Hormone Therapy for Menopause: A Guide to Doses, Levels, and Delivery Methods | Dr. Susan

I'm going to assume anyone listening to this is already on board with the idea that taking menopausal hormone therapy is a good idea so let's just start with that Baseline and if you disagree that's fine so if you've decided that you want to do that how do you get it how do you pick the right dose how do you know if you're on the right dose the idea that pellets are unstable and cream or spray or patches are not that's just wrong [Music] hi friends and welcome to this week's episode if you're just joining me I'm Dr Susan I'm a board certified gynecologist and a certified menopause practitioner I have dedicated my whole working life to taking care of women in per menopause menopause and Beyond women like me who have the goal of feeling great now and also build the healthiest 90-year-old version of ourselves because we want to live a long time and feel good in the meantime reduce the risk of preventable diseases and then keep ourselves mobile active and doing the things we love for as long as we can so everything I talk about has something to do with that and today I'm going to talk about something that is quite confusing and I'm guessing if it's confusing for me it probably is for you too I'm going to assume anyone listening to this is already on board with the idea that taking menopausal hormone therapy is a good idea so let's just start with that Baseline and if you disagree that's fine I've got lots of other videos about the science behind why that might be a good idea however once we've decided that we're going to do this right we're talking about estradi which is the primary estrogen that we produced from our ovaries all of our Lives progesterone which is the wonderful hormone that we make after we ovulate and then we make messes about when we're pregnant and testosterone which you all know by now we we actually make lot more of than estradi and it's a very important hormone for lots of things so those three hormones so if you've decided that you want to do that how do you get it how do you pick the right dose how do you know if you're on the right dose and just to make things more confusing every different delivery method has a different dosing schedule let's start with estradi so this is the hormone again we've made from our ovaries all of our lives one thing that we know from lots of data lots of studies in the past um even young women on birth control pills we know there's a slightly increased very tiny increased risk of blood clotting events when we take estrogen by mouth so because there are other options we generally don't want to do that so let's just take that one off the table and if you are taking an estral product by mouth I would stop and switch it over to one of the others in the old days we had no other options but now we do so we want to go with the safest alternative and that's going to be some kind of transdermal across the skin or Not by mouth form of estrad so that could be a patch a cream an injection gosh you could get little drops that go under your tongue you could get a pellet the little things that go under your skin any of those would be safe in that respect because they're not taking that primary what we call first pass through the liver now if you take a pill it's got to go through your stomach and then it's got to take a big trip through the liver before it gets into your bloodstream and in doing that it causes some problems we've only got one liver we don't want to give her extra work to do and it messes up our blood clotting factors all right so let's take that one off the table so patch cream we can get those from regular Pharmacy so the FDA has approved aad in the form of a patch great product there are a bunch of different doses I'll talk to you about that you stick it on your skin last for about half week 3 to four days so for example you change it on Monday and Thursday or Tuesday and Friday but you're basically wearing it all the time stays on through exercise stays on gosh I was even swimming when I used mine you know probably comes off if you swim a lot so a short of that it's good for normal bathing normal exercise and then you're getting estrogen all the time without it going directly through the liver so that's one option uh the fda's also approved a gel called Diva gel little packet put it on your arms go like that once a day that's great now you have to do it every day kind of dry your arms but many women like that there's one called evamist which is a little spray there's some other generics similar idea suffice to say you can get FDA approved estradi in a transdermal form from any pharmacy and that's perfectly great now you can also get estradi from a compounding pharmacy and that's a type of Pharmacy where the pharmacist is making something a little bit more specific for example the FDA has not approved estrad in pellet form yet so you can get testosterone or estrogen pellets made by very reputable very high level compounding pharmacies and just to say compounding pharmacies have different levels of reputability just say and these come from very highly reputable compounding pharmacies that have incredibly high level of internal validation testing and so on so you you it's just not correct to say that compounding pharmacies are bad and FDA approved drugs are good and we've talked about that before however the regulation is a little bit different so you want to be careful so you could get estr from a compounding pharmacy in the form of a pellet again a cream they can make all of this stuff uh but different ways to get it now Within These the dosing is completely different and this is where it gets a bit tricky so some doctors say in fact the American College of Oben has the opinion that there's no need to check hormone levels on menopausal women and to give the amount of estrogen that makes symptoms go away now I believe that was a good idea for a long time until I started checking blood levels and saw that they were all over the place so I do not agree with that I do think it's important to check blood levels because I'll tell you why in a minute the dosing is so crazy and different between one product and the next that if we didn't check blood levels I don't know how in Earth we would know that we have you on a safe amount that's going to be beneficial for your health so my opinion is you definitely should check blood levels here's an example one would think and I was led to believe that if you're wearing an estrad patch you have it on all the time your blood level of estrad should be pretty much the same week right that's what they lead you to believe that is so far from the truth we've CH blood levels on the same patient on the same patch and it's been from zero to way too high because there's a million things that affect how we absorb things through our skin the temperature whether there's a little water bubble underneath it how old the patch is you get much higher levels the first day than the fourth day lots of other things what you might have put on your skin whether you took a bath or a shower if you exercised or you didn't so there is fluctuation even with a patch and not to say there's anything wrong with fluctuation because our estrogen's fluctuated all of our lives but I do want to just point out the idea that it's stable is false cream you're putting on once a day so guess what happens the level goes up really high in the first two hours and then it drops down so if we drew your blood 2 hours after you put the cream or gel on you'd get a sky high level and then if we checked it 24 hours later it would be close to gone again there's nothing wrong with fluctuation because it's fluctuated all of our lives but we don't want it to go from way too high to zero so this happens sometimes and so if you're someone who's using a cream or a gel and you're not feeling stable that could be something to consider um now most patients do just fine with divigel there nothing wrong with it I'm just pointing out that the levels are all over the place and this might be why there's a suggestion not to check because most doctors don't really want to see that their patients estrad is 800 which is way too high or zero um and so they just say well just put it on and off you go well I don't know there's an argument and it's a good one that what we're seeing in our blood doesn't necessarily indicate what our cells are seeing because just because our blood levels are zero the cells have still got some estrogen in them from the day before so all of that's true but just to say I think checking blood levels is a good idea to make sure we're not at some crazy high or crazy low level now pellets I don't know why people like to get so upset about pellets it's the same exact stuff it's bioidentical estradi in a benign powder that's just put under your skin through a tiny little poke in the skin I have one in my bottom it's not perfectly stable but again nothing is it's a whole lot more stable than these other options uh but yeah it goes up it spikes a little bit in the first two weeks it stays relatively stable and then it starts to decline and so there's a little bit of up and down with a pellet depending on what brand you use the way they're made some of them are pressed in these concentric circles so you might see a little bump when the outside of the next Circle dissolves and so on but again our hormones have been going up and down all of our lives and the idea that pellets are unstable and cream or spray or patches are not that's just wrong this is where it gets really funny the dosing how do you pick the dosing so a patch let's go back to Patches you might see a number like for example a common dose to start on would be 0.05 millgram a day okay so you're getting 05 milligram a day that's a good amount the equivalent to that in a pill would be one milligram a day multiple times higher because most of it's lost in the process of going through the liver so the idea is that the patch you're going to get much more of and the pill you're going to lose most of it okay so hold that thought so in a patch you're getting 0.005 milligrams a day well in a cream generally it's the same dosing as a pill like half a milligram a day or 1 milligram a day so the difference between half a milligram and 0.005 mg is 10 times right so the idea is that you lose 9/10 of the cream and you're getting 100% of the patch and then you're not supposed to draw blood levels really I mean you can kind of see why this is a little bit of a boy experiment how do you know how much cream you're getting or how much patch you're getting or how much anything you're getting unless we draw your blood I don't and I can tell you having drawn blood for many years it is all over the place which is why I personally use a pellet because yeah there's a bit of variation during the 3 months but not nearly that much so point being it probably doesn't matter much if we have fluctuations up and down again cuz that all of our lives our estrogen went up and down but we don't want it to be crazy high and then zero within a 24-hour period of time so again cream you lose most of it pill you lose most of it the patch the idea is that you don't lose most of it but sometimes you do I've got patients who are wearing a patch and their rester dial zero they're just not getting it at all and so we we've just really got to check I think so so that's kind of a fun fact about estrad the dosing is 10 times different depending on what product you choose well the same thing applies to testosterone you cannot get testosterone in an FDA approved form yet for women which makes no sense because men have over 18 types of FDA approved testosterone including a cream a gel a solution a nasal spray even a pellet yes and so testopel is FDA approved so the FDA has approved pellet technology they've recognized that it's good they proved it for a men I mean it makes no sense I made another video about that so I won't bore you about that but the idea that pellets are not FDA approved and that makes something wrong with them is just false test testosterone is FDA approved it's a natural hormone we've had it our whole lives it's approved in multiple multiple forms for men including pellet form so you know what's the difference with men and women except that outd doing is 10 times lower so with testosterone we've got the same choices with the caveat that we don't have the FDA approved ones so all testosterone products have to come from a compounding pharmacy right now which is annoying but here we are I did not make the rules if I made the rules they'd all be FDA approved here's something funny the American College of Oben that's the board that kind of tells us what to do as gynecologist and they're fantastic and I love them and they do amazing research and they're wonderful but sometimes they say some things that don't make sense so here's one the American college Robi Jen has recognized and suggests using transdermal testosterone for the treatment of low libido also called hypoactive sexual desire disorder that's the fancy name for low sex drive because many Studies have shown that using transdermal testosterone helps with that issue helps with libido for postmenopausal women so they said great let's do that let's give women transdermal testosterone but they simultaneously say that they do not approve compounding phes so then how on Earth do we get it so what they suggest this is where it gets really funny is that you get the FDA approved mail products and just use one tenth of it well I don't think they actually have gone to the pharmacy and tried to do this I have so if you get a male patch and try to cut it into ton well it's not going to be perfectly accurate and you're going to have all these little pieces of plastic it's hard to do and by no means it's that accurate me it's impossible to do that accurately so that would be one way and for some reason that's better than compounding or you could get the little packet of male cream and somehow divide that into ton I mean it's that would be impossible and if you tried it you would be so far off from one tenth it wouldn't even be close so somehow that's better than compounding you could use the male nasal spray but you can't divide that by ton you can see where we're going I mean how on Earth can you use FDA approved male testosterone products and divide the dose by 10 accurately you can't it's impossible the male testopel it only comes in one dose you can't divide that by a ton so they're simultaneously recognizing that it's really good and women need it but then also saying that we can't use compounding Pharmacy so therefore it's impossible to get it I mean it you know sometimes things don't make sense so in the current moment we have to think use our minds and out of those two choices cutting a male patch into 10 or using a very good compounding pharmacy by far that's going to be much more accurate and either way we would want to draw blood to make sure that we're getting into the right range for women so physiologic range for women means not too high right because we all know testosterone too high causes a lot of adverse side effects okay so how much should we get well we're just going to assume that we've agreed that testosterone's good because there are studies proving that it is and then how much do we get well pellets um have a little calculator that one could use and I don't use that because I think that's way too high in our office we use 1 to 1.5 mg per kilogram of body weight okay so no more than 1.5 I would start with one milligram per kilogram that's not very much um let's take a woman like me who's getting 50 milligrams over 100 days so I'm getting 50 milligrams over 100 days obviously that's half a milligram a day 0.5 milligrams a day on average of testosterone over about three months and a half so rather let's just say 100 days for easy math five okay so if you get testosterone cream you would get 10 times that much again so 5 milligrams or even 10 milligrams would be the recommended amount in a cream in Australia they their equivalent of the FDA has a product that's available fromes approved by the government and it comes in 5 milligrams and the instructions are to use 5 milligrams once a day and then increase it to ton if you want to well that's kind of a big range and again when you put the stuff on we've done this so if you put 5 milligrams of testosterone that's 10 times what's in my pellet just saying do not draw your blood in the first few hours because it'll be crazy High um if I put 5 milligrams of testosterone on my arm or inner thigh or back of my calf or wherever you want to put it and then I drew my blood two hours later my testosterone level would be a thousand it would we've done this now 24 hours later it would be 50 um so that's fine but just to say the idea that many doctors are suggesting that testosterone cream is better or safer or more stable or any combination of words that you want to use than a pellet it's just wrong you know when I get my pellet if I checked it two weeks later and we're doing this study in our office right now actually it does shoot up a little bit not nearly that high though of course everything goes up a little bit at first any pill you take it's going to be a bit higher for the first couple of hours and then it'll settle down whether it's aspirin or thyroid medicine or cholesterol medicine everything your vitamins everything goes up and then it settles down creams go up super high because the skin absorbs it very rapidly and then it dissipates quite quickly what's some other ways well there's a little thing called a Troy which is a lozen that you put in your mouth the idea with that is it dissolves into the tissue on the inside of your cheek and very little of it gets in your stomach and so that's good for the liver well we see the same thing with trois if we measure your blood levels 2 hours later it's going to look crazy high and is that terrible no not really I mean hormones go up and down but again the idea that these non pellet ways of getting hormones are more stable is false it try it to put a Troy in and have your doctor draw your blood two hours later here's a Curious Thing most doctors who understand this at all will tell you do not get your blood drawn for at least 6 hours after you've used a cream or a Troy because otherwise you will scare yourself with the result I mean that's a good idea but the fact is it's crazy high in that first six hours just cuz you're not checking it doesn't mean it's not arguably way too high so these are all valid suggestions I think they're all fine I have patients who use a cream I have patients who use a Troy I have patients who use pellets they're the same stuff there's some fluctuation that's okay but I'm definitely not on board with not checking blood levels I think you have to I mean how on Earth would you know otherwise in my opinion you couldn't possibly know and then progesterone is a little bit easier now progesterone we do take by mouth because it has this particular side effect of making as sleepy and most people love that CU most of us can't sleep so if you take it by mouth Yes you need a really high dose compared to what you might use in a cream or something else because it U is mostly metabolized by your liver and your dose you get in your bloodstream is not that much but taking 200 milligrams of progesterone by mouth is absolutely safe the liver doesn't mind it it makes you sleepy we intentionally want to make use of the fact that it goes up really high for a few hours while you're sleeping and then it drops down so in that particular situation it's fantastic that it goes really high and then drops down cuz we want really high at night and not during the day that's why I'm not a big fan of progesterone cream because you'd be sleepy if you were getting enough to make a difference or any other kind of progesterone that's being delivered all day long progesterone is a bigger molecule it doesn't absorb very well through your skin so we don't see the benefit for sleep and other things so I'm not such a fan of that I just give it by mouth I take it by mouth myself and yes we know it's high at night lower in the morning that's fine all of these hormones go up and they come down so we can use that to our benefit if we want to get the benefit during sleeping hours but just don't believe the hype that pellets are bad or wrong or less stable or any of the above because I promise you if you measured your blood after putting on that testosterone cream that a lot of my lovely colleagues recommend if they measured it it would be Skyhigh so they say don't measure it well that's one opinion so and anyway I hope you enjoyed this conversation it's really confusing 10 times more in a cream than in a patch trying to take the FDA approved mail stuff and cut it into 10 we've got the American College of OB Jin saying yes testosterone's really beneficial for sex drive let's use it but we don't have any products that you can use now you can fly to Australia and get the cran most of us don't want to do that but um you could or you could just go to your local compounding pharmacy and they can make it for you anyway you don't have to do any of this I just want you to be educated when you make a decision so now you know more than your doctor when you're wondering what dose you're getting and whether it's the right one for you I do not know how you would possibly know that unless they drew your blood and if you're using a cream or a Troy tell them to wait 6 hours cuz it's going to look crazy high before that and if you're using a pellet doesn't matter what time of day you do it because it's reasonably the same throughout the day sounds good to me that's why I have pets in my bottom anyway I hope you enjoyed this video If you learned something don't forget to share it with your friends and I can't wait to see you next week [Music]

Channel: Dr. Susan Hardwick-Smith

Views: 27,745

Keywords: drsusan, susan hardwick-smith, women's health, Menopause, perimenopause, menopause symptoms, menopause age, what is menopause, symptoms of menopause, menopause signs, hot flashes, early menopause, post menopause, estrogen, signs of menopause, menopause hot flashes, menopause weight gain, menopause test, menopause supplements, age of menopause, menopause weight loss, menopause treatment, middle age, middle aged woman

Id: 8TJ3zsmir6s

Length: 23min 49sec (1429 seconds)

Published: Wed May 15 2024