When I recommend using progesterone to a patient, the topic of whether to use cream or the oral form always comes up. The question “Which one is better?” invariably is asked, and my answer is almost always, “That depends.”
My impression is that while both the cream and oral form are equally effective across the entire population, when you consider an individual patient, there may be a good reason to choose one over the other.
In support of the equal effectiveness is a study in the Journal of Clinical Pharmacology which showed no difference in drug exposure when oral and cream forms of progesterone were compared.
The main difference stems from the fact that when any medication is taken by mouth, the liver becomes a major factor, standing there with open arms to try and do what it thinks is right–metabolize it and prepare for removal from the body. This can be a good thing (ridding the body of a toxic substance, or turning a medication into a more active form), or a bad thing (inactivating a helpful substance or creating a toxic metabolite).
When progesterone is applied to the skin, it is dispersed through the body in a more uniform fashion. Thus the liver is not exposed to the high concentration of progesterone that occurs immediately after ingesting the hormone orally.
A few important things to know about the two forms of progesterone are that:
1) Because of the differences in absorption and metabolism, the doses of oral and cream progesterone are quite different. Generally a higher “dose” of progesterone is required when it is used orally. There is also no standard formula for converting between forms as everyone’s absorption and metabolism are different.
2) Oral progesterone is not hard on the liver, does not create any systemic issues (as opposed to oral estrogen), and the metabolites are not harmful. In fact in some individuals the metabolites may improve sleep.
3) Some patients simply “feel better” on one form or the other.
So what are some of the things that I consider when deciding with the patient which form to use?
-Some patients find it easier to remember to take a capsule than to rub on a cream, and it can’t help if you keep forgetting to use it.
-Oral progesterone may worsen reflux symptoms in sensitive individuals, and can also cause a feeling of intestinal bloating. These may be dose dependent.
-Oral progesterone may improve sleep better than cream in some individuals, but may cause grogginess in others.
-May be easier to adjust the dose as changes can be made in smaller increments than you can with capsules.
-High or low cortisol states may make more of a difference with the cream than with the oral form.
-In patients with liver issues, or in those who are using multiple medications or substances which are processed by the liver, the cream may be a better option.
So, like all things in hormone replacement, there is no “one” answer, but there is a “right” answer, and it is up to both of us to find it.