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How to start on HRT


From a scientific standpoint, hormone replacement therapy (HRT) is just that, replacement and therapeutic. For a medication to be called hormone replacement the low hormone levels must be raised to normal. Further, the hormone must be delivered in the safest way, and always bio-identical in chemical structure. It is important to understand that the drug Premarin™, which has been called HRT for decades, replaces no hormones at all. Since 2007 the NIH and its manufacturer, Pfizer, no longer refer to Premarin™ as HRT but as HT. Dropping the 'R' from calling Premarin™ HRT is a step forward in being honest with the public. The next step would be to withdraw it from the market because it is not therapeutic either.



Vocabulary you'll need to read this section


Definition of gonads:                                   In a woman the gonads are called ovaries and in a man they are called testicles.  The gonads of women and men have the same functions and provide the same hormones. The gonads provide healthy levels of gonadal hormones, progesterone, estradiol, testosterone, and dhea and have two functions


1)      Keep the entire body healthy for your entire lifetime

2)      Provide eggs and sperm for reproduction.



Definition of gonadal hormones:              Gonadal hormones are the hormones produced by the gonads, ovaries and testicles. The gonads of women and men produce the same hormones, estradiol, testosterone, progesterone and dhea in differing amounts. The gonads are controlled by the same brain hormones, FSH, follicle stimulating hormone, and LH, luteinizing hormone.



Successful HRT is used in the treatment of low thyroid, low cortisol, and many other low hormone conditions. Successful HRT is used long term and not stopped unless the body can bring hormone levels back up to normal. Typically, once a person starts on HRT it is for life. The reason it is for life is that our bodies have the same hormonal needs in our old age as in our youth. For instance, thyroid replacement is used in people of all ages from the very young to the very old. In fact, all of our hormones are necessary to maintain our health. That is what makes HRT therapeutic, raising our hormone levels to normal maintains our health. If your doctor or healthcare worker discourages a hormone regimen for long term use then that is a sure sign it is not genuine hormone replacement treatment.


In general, everyone over the age of 30 years could start replacement of gonadal hormones.  The gonadal hormones are supplied by two endocrine organs, the gonads and the adrenal glands. The gonadal hormones are primarily from the gonads, ovaries and testicles, but also a small amount produced from the adrenal glands. At around age 30 years the adrenal glands start to produce less hormones. The brain, which stimulates the gonads to work, senses that hormone levels have dropped and increase its stimulation of the gonads to work a bit harder to produce a bit more hormones to bring levels up to normal.  Without supplementation the gonads are strained and eventually can't keep up. The strain is seen with reduced fertility, increased rates of birth defects from quicker than normal maturation of egg and sperm, irregular periods and an overall reduction in general health.


Getting started


Step 1:

If possible measure all of the gonadal hormone levels. The same hormones, Progesterone, Testosterone, Estradiol, and Dhea, are measured for men and women. If this is not possible then you can check levels after you start your regimen. 


Even though it's always best to have levels checked before starting any regimen the reality is that most doctors will not measure levels on women over 50 years old and only estradiol levels on women over 40 years. For men, most doctors will measure testosterone levels but not estradiol, progesterone or dhea. To get replacement right, all of the gonadal hormones should be measured regularly.


Step 2:

The easiest way to start gonadal hormone replacement is with estradiol and progesterone for men and women.


For men, the ideal level for estradiol is 20-30 pg/ml

For women, the ideal level for estradiol is 50-150 pg/ml


For men, the ideal level for progesterone is 1000-2000 pg/ml

For women, the ideal level for progesterone is 1000-2000 pg/ml for two weeks 

                                                                                            2000-4000 pg/ml for two weeks

Note:    If the higher progesterone level, 2000-4000 pg/ml, is uncomfortable, i.e. causes bloating, depression, then keep progesterone levels at 1000-2000 pg/ml every day


How to achieve these levels?

For men, estradiol level is usually too high and progesterone level is too low. To reduce estradiol levels to normal and raise progesterone level to normal start on a low dose of progesterone. Normal progesterone levels will reduce estradiol levels to normal. Many, many doctors are unaware of this. Having normal progesterone and estradiol levels can shrink an enlarged prostate. Normal levels can do this because abnormal levels, high estradiol and low progesterone, will increase the size of the prostate.


For women, estradiol is usually too low and progesterone is also too low. To increase estradiol levels choose a transdermal (across the skin) product, not an oral estradiol. To increase progesterone choose a transdermal (across the skin) product.


Step 3:

Now it is time to think about testosterone replacement. For women and men it is straight forward because the level is steady.


For women, the ideal level for testosterone is 400-800 pg/ml

For men, the ideal level for testosterone is 4000-8000 pg/ml


Step 4:

Now is the time to choose hormone products. It is important to choose transdermal, skin creams and gels, whenever possible.  Always start low because you must give your body an opportunity to adjust.  After changing a dosage wait about 4-6 weeks to retest your levels. You are trying to replace 1-4 hormone levels and it will take time. It may take 6 months to a year so please be patient.  It will be worth it.


Always test your hormone levels approximately 10- 12 hours after your last dose. You do this because hormone levels will peak at night and then drop by half in about 12 hours. For example, if you apply testosterone gel at 10 pm the level will peak and be about half that level by noon the next day. If your level is 4000 pg/ml at noon then it was about 8000 pg/ml the previous night.


Try to get all of your levels inside the recommended range. However, you must feel comfortable. If you feel better at a lower level then stay there. The most important thing is to feel good.


Progesterone products:

For men, there are only two options; compounded cream from a compounding pharmacy or a pre-made progesterone cream like Pro-Gest from Emerita.


Typical dosage for men is 6-12 mg/day usually at bedtime. Start at the lowest dose and recheck all of your gonadal hormone levels in 4-6 weeks. Increase by 3 mg/day as needed until you reach your goals for progesterone and estradiol levels.


For women, there are three options; compounded cream from a compounding pharmacy, a pre-made progesterone cream like Pro-Gest from Emerita, or a prescription pill, Prometrium™.


Typical dosage for a woman is progesterone cream 20-60 mg/day usually at bedtime. Again, start at the lowest dose and recheck all of your gonadal hormone levels in 4-6 weeks. The lowest dose of progesterone cream is 20 mg/day and for Prometrium™ is 100 mg/day. Some women like to cycle their progesterone dose. To cycle the progesterone dose use Prometrium™ 100 mg/day at bedtime for the 1st to the 15th of the month and use Prometrium™ 200 mg/day at bedtime for the 16th to the 31st of the month.


Progesterone is important to replace whether you have a uterus or not. Progesterone is used by the brain and the entire body and all people, men and women, should have normal levels along with normal levels of their other gonadal hormones.


Progesterone can make you feel sleepy, tired and bloated. Always start with the lowest dose. If you want to lower the dose then do that. The most important thing is to feel good.


Estradiol products:

For men, estradiol is not usually replaced. However, if it needs to be replaced a transdermal (skin gel) product like Estrogel can be used. This product is more suited for men and is too low a dose for women.


For women, estradiol should be replaced with a transdermal (skin cream or patch) product. Women can use a 0.1 mg. Vivelle patch. The lower dosages (0.075 mg, 0.05 mg, 0.0375 mg, 0.025 mg) are too low and are not recommended.


Estradiol can also be replaced with a transdermal cream. Products like Estrogel, estrosorb, and Divigel provide too little estradiol and are not recommended as there is no reasonable replacement being done.  Compounded estradiol is available by prescription from a compounding pharmacy. Typical doses are 0.5-1.5 mg/day applied at bedtime. Always start at the lowest dose and recheck levels in 4-6 weeks. 


Estradiol can make you feel edgy and tense. If you are more comfortable at a lower dose then do that. The most important thing is to feel good.


Testosterone products:

For men, only use transdermal cream or gel. Typical dosages are 2.5 g/day to 5.0 g/day to start. Begin by applying in the morning. Your testosterone may go down initially because your gonadal production can be suppressed by using supplemental testosterone. If this happens the dosage can be increased. You can also apply 1/2 of the testosterone cream or gel in the morning and the other 1/2 at bedtime. There are several pre-made products available like Androgel and Axiron.


For women, there is only one option and that is compounded testosterone cream from a compounding pharmacy. Typical doses are 0.5-3 mg/day applied at night. Start at the lowest dose and increase as necessary to achieve normal blood levels.


Testosterone can make you feel curt and short tempered. If you are comfortable at a lower level then do that. The most important thing is to feel good.


Dhea products:

For women and men, this is the only product that it is ok to take orally. Like all the other gonadal hormones start out with the lowest dose and retest all of the gonadal hormones in 4-6 weeks.


In general, for women and men, the dosage is similar, 10-50 mg/day. It is very important to start out at the lowest dose and recheck all gonadal hormone levels in 4-6 weeks. Increase in 10 mg/day increments.


Dhea products are sold over the counter so you should be able to buy it at a vitamin or nutrition store or online. If you can't find lower dosages to start, you can take 25 mg/three times a week, i.e. Monday, Wednesday, Friday or Tuesday, Thursday, Saturday.


Finding the right dosage of all of the gonadal hormones will take time. It may take as long as 6-12 months. Every time dosages are adjusted you will likely begin to feel more and more like yourself.  However, you may only get to 80-95% of how you used to feel. At some point you will have to make peace with the fact that that is as close as you can get with the pharmaceuticals available today.


Step 5: (coming soon on our website)

Keep track of your progress. You can use the spreadsheet that we have or use a notebook. Be sure to use the same units every time, ie pg/ml, pmol/l, etc. You can use the units calculator on our website.


This is a journey for you and your healthcare provider. You have an illness, hypogonadism, and it may be severe. When it is severe it is called profound hypogonadism. It is treatable and with a healthcare partner you can find relief from its symptoms and significantly improve your health.


If you have any questions along the way please contact me at beth@diamondrf.org


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