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:
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 thi
