7/26/2008

Hormones: Dos and Don'ts

As I explained in Natural Hormones: Why doctors are clueless? section, most doctors are still following the highly biased guidelines drug companies have laid out for them and clueless and confused when it comes to safe and effective use of natural hormones (see also what PremproCounsel Legal Team has found).
So, here is the dos and don'ts of menopause hormonal health management and the relevant research papers, in case your doctor is one of those confused and misinformed.
Important: Don't let your doctor overdose you. 
  1. Doctors are brain washed to think: most of oral natural progesterone or estrogen gets "digested", therefore it requires 10 times more than what you actually need. 
  2. Doctors are brain washed to think: natural progesterone or estrogen does not get absorbed much through skin, therefore it requires 10 times more than what you actually need.  
  3. Doctors are brain washed to think: your blood hormone level (98% inactive, 2 % active form of hormone) has to achieve the same level as normal reproductive age level by supplementing active form of hormone (micronized powder in gel cap or liquid in cream, oil, gel, patch, spray, etc.), and measuring inactive form of hormones.  Although what really matters is the level of active form of hormones and the traditional blood test is not sensitive enough to keep track the active form of hormones.
  • One time I consulted a doctor who seemed better informed. When I asked him about oral progesterone, he prescribed me 100mg capsules. It made me so tired and lethargic I had to quit after 2 days. 

Dos:

1. Use natural bio-identical hormones at lowest dose necessary in transdermal forms (skin cream*, patch, oil, spray, vaginal gel/cream/ring**). The higher the dosage the more bleeding and spotting will occur, not to mentions all the overdose side effects and hormonal imbalance risks. For many women with intact ovaries, 20mg/day progesterone cream without estrogen can completely eliminate hot flashes and other menopausal symptoms during the early post menopause years (see the table below). 0.025mg/day transdermal estradiol + progesterone is enough to control menopause symptoms for most women, 0.05mg/day transdermal estradiol + progesterone will take care the rest[1]. For protection of uterine lining (endometrium), as low as 10mg/day vaginal progesterone can protect uterus against estrogen stimulated proliferation, although individual differences exist. Keep in mind that maximum daily progesterone secretion during normal cycle is around 30mg.
*Caution: for the progesterone cream to be well absorbed and protected from oxidation, it has to be suspended in some protective delivery medium (e.g. liposome) or dissolved in protective oil such as vitamin E. Gritty and/or watery cream is not effective. High quality cream will resist oxidation up to 3 months after opening, but not much more. Also, the cream has to be rubbed in well to clean and soft part of skin free of mineral oil to ensure absorption.
**Caution: vaginal rings are know to cause tissue irritations and should be monitored closely.
2. Start progesterone supplementation with the first sign of menopause transition to prevent estrogen dominance. The progesterone level drops several years before menopause, while estrogen level stays normal or higher[2]. Even during the early post menopause years, the estrogen level stays high enough to stimulate endometrial proliferation[3], therefore progesterone supplementation is needed to prevent estrogen dominance syndromes including uterine cancer.
3. Use continuous regimen (no estrogen only days). There is no need to induce bleeding to protect your uterus in post menopause years (D L Moyer et al. 1993[4]). Low dose progesterone (as low as 10 mg/day vaginal and 30 mg/day skin cream) is enough to protect uterus lining (endometrium) in the continuous regimen when combined with low to medium dose estradiol (see the table below). However, it is normal to see some spotting or bleeding at the beginning of continuous regimen. Continuous regimen is also important for protection against ovarian cancer[5].
4. Get regular check-up. Although maintaining healthy hormonal balance the right way will reduce various health risks, it will not make you bullet proof.

Don'ts:

1. Use of unopposed estrogen is not justified even for women without uterus. Besides the well known uterine cancer risk, it raises risks of breast cancer[6], ovarian cancer [7] [8], stroke[9], dementia[10] and a wide range of estrogen dominance syndromes. In other words, whenever you use estrogen, you need to use progesterone (bio-identical) along with it. Anybody who says otherwise is ignorant of the differences between the real and fake progesterone as well as the serious nature of estrogen dominance syndromes.
2. Use of fake hormones of any kind is not justified for any condition. They raise breast cancer risk[11], blood clot risk[12], bad cholesterols[13], to mention just a few. How can you tell which one is real? If the active ingredients does not simply say "progesterone" or "estradiol" or "17-beta estradiol", stay away. Note also that all birth control drugs are fake hormones.
3. Use of oral hormone delivery (pills, capsules) is not justified for any condition. It negatively affects cholesterol[14], cardio-vascular risk[15], and metabolic risk factors[16]. It is less effective in controlling uterine lining[17]. It burdens liver and kidney[18], raises gallbladder disease risk[19]. Oral progesterone can cause fatigue, depressive mood, and PMS like symptoms due to the high standard dose (100 mg capsule is the lowest available) and high rate of metabolic conversions, especially when it is not in balance with estrogen level[20]. Progesterone and its metabolites are GABAa receptor activators (i.e. They act as tranquilizer). Given a large enough dose, it can induce drunkenness and slow down digestive as well as cognitive functions[21].
4. Use of venous blood hormone tests for measuring hormone supplementation level is useless. It's been known that the plasma hormone levels and uterine lining status do not correlate (Trevoux, et al. 1986[22], Sojo-Aranda et al. 1988[23], ). The same applies when you try to see the effects of hormone supplementation (Ficicioglu et al. 2004[24], Tavaniotou et al. 2000[25], Friedler et al. 1999[26]). Measuring hormone levels in venous blood, be it plasma or red blood cells, free or bound, is like measuring oxygen in venous red blood cells and concluding the person is suffocating. Saliva or capillary blood spot test reflects what's delivered to the tissues much better. However, there is no need to use such indirect measures that go through a rapid change with each application[27] [28] [29]. When you need to know if the symptoms improved, you measure the symptoms. When you need to know if the uterus is protected, you check the uterus, and so forth.
Table 1. Continuous regimen studies with transdermal (non oral) natural progesterone on post menopausal women
Study
Size/duration
Estrogen
Progesterone
Results
Leonetti et al. 1999[30]
43 (47 placebo) women within 5 years of natural menopause,
1 year trial
no estrogens
(daily multivitamins and 1200 mg of calcium)
quarter teaspoon of cream (containing 20 mg progesterone) to the skin daily or placebo
vasomotor symptom relief: 25 of 30 (83%), 5 of 26 (19%) with placebo, complete relief in 11 of 30. Most reached maximum relief after the first month.
no bone loss or gain
spotting: 8 women
Leonetti et al. 2003[31]
32 women
time since menopause (7.1 ±6.2 years)
28 day trial
premarin (oral conjugated estrone) 0.625mg/day
started 2 weeks before progesterone to stimulate endometrium
twice daily transdermal application of 0%, 1.5%(30mg /day), or 4.0%(80mg/day) P in 1000 mg cream, adjusted by body weight
The endometrial proliferation scores (EPS)
Initial EPS=2 a Final EPS=0 for 30mg and 80mg group, no change for 0% (placebo) group
0=inactive,
1=scantly proliferative,
2= moderately proliferative,
3= proliferative,
4= highly proliferative.
Spotting occurred in 3 during the washout estrogen-only period, 3 during the first 2 weeks of P treatment (2 in 0% group, 1 in 1.5% group)
greater than 98% compliance
Arvind Vashisht et al. 2005[32]
41 (3 of 44 did not complete)
48 week trial
1 mg transdermal estradiol daily
40 mg transdermal natural progesterone cream daily
At 24 weeks, 48% remained entirely amenorrhoeic. At 48 weeks 35% had been entirely amenorrhoeic and 50% had either no bleeding or spotting alone. The number of bleeding episodes did not reduce with time.
32 % proliferative or hyperplastic.
Arvind Vashisht at al. 2005[33]
same as above
same as above
same as above
Women reported significant reductions in menopausal symptoms, as measured by the Green Climacteric Scale, after 24 and 48 weeks of combined treatment.
D de Ziegler et al. 2000[34]
67 women for 6 months
estrogens (not specified)
most likely transdermal estradiol 0.05 mg
vaginal progesterone gel (Crinone 4%= (45 mg) twice weekly
54 (80.6%) of 67 amenorrhoeic throughout 6 months. No hyperplasia
Cicinelli, Ettore et al. 2002[35]
26 women,
I year
transdermal estradiol 0.05 mg
vaginal progesterone gel (Crinone 4%= 45 mg) twice weekly
287/350 (82%) cycles were amenorrheic. endometrial atrophy in 24 (92.3%) cases and signs of decidualization in 2 cases.
Hamada et at. 2003[36]
20 women
16 weeks
vaginal ring estradiol 160 microg/day
4 month vaginal ring progesterone 10 or 20 mg/day.
Significant decreases in the incidence of hot flushes and night sweats as well as a striking improvement in mood scores as early as 2 weeks after insertion.
Increased vaginal discharge within the first 6 weeks.
Endometrium thickness of <3mm
Vaginal bleeding was more frequently apparent among users of the 20mg ring, although bleeding and spotting were confined to the first 6 weeks.
Ben-Chetrit et al. 2005[37]
29 women
ring kept 4 to 6 months
11 dropped out due to side effects
same as above
same as above
Reduced climacteric symptoms, prevented endometrial proliferation, and provided an acceptable bleeding pattern.
Endometrial thickness increased in 6(20%).
Suvanto-Luukkonen et al. 1998[38]
15 women
I year trial
percutaneous estradiol gel containing 1.5 mg estradiol daily
natural progesterone 100 mg daily vaginal
After 12 months of therapy, no significant change in endometrial thickness (2.5 mm -> 2.4mm), 5 had inactive or atrophic endometrium, 10 were proliferative. No hyperplasia.
Notes: Red indicates excessive dosage, oral form, or otherwise problematic, that should not be followed.

[1] H Gadomska, E Barcz, A Cyganek, Y Leocmach, H Chadha-Boreham, L Marianowski. Efficacy and tolerability of low-dose transdermal estrogen (Oesclim) in the treatment of menopausal symptoms. Curr Med Res Opin. 2002 ;18 (2):97-102,
[2] Santoro N, Brown JR, Adel T, Skurnick JH. Characterization of reproductive hormonal dynamics in the perimenopause. J Clin Endocrinol Metab. 1996;81(4):1495-1501.
[3] R Trevoux, J De Brux, M Castanier, K Nahoul, J P Soule, R Scholler. Endometrium and plasma hormone profile in the peri-menopause and post-menopause. Maturitas. 1986 Dec ;8 (4):309-26
[4] D L Moyer, B de Lignieres, P Driguez, J P Pez. Prevention of endometrial hyperplasia by progesterone during long-term estradiol replacement: influence of bleeding pattern and secretory changes. Fertil Steril. 1993 May ;59 (5):992-7
[5] Tomas Riman, Paul W Dickman, Staffan Nilsson, Nestor Correia, Hans Nordlinder, Cecilia M Magnusson, Elisabete Weiderpass, Ingemar R Persson Hormone replacement therapy and the risk of invasive epithelial ovarian cancer in Swedish women. J Natl Cancer Inst. 2002 Apr 3;94 (7):497-504 1.
[6] Unequal risks for breast cancer associated with different hormone replacement therapies: results from the E3N cohort study. Agnes Fournier, Franco Berrino, Francoise Clavel-Chapelon. Breast Cancer Res Treat. 2007 Feb 27.
[7] James V. Lacey Jr. et al., Menopausal Hormone Replacement Therapy and Risk of Ovarian Cancer, 288 JAMA 334 (2002).
[8] Karen Wernli, Polly Newcomb, John Hampton, Amy Trentham-Dietz, Kathleen Egan. Hormone therapy and ovarian cancer: incidence and survival. Cancer Causes Control. 2008 Feb 9
[10] Shumaker SA, Legault C, Kuller L, Rapp SR, Thal L, Lane DS, Fillit H, Stefanick ML, Hendrix SL, Lewis CE, Masaki K, Coker LH; Women's Health Initiative Memory Study. Conjugated equine estrogens and incidence of probable dementia and mild cognitive impairment in postmenopausal women: Women's Health Initiative Memory Study. JAMA. 2004 Jun 23;291(24):2947-58.
[11] Agnes Fournier, Franco Berrino, Francoise Clavel-Chapelon. Unequal risks for breast cancer associated with different hormone replacement therapies: results from the E3N cohort study. Breast Cancer Res Treat. 2007 Feb 27
[12] J L Ambrus, I B Mink, N G Courey, K Niswander, R H Moore, C M Ambrus, M A Lillie. Progestational agents and blood coagulation. VII. Thromboembolic and other complications of oral contraceptive therapy in relationship to pretreatment levels of blood coagulation factors: summary report of a ten-year study. Am J Obstet Gynecol. 1976 Aug 15;125 (8):1057-62,
[13] U B Ottosson Oral progesterone and estrogen/progestogen therapy. Effects of natural and synthetic hormones on subfractions of HDL cholesterol and liver proteins. Acta Obstet Gynecol Scand Suppl. 1984 ;127 :1-37,
[14] M Erenus, B Karakoc, A Gurler Comparison of effects of continuous combined transdermal with oral estrogen and oral progestogen replacement therapies on serum lipoproteins and compliance. Climacteric. 2001 Sep ;4 (3):228-34
[15] Karine Lacut, Emmanuel Oger, Jean-Herve Abalain, Marie-Pierre Moineau, Dominique Mottier. Effects of oral and transdermal 17 beta-estradiol combined with progesterone on homocysteine metabolism in postmenopausal women: a randomised placebo-controlled trial. Atherosclerosis. 2004 May ;174 (1):173-80
[16] J C Stevenson, D Crook, I F Godsland, B Lees, M I Whitehead. Oral versus transdermal hormone replacement therapy. Int J Fertil Menopausal Stud. 1993 ;38 Suppl 1
[18] K A Steingold, D W Matt, D DeZiegler, J E Sealey, M Fratkin, S Reznikov. Comparison of transdermal to oral estradiol administration on hormonal and hepatic parameters in women with premature ovarian failure. J Clin Endocrinol Metab. 1991 Aug ;73:275-80
[19] Bette Liu, Valerie Beral, Angela Balkwill, Jane Green, Sian Sweetland, Gillian Reeves. Gallbladder disease and use of transdermal versus oral hormone replacement therapy in postmenopausal women: prospective cohort study. BMJ. 2008 ;337 :a386
[20] B de Lignieres, M Vincens. Differential effects of exogenous oestradiol and progesterone on mood in post-menopausal women: individual dose/effect relationship. Maturitas. 1982 Apr ;4 (1):67-72.
[21] E W Freeman, L Weinstock, K Rickels, S J Sondheimer, C Coutifaris. A placebo-controlled study of effects of oral progesterone on performance and mood. Br J Clin Pharmacol. 1992 Mar ;33:293-8
[22] R Trevoux, J De Brux, M Castanier, K Nahoul, J P Soule, R Scholler Endometrium and plasma hormone profile in the peri-menopause and post-menopause. Maturitas. 1986 Dec ;8 (4):309-26
[23] I Sojo-Aranda, R Alonso-Uriarte, M Gonzalez-Diddi, V Cortes-Gallegos. The biological expression of natural progesterone. J Steroid Biochem. 1988 Aug ;31 (2):219-22
[24] C Ficicioglu, B Gurbuz, S Tasdemir, S Yalti, H Canova. High local endometrial effect of vaginal progesterone gel. Gynecol Endocrinol. 2004 May ;18 (5):240-3
[27] O'leary P.; Feddema P.; Chan K.; Taranto M.; Smith M.; Evans S. Salivary, but not serum or urinary levels of progesterone are elevated after topical application of progesterone cream to pre-and postmenopausal women. Clinical Endocrinology, Volume 53, Number 5, November 2000 , pp. 615-620(6)
Topical application of progesterone cream will show up in saliva within 30 to 60 min., and reaches high peak in 1 to 4 hours, then falls thereafter.
[28] E Cicinelli, S Sabatelli, D Petruzzi, S Stragapede, M Lapenna, G Balzano [Transvaginal absorption of an oleic solution of progesterone (Gestone) in fertile women] Minerva Ginecol. 1995 Mar ;47 (3):99-102
P in oil 100 mg, Blood P level peaked in 1 to 4 hours, was still higher than baseline after 24 hours.
[29] B Villanueva, R F Casper, S S Yen. Intravaginal administration of progesterone: enhanced absorption after estrogen treatment. Fertil Steril. 1981 Apr ;35 (4):433-7
The peak level can be 20 to 40 times baseline. After how much P given not mentioned in the abstract.
[30] H B Leonetti, S Longo, J N Anasti.Transdermal progesterone cream for vasomotor symptoms and postmenopausal bone loss. Obstet Gynecol. 1999 Aug ;94 (2):225-8
This confirmed the common observation of those doctors who have been recommending progesterone skin cream for menopausal symptoms that 2 in 3 women in the US can manage menopause with progesterone only therapy.
[31] Leonetti H, Wilson KJ, Anasti JN. Topical progesterone cream has an antiproliferative effect on estrogen-stimulated endometrium. Fertil Steril 2003; 79: 221-222.
Premarin 0.625mg was the most often prescribed estrogen in the US at the time, and they demonstrated natural progesterone cream can be combined effectively with it instead of Provera, which has been know for its multitude of side effects.
[32] Arvind Vashisht, Fred Wadsworth, Adam Carey, Beverley Carey, John Studd. Bleeding profiles and effects on the endometrium for women using a novel combination of transdermal oestradiol and natural progesterone cream as part of a continuous combined hormone replacement regime. BJOG. 2005 Oct ;112 (10):1402-6
I wonder why they used 1 mg /day transdermal estradiol, which is 40 times higher than what's needed. No wonder 40mg/day progesterone cream could not control endometrium adequately. Doctors at Chelsea and Westminster Hospital, London, UK are starting to realized that they cannot simply dismiss progesterone cream based on serum/plasma hormone level like they did in their 2000 study. However, they did not learn much about the right estradiol dosage since. Or was it their main aim to discourage the use of progesterone cream? Whatever the reason, I hope they are not routinely prescribing such a high amount of estradiol to their menopause patients.
[33] Arvind Vashisht, Fred Wadsworth, Adam Carey, Beverley Carey, John Studd. A study to look at hormonal absorption of progesterone cream used in conjunction with transdermal estrogen. Gynecol Endocrinol. 2005 Aug ;21 (2):101-5
[34] D de Ziegler, R Ferriani, L A Moraes, C Bulletti. Vaginal progesterone in menopause: Crinone 4% in cyclical and constant combined regimens. Hum Reprod. 2000 Jun ;15 Suppl 1 :149-58
[35] Cicinelli et al. Twice-weekly transdermal estradiol and vaginal progesterone as continuous combined hormone replacement therapy in postmenopausal women: A 1-year prospective study. American Journal of Obstetrics & Gynecology. 187(3):556-560, September 2002.
[36] A L Hamada, T Maruo, T Samoto, S Yoshida, H Nash, I M Spitz, E Johansson. Estradiol/progesterone-releasing vaginal rings for hormone replacement therapy in postmenopausal women. Gynecol Endocrinol. 2003 Jun ;17 (3):247-54
With the local effect of transdermal delivery, 10 mg/day progesterone is enough to control endometrium even with relatively high dose of estradiol used in this study. They also demonstrated that enough hormones reached brain to control menopausal symptoms and mood.
[37] Avraham Ben-Chetrit, Drorit Hochner-Celnikier, Tzina Lindenberg, David Zacut, Shlomo Shimonovitz, Hadassa Gelber, Irving M Spitz. Vaginal ring delivering estradiol and progesterone: a possible alternative to relieve climacteric symptoms. Isr Med Assoc J. 2005 May ;7 (5):302-6.
The vaginal ring was apparently abrasive and irritated the tissues, which caused 11 of 28 people to dropout. I wonder how they did in the Japanese arm of the study, which does not mention anything about it in the abstract. I wonder who would use vaginal rings if they know they can try progesterone skin cream to see if it work for them.
[38] E Suvanto-Luukkonen, H Malinen, H Sundstrom, J Penttinen, A Kauppila. Endometrial morphology during hormone replacement therapy with estradiol gel combined to levonorgestrel-releasing intrauterine device or natural progesterone. Acta Obstet Gynecol Scand. 1998 Aug ;77 (7):758-63
This study was done to demonstrate the superiority of levonorgestrel-releasing intrauterine device (LNG-IUD). The high doses reflect the attempt to achieve "normal" plasma level commonly believed necessary at the time. Too bad they did not create natural progesterone releasing device. Although, I cannot imagine inserting IUD in my uterus even if it is natural progesterone, much less a fake progesterone like levonorgestrel.
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7/25/2008

Natural Hormones: Why are doctors clueless?

If you've never been exposed to this seemingly simple issue of how to maintain the hormonal balance and health, you are probably wondering why the controversy? In this day and age--with all the technologies to measure even the tiniest trace amount of hormones anywhere in the body, and drugs to block any hormone almost at will, plus manufacturing capabilities to produce hormones of any shape or form whether they exist in nature or not--you might think that all the experts would agree on the basic facts. But with billions of dollars for drug companies at stake, the quality of life (if not life and death) of billions of women and men get caught up in confusion.
When I was told "You should be using natural progesterone." by a nutritional supplement dealer, my response was "But, I don't have uterus and my doctor told me…". Before I could finish my sentence, she told me "You need to read this." and pulled out a printout of some summary information on the subject. I took it home, and as I started to read it, I realized what I was reading, if true, was a major medical blunder in modern medicine. You might even say it has a smell of conspiracy that makes "the Vast Right-Wing Conspiracy" on Bill and Hilary Clinton pale in comparison (see what PremproCounsel Legal Team has uncovered). That was 1998, many years before the Women's Health Initiative (WHI) clinical trial was terminated with shocking results in 2002.
In case you are not familiar, the clinical trial found that women treated with combined Premarin (estrogen from horse urine) and Provera (a fake progesterone) therapy experienced higher rates of breast cancer, stroke, heart attack, pulmonary embolism, and blood clots. (In 2003, Premarin-only arm of the same study was also stopped early with increased risks of stroke and dementia. Another study done by National Cancer Institute (NCI) found that long-term estrogen-only use significantly increased the risk of ovarian cancer.)
Actually it wasn't shocking to those in the know, including the drug companies. Most of those side effects have been known and listed on the warning labels, albeit not adequate. So, after spending millions of dollars of tax-payer's money and exposing tens of thousands of women to the hazardous substances, there was an eerie silence instead of a swift action to ban the dangerous fake hormones along with the so called "standard HRT". Then the damage control began. They went back and "reanalyzed" the WHI clinical trial data and stepped up their campaign to tell doctors that it's OK to continue the "standard HRT". Their claim was that if you just look at the younger, healthier subjects, they were OK, and besides, there is nothing better anyway. Of course women aren't buying it (neither the French[1], nor the Brazilians), but it's what the US doctors are told in their medical journals, in their professional society's position statement[2], and fellow physician speakers, most of whom are paid by drug companies.

History

It all began when it became clear that real (natural bio-identical) hormones are not easily absorbed when taken orally because most of it gets "digested" (converted or metabolized to some other forms of hormones), and the drug companies opted to tinker with the hormones to make indigestible fake hormones rather than figuring out effective delivery methods of the real hormones. For one thing, there is more money in selling patentable artificial (fake) substances than in selling naturally occurring substances that are not patentable.
Of course, there are always ingenious people who see a need and figure out a way. If you need to avoid digestion, you use other routes--such as skin. Skin can absorb lots of things. Luckily, progesterone has been one of the safe hormones available without prescription in the US. So, progesterone skin cream and oil became available as over the counter supplements. It did not require any large scale studies to convince the consumers. All you need to do is to try it out yourself to see it work for you. It is inexpensive, easy to use, and safe. By the time late Dr. John R. Lee published his first book of the "What Your Doctor may Not Tell You About …." series in 1996, there were more than 30 companies manufacturing and selling progesterone cream he found suitable for supplementation.
Then, there surfaced a group of people--a propaganda machine, if you will--who started to publish articles in medical journals to discredit everything related to natural bio-identical hormones, especially the progesterone cream available over the counter or from compounding pharmacies[3][4][5]. First they thought they were on firm ground when progesterone cream failed to raise plasma progesterone level to a luteal (after ovulation) level and failed to induce bleeding with cyclic regimen. They were confident that was pretty good evidence to convince doctors that progesterone cream was no good. Then they found out that the world of menopause hormone therapy had shifted to continuous regimen and that low level progesterone had been demonstrated to be enough to protect uterine lining from hyper proliferating (the cause of uterine cancer) without inducing monthly bleeding (D L Moyer et al. 1993[6]).
They also found out that saliva or capillary blood hormone test will show a strong evidence of absorption. But, they were not deterred. They are still pushing the propaganda by discrediting saliva test itself by saying that saliva hormone levels do not correlate with plasma hormone levels[7]. No logic or data is presented in support. It is just an inconvenient fact that they want to ignore.
First, saliva test was used simply to show that a plenty of progesterone gets absorbed[8]. The timeline and the amount of hormones that show up in saliva after application is a separate issue. Besides, since when did the plasma hormone test become a reliable indicator of progesterone action in women's body? There are plenty of evidences to prove it is not (Trévoux, et al. 1986[9], Sojo-Aranda et al. 1988[10], Friedler et al. 1999[11], Tavaniotou et al. 2000[12], C Ficicioglu et al. 2004[13]). Yet they argue the lack of correlation with the plasma progesterone level discredit the saliva test (I can argue the exact opposite; The lack of correlation discredits the plasma hormone tests). By making these disingenuous baseless arguments, they are discrediting themselves.
Evidently, some of them became so disparate as to make up lies[14] about late Dr.John R. Lee who dedicated his retirement years to educate the world the importance of progesterone in women's health and how safe and easy it is to maintain hormonal balance and health using over the counter natural progesterone cream, while pointing out the danger of fake hormones used in birth control pills and conventional HRT. It is not hard to imagine, that very fact --easy, safe, inexpensive, and effective-- could be the exact reason why some in the drug industry and medical establishment try so hard to discredit its use. Over the counter natural progesterone cream can be a serious competition that can affect their bottom lines.
Transdermal application of steroid-sex hormones are not limited to natural progesterone cream and all steroid-sex hormones are of similar size and structure. Transdermal applications such as Cortisone cream, estrogen and testosterone (both fake and real) in patch/cream/gel/oil/spray form, fake progesterone/estrogen patch for contraceptives, vaginal rings/gel/cream containing natural progesterone and estradiol have been FDA approved, and known well absorbed. So if they want to claim natural progesterone in cream form some how can not be absorbed and ineffective, they need to demonstrate the biological mechanism of why natural progesterone alone behaves differently. Anything short of that should be rejected.
When they realized there is no scientific basis to argue that progesterone cream cannot be absorbed, instead of calling to ban the fake hormones that have been proven dangerous, they started to argue there is no evidence that natural bio-identical hormones are safer than fake hormones that have been proven dangerous, and until some large scale experiments are conducted, you need to assume they are equally dangerous[15] and need to control them the same way (meaning no over the counter products should be allowed). They are trying to convince doctors as well as FDA that access to nature hormones should be restricted. FDA's move to restrict doctors' access to natural hormones through compounding pharmacy was defeated thanks to those who staid vigilant[16] [17].
Let's get it straight. We already have decades worth of research data on natural hormones. After all, they are exact bio-identical substances to what our body makes. That means every research that looked at endogenous hormone status of women from menarche to menopause and beyond is part of natural hormone research. It is disingenuous to pretend those research have no bearing on natural hormone supplementation.
The North American Menopause Society 2008 Position Statement[18] speaks louder than anything else about who is controlling the information with whose interest in mind by their failure to differentiate the proven dangerous fake progesterone (progestins such as medroxyprogesterone acetate used in Provera and Prempro, norethindrone acetate, etc.) from natural progesterone (in 2004 Position Statement, they did not even bother to mention natural progesterone). Their bias becomes even clearer when you put it next to the 2004 position statement of Brazilian Society of Endocrinology and Metabolism that concluded "Whenever possible, one should use 17-beta estradiol, associated to natural progesterone" (both 17-beta estradiol and natural progesterone are the main hormones produced in ovaries).
The fact is the train has already left the station while doctors are all confused, misinformed, and disoriented by those disingenuous propaganda articles in the aftermath of the Prem-Pro WHI clinical trial fiasco. Millions of people have been using over the counter progesterone cream all over the world. If you are given a choice between a drug that is proven dangerous and a hormone your body used to make and thrived on, is there any doubt about which you chose? Unlike the fake hormone Prempro that some doctors are still routinely prescribing despite the fact it's been proven dangerous and notorious for its compliance problem (it makes you feel miserable and many will stop using it), the over the counter natural progesterone cream has many satisfied customers who continue to use it. By keeping doctors ignorant and misinformed, the medical community will further lose credibility they have already lost by the Prem-Pro clinical trial fiasco.
References

[1] Fournier, Franco Berrino, Françoise Clavel-Chapelon. Unequal risks for breast cancer associated with different hormone replacement therapies: results from the E3N cohort study. Breast Cancer Res Treat. 2007 Feb 27
This study compared different progestogens (natural progesterone and fake ones) in combination with transdermal estradiol) in long term post menopause hormone replacement therapy. Natural progesterone was the clear winner. Estrogen only (either oral Premarin or transdermal estradiol) turned our not safe against breast cancer either.


[2] Menopause. 2008 Jun 20; Estrogen and progestogen use in postmenopausal women: July 2008 position statement of The North American Menopause Society.
They are making all sorts of excuses to encourage doctors to continue using HRT regimens the WHI studies proved dangerous. At the same time they discourage the use of other alternatives, especially natural bio identical hormones、claiming you need to assume they are just as dangerous as the fake ones.
[3] J Gen Intern Med. 2007 Jul ;22 (7):1030-1034 Bioidentical Hormones for Menopausal Hormone Therapy: Variation on a Theme. Adriane Fugh-Berman, Jenna Bythrow
A propaganda article to scare doctors away from natural bio-identical hormones. In one breath they say fake hormones are OK to use although they are proven dangerous. In another breath they attack natural hormones because the studies that proved its safety and efficacy is not perfect. Basically they are disregarding any and all evidences that does not agree with their desire to continue the status quo of using dangerous fake hormones.

[4] J Obstet Gynaecol. 2007 Oct ;27 (7):655-9 Transdermal natural progesterone cream for postmenopausal women: Inconsistent data and complex pharmacokinetics. M A A Elshafie, A A A Ewies
Another one of those propaganda articles to scare doctors away from natural progesterone cream. Which do you choose? Drugs proven dangerous or over the counter supplement products that have been used by millions of satisfied customers and plenty of studies to prove it is safe and effective? They are counting on doctors ignorance about hormone tests other than those using venous blood. They are telling the doctors it's too complex for them to understand and does not bother to explain. Or, they don't have any explanation?
[5]Med J Aust. 2005 Mar 7;182:237-239 Transdermal progesterone creams for postmenopausal women: more hype than hope? Barry Wren
Another one of those propaganda articles. He runs progesterone cream studies that fail to show positive results and claims that his failure to show positive result can discredit studies showing positive results. In the world of science, you cannot prove something does not exists. One demonstration of positive result is enough to prove it exist. When he found saliva test can detect progesterone at high level, he simply pushed it aside by saying "The level of progesterone detected in saliva was up to several hundred times greater than that measured in blood. This suggests that progesterone is probably concentrated and excreted by the salivary glands instead of filtering passively down a diffusion gradient from red blood cells to saliva." Here, he feels no need to dig deep into the underlining biological mechanism to solve the puzzles. He simply discredit the saliva test by disingenuous argument and baseless speculation, clinging on to his earlier argument that "slight/no increase in plasma progesterone" is proof enough that progesterone cream does not work.
The disingenuous nature of his arguments gets totally exposed when he makes up lies about late Dr. John Lee designed to give impression that everything he said about progesterone cream was to promote the progesterone cream he developed and sold. A total lie. Dr. Lee did not develop nor sell progesterone cream.
[6] D L Moyer, B de Lignieres, P Driguez, J P Pez. Prevention of endometrial hyperplasia by progesterone during long-term estradiol replacement: influence of bleeding pattern and secretory changes.
Fertil Steril 1993 May ;59 (5):992-7
[7] John G Lewis. Steroid Analysis in Saliva: An overview. Clin Biochem Rev. 2006 Aug ;27 (3):139-46
Another one of those propaganda articles. He discredit saliva test by noting a lack of correlation between blood and saliva progesterone levels. He obviously believes that venous blood hormone level is the true indicator of how much hormone is available to various tissues in the body. This is another area doctors are not adequately trained and he thinks he can get away with his disingenuous baseless speculation.
[8] O'leary P.; Feddema P.; Chan K.; Taranto M.; Smith M.; Evans S. Salivary, but not serum or urinary levels of progesterone are elevated after topical application of progesterone cream to pre-and postmenopausal women. Clinical Endocrinology, Volume 53, Number 5, November 2000 , pp. 615-620(6)
[9] R Trévoux, J De Brux, M Castanier, K Nahoul, J P Soule, R Scholler. Endometrium and plasma hormone profile in the peri-menopause and post-menopause. Maturitas. 1986 Dec ;8 (4):309-26
[10] I Sojo-Aranda, R Alonso-Uriarte, M González-Diddi, V Cortés-Gallegos. The biological expression of natural progesterone. J Steroid Biochem. 1988 Aug ;31 (2):219-22
[13] C Ficicioglu, B Gurbuz, S Tasdemir, S Yalti, H Canova. High local endometrial effect of vaginal progesterone gel. Gynecol Endocrinol. 2004 May ;18 (5):240-3
[14] Barry Wren Transdermal progesterone creams for postmenopausal women: more hype than hope? Med J Aust. 2005 Mar 7;182:237-239
[15] Adriane Fugh-Berman and Jenna Bythrow, Bioidentical Hormones for Menopausal Hormone Therapy: Variation on a Theme. JGIM 2007
[18] Menopause. 2008 Jun 20; Estrogen and progestogen use in postmenopausal women: July 2008 position statement of The North American Menopause Society.
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