Menopause Matters Forum
Menopause Discussion => All things menopause => Topic started by: laszla on February 14, 2022, 12:09:59 AM
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Hi all, 55, estrogel 2 pumps daily since 2018, utrogestan 10 days a month, a little testogel 3 times weekly. Never had hot flushes but appalling anxiety and chronic fatigue, also weight loss, low BMI, can’t gain weight, don’t have an eating disorder (cancer investigations for weight loss turned up nothing).
In November I finally got an appointment at meno clinic, had blood tests and dexa scan. Appalled to learn estrogen level was very low (a little over 100), especially as I was simultaneously diagnosed with osteopenia, with hip measurement being just a couple of decimal points away from osteoporosis.
My ‘free’ testosterone was also miniscule probably because of high levels SHBG. Thyroid, vit D and ferritin all ok.
In view of this I am anxious to get my estradiol blood levels up, having researched here and there it seems that for bone health you’d need at least 300-400 pmol.
Clinic follow-up is 5 months after first appointment, so I took it upon myself to increase estrogel dose to 3-3.5 pumps daily. My general symptoms of fatigue/fog/anxiety since then have been slightly worse.
Last week I had blood tests and the estrodiol level had increased to 220 pmol after 2.5 months (which I understand should be long enough to absorb a new regimen).
It’s an improvement but not good enough for the purposes of bone health and as I could only go up another half pump and doubt if that gives scope for a sufficient further increase, I’m thinking I don’t absorb the gel well and should perhaps ask to switch to Lenzetto spray or patches – does this seem reasonable?
I know some people advise that symptoms are more important than blood numbers and generally I agree but in the specific instance of bone strength it seems that numbers do matter.
At the same time, in this recent test my testosterone has gone down a lot, even the total number was very low, let alone the “free” testosterone. Given that overall I feel slightly worse despite the increased E2, I wonder if low T may also be the culprit.
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Hi laszla
First of all sorry to hear about your ongoing problems.
Re bone health - I don't know where that figure of 300-400 pmol comes from? There must be some recent research. Previpously a paper I read (as I recall) gave the absolute level as much lower - maybe half that. Yes symptom relief is very important but if the minimum (recommended) level to prevent osteoporosis is lower then you have less need to worry. However I may be completely out of date about that.
More important is the osteopenia so in that case I would also want to be much more above the minimum for well being as well as bone protection, and the younger you are the higher you would want it to be, symptoms aside. I did read also a while back that originally hRT oestrogen dose was designed to average the level of oestrogen over the natural menstrual cycle ( which of course varies from woman to woman) so that women did not experience severe oestrogen deficiency, but this was indeed around 350 pmol/l (as I recall).
Could you post your total T measurement and SHBG at your last test?
Yes that could be the cause of some of your ongoing symptoms and be guided first by your libido - if you are not taking any medication which can depress this ( eg some ADs), then if this is still low then T could well be partly to blame as you say.
Hurdity x
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Thanks Hurdity,
Off the bat, Professor Studd (RIP) was one of the sources I saw recommending a minimum of 300 pmol for bones and much higher than that for depression and fatigue:
"Osteoporosis can usually be prevented by oestradiol therapy and the bone density can be increased in established osteoporosis by the use of oestrogens which produce plasma oestradiol levels of at least 300 pmol/L."
"There is also evidence that plasma oestradiol levels of 800 pmol/l may be necessary for the improvement of depression in the climacteric woman"
He also says that higher doses of estrogel are needed for bone density and chronic fatigue/depression than are needed for vasomotor symptoms (which I've never had, I'm always freezing)
I will try to find other sources but recall others also mentioning quite high numbers for overall wellbeing.
My SHBG in both my penultimate and recent test was about 135, so the increase in estrogel had no impact on it. Testosterone three months ago was 1.2nmol (but with that SHBG, free T was very low) and in latest test they couldnt even calculate the free T because the total number of T was less than 0.4
Libido is non existent - I take no ADs as I am determined to try raising my hormone levels to decent numbers and as mentioned in other posts, GP support is non existent/negative and Chelsea & Westminster meno clinic inadequate as the follow-up appointment wait is 5 months and they do phone only which I don't think works at all for something as fraught as menopausal misery that attacks on so many fronts, at least not in the first instance.
Hence, it's imperative that in the meantime I take steps myself to improve my current state.
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Bumping this - would be grateful for any suggestions as to how to raise my estradiol, thanks
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Bumping this - would be grateful for any suggestions as to how to raise my estradiol, thanks
Hi Laszia, just spotted your post and wondered how you were getting on and whether you have started on testosterone medication? Reading your issues I think that low testosterone could be a problem as I also have virtually non existent free testosterone, zero libido and, even though I am on estrogel (3 pumps a day) I have a lack of energy, particularly when it comes to strength and stamina during and after exercising.
My estradiol levels are at about 800 so I am receiving enough there, but completely feel for your frustration on levels. I have also read in a couple of sources that 350/400 is the recommended level for optimum bone health. If you have reached the maximum number of pumps of estrogel then perhaps it might be worth considering the patch to see if you absorb better. The only downside would be in moving from one more of HRT to another as it can cause all sorts of symptoms changing over. I had tried it once and only lasted a couple of days before going back to the gel. I'm also on the waiting list to see the meno clinic about testosterone treatment so hoping they might help. My added big issue is my hair is getting rapidly thinner and my thyroid is fine so in a referral to Dermatology.
I hope that you're getting the support and advice you need from your GP/ specialist.
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There is no recommended minimum dose for bone health.
I recently posted many papers where researchers found that very low dose HRT offered enough estrogen and the concensus was that any was great.
If you search the forum for bone and minimum and my previous posts you’ll find about 5 papers I posted all saying this…
Prof Studd might say this but I don’t know what he’s basing that on or why his recommendations should carry more weight than many others…
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Just seen this and your queries re Testosterone. Definitely think you should look at taking it, your free T being that low is going to be impacting your energy levels, brain function etc I felt much better after adding T myself.
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Hi laszla
Off the top of my head from previous research on SHBG, the following thoughts come to mind
Magnesium and Zinc lower SHBG
High protein diet lowers SHBG
There is a cortisol connection with SHBG levels, so it could be worth you having a 4 point saliva cortisol and Dhea test. Zrt tab is a good one to use. Or the Dutch test but this would be more expensive as you’d need a functional practitioner to order the test.
Yes as ATB suggests increase your testosterone dosage.
I have low weight and bmi, which I believe is a malabsorption issue caused by a leaky gut. So focusing your attention on gut health could be a way forward.
X
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Just seen this and your queries re Testosterone. Definitely think you should look at taking it, your free T being that low is going to be impacting your energy levels, brain function etc I felt much better after adding T myself.
Did your GP prescribe T to you directly or were you referred to a menopause specialist? My GP would not prescribe it so I have been on a waiting list for over 7 months now to see a specialist at a menopause support clinic. So frustrating...
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Girlagogo, I went private. The NHS only prescribe it to women if you have very low libido and they make you try other things first.
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Thanks so much Girlagogo for checking in. Sadly, my testosterone was and continues to be low despite my being on regular testogel, at least at my last tests which were in June, next ones will be done in September (and I absolutely agree with you ATB that T will affect all those symptoms). I hope you managed to get it prescribed for you Girlagogo.
The most likely reason for non absorption seems to be my high SHGB which has actually increased since I wrote in February and the most plausible explanation seems to be the low weight/bmi which I can't seem to raise despite best efforts, if anything they've further decreased by a small amount (thanks for the lowering SHBG tips Marchlove, only thing I haven't tried there is the saliva cortisol test so might look into that).
At the same time my plasma estradiol finally did go up (after a 3 month switch to patches sent it re-plummeting to 160) and at last count was at about 500, achieved by taking 5 pumps of estrogel daily though at Chelsea they say I might need it to be up to 800 pmol for hormonal depression, also my high SHBG is likely to affect its absorption as well, though probably not as much as for the T.
But even this increase has definitely helped, particularly for mental state which was dire, dangerously so at times, and stamina/muscle strength too are better though there is still room for improvement, particularly in the second half of the month which is still tough.
Prof Studd might say this but I don’t know what he’s basing that on or why his recommendations should carry more weight than many others…
Prof Studd based those recommendations on decades of prolific studies that saw him awarded a D.Sc for his research findings and the Blair Bell medal from the Royal Society of Medicine to the doctor who has made the biggest lifetime contribution to their speciality.
Setting aside accolades, virtually all the advances in meno/HRT that are now increasingly mainstream were pushed by him in this country, and subsequently by his pupil Nick Panay, eg. the move away from equine estrogens, transdermal delivery of estrogen, the use of micronized progesterone, the benefits of testosterone for women (not only for libido as many dinosaurs are still claiming), the ad hoc dosing of progesterone to accommodate prog intolerance, and, more widely, the idea of individually tailoring treatments.
And perhaps even more than the strictly physiological aspects, he was the first gynaecologist here to consider the mental health aspects of menopause (and PMS), the - for some women - debilitating anxiety and depression that it seems many doctors still either ignore or write an autopilot AD script for.
Much of the research he and Panay conducted included numerous studies on estrogen’s effects on bone density where he amply demonstrated that the skeletal response is very much dose-dependent and proportional to the plasma oestradiol level obtained with HRT.
So while low dose E2 might increase bone density (though it seems odd that the 2004 Ettinger study added high calcium & vit D supplementation to the estrogen – given that they too both help bone density it’s not clear how they could differentiate which component/s made the difference and by how much), it’s likely to increase it more at a higher dose and one of the specific categories Studd identified as being vulnerable in this area are precisely low BMI women (he also founded the Royal Osteoporosis Society so was far from a casual visitor to the world of bones).
As he asserted, treatments need to be tailored so while I might look into my 80-something mother getting an ultra-low dose of E2, that would not be the right approach for many younger women and almost certainly not for thin middle-aged women (and even less so if they had hormonal depression and/or other debilitating symptoms).
Apart from the improvement of my mental wellbeing, concretely I can also say that my recent follow-up DEXA saw my previous osteopenia-level hip and NOF scores decrease by 1 and 2 decimal points respectively so that now I am right on the borderline of ‘normal’ rather than firmly in the osteopenia category.
So yes, as far as I’m concerned the recommendations of Studd and his followers carry much more weight than others and incidentally inform the guidelines of most of the progressive practitioners around today in this country, eg. Newson etc. (I was also given the 300-400 pmol minimum in Italy where there’s also a lot of advanced research on HRT).
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I get all that laszla, I just want to put across the other point of view which is the one the BMS has - which is that there is no minimum recommended dose for bone health and any amount is protective. That is also the point of view upheld by many other research papers - reposting this post I made on a previous thread to save time:
https://www.webmd.com/osteoporosis/news/20040504/ultra-low-dose-estrogen-patch-helps-bones
"The study enrolled more than 400 postmenopausal women aged 60 to 80. All had thinning bones and were at higher risk of having a spine and/or hip fracture -- as indicated by bone mineral density tests. The women also had blood tests to look for markers of increased bone turnover.....Researcher Bruce Ettinger, MD, of Kaiser Permanente in Oakland, Calif., tells WebMD that the ultra-low dose patch significantly increases bone density in the spine and at the hip.
"The dose in the patch is only about "one-fourth the traditional 0.625-milligram dose" contained in most estrogen pills used in menopausal hormone therapy,""... The study results are good news says Nahum. He tells WebMD that the new study confirms something that he and other obstetrician/gynecologists have long suspected: "A little bit of estrogen goes a long way."
The patch which they made is now on the market and is called Menostar. It is just 14mcg of estrogen: https://www.rxlist.com/menostar-drug.htm#indications I think I'm right in saying that it actually doesn't need any progesterone to oppose it because the estrogen is so low.
And here:
https://pubmed.ncbi.nlm.nih.gov/16607111/
And here:
https://www.uptodate.com/contents/menopausal-hormone-therapy-in-the-prevention-and-treatment-of-osteoporosis
"Women who seek MHT for menopausal symptoms in their late 40s or early 50s will have the additional benefit of a reduced risk of bone loss and fracture [3,4]. In such women, a separate first-line drug for prevention or treatment of osteoporosis is usually not required with estrogen (estradiol) doses equivalent to or higher than 25 mcg/day of transdermal or 0.5 mg/day oral. Lower doses of transdermal estradiol (14 mcg) have also been shown to have skeletal benefits. With this ultra-low dose of transdermal estrogen, bone density should be monitored in women at high risk for osteoporosis and fracture as another agent (eg, a bisphosphonate) may be needed."
And here: https://academic.oup.com/jcem/article/85/12/4462/2852143
"The purpose of this study was to examine the effects of three doses (0.25, 0.5, and 1.0 mg/day) of micronized 17β-estradiol on bone turnover, sex hormone levels, and side effects compared with placebo in healthy older women...All markers of bone resorption significantly decreased at 12 weeks on treatment compared with placebo and returned toward baseline at 12 weeks posttreatment. ... Based on equivalence testing, the response of markers of bone turnover to therapy with 0.25 mg/day was similar to that seen with 1.0 mg/day.... We conclude that low dose of estrogen (0.25 mg/day 17β-estradiol) reduced bone turnover to a similar degree as that seen with usual replacement therapy (1.0 mg/day 17β-estradiol), but had a side effect profile similar to that of placebo. In our study additional increases in estradiol levels, as seen with 0.5 and 1.0 mg/day 17β-estradiol treatment, resulted in more side effects without evidence of additional benefit to bone. These data suggest that 0.25 mg/day 17β-estradiol may be an effective and tolerable agent for the treatment of osteoporosis in older women. "
And there are many more.... I'm sure if someone already has signs of problems, it would for sure be beneficial to give them a higher dose because it does seem to be dose dependent. But for someone entering menopause with decent bone health, it does look like even low levels of estrogen will enable them to maintain that - even if not to gain any.
Maybe the jury is still out on this one and we need to wait for some kind of conclusive position to come out...
By the way, Lara Briden has an interesting take on bone health, which is that dexa scans and poor results are actually not predictive of future fracture risk. What is predictive, is balance - people with poor balance are more likely to fall and get fractures. And if they just assess how well older people can balance, this tells them more about fracture risk than dexa scans do(!!).
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I’m sorry to hear of your difficulties laszla.
This is a fascinating discussion. Re bones, there’s a lot of research on vit K2 and magnesium being helpful. Also boron - though some women in meno find it makes hot flashes worse. There was a news item on yarslburg cheese being really good for bone health.
I can also recommend Pilates for bone density. There’s also something called the scarbourogh fair diet (apols for spelling) where herbs such as rosemary and thyme and eating oranges all increase bone building mechanisms. All alongside hrt of course.
My recent blood test said 135 oestrogen was “borderline” Too low on 50 patches. I’m not sure on what reason but I imagined was for bones. Gp said 600 was desirable so I’ve a way to go.
Do you eat meat? Lamb is good for zinc and protein, also full of oleic acid.
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AFAIK the BMS has no guidelines on optimal levels of estradiol for bone health or anything else. Not to mention that they are a distinctly conservative operation (there was a MM thread on this re a recent statement they made) who refuse to allow that testosterone is useful for anything but libido and have the temerity to state that most menopause care is “ably provided by primary care teams".
Again, the 2004 Ettinger study gave all the women vit D and Calcium along with the estrogen, making it impossible to isolate the efficacy of any one ingredient, not to mention that it was for much older women, 60-80.
From what I can see of links 2 and 3 they don't seem to bring in other studies but simply refer to the 2004 one, while the second study in the fourth link used even older women than the first one, over 65.
So while in some instances it might be appropriate to give a low dose - I already mentioned the example of my 80-something mother - there is nothing I find persuasive with regard to low doses being remotely suitable either in my particular circumstances, the topic of this thread, or generally for younger women unless they had serious contraindications for higher levels of E2.
I was advised to greatly increase my plasma estradiol for two principal reasons and in both cases that demonstrably helped while the lower dose had me ready to check out and with osteopenia despite a pretty rigorous exercise regime.
Good balance is certainly something all women should work on but if you do fall or get pushed over (not that uncommon in London) it’s not going to help the impact on your bones and muscles if they’re brittle and weak. My mother has been a lifelong exerciser, is super slim, has never smoked, barely drinks, eats an exemplary Mediterranean diet but never took HRT and now has bad osteoporosis, heart disease and some cognitive impairment.
Thanks for your input Clarella, I do take vit K2 and magnesium. I’ve never heard of the Scarborough fair diet – those ingredients sound right up my alley so will definitely look into it! I do yoga, weights and about 2 miles walking daily, I get my protein from fatty fish, eggs, some fermented soya foods like miso, pulses and enough nuts and seeds to feed an army of squirrels, but I don’t eat milk products or meat (I saw that thing on the Yarlsburg cheese too and advised it to my mother who does eat cheese).
It's good to see that your GP is suggesting a good amount of plasma estradiol, hopefully you will get closer to that number. I doubt I’ll ever get to the top of the range suggested to me but already have made progress from my initial numbers that were similar to yours.
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Very interesting thread, thank you laszla.
Just wanted to throw another study into the mix regarding testosterone and it’s effect on BMD. After all, healthy younger women have far higher circulating levels of testosterone than estrogen so it mustn’t be left out of the equation.
https://academic.oup.com/jcem/article/96/4/989/2720846
X
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Very interesting. But since testosterone comes from the ovaries (and declines when estrogen declines), how do we know the effect of this is due to testosterone and not due to some women having more estrogen from their ovaries for longer....? I mean, both hormones would decline around the same time....?
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Thanks for that Marchlove. I've no doubt that T also plays an important role in BMD and more, and the study suggests that some of T's effects are oestrogen independent (with the ubiquitous caveat that "more studies are needed"!). Now I just have to try and raise my values which are even more reluctant to increase than my estrogen has been... x
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It’s a difficult one Joziel, testosterone is also made in the adrenals and apparently depending on how healthy they are, testosterone can be the more dominant hormone post menopause, albeit at a lot lower level.
My testosterone seems to have no problem increasing but that is probably because my estrogen dosage is quite low.
No idea whether this is of more benefit to me bone wise as not done enough research, but just going on how I feel.
Of course laszla it is of utmost importance for you to know what hormone will be most beneficial, as you already know that you need as much protection as you can get.
Let’s keep researching x
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Very interesting thread, thank you laszla.
Just wanted to throw another study into the mix regarding testosterone and it’s effect on BMD. After all, healthy younger women have far higher circulating levels of testosterone than estrogen so it mustn’t be left out of the equation.
https://academic.oup.com/jcem/article/96/4/989/2720846
X
Interesting article hinting at a role of testosterone. However this was an association sutdy and correlation does not equal causation. The key points were at the end of the abstract:
"Mechanistic studies are required to determine whether a causal relationship exists between T, bone, and body composition in this population and the degree to which any T effects are estrogen-independent."
"A causal relationship" is the crucial point here.
Interesting though :)
Hurdity x
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Hi again
I don't have time to quote the posts in detail- but this is an interesting discussion of a crucial question which forms the basis of arguments for taking HRT and dosing ie the protection of bones.
I have always understood that the effect of oestrogen on bone turnover to be dose dependent, hence the licensing of medium doses of oestrogen to help protect against osteoporosis - as per the menu on this website where the medium to higher dosages are given an asterisk and lower doses are not.
Secondy that ANY additional oestrogen is going to reduce bone turnover hence the use of the Menostar - but that this cannot be said to be equivalent to higher doses and will not give such a high protection. [incidentally the product info I read some years ago suggested an annual course of progestogen to reduce any potentially thickened lining as I recall].
Having had a quick glance at this paper: And here: https://academic.oup.com/jcem/article/85/12/4462/2852143 the critical point as laszla mentions is that is was carried out in OLDER women, past menopause, and the study says that in these women ( median age 75 or something?) bone turnover rates are much lower anyway.
The discussion highlights how different the situation is for younger women - ie most women on this forum and who are considering HRT, with studies indeed showing dose dependence (I have not looked in detail at the studies just glanced at the points made). In other words, in general, for younger women higher doses give more protection .
Re absolute oestrogen levels - there has been discussion about this and a have no papers to quote, but sometime ago I did find a paper where this was investigated and I do remember the absolute estradiol levels for osteoporosis protection ( and I dont know what markers were used to measure this) were much lower than I thought at something like 165 - 200 pmol/l though this would be a minimum and the oestrogen dose to achieve this would vary between women due to absorption.
That's all have time for now and hopefully my (hastily made) points are a correct interpretation but thanks for posting all of this...
Hurdity x
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Very recent study-
Perimenopausal Bone Loss is associated with Ovulatory Activity
https://mdpi-res.com/d_attachment/diagnostics/diagnostics-12-00305/article_deploy/diagnostics-12-00305-v2.pdf?version=1643166935
M x
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Marchlove, that's very interesting. It supports what Lara Briden says - she believes that progesterone (body identical!) is really important for bone health and that we need to have ovulatory cycles because only when we ovulate do we then produce those high levels of progesterone. If we don't ovulate, our progesterone stays low and we have an anovulatory bleed instead of a period.
Which in turn supports the idea of using body identical progesterone during perimenopause, since this is when a lot of women stop ovulating regularly - even if they are bleeding regularly, a lot of those bleeds will be anovulatory. Lara Briden recommends supporting with body identical utrogestan during the luteal phase of the cycle, when usually the body would produce progesterone itself, after ovulation.
By the way, this is all very conflictual with the research on combined pills and POPs. Because that research has found that they don't have an impact on bone density - even though they stop ovulation. I looked into this when I first got worried about desogestrel, which suppresses estrogen to a low level. I wanted to check it then didn't affect BMD. And according to research, it doesn't. That makes no sense to me, because it can suppress estrogen to a really low level, like 50pmol or something, and also stops progesterone due to no ovulation - and we know that in peri and menopausal women that would be associated with bone loss.
So I don't understand why stopping ovulation with contraceptives (using synthetic hormones which aren't going to help health and BMD) doesn't cause a loss to BMD but when ovulation stops happening regularly during peri, it somehow does??
I also can't believe that we don't conclusively have these answers to the female body and how it works and it is 2022, we have landed on the moon and developed the internet and can somehow bring dead pigs' brain cells back to life - yet we don't understand how the hormones of 50% of the planet work, on a very basic level. We should all be outraged by this.
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I also can't believe that we don't conclusively have these answers to the female body and how it works and it is 2022, we have landed on the moon and developed the internet and can somehow bring dead pigs' brain cells back to life - yet we don't understand how the hormones of 50% of the planet work, on a very basic level. We should all be outraged by this.
Well said joziel.
Wx
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Yes it is very odd Joziel, makes we wonder if the research is done by the pharmaceutical industry or those with conflicts of interest, after all combined pills and POPs must be good money spinners.
Independent research for women is what is required, but who is going to pay for it???
Take testosterone for instance, huge amount of studies showing how it contributes to bone health in men, but I could hardly find any studies for women.
Yes Lara Briden is very much this way of thinking and certainly more ladies on this forum are experimenting with lower doses of estrogen certainly in peri.
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Lara briden shared an article querying of the COP was reducing women’s drive to achieve due to testosterone suppression today - I don’t read it but I did also wonder if it had an affect when I read her books and she talks about ovulation.
Gp was happy earlier with over 200 for bone but I wasn’t as still not feeling great.
I’m sorry to hijack the thread - could continuous utrogestan affect/ stop ovulation? I’m trying it for more consistency. I use vaginally. May try orally - actually could that help bones?!
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I'm not totally on board with Lara Briden when it comes to testosterone. She seems quite against it and bangs on about it causing weight gain. I don't know what research that is based on. Surely it depends if your hormones are optimised and if you're taking the correct amount for a woman...
If you are peri, then you might not be ovulating anyway every cycle. That's when we start to get a lot of anovulatory cycles. If you're taking utrogestan, then you're not dependent on ovulation for progesterone from the corpus luteum - you're getting it from utrogestan. If you're only taking it at 100mg continuous, I don't think you will be stopping ovulation - that's not a high enough dose to stop ovulation if you are peri. Which is why you might get breakthrough bleeding. It might be best if you get bleeding to stop it for 3 days a month at least, so you can schedule that bleed.
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I agree joziel. LB hardly mentions testosterone as a benefit in her books. Indeed quite rightly she makes great mention of PCOS, a much misunderstood condition, which indeed needs far better understanding and treatment.
My research of testosterone regarding its monthly cycle, seems to show that at ovulation it increases inline with estrogen and sort of follows the same natural decline.
It’s diurnal rhythm also shows a peak early morning.
This must all have great significance on our natural ovulation and it makes me wonder if we should be supplementing testosterone somehow in a way that somehow replicates this? X