Progesterone: do I need it or not?

This is an eternal question wherever women in surgical menopause are discussing their hormone needs, and it can be difficult and confusing to figure out the answer.

There are actually a number of issues here, and it's important not to confuse one with another. Things get trickier because when we discuss this hormone with our doctors, we often end up in an apples-and-oranges situation where we're actually talking about different things. Add to that a massive marketing campaign and you can get deeply conflicting answers depending on whose version you're reading.
Let's see if we can clarify the situation by looking at the typical uses of progesterone and how they relate to us in surgical menopause.

Estrogen "dominance" and the infamous Dr. Lee

Search around the internet and you'll find that Dr. John Lee seems inescapably tied to any discussion of progesterone. Read some of the sites where his work is featured and soon you will believe that you suffer from estrogen "dominance" and that all your ills can be cured by the application of progesterone, the more the better.

This is sales pitch. Just like that coating under your car that means more profit for the dealer than you, so this originally was a sales campaign for Lee's books and products. But there's one major problem here: estrogen "dominance" is an invented condition and even if it were real, it wouldn't apply in surgical menopause.

Where this progesterone issue has real meaning for women is in natural perimenopause. Although the term "estrogen dominance" is purely a made-up marketing ploy, in fact women in natural perimenopause typically experience a decline in progesterone production before they do in estrogen. This leaves them at the mercy of their wildly swinging estrogen levels, which cause many of the symptoms of the perimenopausal transition. Supplementation of progesterone during this time can help even out those swings by using the normal inter-relationship between these two hormones, estrogen and progesterone, to dampen them down.

So while there's no "disease" of "estrogen dominance," the entirely natural fluctuations of perimenopause can be smoothed by bringing these two major hormones back into better balance by covering that relative shortfall in progesterone until estrogen production falls enough to be in better balance with a woman's own menopausal supply. That's a temporary situation, albeit one that typically lasts several years.

But that's not us in surgical menopause.

For us, the transition happens in the operating room and although we have a period of getting settled in on our new post-ovarian needs and supplies, we don't have that perimenopausal mismatch and upheaval of declining ovaries. Even if we were in natural perimenopause before surgery, that situation ends when we make our transition to full menopause: it doesn't matter if then we were imbalanced in our ovarian hormone output; now we are wholly reliant upon post-ovarian supplies and we have an entirely different level of needs we're meeting with that supply now that we're in in menopause.

So no matter what you personally believe about Dr. Lee and his catchy marketing terminology, if you are in surgical menopause, this argument simply doesn't apply to you.

Uterine protection: it's why your doctor says no

Many women who have read or heard about progesterone supplementation or have taken oral contraceptives during their fertile lifestage wonder: don't I still need progesterone as one of my hormones supporting good health? And when they ask their doctor and receive a resounding NO, they're very confused.

Yes, our bodies do still use and require progesterone in surgical menopause.

The issue your doctor is addressing, however, is not this basic one of hormone physiology. Your doctor is instead answering the question of whether or not there is a medical reason for him to prescribe progesterone for you.

The primary FDA approval for prescribable forms of progestogens (a group term used to describe the human hormone progesterone plus its synthetic versions, the progestins) is to prevent excessive stimulation of the lining of the uterus by estrogen, a situation that can lead to development of cancer. Doctors are for the most part required to prescribe drugs for the uses for which they are approved, which is taken by many doctors to mean: if it's not approved for a use, that means that it doesn't work for that use. By medical reasoning then, the only thing that progestogens can do in the body is provide uterine protection and, clearly, after removal of our uterus we certainly don't need that. Hence, we don't need a progestogen.

Why won't your doctor answer your question about hormone needs rather than prescribing? Because that's what doctors do: they diagnose and prescribe medical treatments for disease states. What they don't do is teach us about physiology, and so it's up to us to recognize that we're simply not communicating on the same terms in this situation. Instead of asking do we need it, then, we need to be prepared (and there's more on this below) to support our request that we give it a try—an entirely different question.

But I got a test done and it showed that my levels were very low!

Because our bodies can—and do—convert our ovarian hormones one into another, we can't look just at any single hormone level and understand the full situation. Progesterone levels in the blood don't really measure how much progesterone activity is going on in our systems; they just measure how much is circulating in our bloodstream at that particular moment.

The most common situation in which we experience this apparent shortfall arises is early in surgical menopause. That's when a woman is working to get her new hormone needs balanced out against her hrt supply but isn't quite fully covering her needs with hrt. When that happens, our bodies place a priority on estrogen and use every resource available to produce it. One of the most important resources we can turn to that use is our pool of progesterone, produced by our adrenal glands from more basic constituents. Because estrogen is a higher priority, we'll stint our progesterone needs—or anything else that progesterone can be used to manufacture (and there are a number of them)—in order to come as close as possible to meeting our estrogen needs.

Obviously, when this is going on, our estrogen needs are, we hope, close to met but our progesterone will measure low. Beyond this, our system is stressed because we're in a crisis mode, pulling from here to patch up there. But if we "read" this situation as primarily one of a lack of progesterone, though, we're likely to just go on propping up imbalance by adding more progesterone to support this misalignment of supply and demand...and stress.

If, instead, we understand this cascade of hormone priorities and supply, we'll also understand that the recommendation of the American Association of Clinical Endocrinologists Medical Guidelines for Clinical Practice for the Diagnosis and Treatment of Menopause (free signup required to read) makes sense when it specifies that we need to work on meeting our estrogen needs with hrt as well as possible before we even consider whether or not we need to supplement any other hormone.

When we supplement our estrogen as well as possible, then we no longer need to prop estrogen up with progesterone (or any other hormone). Once our estrogen needs are covered and we have recovered from the stress of skimming progesterone for that purpose, then, and only then, can we decide whether or not we need to supplement our progesterone. Only then does a progesterone level even begin to speak to the actual state of our progesterone capability.

Let's repeat that because it's so important: before our estrogen needs are fully met by our hrt, we simply can't use the results of a progesterone level because that level just plain doesn't measure our actual progesterone capability or needs: it only measures the stress put on our systems by imbalance. We need to take estrogen out of that equation—by meeting our estrogen needs fully—before we are looking at any reasonable assessment of our progesterone needs.

So do I ever need it?

Maybe yes; maybe no. It's easy to read online and come across the assertion that because we used to make it with our ovaries and now don't have ovaries, of course we need to take some as part of our hrt. But as with many such simplistic assumptions, that isn't the whole story and is likely to lead us astray if we just take it at face value.

Yes, if we had an oophorectomy we did lose our ovaries and that reduced production. But at the same time, a woman in the menopausal lifestage has lower hormone needs overall because she's not supporting fertility, the consumer of most of our (former) ovarian output. The way it works out, then, is that our adrenal production capability often matches our post-fertile needs just fine. It's not that we're not using progesterone; it's just that we often don't need to supplement beyond what we're already producing. HRT dosing is about unmet needs, not overall systemic needs. We still produce most of what we need ourselves; we only need hrt to close the gap between what we make and what we need for post-fertile physical functioning.

Many women's bodies actually do just fine meeting progesterone needs once estrogen needs are met fully. Many women in surgical menopause, if they decide that they need to supplement progesterone, need do so only at a very low level, well below the typical prescribing levels based on the need of women with uteruses.

How do we decide, then, whether or not we need to supplement our post-ovarian progesterone supply? Once our estrogen needs are fully met and we've had a month or two to settle in on that adequate supply, we can look at remaining outstanding symptoms. We've discussed balancing progesterone and the symptoms of progesterone imbalance elsewhere on this site, and that's where you should go for the details on that part of the process.

If we are in fact experiencing effects that are indicative of low progesterone coverage, then we might experiment with a small amount of progesterone to see if that makes the difference we hope.

Remember: our goal in surgical menopause is to meet our current, post-fertile needs, not the needs we may speculate we had in earlier life stages. Excessive progesterone supplementation leads to very unpleasant symptoms as well as some very significant risks. It's also not magic: it only "fixes" things that are directly attributable to a deficiency of its actions. Further, because progesterone interacts with many hormones and many systems, the process of altering our progesterone levels is the most uncomfortable of all our ovarian hormone adjustments. Working with a small trial dose to see what effect that has before jumping in with both feet is more gentle on our bodies than over-estimating and then suffering the disruptions of a large transition and a situation of excess.

Therapeutic use or disuse of progestogens

We don't want to leave this topic without taking note of a few special situations. Some women don't have the luxury of adjusting their hrts solely for optimal balance and wellbeing, and many of those situations involve progesterone.

Women who have endometriosis often use a progestogen to help suppress the growth of their endo implants. For that strategy to be effective, they need to deliberately produce a situation of progestogen-heavy imbalance to be sure all of the influence of the estrogen they are taking is countered. For these women, the needs of endo control take a higher priority than just comfort although there are some measures we can take to reduce that systemic impact and risk.

So too, women who have no ovaries but still have their uterus will need a progestogen to prevent the estrogen they're making and taking from causing a cancerous stimulation of their uterine lining. This is another situation where health needs trump comfort, although there are methods of managing those progestogens to limit their influence in overall hormone (im)balance.

Some other women will want to exert special care when working with progestogens. Women with Polycystic Ovary Syndrome (PCOS) often have elevated testosterone levels, even once their ovaries have been removed, and for them, the fact that progesterone can be converted to testosterone often raises their risk situation more than reaching for better hormone balance might improve it. While the hormonal perturbations of PCOS are not yet well understood, in practical terms, supplementation of progesterone by these women rarely seems useful or productive of improved hormone comfort.

Women with metabolic diseases such as diabetes or PCOS may also need to watch their progesterone very closely for another reason: progesterone tends to worsen insulin resistance when it is heavy in overall balance related to estrogen. While good hormone balance has a normalizing influence upon our metabolism, we need to use extra care to be very slow and gentle when making adjustments if we need to avoid upsetting our sugar/insulin dynamic.

And women with autoimmune disorders of the inflammatory sort may find that progesterone supplementation, especially when first introduced or when used to excess of needs, can worsen their disease control. There are no absolutes here, but because progesterone affects the type of inflammatory/anti-inflammatory factors our bodies might make, use of progestogens hrts can be more complicated for autoimmune sufferers.

So what's the bottom line?

We only need to supplement our progesterone when we need a larger supply than we are producing. That's something we can't even begin to determine until we're meeting our estrogen needs as well as possible. It's also important to remember that progesterone is a powerful hormone and can be just as disruptive as it can be valuable if used out of balance with our overall needs, whether for hormone balance or disease control.

And if we're discussing progesterone supplementation with our doctors, we need to be clear that we're not talking about the standard prescribing indications for progesterone, but rather a small increment of coverage that will make our estrogen hrts a better fit for us. How well we're prepared to provide such justification rather than simply asking our doctors "don't I need some progesterone too?" will have a great influence on how that conversation goes. There are many answers to the question of whether progesterone supplementation is needed, and we need to do the thinking beforehand to be sure which question it is that we are asking if we want to receive a useful and productive answer.