What's the best type of progesterone to use as a part of menopausal hormone therapy?
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- เผยแพร่เมื่อ 6 พ.ย. 2022
- What's the best type of progesterone to use as a part of menopausal hormone therapy? Ever wonder what is the best kind of progesterone to use when starting menopausal hormone therapy? Is synthetic progesterone or bioidentical progesterone better? What about compounded or commercially available progesterone? In this video, I walk you through how to know if your progesterone is what you need in your hormone therapy regimen.
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What are your remaining questions about progesterone? Ask me below!
Hi Heather! Is it enough to take 100mg of Prometrium vaginally every other day to offset an estrogen patch of 0.75 mg?
Dear Dr. Hirsch: I'm taking a 10 mcg Yuvafem vaginal insert a couple of times weekly (intact uterus), should I be taking progesterone?
Two Good questions still unanswered...curious to know your advice
@@casperinsight3524
😂👍
@@user-xs9835 I would like to know this as well. Do you have any answers? Thank you!!!!!
Can't understand why progesterone is ignored if uterus removed. Progesterone has many good uses in addition to be protective to uterus. Bones, anxiety, sleep, bones, bones, bones, sleep. Those things matter.
Exactly! My thoughts is because big pharma needs a continuous stream of customers
While some of what you state is true, some seems confused. Progesterone is not “ignored” if one does not have an uterus. It simply isn’t strictly medically necessary to oppose estrogen therapy. Nothing nefarious happening. Just science.
@@debbiehannah8510”Big pharma” as you put it would benefit either way, so…
@@victoriaboster1177 you just contradicted yourself
How about when a person has Anxiety and can’t SLEEP?! I work 55 hours week as Law Enforcement and I can’t deal with this NO SLEEP thing!!!
TY for keeping your videos short & concise, appreciate your straightforward direct communication. Thx for keeping it simple and easy to understand ~ Cheers
Just wanted to say I really appreciate your content. I’ve been receiving really bad advice from providers and I’m glad to have some knowledge. Nurse practitioner-in-training at my GP literally told me that I could consider HRT if I didn’t mind getting breast cancer (!!!!!) - she is currently in school now! I was referred to an OB-GYN who told me that bioidentical HRT is only available as compounded. It goes on and on….
Thanks again Heather. You cleared up so many questions and explained in easy to understand terms!
I really appreciate your view on this subject. I am taking BHRT and get my hormones from a compound pharmacy. I am doing really well since starting this therapy since 7 mos ago.
Thanks for the video Doc. What is your take on oral bioidentical progesterone in liquid form?
Was going to start my patch tonight, I was wondering why she didn’t give me a progesterone to go with it… so I came to TH-cam and found this video. I’ll call my dr tomorrow and wait to start the patch. Ty
It needs to be combined if you still have uterus, otherwise it can cause uterus cancer. You can do Marina coil, its the safest.
Love your work Dr H.
It has helped me as a NP in Ohio. I try to use the FDA approved products when I can but I have a few patients (and myself) who avoid red dyes and some that are allergic to peanut oil in the FDA approved Prometrium available at local pharmacies. For these cases us use a reputable compounding pharmacy that can make it in olive oil. Curious your thoughts on this ?
would love to hear where you have this made
Very informative video. I have been suffering from insomnia due to perimenopause, now I’m thinking of placing IUD / Marina coil . Does it normally helps towards sleep? Or progesterone tablets helps towards insomnia issue. Thanks
Thank you for providing such great information. How do we get in to see you? Nobody returns my calls at your B&W location for an appointment. Would love a consult.
Any thoughts on the Combi patch I'm so afraid to start it
I am 59 no cancer issues, but I do have heart palpitation any advice or direction would greatly be appreciated ❤
Hello. I am a 46yr old woman. Very healthy. No illnesses no history of any type of cancer. Never was able to have children. Unsure as of why I do have a uterus and ovaries. I just started an HRT with testosterone And progesterone. Do I need to add DIM ??? I don’t take any type of medications and I still have regular periods
I still have my uterus and i have small fibroids. I am worried about how the estrogen will affect the fibroids. I am 56 and trying to decide about hormone therapy. Thank you!
I'm trying to research risk of blood clots as related to progesterones here, already knew about estrogen risks of blood clots but am just now being alerted to blood clot risks of progesterone and trying to see what the risk really is versus being told I can't have it and now have to deal with menopause symptoms which are through the roof
I’ve been on compounded hormones (oral DHEA, progesterone, porcine thyroid, low dose naltrexone for autoimmune, estrogen cream, testosterone cream) for 5 years. I do very well after working with my doctor (who is a 10 hour drive away) over the years, but the cost of the hormones and my very frequent practitioner visits keep going up and up. I’ve been looking for alternatives that might be somewhat offset by my insurance. I am so confused and definitely don’t want to return to the place I was health-wise when I found my doctor and started hormones. I take oral progesterone and I don’t have a uterus. I’m wondering if I can omit the progesterone. My dose is lower because I get very depressed when it’s increased.
However, I’m really good these days and I’m afraid to mess with my plan. Financially, though, I need to make a change. I found a pellet provider locally in my tiny town, but the pellets give me pause. I don’t like the idea of them in my body with no control over lowering the dose,and I’m listening to my intuition. I watched your video about the pellets and read the many comments. Wow!
I’m finally at my goal weight. I’m fit and healthy for age 62. I don’t want to quit the hormones. I’m really confused about what to do.
Is HRT with an estrodial patch and micronized Progesterone considered safe for woman with dense breast tissue?
Do you recommend natural progesterone from wild yam ?
Hi there! love your videos! I'm currently taking vivelle dot patch at .1 and micronized progesterone 100mg. I also take estradiol cream 1 gram twice a week. sometimes 3 times a week. I have seen weight gain since starting the hrt months ago. My diet has not changed. I track everything. the first question is: is the progesterone at 100mg adequate with the patch a a .1? next, can progesterone cause weight gain? thank you , Carla
It may cause some water retention. I would increase the progesterone to 200 mg, however, to match your dose of estradiol in the patch.
I recently had a benign nodule removed from my breast. I am on an HRT patch with oral progesterone. Would it be safer to have the progesterone delivered by an IUD versus oral?
I find prometrium makes me super fatigued throughout the day after taking it the night before. Any other options? My Dr suggested mini pill. Thank you
Can you have an IUD plus take Prometrium?
Bywinona combined continuous cream safe?? Progesterone not in pill form. Will it still protect if you have a uterus? B
You keep bringing up the lack of FDA regulations surrounding compounding pharmacies. Can you do a video on this? Maybe delve a little more specifically into this topic so that we know exactly WHY compounding pharmacies are putting out an inferior progesterone? I've had 2 PharmD's recommended a compounded product for me for sleep. It's my understanding that there are actually tight controls surrounding the more reputable compounding pharmacies in the US...?
So, my remaining question about progesterone is: If you are on the Vivelle Dot 0.075% 2x weekly for your Estrogen Replacement and you were RX'd to take the Prometrium for your Progesterone replacement because you're healthy and yes, have an intact uterus, and you are extremely dizzy, nauseous, vomiting and feel very 'out of it' overall & the initial Prometrium dose is only at the minimum of 100 mg., AND years ago during your only pregnancy you experienced several issues with natural produced progesterone such as: vomiting as many times as 13x per day, dizzy, nauseous, out of it/disoriented, lost 13 pounds from this during your first trimester, now decades later in Postmenopause; what form of Progesterone is going to be best for someone like this to go along with the Vivelle Dot for your estrogen?
I’m on estradiol 0.1 mg patch and progesterone 200 mg pill 💊 form. Can add use DIM or it’s not necessary?
If I have an iud should I worry about the breast cancer risk?
I have the Femring and Mirena. Still have heavy periods. Is it possible the Mirena is not enough progesterone or the wrong type of progesterone for me?
Can i use synthetic and bio identical progesterone together?
I don't tolerate the micronized progesterone well - it tends to make me dizzy and nauseated and it doesn't help my sleep. So I am going to try aygestin. Just took my first one tonight, and hope that this will be better.
Please educate women that some may not tolerate the micronized progesterone and may want to try other options. Thank you for an informative video!
How is it working for you? Curious, because I'm also sensitive to micronized progesterone and looking for an alternative.
@@aspegel5281 the alternative - Aygestin - was much worse. I went off that and back on the progesterone. Tho I don’t much care for it, I can’t think of what else to do that I would be comfortable with.
Which certification should I look for in a women's doctor? I'm trying to find someone who is an expert with women's hormones and OBGYN.
I don't have my ovaries, but still have my uterus, which should i ask for? Im interested in the estrogen or bio, what dose is most effective? 5'7" 185lbs. I have horrible sleep & skin, hair, & hot flashes....
i have a question please my 43 year old wife had 1 very large cyst on her left ovary,her gyno doc. removed but left the other ovary that also had a smaller cyst,the gyno was afraid to remove both ovaries due to bone & heart problems later in life,she put her on the depo injections once every three months but these make her very very week and now shes bleeding very heavy again,isnt progestetone a better choice to balance out the high estrogen or should she keep taking the depo.???? thank you,
How common to get heavy side effect which affect everyday life from taking oral micronized progesterone?
I had a complete hysterectomy so I don’t have a uterus. I have been on estrogen for a couple of years and it helps a lot, but I started feeling super emotional and have crazy hair loss. My dr tested me and said my progesterone and testosterone is low, so she said I’ll put you on progesterone but not testosterone because it can effect your mood negatively. Is it necessary for me to take the progesterone if I’m low without a uterus? Will it hurt me? Can it help hair loss? Also she put me on 200mg and it’s making me feel super tired and dizzy.
Does prometrium only come in oral forms?
Not ‘ a little sleepy’
I just had a 26 hour melatonin hangover and painful headache by NOT reducing my usual melatonin dose and adding Progesterone!
Does this flare melasma? It’s the same as birth control or pregnancy right? So women w melasma just never get a break ?
Progesterone has other necessary effects on the body and should be part of every hrt program.
So... what about compounded formulas
Is there a generic version of prometrium/micronized progesterone?
Hi dr.Hirsch.I wondering can I losse hair in perimenopause ?My hair become so thin,dry,i feel like I dont't have lots of hair like before..I do have bone pain ,insomia..I'm 44 now..Simptome come in mine 42..brain fog ,like I'm not myself,fear for no reasons.lots of crying,feel so sad.ect..What can I do to feel normal again?
That is the million dollar question ...What can I do to feel normal again ?!
It varies from woman to woman, unfortunately what works for one doesn't work for all. We are all unique and have individual requirements. Thankfully there seems to be more and more effective options available and its great hearing what works and what doesn't in the comments.
Hi
What about peanut allergy
How does Prometrium impact motility in the small intestine?
In one day how I can take Progesteron in in one day for how long?
I have not my priode and warm and cool please help me
Do you need to take progesterone with premarin/estrace creams? Thanks in advance for your reply
No, you don't. Vaginal estrogen is not absorbed into the bloodstream so you don't need progesterone.
Does food increase or interfere with the absorption of oral progesterone? as with medications some are advised to be taken with food or on an empty stomache what is your thoughts and advice?
I was told to have some food in tummy otherwise poor absorption (ie 2-4 hours after dinner)
Thank you! I do have a question about progesterone therapy tables under the tongue, it’s safe? What are the side effects.
Don’t put any kind of tables under your tongue.
@@suzanneemerson2625 WHY?
I have been on estrogen patch with a Mirena IUD since Feb 2020. I haven't had any issues but now I'm concerned that the synthetic IUD may not be ideal due to the increased risk. The more information I try to absorb the more confusing this gets sometimes.
I love the IUD - because there is very little, if any, systemic absorption (it stays right in the uterus) watch my IUD video next!
@@heatherhirschMD Good to hear - looking forward to the IUD video, thank you!
But if the progestin is confined to the uterus, wouldn’t that cause a situation where the estrogen is unopposed or dominant?
Be careful with the IUD. I got the Mirena and on Day 2, I started to have crippling anxiety and I've NEVER had anxiety. I lasted one month before I had an NP take it out and I immediately felt better. No systemic absorption? Yeah, that's not true for some of us.
@@lokiteddy I was a psychiatric nurse and saw many women become psychotic on mirena
Is there a micronized Prometrium without peanut oil?
Thanks for addressing an ablation.
I really really wanted to take the micronized progesterone but … NOPE . I felt soooo bad . I’m talking dizzy , sad , angry and so I had to switched to the synthetic. I did not want to take on any extra risk but the micronized was a no go .
doesn't taking the mirena introduce a synthetic progestin causing hormonal disruption? doesn't mirena shut down our body's own progesterone? I have a mirena for heavy bleeding but don't like the fact I'm introducing synthetic hormones into my body vs. having the IUD removed and then taking micro progesterone or Ona's progesterone cream to supplement. any time you are adding a disputer to you system you are just that disputing hormones.
Great clarification of types of progesterone. I'm on compounded progesterone and I think I'm gonna switch to micronized progesterone. I have also been prescribed estriol (is this estradiol?)and progesterone in a cream, but my labs are not low for my age, I've been on them for 2 weeks and have not seen any improvements in my sleep (my doctor wanted to wait until my labs were back before recommending other supplements/prescriptions). I do have low testosterone and DHEA, which I think is causing my weight gain and lack of libido. I've seen many videos that blood tests are not needed, but I think they should be tested at least 1 time to understand what's going on. I am seeing my GP and a Naturopath, but not convinced of the testing and prescriptions that are compounded (not regulated by FDA). I would like to see a video on DHEA and testosterone. Thank you!
Hi Mary, I am not a doctor, but as far as I know estriol is the type of estrogen your body produces during pregnancy. It is not the same as estradiol. There are 3 types of estrogen produced by our bodies: estrone, estradiol and estriol, so definitely not the same thing.
Estriol is not the same as estradiol, and I would recommend estradiol + micronized Prometrium!
I'm 57 and I started 0.05 estriadol 1x/wk patch and 100mg micronized progesterone pill nightly 3 months ago. I was so frustrated when I still wasn't sleeping after 2 weeks. It took about 6-8 weeks for the sleep benefits to start for me. Now I get 6-7 hrs a night.
That's with me having a poor diet, being 40 lbs overweight and staring at my phone until bed. I'm working on working out, diet cleanup and no phone after 9pm. I believe I can get to 7+ consistently if I help the hrt do its job. Hang in there!
I understand estradiol is the primary estrogen required and most effective
DHEA did worders for my energy and libido
I have been using medroxyprogesterone with Estradiol since I was 58. I am now 74. I was on the British protocol of very very low medroxyprogesterone, and it caused me to have menstrual flow until last summer when I decided to go back to the American protocol of increased medroxyprogesterone. What I don’t understand is why medroxyprogesterone ALWAYS causes my skin to break out in my rosacea area. Instead of taking it daily, I start taking it every other day because it always causes a reaction of blemishes. I have been traveling in Europe and I will be returning to the states in February so I will take this up with my gynecologist. But no one else seems to mention this reaction. Do you have any insight?
I'm not sure about the breakouts, but are you staying when you increased your progesterone you didn't have break through bleeding?
I started eating and taking more pre and probiotics and that seemed to be the thing that helped my rosacea. Just found out celery is a good probiotic. Who knows.
You SHOULD take progesterone even if you don’t have a uterus . It’s protecting from other cancers like breast . We do not just protect the uterus with progesterone .
I am 49, I just saw a new gyno and she took me off birth control which was given to me by my previous doctor to help with perimenopause symptoms. This new doc gave me progesterone 200mg. I do not have history of any cancer but I have severe menopausal symptoms. Hot flashes, weight gain, etc. Do you have any suggestions?
were you on yasmin did it help with hair loss?
Prometrium causes me severe insomnia , and anxiety. What do I try now? Currently trying compounded progesterone torches, however wud prefer something FDA approved. Ideas?
I am exactly the same oral Prometrium gives me anxiety and insomnia. I have been using it vaginally every other day. I have also found that taking the progesterone and estrogen at the same time ( in the evening helps). I use Lenzetto spray for mz estrogen.
I take oral medroxyprogesterone and have no problems.
Not me it calms me so much, sleep great but too sedating for me can't even drive! I stopped.
How do you know what dose of progesterone will be best? I was on .05 estrodial patch with 100 oral micronized progesterone. My doctor lowered my dose of estrogen, got very depressed and anxious so went back to .05 estrogen patch. After a couple months I'm having spotting and bloating and slight pain i got with my periods. I haven't been sleeping well at all. I don't want to lower my estrogen as i ain't want to be depressed. Would it be reasonable to try 200 progesterone? My doctor appointment is another month out had two month wait.
If your peri menopause or still having periods you need 200mg utrogeston
I started taking vaginal estrogen for atrophy symptoms. When I started taking micronized oral progesterone my urine urgency and frequency started AGAIN. I started to use progesterone cream and hope this will be better than nothing?? Thoughts would be appreciated. Thank you.
Progesterone cream does not absorb well, it is compounded, so I would recommend the IUD to avoid systemic progesterone but to be better protective then the cream
Are the compounded troches synthetic?
These are compounded so I would strive for FDA-approved progesterone.
Any recommendations for Hormone Health care Professional near me? Michigan
I’m on 200 mg compounded oral micronized progesterone because 200mg of Prometrium caused me to be dizzy and tired- even taken at night. I’ve been feeling great with this and 0.075 patches. ❤
have you experienced any weight changes (gaining) with the progesterone?
Good to know ...thx for sharing
Yes please, let us know about weight changes?
I gained 5 lbs in 2 weeks…
Micronized and prometril is the same thing ?
Can I insert the 100mg capsule vaginally instead of taking orally??? I also have the estradiol gel.
44 yr old “Healthy" (no high bld pressure, "fantastic" cholesterol levels, non smoker, minimal to 0 alcohol intake) and still have uterus and ovaries (was able to get pregnant easily with 4 children, last at 35yr old).
Gyn MD started me on 5mg synthetic progesterone EVERY day orally approx 4 weeks ago.
NOT having much peri-menoupausal symptom relief (ie: still have foggy brain, fatigue, low mood/semi crazy emotions, lack of sleep).
ONLY progesterone did was stop my periods which had previously become IRREGULAR and HEAVY AS F**K last 2 years with insane PMMD.
I still have CRaZY-A*S mood swings.
Should I ask for estrogen too? Or estrogen only? Or increase progesterone?
I cant find a legit hormone MD within 75 miles of my location as I am in a rural area in Michigan.
Sounds like estrogen would be good to consider as well.
Why does progesterone give me insomnia and anxiety? I want the 😴 sleep it gives most people. Is that normal? My Dr. prescribed 200mg along with .05 patch. Even at 100 mg I get the insomnia. Does the Mirena cause acne, hair loss, weight gain? Thank you for all you do. I love your videos!
No, the Mirena is great for reducing the progesterone side effects. Definitely watch that video next!
@@heatherhirschMD I will watch. Thank you so much for responding!!
@@anacaro2516
Good to know, curious what the specific options or alternatives are ?
Please elaborate on dosages, brands, oral, creams, IUD's, etc
Hi Heather, my wife Christina tried to get a appointment with you recently but couldn’t. Maybe that’s why you said you have a big announcement coming. 👍
What if I have had a hysterectomy because of Ovarian Cancer. My Dr wont give me any helpfor these horrible night sweats and hot flashes. She threw me in to a hard menopause because of surgery and just left me to suffer. I don't give a darn what might happen my life is bad now because I can't go do anything because of menopause.
Mary I think you can still go on hormone replacement. Just worry about your mammogram. It takes a while to find the right combination of HRT for this issue, but stay away from pills and do a patch with divigel and micro progesterone with compounded testosterone 2.5 And check for that breast cancer gene before stating your treatment.
.
Try to get on an estrogen patch. You don't need progesterone if you don't have a uterus. Good luck. 👍
Hi! My main symptom of menopause is insomnia. I started with .5 estradiol patch and 200mg oral prog. But the Prog upset my stomach. My Dr. Prescribed compounded prog cream but now I am reading and hearing that the cream may not protect my uturus. What are my other options for HRT helping my sleep? Thank you!
My PharmD told me that prog cream will do NOTHING to help sleep, and she was right. My problem isn't falling asleep- it's staying asleep. I'm up for 2 hours at 3am most nights. Prog cream did nothing. I consulted 2 PharmD's and they both suggested sustained-release progesterone at night.
You mean .05 patch, right? :)
I'm perimenopausal, so we're starting conservatively with sustained-release compounded oral progesterone at 50 mg and will up the dose as needed. She doesn't want to start me on estradiol until I've stopped cycling. I'll report back!
@@lokiteddy how has it been? I have similar issues. Have bought the HRT but don’t have the courage to start…
@@Chak17 I hear you. I had a bad reaction to the progesterone- it kept me up, and when I did sleep, I had nightmares! Trying to figure out how to take it now. 😢
What about progesterone only IUDs? My understanding is this cause the least risk as the progesterone is contained only in the uterus and therefore significantly reduces the risk of breast cancer.
As for FDA approved????🤔😒 I'm afraid this doesn't give me any peace of mind.
Great information but you lost me by speaking in "high speed" mode...why do fast???
Do i need progesterone if i dont have a uterus?
You do if you have endometriosis
Why is not there any bio, identical, progesterone patch? Taking pills and creams is such a nuisance and doesn’t work for everyone
Exactly 💯
I saw a reel of Dr Mary Claire say she's on the combipatch, BUT that's a progestin which is not bioidentical. I asked her about it - no response 😢
I believe it's the size of the molecule - it's too big to absorb through the skin.
U progest (Micronized progesterone)200 mg oral or vaginal use which is the best method
What do you do if you are progesterone intolerant? I have the oral, 100mg but when I take it my heart races, my mind races and after 1 pill I don't sleep even a wink for 2 full nights, I've heard to try in anal but I work FT and I'm too scared to try it again, I tried it 3 different times oral and each time it did this. My Dr said if I can't take the P then I need to not be on the patch. I am currently using OTC micronized progest cream but my dr told me that will not protect my uterus
I had tried hrt and pills in progest and pellet testosterone and then realized it’s not for me and bad. I am now on climara pro and Live it! I probably wont menopause for another 5-8 years but on it to stave of osteoporosis, labs are great and I feel good but on the other stuff i was so tired and froggy on progesterone pills yuck! And the testoserone pellets and estradiol were terrible. Actually the so called het dr was terrible and just winging it 🤦🏻♀️ started doing myniwn labs and testing and feel better and for dr to give me climara pro patch. As a former nurse i should’ve know some docs are quacks. My father i. Law a retired doctor told me mist are over weight and just push what inusrances want
Hi, I'm curious if you've started bleeding on ClimaraPro? I tried it earlier this year and unfortunately while I felt good I began bleeding consistently after my 3rd month and had to stop using it. Trying to find an alternative is frustrating! Best of luck to you on your HRT journey.
@@melymel36 I’ve been on it going on 6 weeks now and started 3 weeks before my next cycle and it came pretty much on time, as I am usually 2-3 early sometimes or on time, it seems to rotate i notice. Climara pro has not affected that so far but my dr did say give it 3-4 months to see how my body fully adapts to it. I am a athlete and literally trained 5-6 days a week both strength training and a few intesity levels with sprints. My energy levels have not plummeted on this combo w progesterone and I can still go hard as where with the others the progesterone hit me like sleeping pills and even taking at night i did Not wanna wake up and was froggy. I have natural high energy levels and dont need help but preciously i need fake energy and resorted to coffee for energy. On climara so far i’ve been able to train hard and even i to my luteal phase can still strength/ power weight train up until my period this past round. Yeah It’s like Hrt and birth control is like tryna find a good therapist, and kissing a thousand frogs before hopefully tryna meet that Prince 🤦🏻♀️🤣 I’m glad i didnt have to jump through too many hoops for HrT and I just hope climara keeps working. I like the patch simplicity but had to use a glucose monitor sticky tape to keep it on because i sauna dry and infrared 3-4 times a week and i sweat Alot and drenched so i learned fast to tape over and been food the 5 weeks so fat. I wish You the Best on finding what does work for you, this is one area that trial and error is worse than trying to find that unicorn 🦄 prince lol ☺️
You clearly don't understand the power of progesterone to everyone watching this the power of progesterone Nikki Williams please watch it she does not know on this video what she's talking about she's saying that you don't need progesterone if you don't have a uterus that is clearly false information it's very very important hormone in your body whether you have a uterus or not
I'm estrogen dominant so do very well on Progesterone cream only: Ona's Natural
Bio-identical is synthetic by definition. This video is quite confusing to me.
I want Prometrium, but my insurance will not cover it.
This it’s dumb all women need to start taking progesterone on the perimenopause due to estrogen dominance, then later in menopause add estrogen if needed obviously after test.
Also please DON’T take synthetic progesterone it has peanut oil and obviously it’s not good for us!!!
I have tender breast and am using vag. estogen I'm 68 and was getting bladder infections this has really helped should I quit the estrogen?
I get actual progesterone from my doctor and estradiol
U progest (Micronized progesterone)200 mg oral or vaginal use which is the best method