Further, we have to remember that much of the publicity about progesterone use, especially the marketing-based press, is aimed toward women in natural perimenopause, not us in surgical menopause. If you're not clear on the difference, you may want to check out our article on natural vs surgical menopause before reading further here.
The only major instance in which progesterone is likely to be used by itself in surgical menopause is in the immediate post-op period following a hyst for endometriosis, when it is sometimes used to suppress the regrowth of the microscopic endo remnants left after surgery.
The big disclaimer about progesterone
Adding progesterone when you've been on estrogen
If you have been on (a roughly adequate dose of) estrogen alone and add progesterone, you may find you need to reduce your estrogen dose or already be a little low on estrogen when you add the progesterone. This is due to the well-documented action progesterone has as an estrogen-sparing hormone a well as itself being able to be converted into estrogen to make up a supply shortfall of that hormone. Whether you choose to do this "on spec" at the same time as you introduce the progesterone or whether you decide to wait to do this until after you have settled down somewhat on your progesterone dose, you should at least be aware of this possibility. There are no clear guidelines for how much of a dose reduction (if any) will be necessary, but our sense of it is that this is a rather small amount—certainly no more than 20% of your dose and probably somewhat less, if you were more or less at the right level of estrogen before.
If you are presently in a state of estrogen excess, it would seem gentler on your system as well as your risk profile to try to drop some of that estrogen, so you are down to the start of feeling low, before adding the progesterone. The idea that progesterone, because it can act counter to estrogen, will somehow reverse the effects of excess estrogen while you continue to take more estrogen than you need is a seductive but generally unrealized bit of wishful thinking.
Progesterone often makes us feel worse before we feel better, thanks to its pivotal role as a precursor of other hormones as well as its ability to share some receptors with estrogen. But that's only part of progesterone's work. It's also quite important in overall brain cell irritability, something that is pushed in the other direction by estrogen's neurostimulatory effects. At the same time, it specifically affects centers in the brain that control thermoregulation and balance (that is, physical balance as well as dizziness) and mood. These are some of the same brain areas affected by such drugs as Xanax and those targeted by some aspects of general anesthesia. Elsewhere it affects copper and zinc levels, which interact with thyroid hormone function, and metabolic (glucose metabolism) functions such as insulin uptake by cells. It tends to affect prostaglandin synthesis, which in turn has inflammatory implications throughout our systems on things all the way from joints and bowels to minute cardiovascular changes and even, it's being researched now, affecting the development of cancers. [booming ad voice]And much, much more![/booming ad voice]
Less critical to our understanding of the impact of progesterones effects are these specific details; what's more important is recognizing that all of these are tremendously complex and responsive systems in their own rights, and all of them rely on many enzymes and molecular activities (which are in turn, of course, reliant on a whole host of other factors and congruences) for proper conduct. What it all means is that when we alter the overall supply of progesterone, we are going to see a lot of changes throughout our bodies and they are going to take quite a few feedback iterations to all shake out as we adjust to this new supply situation.
Functionally, then, it's a long process (weeks to a couple months) and it tends to be an unpleasant and disruptive one for at least the first week or two when the worst (greatest) imbalanced swings are occurring. These responses can be hormonal-seeming, affecting our estrogenic-balance cues, as well as unrelated (dizziness, groggy, sleepy, mood, hunger, overall fluid balance). But these are, in those first weeks, all about the adjustment process and really not so much about the hormone itself. This is true generally of hormones and hrts, but nowhere more so than with the introduction of progesterone.
The key, then, to adding progesterone is to not be alarmed by initial reactions. Unless you keep getting worse after the first week, as we mentioned elsewhere, you may want to keep going to see how things feel after the second week. It often takes a full two weeks for initial symptoms of progesterone adjustment to abate. Shall we repeat that? It is normal to feel worse for a couple weeks when starting progesterone.
Tuning estrogen and progesterone at the same time
You may want to pick your starting dose of estrogen at the lower end of the range, knowing that the progesterone may boost it, and you won't want to overbalance yourself with progesterone. For reasons given elsewhere, we think it especially makes very little sense to start these two hormones in one combined form. Starting with two separate preparations allows the doses can be tuned individually. If the doses are mismatched in one combined formulation to begin with, altering the dose of that formulation up or down is not likely to affect the underlying proportional imbalance between the two. If a combined product's convenience is important to you, you might consider using individual supplies until you determine your correct dose of each and then having them blended.
Once through those first throes of introduction, our sense of balancing these two hormones is that it is often clearer to lower the estrogen and then tune with the progesterone, so long as you are not seeing symptoms of progesterone excess.
Adjusting progesterone temporarily
There's no point to fussing over it, beyond making sure that you are not subjecting your supply to excessively hot or airy conditions. When they start to feel they're coming up short, many women just increase their dose a tad at the bottom of the container and scale back to the former dose when they open the next. So long as you know it's happening and it's predictable, it shouldn't send you into a tailspin. It's normal. Don't sweat the small stuff.
Visualizing estrogen-progesterone balance
The first is how well each hormone meets our background needs for it. Regardless of how the two hormones may or may not be balanced with respect to each other, if the sum total still leaves unmet needs, we're going to have symptoms where gaps in our hormone coverage show up. Different women have different systems that are more sensitive to the fine edge of "enough" than others. For some, it's the first twinges of vaginal atrophy; for others, it's unwarranted moodiness. Whatever yours is, it's about your background ability to meet all of your hormone needs.
The other aspect of balance is how the two hormones interact relative to each other. We like to visualize this much the way an old-fashioned balance scale would look if we piled all of our estrogen effects on one side and all of our progesterone effects on the other. If the scale tilts down on the estrogen side, say, then one of two things may be happening: either we have too much estrogen on that side of the scale or we don't have enough progesterone on the other side. The scale doesn't tell us if either side has the correct amount; it only tells us the general direction of the imbalance between the two.
So too, if in our bodies we see signs indicative of estrogen excess, that might be due to too heavy a dose of estrogen but it might also be due to too light a dose of progesterone. And the same thing is true in reverse, of course: if we see too much weighting towards the progesterone signs of excess, it could be due to either an excessive progesterone dose or an overly light estrogen intake.
How do these come together? Don't they overlap? Uh huh. But it's important to keep in mind both parts of this, the needs and the inter-relationship. If we don't, we run the risk of seeing an imbalance to this side, taking a little more of the other to bring things up, then swooping into the other tilt so we add a touch of the opposite hormone...and before long, we've blown ourselves away with excesses of everything. So if we can remember that needs set the general order of magnitude and balance does the fine tuning between them, we've got a more nuanced concept as well as one that is much less likely to lead us hopelessly adrift.