Question: I get my bio-identical hormones prescribed by an anti-aging doctor and I have an OBGYN. I am 57 years old. I use a Bi-estrogen cream every day in the morning and every night. I use Progesterone cream every night. I also take a capsule of Progesterone every night and lastly Testosterone cream in the morning 5 days per week. My OBGYN says I am taking a huge amount of Progesterone and Estrogen and scared me with some of her facts.

I feel stuck in the middle due to getting my HRT from an anti-aging doctor and then my OBGYN upset at the amount I take, so I called the compounding pharmacy who said I was not taking a huge amount of any of them and actually was taking an average amount.
What is the calculation formula to see how much I am actually taking to compare to others and to be able to decide if I truly am taking too much?

Larry’s Response: I am unclear about how much of these hormones you are actually taking because I am not the pharmacist who filled your prescription. Regardless, I will attempt to address what I think is your underlying concern, whether you are taking too much or not enough hormone replacements.

Let’s start with the suggestion that bio-identical hormones are better than the commercially available synthetic versions. This is rationally true. There is no legitimate reason why a synthetic substance would be equal to or superior to something that is commonly made in the human body. Bio-identical hormones are made in laboratories, not extracted from humans. So, in that respect they are synthetic, not natural, nor extracted from natural products. However, their chemical structure is identical to human hormones. This can be confusing and even the drug companies seem to get it wrong.

There is a thyroid substance on the commercial market called Synthroid. The name suggests that it is a synthetic version of a thyroid hormone. However, Synthroid is levothyroxine (sometime called T4) and it is one of the naturally occurring thyroid hormones. Synthroid isn’t synthetic at all. It is actually one of the bio-identical hormones.

I have a long history with bio-identical hormone replacement. I have looked at thousands of saliva test results and done my best to help design appropriate replacement regimens. I bought into the idea that women actually develop an estrogen deficiency near or at menopause. I long believed what practically everyone believes. However, upon further investigation I have found that the drop in estrogen levels is not enough to cause the distress that women report. In fact, it is the decline in progesterone that causes the most difficulty because it dramatically unbalances the relationship between estrogen and progesterone.

Add to this fact the knowledge that our environment – the food, water, air, and so on – is loaded with substances that act like estrogens in the body. What are referred to as symptoms of low estrogen are more likely symptoms of estrogen dominance – normal or low levels of estrogen combined with estrogen-like toxins and a progesterone deficiency (no ovulation means practically zero progesterone).

A doctor in the 1960s published a book that described how every woman needed estrogen at menopause. The book was supported by funds from the drug company that was selling conjugated estrogens (Premarin). The premise of the book is wrong because it suggests that women are somehow designed wrong and that using estrogen supplements will correct the problems.

Mother Nature doesn’t make those kinds of mistakes and she is not likely to have set things up in a way that a woman would need horse estrogens to make up for the ones she no longer makes. That book has had a major impact on the beliefs of practically every woman and her doctors. It is from that misguided belief that proponents of bio-identical hormone replacement therapy have become popular. The basic premise remains the same – women need estrogen. Coupled with the fact that bio-identical estrogen is superior to the synthetic (horse) versions, bio-identical estrogen is prescribed. If the woman doesn’t actually need estrogen supplements, she really doesn’t need them – synthetic or bio-identical.

I continue to dispense biestrogen and triestrogen as ordered, but I am no longer convinced that the majority of women need additional estrogen – progesterone, yes, but not estrogen. I am in a small minority on this point, but my direct experience over many years shows that progesterone itself is far more important, and safe, than any other combination that also contains estrogen.

As further evidence that women don’t need additional estrogen is the history I’ve experienced with my mother, grandmother, and even my wife. Like most women of the past years, they made it through menopause with minimal discomfort. They didn’t complain about symptoms the way women today complain. Were those women stronger, more stoic, or indifferent? No. I am convinced they would have complained vigorously if they had been suffering hot flashes at the rate women do today. The difference between grandmothers and women today is that those women weren’t exposed to levels of estrogen-like toxins anywhere near what we experience today. Again, this supports the situation of estrogen dominance, something which can be alleviated by balancing estrogen activity with progesterone.

One salient point in this discussion is that cholesterol is the substance from which all other hormones are generated in the body. Cholesterol becomes pregnenolone, which becomes progesterone, which is then manipulated as necessary to produce other hormones. Another point is that at menopause, progesterone levels fall far more on a percentage basis than estrogen – or even testosterone.

All of this is to arrive at one point.

It is unlikely in my analysis that women need additional estrogen because they are already estrogen dominant – and so are men. All of us, then, would benefit from the balancing activity of progesterone.

I am not in favor of oral doses of hormones. Exposure to digestion and actions of the liver inactivate the vast majority of hormones consumed in a capsule – as much as 90%. Some people use progesterone in capsules for just that reason, however. It seems that some of the progesterone metabolites cause relaxation, lower anxiety, and help sleep. A person who takes a 95mg capsule of progesterone might actually experience an increase of 9.5 to 19mg of progesterone. The rest is changed and/or inactivated.

I usually recommend 20mg of progesterone applied once or twice daily, in a cycling schedule governed by the menstrual cycle or the calendar. Women who are still cycling often find good relief from applying 20mg daily from about the 13th day of their cycle to the 26th or 27th. Some women with excessive symptoms will use it once daily from the first day to the 12th, then twice daily from the 13th to the 26th. Stopping for a few days each cycle is important..

Women who are not having periods follow a similar schedule, but use the calendar to keep track. They apply 20mg from the first to the 12th, then twice daily from the 13th to the 26th, then stopping until the first of the next month at which time they begin applying it once daily – and the cycle continues.

Based on my conclusions, any amount of additional estrogen may be too much. If zero is enough, anything added is unnecessary.

When it comes to progesterone, oral only has a place when the doctor is looking for the effects of the metabolites, not the progesterone itself. It works very well to ease the symptoms of PMS (and its sisters). I have learned that topical progesterone is a superior method for actually increasing progesterone levels inside the body. The amount is 20mg to 40mg daily and there is always a time when none is applied.

If I better understood your specific doses I could probably offer more specific suggestions about your dosing. Good luck.