Biest (Medication) Guide for Menopause: Side Effects, Dosing & More

Biest may be the preferred way to treat low estrogen in the setting of menopause. 

Learn more about why this combination medication is preferred to other formulations, how it works in your body, how it may be protective against breast cancer, how to dose it and more

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Bio-Identical Hormone Replacement Therapy & Biest 

Bio-identical hormone replacement therapy is the use of hormones which look exactly like the hormones your body produces naturally. 

These hormones are then given to patients to relieve problems associated with hormone imbalance (such as low estrogen). 

Biest is a perfect example of a bio-identical hormone and it is often (or should be) used to treat cases of low estrogen and menopause. 

But what exactly is biest?

Biest is a combination of estrogens formulated into one compound. 

Thus the name "bi" (meaning two) and "est" (referring to estrogen)

list of bioidentical vs synthetic estrogens

The two estrogens included in this are estradiol and estriol. 

Estradiol is considered the most powerful and most potent estrogen in the female body while estriol is considered a much weaker estrogen (1).

Biest is most often used as part of HRT (hormone replacement therapy) for women who suffer from menopause and low estrogen. 

Because of its unique properties, it may be preferred when compared to synthetic estrogens such as those found in birth control pills (2).

Using Biest for Menopause & Low Estrogen

Does using biest have any benefits over more traditional medications such as estradiol?

The answer is probably and here's why. 

Biest includes a combination of the most powerful estrogen that your body produces naturally (estradiol) and a weaker, more protective estrogen (estriol)

In order to understand the benefit, you need to know just a few basics about HRT. 

The first has to do with the concern over using estrogens and estrogen therapy to treat low estrogen. 

In the early 2000's there was a study (the Women's Health Initiative) which showed that using estrogen, specifically in the setting of menopause, may lead to an increased risk of heart disease (heart attacks), breast cancer, stroke and venous thromboembolism (3) (blood clots). 

Up until this point up to 30-40% of women who were post-menopausal were using HRT (4) which was being actively prescribed by Doctors.  

The women undergoing treatment for HRT during this time were experiencing significant relief from their symptoms but were placed at an increased risk of the events listed above. 

This caused a massive shift in thinking among physicians and MANY women were pulled off of HRT in a hurry. 

percentage of women using HRT prior to 2002 and after

This study has had a lasting impact on many physicians who are unwilling to prescribe HRT due to this perceived risk (5).

The problem with the study is that it tested what are known as synthetic estrogens, such as Prempro, Premarin and progestin (pharmaceutical variants of actual hormones that females produce naturally). 

Even though these hormones are NOT the same as the hormones that your body produces naturally (these are referred to as bio-identical hormones), both bio-identical and synthetic hormones have been lumped into the same category in terms of these risks. 

The problem with this is that many studies show that the negative side effects seen in this study may have been primarily due to the fact that these hormones were synthetic and not bio-identical (6).

This is a long introduction to biest, but this is where biest takes center stage.  

Studies have shown that there is indeed a difference between how stimulatory certain estrogens are on tissues such as breast tissue and endometrial tissue. 

What this means is that there are weak estrogens and strong estrogens, and some estrogens may be balancing the effects of stronger estrogens (7).

Estriol is an example of one of these weaker estrogens and one that has the potential to combat the increased potency of estradiol (8) (especially when used alone). 

In fact, newer studies have shown that the use of bio-identical hormones does not show an increased risk of these negative side effects (cancer, stroke, etc.). 

Wouldn't it be nice if you could use the exact same hormones that your body produces naturally to completely eliminate the symptoms of menopause, without experiencing the increased risk of heart disease, breast cancer and so on?

Well, that's the logic behind the use of biest and other bio-identical hormones. 

It's important to realize that no hormone is perfect, however, so before you jump in and use biest you need to be evaluated by a physician to assess your own personal risk.  

Dosing Based on Symptoms & Blood Tests

Another important factor, as it relates to risk factors and side effects, is the dose of your medication. 

The best approach to take, when using hormones, is to use the absolute minimum amount of hormone necessary to completely resolve all of your symptoms and without causing the symptoms of excess hormone. 

This can be done by carefully monitoring your symptoms and by watching your serum levels of estradiol and progesterone (you can also assess your hormones via 24-hour urinary testing as well). 

Biest is usually formulated with 80% estriol and 20% estradiol

This ratio can be adjusted based on the needs of the individual. 

For instance:

Your Doctor may prescribe 70% estriol and 30% estradiol or even 90% estriol and 10% estradiol. 

The idea is to use no more estradiol than necessary to help reduce the symptoms of menopause and to balance that with a sufficient amount of estriol. 

The estradiol component of biest can be manipulated (either up or down) if you are struggling with persistent symptoms. 

Remember:

Estradiol is the most potent estrogen in the body and the symptoms of menopause tend to be primarily caused by the reduction in estrogen (9) (estradiol) produced naturally by your ovaries. 

In order to achieve symptomatic relief, you NEED some estradiol, but you don't want to use too much

Women who are post-menopausal, and experiencing side effects such as hot flashes, weight gain, and depression, will often notice a near immediate reduction in their symptoms when starting biest (10).

Dosing can be started at a very low dose and increased until the side effects stop. 

While you are adjusting your dose make sure that you monitor for symptoms of excess including breast tenderness and menstrual bleeding (more on side effects below). 

Your Doctor can, and should, work with you as you start biest to help titrate and tweak your percentage to find an optimal level for you. 

This may take some trial and error, so be patient!

As a provider, and after treating hundreds of patients, I can tell you that no two women are exactly alike. 

The amount of hormone that they require will be different and unique to their body. 

But taking this approach has allowed me to help 98+% of women suffering from menopausal symptoms. 

Application (How to use Biest effectively) 

So, how do you use biest if you plan to take it?

Biest is usually formulated in either a cream or a gel by a compounding pharmacy. 

This may be different from other hormones you are used to taking because most medications are taken orally (meaning by mouth). 

Taking hormones transdermally (through the skin) or via injection (with a shot) is usually better when compared to orally due to the avoidance of the first pass metabolism by the liver (11).

When you take a medication by mouth, the medication must go through the intestinal tract where it is absorbed and then processed directly by the liver via the portal system. 

The liver will then break down a large percentage of the hormone into smaller pieces to help your body get rid of it.

This may lead to concentration of the hormone in the liver which can stimulate hepatic protein synthesis and may increase inflammatory markers and markers of coagulation and so on (12).

The use of oral estrogen also dramatically increases the creation of sex hormone binding globulin which can bind to and inactive testosterone (which is in low supply during menopause!). 

Once the hormone is broken down it is then sent to the heart where a portion of the original hormone absorbed is directed to your cells and tissues.  

This process should be compared to the natural process that your body goes through when it releases hormone through endocrine glands (hormone glands). 

Your body releases hormone directly into the bloodstream where your hormones go straight to target tissues FIRST as opposed to being broken down by the liver first

In almost all cases, it's best to mimic the natural flow of the body when using hormone replacement therapy. 

For this reason, the transdermal route may be preferred over oral medication. 

In addition, when using biest, you'll also want to make sure that you put it on the appropriate place on your body. 

The forearms are perfect "real estate" for hormone application because the skin is thin (13), there isn't very much fat there and your superficial veins will carry the hormone directly to your heart for pumping throughout the body. 

Other areas that biest can be used include the inner thighs, vaginal area, peri-anal area, and neck. 

If you are using other hormones, such as testosterone or progesterone, make sure that you do not apply more than one hormone to the same spot on your body at a time. 

Some hormones, such as progesterone, will need to be alternated each time you use them. 

Another quick tip:

Estrogen has an enhancing effect on the skin and can help reduce wrinkles/age spots (14).

Some patients will apply their biest to their forearms and then do a quick swipe of hormone on the back of their hands, neck and even face

You don't want to apply the hormone to these places directly, but a small residual amount may work wonders! 

Side Effects to Watch out for

Side effects from biest tend to come from either underdosing or from overdosing. 

It would be unusual to respond directly to the active hormones because your body has been producing them naturally for many years (remember they are bio-identical). 

With this in mind, you can imagine a scenario in which you might be reacting to the absolute dose vs the hormone itself

For instance: 

Using an insufficient dose will lead to the persistence of symptoms such as hot flashes, weight gain, and depression. 

This does NOT mean that the medication is causing these symptoms, instead, it may mean you need to increase your dose. 

Symptoms that you are not using enough biest may include:

  • Persistent hot flashes
  • Persistent weight gain
  • Persistent mood issues or depression
  • Persistent vaginal dryness and decreased libido
  • Persistent night sweats or insomnia

On the other hand, it's also entirely possible that you are using TOO MUCH hormone and may be experiencing side effects associated with excessive dosing. 

This would be an indication to cut down on your dose because excessive dosing may lead to overstimulation of estrogen receptors and may increase your risk (if continued long-term) of breast cancer and so on

You can find a list of excessive dosing below: 

  • Breast tenderness
  • Menstrual bleeding
  • Abdominal cramping
  • Water retention or bloating
  • Nipple tenderness
  • Breast fullness or enlargement (with or without tenderness)
  • Pelvic cramps (with or without bleeding)
  • Continued hot flashes at very high doses (hot flashes may subside and then persist if dosing is extremely high)

When using biest ensure that you do NOT experience the side effects listed above. 

If you do, then reducing your dose (or stopping for 2-3 days) should be sufficient to bring you back to normal. 

If there is any confusion about your dose make sure to discuss it with your physician or re-order blood tests. 

How to get Biest from your Doctor

In order to get biest, you will need a prescription from a physician (MD or DO). 

Most conventional doctors, such as family practice doctors or endocrinologists, may not be familiar with using biest or other bio-identical hormones. 

The reason for this has to do with the fact that hormone replacement is not taught in medical school. 

So, in order for a physician to be knowledgeable on the subject, they usually have to take extra classes or courses to help bring them up to speed. 

The logic and theory behind bio-identical hormone use are also vastly different from the conventional hormone replacement therapy model that standard physicians use

Conventional doctors don't have a problem giving out massive doses of insulin, birth control or steroids, but they seem to have a problem when it comes to bio-identical hormones. 

Much of this simply has to do with the fact that they are not educated on the topic. 

It's my experience that most physicians when they see how effective these hormones can be, and when they are confronted with the studies that show they are effective (15), they tend to be willing to give them a try. 

But having this discussion is generally not worth your time or effort when you can find a physician who specializes in hormone replacement therapy relatively easily. 

If you are interested make sure you look for a doctor that specializes in Integrative medicine, Anti-aging medicine or functional medicine. 

Most women find that their symptoms are taken more seriously and they are "listened to" by integrative Doctors compared to conventional physicians (this is actually seen in studies (16)). 

Final Thoughts

Biest is a combination medication used to treat low estrogen which can also be very effective in menopause. 

This formulation of estrogens contains both estradiol and estriol and may be superior when compared to just estradiol alone. 

Estriol may help to reduce the powerful impact that estradiol has on breast and endometrial tissues by acting as a minor anti-estrogen. 

If you are considering using HRT for menopause then biest may be the preferred option because it is bio-identical and contains a more complete hormone profile when compared to generic pharmaceutical medications

As always, ensure that you titrate your dose based on your body and on your symptoms. 

Doing this should reduce your risk of negative side effects. 

Now I want to hear from you:

Have you used biest previously? Are you using it now? 

Has it helped reduce your symptoms?

Why or why not?

Leave your comments below! 

References (Click to Expand)

This post was most recently updated on March 11th, 2019

Dr. Westin Childs

Dr. Westin Childs is a Doctor of Osteopathic Medicine. He provides well-researched actionable information about hormone-related disorders and formulates supplements to treat these disorders.He is trained in Internal Medicine, Functional Medicine, and Integrative Medicine. His focus is on managing thyroid disorders, weight loss resistance, and other sex hormone imbalances.You can read more about his own personal journey here.

30 thoughts on “Biest (Medication) Guide for Menopause: Side Effects, Dosing & More”

  1. Hi,

    I have been using Bi-EST 80/20 for two years along with progesterone cream (10 MG at night only). I have undergone many salivary tests to try and get the levels right but it seems to be a vicious cycle for me. During this two year period, my hot flashes and night sweats have not gone away. They have lessened, but there are times when they are out of control, especially during the night while trying to sleep. I never feel cool at night and this has greatly affected my quality of life.
    The highest dosage I have been prescribed is 0.2MG CR, 2 clicks twice daily. Keep in mind that I am 118 pounds, 5’4 1/2 inches and am 50 years old.

    The Most noticeable side effects of the HRT for me are bloating and blurred vision.

    I haven’t slept well since I started menopause. The hot flashes and night sweats are the main cause, but menopause has changed me— I also have increased anxiety and depression, even while on the HRT (that seeks to be a vicious cycle). I would appreciate your advice.

    Thank you,
    Stacey

    • Hi Stacey,

      I generally don’t recommend dosing based off of salivary testing. The best way to determine if you need the right dose is a urine test which can help you to understand how your body is metabolizing estrogens to determine if your estrogen quotient is sufficient. To get this information you need a urinary test (usually a 24-hour urine test).

    • Hi Stacey, Although this is a while after you posted, I am experiencing exactly the same thing. A bit of background: I used progesterone cream for 2-3 years prior to using bi-est. I used the cream at high doses for a while. Felt great for a while but it wasn’t until my estrogen dropped that the anxiety – chest jitters and inability to focus at work, general sense of “losing it” – kicked in. Then I tried adrenal herbs. I cannot strike a balance. Now I don’t feel good unless I use a double dose of bi-est. Wondering if I used too much progesterone from 45-48? It can store in fat. Hoping you read this and can respond…how are you doing and if good…what did you do to get to being good again? So frustrated. Feel like I’ve lost myself.

  2. I am 56, postmenopausal using Biest 50/50 to reduce hot flashes and for anti-aging. Current dose is E2- 0.1 mg and E3- 0.1 mg, progesterone 36 mcg/ G using 10 clicks daily M- Sat.
    I’ve had my levels tested using a slightly lower dose and it hardly made a difference in my testing results although my hot flashes did significantly improve. I’ve been reading about dosing and it appears this is an extremely low dose. Can you elaborate on what the optimal Estrogen/progesterone levels to aim for are and your thoughts on dosage? (Thyroid function has been improved using compounded T3/T4 with levels acceptable to my DO)

    Thank you.

    • Hi Cheri,

      When I use progesterone and estrogen I try to reduce the symptoms of menopause while avoiding the symptoms of excess estrogen/progesterone and minimally impacting estrogen/progesterone serum labs. I don’t have specific ranges as they vary based on the individual.

  3. I have been using Biest since 2011. I went into early menopause after a car accident in 2009. My symptoms were severe. I could not carry on a competent conversation, I lost my train of thought very easily. I had severe hot flashes, overwhelming night sweats, and trouble sleeping. All of these symptoms caused me to lose hope with life. I was demoted at work, my family was falling apart, and I was angry all of the time. Once my DO prescribed my compounded bio-identical hormones, and I began taking them daily. I lost weight. My memory came back, and I was able to sleep again. I still have the occasional night sweats, but they are bearable. I would also like to mention, that I take 125MG of Progesterone as well. Both of my hormones are taken in lozenges forms. I have my life back! I recommend this treatment to any woman who is struggling with severe menopausal symptoms. Thank you.

  4. Hi I just started Biest at the lowest dose, half a ml of .50

    I’m 49 and my periods are still monthly but range from 21-40 days.

    When I use this I feel a bit weird. Hard to describe but a little anxiety in my chest area, or a feeling of “coolness” or “menthol” like feeling.

    I’m wondering do you give this to women still menstruating? I got it for my anxiety, fatigue, depression and other perimenopausal symptoms. Thanks.

  5. I’ve been using for 2 days. The doctor said 4 pumps, but I’m only doing 2. Have cramps about 2 hours after. Exactly like my period used to be. I’m 66, postmenopausal.

  6. Hi, I’ve been taking Biest (C-Biest 80/20) orally for the last 4 years and prior to that Prempro. I have a couple questions. I’ve been diagnosed recently with Hypothyroidism and have Thyroid nodules and a cyst on the left side of my neck. Can Biest cause Thyroid problems? Also if I nap in the daytime I wake with a throbbing headache which I’m positive is caused by Biest. I never experienced this till I went on HRT. A doc friend told me it interferes with the Pituitary gland…any thoughts?

    • Hi Carol,

      All hormones (including biest) interfere with your pituitary hormones because of feedback loops (this includes birth control pills, etc.). This isn’t the problem, though, as symptoms arise from your dose, not the fact that it can reduce pituitary function. If you are experiencing negative side effects then it’s most likely dose related.

  7. Hi,
    I always read your blog, thanks for sharing the information. I am 42, due to endometriosis surgery my ovaries are stopped working and periods are stopped. I went to a doctor, she tested my hormones and she prescribed bio identical hormone. She was saying my estrogen levels are very low. She gave BIEST (50:50)0.288mg+ prog 4.6% per GM. Am I I using lower dose or high dosage? Is it ok use this dosage or not? Last one month I been using this, I see my breast size increased, 3 pounds weight gain. Sometimes middle of night feel hot flashes. Suggest any other ideas? I am using 32.mg WP thyroid medicine too.

  8. I’ve been using biest cream 80/20 for years and just started using it vaginally but my breasts have enlarged and are very tender… should I cease using it vaginally and go back to putting it on my skin or will the breast tenderness subside.

  9. I took bio-identical progesterone in a pill form made from wild yam extract while I was perimenopausal and it was a lifesaver. About a year ago I began menopause and the progesterone seemed to make my hot flashes, palpitations, and anxiety worse so I discontinued it and noticed some improvements for a while. This relief was short lived and I started a biest cream for my symptoms which seems to help… however I am wondering if I need to take some bioidentical progesterone with it? When I tried both together it seemed to increase the hot flashes and anxiety again.. I thought women needed both hormones for balance and that estrogen alone without progesterone would not be safe. Is that correct? Should I just try to adjust the dose of each to find the right balance?

    • Hi Ann,

      Yes, most women do well on a combination of both progesterone and estrogen but it’s not true for all women. Some women can do well on one without the other and vice versa. It depends on a number of factors.

      • When using the Biest cream is it best to apply morning and night or just once per day? I am still trying to adjust my dose to figure out what amount relieves my symptoms and am having difficulty getting to that point. It seems that on some days, the dose applied in the morning has perhaps not lasted very long and I have tried to apply an extra dose midday to get relief. Is this not advised ? Is it better to increase the dose taken earlier rather than add an extra dose midday. Should a dose be lasting at least 12 hours, or less?

  10. Dear Dr. Childs,
    My wife is 69 years old, and approximately 20-25 years ago my wife had a bi-lateral masectomy, radical on her left side where the lump was, and simple on her right side. A few years later, an ultrasound showed “something” on one of her ovaries, and in light of her recent cancer, opted for a complete hysterectomy, both ovaries and uterus. The “something” proved to be non-cancerous.

    Because of the HABITS study, doctors and OB-Gyns have told her they will not prescribe any HRT for her, but after enduring misery for 20 years of surgical menopause–hot flashes, night sweats, insomnia, terrible mood swings, these symptoms appear to be getting worse, and she’s at the end of her rope.

    Because she has no breast tissue, nor any of her female reproductive organs, why is there fear of prescribing HRT for her? What is there to get cancer in?

    She has tried the usual non-hormonal recommendations, to no avail.

    Is there any hope of finding a doctor who would consider prescribing biest or similar bioidenticals for her, or alternately, could any of the OTC bi-est or bi-est transdermal creams, with perhaps a supplement of progesterone OTC transdermal cream be an option for her?

    Thank You very much,
    Sincerey, Rick S, Atlanta, GA

    • Hi Rick,

      Yes, there is certainly hope. I would make sure you look for a doctor who specializes in bio-identical hormone therapy, anti-aging medicine, or functional medicine.

  11. I am just starting therepy with Biest cream (80/20) and Progesterone cream. Please tell me what the average starting dose of each is for menopause. Thanks.

  12. Thanks for this post. I had sudden cessation of my hormone production due to neurotoxin about 3 years ago. I’ve been on HRT for 1.5 years.

    I was started on 0.1 mg Estrogen patch twice weekly. I’m seeing another doctor now that wants to switch me to Biest. I was beginning to have weight gain, breast pain, bleeding, and cramping. I’m starting on 5mg/ML Biest at 1ML per day.

    What should I expect?

    We began using one patch per week vs 2, and are now switching to Biest.

    Also, I was previously also on Progesterone at 50mg/ML apply 1 ML per day. We have decreased that dose to .20ML per day now and the breast tenderness and bleeding seem to be resolving. My new Dr is a bigger fan of Biest and cream, not the patch.

    Thanks for your thoughts on these changes.

  13. I am currently using OTC bi-est and OTC progesterone cream (Iona’s 10%) and tomorrow I go to my doctor for blood labs to see how I am doing. I should note that she gave me a compounded cream months ago (I was away at the time and it was estriol/estradiol/progesterone/testosterone small amount) and could NOT handle the testosterone (made me mad/angry). I kind of would like to use the OTC stuff as it is cheaper (unless I need way more on something/complete hysterectomy/post menopausal. 1/2 thyroid which I am trying to optimize.
    Donna

  14. Hi there,
    I am in my thirties and have been on HRT for 7 years now. I have hypothalamic amenorrhea – I do not get my period unless I am on the pill/withdrawal bleeds. However, I developed liver adenomas – one from OCP (removed 2008) & another 2 when I was pregnant. Without supplementation, my hormones – especially estrogen, FSH and LH are rock bottom and because of the risks of osteoporosis, etc I must use estrogen and progesterone but oral is not ideal because of having to pass through the liver.
    So I have been using estrodot 100mcg patches and progesterone cream. I am now trying to swap to biest – currently using the 80/20 but my gyn is worried the dose of estradiol is too low. Can you recommend what type of biest dosage I should be aiming for to approximate the estrodot patches I was using previously? That dose of estrogen raised my levels to a good amount. When my estrogen is low (& it decreases to 19? Without HRT) I feel terrible. Because of my age, my gyn would like to have my levels as high as possible as safely as possible and feels biest is likely the best way but doesn’t have the experience to prescribe. Could you possibly recommend a dose? And how I could order this, please? I am currently using 1ml of 80/20 morning and 2ml 80/20 at night and 20mg progesterone at night. I don’t have any other symptoms that I know of – no breast tenderness etc but then I have also never experienced PMS so it’s difficult to know.
    Thank you so much.

  15. I was using biest (2.5 mg) for quite a few years during menopause. It helped me significantly compared to if I didn’t have it. I still experienced a couple of years of hot flashing but it was kept to a minimum as long as I ate very healthy foods (mostly organics, no fast foods or refined foods) and supplemented with fish oil (Nordic Naturals or OrthoMolecular) and had 2 T of ground flax seed in my diet most every day. When I missed either of those items, I found my hot flashes were more frequent and greater in intensity. At around 8 years of treatment, the hot flashes finally subsided and I actually felt chilly again like normal people do. My functional medicine doc recently had me stop the biest and now I am on estradiol (1 mg) because I had developed some small uterine cysts, non-cancerous, which may have been related to the biest. So, I’ve had a reduction now and still feeling very good and no side effects.

  16. Hello, I’m Tina I am 34 years old and my doctor prescribed Biest 50/50 daily because of my sex drive has gone way down. My question is where is the best place to apply the cream.

    • Hi Tina,

      Generally, I wouldn’t consider estrogen to be the “fix” for low libido (though it can potentially). Depending on your formulation, you should be able to apply it anywhere on the skin. I typically prefer the forearms or inner thighs as these are prime real estate for absorption and getting medications quickly into your veins (the veins are superficial in these places, especially the forearms). Some women find success with transvaginal application of the creams, but I wouldn’t go this route unless your medication was specifically formulated for this area.

  17. I was just prescribed Biest as a vaginal suppository. Haven’t started yet but was wondering how others were faring using this method.

  18. Hi, I have been on Biest 80/20 for years after having a total hysterectomy. I took a break for a while I tried estradiol and testosterone pellets as well as compounded progesterone. I immediately gained 10 lbs. A year later I am still struggling with the same 10 lbs. and a lot of it is water retention and bloating. 6 months ago I started BiEst again. I cannot tolerate doses over .75 mg, I went from 1 mg. back down to .5, seemed to stabilize a little, then back to .75… My breasts have grown, are heavy and hurting, even though any diet is near perfect and I work out daily, I struggle with extreme water retention, bloating and weight around my hips and tummy. I do not have hot flashes. Unfortunately after consulting so many doctors including functional, naturopath, endocrinology, hormone specialists, nobody can help. After reading your article I am convinced that I need to use less BiEst and that it is causing my issues. No matter what my lab levels are, after years of this I can tell when I’m imbalanced. I am scared, but I’m thinking about stopping for 2-3 days as you mentioned in the above article. And then starting at .25-.5 for a month to see if this helps… Can you give me some input?

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