DIM and dosing for cyclical HRT

[kotpa]

I've been on cyclical HRT for several months with transdermal creams, so I can adjust the dose as needed to alleviate symptoms. However, I'm having a terrible time figuring out how to do this. The last time my blood was tested, the levels were about the same as they were before my periods had stopped (meaning before HRT), which is encouraging, except for a couple of things. One is that my estrone level was about twice the estradiol level, meaning it's too high. When I've tried to cut the estrogen dose (which is bi-est formula with 50:50 mix of estradiol and estriol, NO estrone), I get pretty bad hot flashes at night.

My doctor has suggested that I take DIM to help metabolize the estrone. I am worried about scrubbing my body of estrogen that I actually need, but he says it's supposed to operate on the estrone and not affect estradiol much. I haven't had time to research that to verify it, but I was wondering if anyone here has experience with taking DIM, and also getting the estrogen dose right.

I don't recognise any of what you posted so am guessing you are not in the UK?

DIM?

And women rarely have their hormone levels tested - dose is changed up or down according to symptoms.

Yes, you're correct - I'm in the U.S. I think that cyclical HRT is relatively rare here, so I haven't found any other forum discussing it. DIM is diindolylmethane, which is a compound produced during digestion of cruciferous vegetables (and why they're often recommended for women trying to improve their fertility). Supposedly it helps to balance the different types of estrogen in the body.

I thought from what I'd read in other threads that some women in the UK do use transdermal gels to apply HRT, so I was hoping that someone might have had similar experience in trying to find the right dose. I just always find that the best picture of what hormones and supplements can do is based on the actual experiences of real women rather than doctors who may not really know the details, but few doctors here have ever heard of DIM, either. My doctor is considered an "alternative medicine" practitioner because he uses supplements as well as pharmaceuticals, which is radical over here. :-/

@kotpa Cyclical HRT is used worldwide for women who are not yet post menopause (that's 12 months+ with no period.)

Yes, the trend now in the UK is to use transdermal estrogen as a patch or gel, with a separate progesterone.

The gel is not a cream (I assume you are using Oestrogel which is available in the US?) - it's a clear gel. It's estradiol.

Unless you have had a hysterectomy you ought to be using a progesterone for half of each month too. Which one do you take?

From what you have described, you are making things a bit too complicated for yourself?

The advice here is to use a certain dose to start with - usually the equivalent to 1mg - (which is 2 pumps of Oestrogel) for at least 3 months.

If it's not working properly, then the advice is to increase it to 3 pumps for a couple of weeks and see if that helps.

If you are chopping and changing your dose too often you are not giving your body time to absorb and adjust to any level.

I think your dr is complicating it all far to much by his use of alternative things as well.

I'm using compounded creams, rather than a manufactured formula. Thanks for the information about the typical dose used in the UK. 1 mg was what I started with, but it was way too low. Now I'm trying to figure out the minimum dose that will handle my symptoms without creating excess estrone. It seems that my body isn't converting estrone back to estradiol efficiently, but I think that's typical for women near menopause. It's not desirable because estrone is the most aggressive in case of estrogen-receptor-positive breast cancer. I don't have a family history of breast cancer, but it's always best to be cautious, especially since they make women here get so many mammograms, which blasts the breasts with radiation. That is why my doctor recommended the DIM to help process some of the estrone.

@kotpa In the UK, the British Menopause Society has decided that compounded HRT is nor safe and it's not endorsed as a treatment. There are many statements by them to this effect, explaining why.

Here is one thebms.org.uk/publications/consensus-statements/bioidentical-hrt/

One of the main reasons is their efficacy as well as their safety.
You are perhaps already experiencing the unreliability of getting a standardised dose of estrogen by using compounded.
The same will apply to progesterone cream. It is considered definitely not safe as the cream doesn't protect your womb sufficiently.

Maybe think about seeing someone more mainstream and using licensed products?

In a nutshell, this is what you are using and why the BMS doesn't agree with it for use in the UK :)

cBHRT formulation types
E1 and E3 function as competitive inhibitors of E2 because they use the same receptor. Specialist pharmacies/cBHRT prescribers have interpreted this to mean that E2 needs to be ‘balanced’ with its antagonists, E1 and E3, in order to be physiological. Their rationale forms the basis for compounds such as Biest (E2 plus E3 in a 20/80 ratio) and Triest (E1 plus E2 plus E3 in a 10/10/80 ratio). These combinations are usually compounded with some progesterone and testosterone and/or DHEA

. Concerns include:

^The absence of medical evidence to support the practice of combining E1 and E3 with E2. Is the dosage of estrogen higher than it needs to be to control symptoms or too low to control symptoms?
Is the dosage of progesterone sufficient to protect the endometrium in the presence of estrogen? The absence of warnings on the products regarding potential risks and side effects^

In addition to the issues related to purity, potency and safety of cBHRT, many such products deliver progesterone transdermally in cream or gel preparations. The absorption of the latter is variable with fluctuating tissue availability and as a result may not provide sufficient endometrial protection.

I have separate estrogen and progesterone creams so I can adjust the doses separately. Could you maybe explain more about the progesterone warning, why it's not sufficient to protect the womb? That would seem to be dose-dependent, but I don't see why it should be less effective in a cream than the patch, since both are transdermal applications.

I know that there is always room for error in compounded creams, but there isn't a manufactured option for the formula that I use. I'm pretty knowledgeable about the controversy over the estrogens, so it's not worth getting into deeply here, but I am using a reputable compounding pharmacy, and I am not too concerned about errors in the contents. As for the dose, my doctor says that as long as you're having a period every month, it means that you're getting sufficient progesterone to protect your uterus from overgrowth. I'm having trouble getting the balance right, because my period kept starting a few days early, which I thinks mean I wasn't taking enough progesterone, but this month I used more, and now it's several days late. I'm also cycling the doses to more closely mimic the natural cycle, rather than doing a bang-on/bang-off approach every month. I know that's more complicated, but I believe it's right for me.

I have separate estrogen and progesterone creams so I can adjust the doses separately. Could you maybe explain more about the progesterone warning, why it's not sufficient to protect the womb? That would seem to be dose-dependent, but I don't see why it should be less effective in a cream than the patch, since both are transdermal applications.

My understanding after reading what the experts say, is that micronised progesterone - which is what is used in compounded bio HRT- is not absorbed through the skin properly and that in order to achieve a high level of uptake, the amount needed would be impractical.

With patches, the progestin Norethisterone which is a synthetic type and very different.

Micronised progesterone (which is body-identical) is only available as a regulated product as a capsule, to be taken orally or (off label) vaginally.

Also, the guidance here from the RCOG says that a bleed does not always mean that all the lining is shed or that it's not thickened. Only regular scans or tissue sampling would confirm that.

The answer to your question is here in the quote I left :)

In addition to the issues related to purity, potency and safety of cBHRT, many such products deliver progesterone transdermally in cream or gel preparations. The absorption of the latter is variable with fluctuating tissue availability and as a result may not provide sufficient endometrial protection

Patches contain a very different type of progestin so are not comparable.

.

Thanks for that information. I'll have to ask my doctor about the progesterone options, and also about what frequency of scans would be needed to make sure everything looks okay.