This article is dedicated to all of our readers and listeners.
I have received many questions and comments, and I really appreciate them.
In this article, I’m going to address some of the comments/questions. If one person is asking a question, many others may have the same concern.
Thank you for your comments, questions, and for reading/listening. Love you all to the moon and back. <3 DrValorie
You Asked, I’m Answering:
Question #1: I’m using Bi-est 80/20 cream. Does it really matter where I apply it?
‘I’m using Bi-est 80/20 cream and was told to apply it to areas with less fatty tissue, such as my inner arms, outer thighs, or behind my knees. Does the application site actually matter? Are there certain areas where Bi-est or estradiol cream is absorbed better?’
My thoughts:
Every practitioner has their own philosophy. Which is why it is called a ’practice of medicine’; we don’t always have all the answers. But in my clinical experience, I find transdermal hormone creams work best when applied to the inner thigh.
Estradiol and progesterone are steroid hormones with cholesterol as its backbone; so technically they are fat-soluble.
When you apply a compounded hormone cream, the hormones must first move through all the layers of the skin before reaching the circulation. Where you apply the cream can influence absorption because different areas of the body have differences in skin thickness, blood flow, and underlying tissue
Apply HRT cream to areas with more fatty tissue, blood flow, and heat. Thin-skinned areas such as the inner arms may absorb transdermal hormones differently and, in some women, too quickly. Or thinner skin areas may have less blood flow and feel cooler to the touch, so absorptivity might change or reduce.
The back of the knee has a nice fatty pad that works well, like the inner thigh.
And while HRT is amazing, we do not want to share our hormones. Applying your transdermal HRT cream to the inner thigh can help ensure it doesn’t get on pets and kids. If you apply your HRT to your inner arms, think about how often that area may come into contact with someone else. You hug your partner, pick up a child, cuddle a grandchild, or pet your dog. Sharing is caring, just not your HRT.
Question #2: I had to switch from an estradiol patch to oral estradiol. What changes when estrogen is taken orally?
‘Because of ongoing estradiol patch shortages, I had to switch to oral estradiol even though the patch was my preferred method. Is estradiol absorbed or metabolized differently when I take it orally? Are there different side effects or long-term considerations with oral estradiol compared with an estradiol patch?’
My thoughts:
Taking oral estradiol or an oral biest (estriol and estradiol) is not unheard of. There are women who do very well on it. But it depends on the individual.
Oral estrogen needs to go through the liver. This can put more pressure on a liver that might already be working really hard. So I do not use oral estrogens in women who might already have compromised liver activity from insulin resistance, already on many meds, obesity, fatty liver, MASLD (Metabolic Dysfunction-Associated Steatotic Liver Disease, formerly NAFLD), or an inflammatory lifestyle.
Oral estradiol can increase SHBG (sex hormone-binding globulin). Oral estrogen can increase SHBG, which binds tightly to testosterone. This can potentially lower the amount of free, bioavailable testosterone available to the tissues. Higher SHBG levels can also bind estradiol, but not as strongly as testosterone.
Oral estradiol can increase liver production of certain clotting factors and potentially increase the risk of VTE. Now, I have never seen this with oral compounded estriol and estradiol myself (I have seen it with synthetic hormones and birth control pills). But it could be a big issue, especially in someone with a clotting issue, family history, or clotting condition (such as Factor V Leiden, prothrombin gene mutation (G20210A), antithrombin deficiency, protein C deficiency, protein S deficiency, and antiphospholipid syndrome (APS)).
Side note: Oral estradiol can increase triglyceride levels and cholesterol in some women. But on the other hand, low estradiol levels can increase triglycerides, LDL cholesterol, and total cholesterol.
Oral estradiol can increase TBG (thyroxine-binding globulin). TBG causes more thyroid hormone to become protein-bound. This can potentially change thyroid hormone requirements/dosing in women taking thyroid medication. So always check your TSH, FreeT4, and FreeT3 when increasing estradiol dose or switching to an oral estradiol.
Oral estradiol can increase what’s called CBG (corticosteroid-binding globulin). CBG can bind cortisol and can raise total cortisol levels, which we don’t want to raise if we don’t have to.
Oral estradiol can also increase the risk of gallstones and gallbladder disease, particularly in women who already have other risk factors for gallbladder problems.
The long-term risks of oral estrogen really depend on the individual woman’s overall health, lifestyle, metabolic health, smoking status, and personal or family history of blood clots.
Question #3: My progesterone and testosterone show up on my labs, but my estradiol doesn’t. Am I not absorbing my Bi-est?
‘I’m using a compounded Bi-est 80/20: 1.5mg per gram cream.
Progesterone and testosterone are in my cream that I take daily as well. I also take a compounded 125 progesterone capsule at bedtime.
When my labs were checked, my progesterone and testosterone showed up, but my estradiol barely registered. I was told that I might not be absorbing the Bi-est, but if the other hormones are showing up, am I really not absorbing it? Could I need more estradiol, or could the 80/20 ratio be part of the problem?’
My thoughts:
Honestly, this one is pretty clear. The estradiol dose is too low.
No, really, it's not about absorption per se; it's the dose. In my clinical experience, I have noticed that testosterone seems to be absorbed easily with lower doses in women, and estradiol may need to be raised.
1.5mg of biest (80:20 ratio) = 1.2mg of estriol and 0.3 mg of estradiol.
This is a pretty low dose of biest, which is why it isn't showing up in the bloodstream. I am sure she is absorbing it, but the dose is just too low for her.
- I would keep the progesterone and testosterone at the same dosage and raise the biest.
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I would increase the biest up to 4-5 mg and make sure she applies half (2-2.5 mg) in the morning and the other half (2-2.5 mg) at night.
- Compounded estradiol and estriol do not have a long half-life. So if you only apply it in the a.m., most will be gone 10-14 hours later.
- Run the labs to make sure she is absorbing the estrogen. I would have her apply the biest in the morning and have the blood test for estradiol about 4-6 hours later to make sure she is absorbing it.
Don’t chase the numbers. Figure out her symptomatology and how she is feeling, then pair that with her blood work to determine the best dosing.
I’m answering the next questions in the paid edition.
Continue reading the full Q&A:
- Question #4: Can estradiol be applied to the face, or is estriol a better choice?
- Question #5: I switched from a 0.075 mg estradiol patch to 1.5 mg of Bi-est. How do I know if those doses are actually comparable?
- Question #6: What if I genuinely cannot tolerate progesterone, even when I change how I take it? Can I take it rectally?
Thank you:
I hope these answers helped clear up some of the confusion around HRT. In the full edition, I’m answering three more questions about estrogen for the face, switching from an estradiol patch to Bi-est, and what to do when you just can’t tolerate progesterone.
<3 DrValorie
