People differ in almost every aspect of their physique and metabolic processes. It is irrational to order the same dose of any given medication for everybody. Most often, we determine dosages by their observed effects in each individual person. I tried hard to not make my book a recipe book for ordering progesterone. I added quite a number of clues to follow, however. For instance, I point out that healthy ovulating women's ovaries make 20-24 mgs. of progesterone per day, often reaching a peak of 30 mgs. per day during the luteal phase. Since my goal in treating progesterone-deficient peri- and postmenopausal women is to approximate the normal physiologic levels, I usually try to have them use about 20 mgs. per day for 21-24 days per month. 

Since many women had been deficient in progesterone for many years, and since progesterone is fat soluble, I knew that their fat reservoirs of progesterone were totally depleted. Thus, I often started them on a full 2-oz. jar per month for the first two months to restore normal physiologic levels in their fat; and then I would reduce the dose to only 1 ounce per month. My patients found this was easily accomplished by using a spoon to transfer half of the contents from a 2-ounce jar into another cosmetic jar. Then they labeled one April, for instance, and the other one, May. 

PMS is unique in that it frequently involves stress and higher cortisol levels. Cortisol competes with progesterone for common receptors. Thus, higher doses of progesterone are often needed. For people with PMS, I asked them to follow their symptom responses and to use progesterone cream in a crescendo pattern, starting on day 12 with small dabs at night and then increasing that to two dabs a day (a.m. and p.m.) and finishing the last 3-4 days with bigger dabs so as to use up as much as needed, up to a full 2-ounce jar from day 12 to day 26. By experience, each woman finds the dose that is most successful to her. 

Tests performed by Dr. Zava of Aeron Labs found that the palms of the hands provided the best absorption, followed by the face, neck, upper chest, breasts, and the inner aspects of the arms. Skin of the butt, inner thighs, and the lower abdomen was considerably less effective, probably because the skin is thicker and contains fewer capillaries per inch. So now I tell people to apply progesterone cream in the areas where we blush; that's where the capillaries are more abundant and closer to the surface.

Progesterone Dosing When Using Synthetic Hormones 

I. Perimenopausal woman whose doctor is prescribing estrogen 
There is no reason to give estrogen of any sort to a woman who is still having menstrual bleeding. The fact of menstrual bleeding means she is not deficient in estrogen. However, her periods may be irregular due to progesterone deficiency. She should taper down her doctor's estrogen and start using the progesterone cream, one ounce used up from day 12 to day 26, counting day 1 as the first day of her period. If bleeding starts before day 26, she should stop using the progesterone cream and start counting up to day 12 again, and then start the cream again as directed above. It may take three cycles before she achieves synchrony with her normal cycle. 

II. Postmenopausal woman on ERT 
Since progesterone replacement in women deficient in progesterone may initially (and temporarily) increase the sensitivity of estrogen receptors, she should immediately reduce her estrogen dose by one-half (50%) when starting with progesterone cream. She can do this several ways. If the estrogen dose is a pill that can be broken in half, the process is simple. If the estrogen prescription is a capsule not easily broken in half (such as Premarin), she can take one every other day. That will achieve the same reduction goal. She can also follow the example weaning guide below. It's up to her.

Estrogen and progesterone can be used together during a 3-week or 24 to 25-day time period each month, leaving 5-7 days each month without either hormone. The estrogen dose should be low enough so monthly bleeding does not occur but it should be high enough to prevent vaginal dryness and/or hot flashes. Progesterone cream can be applied intravaginally, 1/4 to 1/2 teaspoon once a day for vaginal dryness. This may be done in addition to or instead of your daily application. The usual dose of progesterone cream is 1/2 of a jar (one ounce) each month. It can be applied to the palms of the hands, the face and neck, the upper chest and breasts, the inside of the arms, and behind the knees. Rotating among the various sites will maximize absorption. The size of the "gob" to use will become apparent as one proceeds through each monthly cycle. 

Every 2-3 months, the woman can experiment with lowering the estrogen dosage even further until she finds the lowest dose that prevents vaginal dryness and/or hot flashes. Since postmenopausal women continue to make estrogen (primarily in their body fat), may women find that estrogen supplementation can be eliminated altogether 5-6 months after starting progesterone cream. The presence of the progesterone makes estrogen receptors more sensitive such that her own (endogenous) estrogen is sufficient. In this process of lowering her estrogen dose, the patient may have to request her doctor to prescribe smaller dose pills or capsules since some are difficult or impossible to break into halves or quarters. 

III. Postmenopausal woman on HRT (estrogen plus a progestin, such as Provera)
In these cases, I recommend that the Provera be immediately stopped when transdermal progesterone cream is added. I have found no ill effects in stopping Provera abruptly. Here again, the eventual progesterone dose will usually be found to be one-half of a 2-ounce jar used up during a 3-week or 24 to 25-day time period. However, since such women have usually been deficient in progesterone for many years, and since the progesterone is fat-soluble, much of it will be initially "lost" into her body fat. For these women, I usually recommend using a full 2-ounce jar each month for the first 1 to 2 months to compensate for the progesterone being stored in body fat. By the third month, she can usually reduce to one ounce per month since her fat-stored progesterone has reached physiologic equilibrium and she will not be storing more progesterone as she did the first few months.

As in situation II above, estrogen should be tapered more slowly. An abrupt reduction in estrogen can trigger resumption of hot flashes or vaginal dryness. These symptoms can be prevented by lowering the dose more gradually. I usually recommend reducing the dose by 50% when starting with progesterone cream. Then, every 2 to 3 months, she can try reducing that dose by 50% again. This process can be continued until she has arrived at the lowest estrogen dose that prevents vaginal dryness. As stated above, progesterone cream can be applied intravaginally, 1/4 to 1/2 teaspoon once a day for vaginal dryness. This may be done in addition to or instead of your daily application.

As above, she may discover that her own (endogenous) estrogen production is sufficient for the need, and supplemental estrogen may then be discontinued. In general, postmenopausal estrogen production is about 40%-50% of premenopausal production. When estrogen receptor sensitivity is returned to normal by the presence of progesterone, the postmenopausal estrogen production is often found to be sufficient. 

Suggested Weaning Guide for Women 
Using Synthetic Hormones 

Please consult with your doctor about stopping your synthetic estrogen hormones. There could be some uncomfortable symptoms. To help make the transition more comfortable, here is a suggested guide to weaning yourself off of the synthetic hormones you are now taking. Some women may feel that they need a longer time to wean themselves, while others are able to "cold turkey" with little or no discomfort. Many factors come into play when you are balancing hormones. A lot of the process depends on how long a woman has been taking the synthetics, how much her dosage is, and in what form she is taking the medication. The important thing to remember is to be consistent with using progesterone cream during the weaning process. The progesterone will be working to help your body balance your hormones. Ultimately, you have to decide for yourself how fast you can wean yourself off the synthetic hormones. Below is an example of a weaning process.