day you step on the scale. It goes up two pounds, down one pound. Up three pounds, down two pounds. Down three pounds, up two pounds. It just fluctuates all the time and we never get a good gauge of what we are doing actually is working or not.

So I would encourage you in your town, in your city, the bigger city you’re in, the easier this will be to find but find a walk-in imaging clinic that has a DEXA scan machine, that’s normally for bone density. But almost all of the new generation DEXA machines can do body composition testing. Or you get literally a very accurate percentage of what your current body fat percentage is. And if you’re trying to lose, let’s say even less 40 pounds or less. 40 pounds is a lot of weight. 180-140, that’s a big deal, right? And I would say that’s probably the majority of where our patients fall into there in that 20 to 50-pound range.

Now granted, is that obesity? Maybe some, whatever. But it’s not the super-obese where they have a hundred pounds or more to lose. And if you’re using the scale to track your progress, that scale is kind of leading you in the wrong direction. So if you go to the DEXA scan place and you get a body fat percentage, check it every so often, and if your body fat percentage is going down, then you’ll know that your strategy is actually working. Then you are able to push through those plateaus, you can make that consistent body fat percentage reduction. Not weight, necessarily, especially if you’re exercising with weights, and doing what we’re talking about, the weight might not change very much. But as long as the body fat’s going down, now your body composition is changing drastically that the eat less exercise more really can not change body composition quite like that. So, that is a different perspective. You’re focusing on something else and you’re seeing true progress as opposed to being lied to by whatever your scale says on a regular basis.

Dr. Davidson: Yes. The scale is evil. Take it in your backyard and bury it and put a nice little grave, spell them. Because you’re never pulling it back out. It’s very deceiving. Especially for women, because we do. We fluctuate up four pounds, down three pounds, it changes. You can also do measurements with the tape measure. Like the bust, the arms. the neck, the quads, the belly, the hips. That’s another way to also track some progress and I have some women that they will not- they get on the scale every single day but most of them I tell them don’t get on the scale. And if you’re going to, maybe once a week or once every two weeks if you really want to see that number. But one thing before I forget is our Facebook page. I’m new to Facebook, I’m 46 years old and I’ve never had a Facebook.

Dr. Maki: You’re like the only one in America that doesn’t have their own Facebook account. You just use mine all the time.

Dr. Davidson: Just to look at things. But now, we actually have the Progress Your Health Facebook page where we talk about hormones [cross talk].

Dr. Maki: We’ve had a page for a while, we’re not necessarily too active on the Facebook page. But now we have because of the perimenopause master class, we have a Facebook group. A private Facebook group. So, it’s just called Progress Your Health, let’s talk hormones, you can search for it on there. And it’s a private group so you have to request to join and one of the admins will certainly allow you in and that’s where we discuss pretty much anything hormones. PMS, perimenopause, menopause, PCOS, hypothyroid adrenals, all these things are kind of fair game and we can all kind of congregate in one particular area. Everyone except you on the planet pretty much has a Facebook group so it will be hopefully a nice place to get to know everybody a little bit better.

Dr. Davidson: Well now I do have one.

Dr. Maki: Yes, yes.

Dr. Davidson: This one.

Dr. Maki: Right. Right. So we are probably going to end up talking a lot more about weight loss, or fat loss, or burning fat. Weight loss is kind of a challenging one, right? There’s a lot of competition, there’s a lot of misinformation out there. And just be a little bit careful with that. Take what we say with a grain of salt as well, and we just learned some things over the years dealing with our patients. But weight loss, we don’t have all the answers, nobody when it comes to weight loss has all the answers. Not even us. But there is a gap between what the research shows and what is being done in everyday life. We want to try to help kind of improve that a little bit so people are actually putting forth all this effort, they are actually able to get the results that they want without having to work so hard.

Dr. Davidson: All right. I think we’re probably good, right?

Dr. Maki: Yes. I think we can wrap this one up. So until next time. I’m Dr. Maki.

Dr. Davidson: And I’m Dr. Davidson.

Dr. Maki: Take care. Bye-bye.

Dr. Davidson: Bye.

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