Balancing progesterone

Some of our readers will be balancing progesterone in conjunction with estrogen. Progesterone is rarely used by itself by women in surgical menopause, even though many assert that it does seem to have a role used that way in natural menopause. Why not? We agree: it seems that if progesterone can be converted to estrogen, just supplying that seems as though it should work. But it doesn't actually work out that way: women who try progesterone-alone in surgical meno just seem to suffer from the creeping dismals, spiraling into feeling worse and worse from unmet estrogen needs. While interconversion works to some extent, then, it doesn't seem to be efficient enough to run the whole system on.

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

We used to use progesterone as a "tuner" for estrogen without a lot of qualms. After all, we all make it, so how bad could just having a bit more, so long as that didn't put us into excess, be? Well, it turns out that the risks of progestogens (progesterone and synthetic hormonal agents that act like it) were not as well understood even a decade ago. Now that we know more about the links between progesterone use and cancer, we are a great deal more hesitant when we see women experiment with this hormone. 

And interestingly, it seems that progesterone supplementation is not quite as vital as we thought around the turn of the century. Then, we were convinced that every estrogen hrt might well be smoothed of some of its rough spots by the addition of a bit of progesterone, and we considered that doing so helped us cope better with stresses. But since then, we've had both the reveal of those cancer risks and the examination of hormone physiology in such documents as the American Association of Clinical Endocrinologists Medical Guidelines for Clinical Practice for the Diagnosis and Treatment of Menopause (free signup required to read) that results in their statement that we cannot even determine whether or not we need to supplement with hrts other than estrogen until our estrogen needs are fully met. Whether it's fallout from those or some other factors that are less visible, we're seeing far fewer women routinely using progesterone supplementation today. It's still being heavily pushed by the compounding pharmacists' "bioidentical" model of multiple hormone prescribing (which certainly makes us nervous in the light of the cancer risks), but otherwise, women seem to be neither using it nor asking about it in the numbers they once did.

And you know what's the most remarkable part of all of that? They're not missing it. We don't have a stream of women coming to our forums to complain of imbalances in progesterone or because their doctors won't give it to them. Once women are finding good balance on their estrogens, they're often in no need whatsoever of progesterone supplementation because, just as the endocrinologists' guidelines predict, well-balanced estrogen allows the body to get by on its own progesterone resources quite well. So if you're on the fence or you're concerned about the risks of progesterone that we're just starting to learn about, you might want to reconsider your estrogen tuning at this point rather than adding another hormone—and risks—to the mix. If you're needing progesterone for therapeutic reasons such as endo treatment, however, there's less of an optional aspect but you might be interested in how different dose forms may relate to your systemic effects and risks, which we explain more about in our discussion of hrt for women with a uterus but no ovaries

Adding progesterone when you've been on estrogen

The estrogen/progesterone relationship is a very complex and ultimately uncontrollable one (which one gets to which receptors first), so it's very difficult to predict what alterations you'll see in both of them as you adjust to progesterone at a higher level of supply. In fact, adding progesterone is the single most complex and also drawn-out adaptation when we are balancing the three major ovarian hormone groups.

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

If you are starting up with both hormones together, the decision of choosing starting doses is doubled in complexity. Basically, though, the start low and go slow premise applies even more in this kind of situation.

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

Quite a number of progesterone cream users have reported that topical progesterone preparations seem to lose strength over time. We don't know whether it has to do with exposure to air, temperature or what, and neither have pharmacists we've asked. Nonetheless, it is a common experience to get to the bottom of a jar and feel as though you aren't quite getting enough of a dose, then start a new jar and go "whoa! this stuff really has a kick to it!"

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

We don't so much go for the "estrogen dominance" terminology popularized by Dr. Lee and his advocates because to us, this seems too simplistic a concept to really describe what we're working with in surgical menopause. Instead, we try to remember that we're working with two separate but inter-related functions.

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.