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The purpose of this section of the web site is to help you
find a HRT program that both relieves your menopausal symptoms and does not cause unpleasant side effects. This
is the 1st of a 5 part series...
| Part
1 | | Part 2 | | Part 3 |
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PART 3 -PROGESTERONE, PROGESTINS & PROGESTERONE CREAM
Conventional wisdom suggests, that women who have not undergone a surgical
menopause, include progesterone, or a progestin, in their hormone replacement program to "oppose" the
stimulatory effects of estrogen on the lining of the uterus. Unfortunately, two of the most common reasons menopausal
women discontinue hormone replacement therapy programs are associated with progesterone and progestin associated
side effects.
The challenge presented, is how to individualize a regimen, that allows menopausal women to receive the documented
health and quality of life sustaining benefits of estrogen replacement, while both adequately protecting the uterus
and avoiding any potential progestogen-related side effects.
What exactly are progesterone and progestins?
Progesterone is a naturally occurring hormone produced by the ovary following
ovulation in premenopausal women. Progestins, are synthetic products, which mimic the effects of progesterone.
The term progestogen, is used to describe hormones that provide progesterone-like activity, and this includes both
progesterone and progestins. Although it may seem a little confusing at first, when I am referring to both progesterone
and progestins collectively, I will use the term progestogen.
What kind of side effects?
Many women are intolerant to progesterone and progestins experiencing unpleasant
symptoms, ranging from mild, to severe and life altering. Other menopausal women object to the withdrawal bleeding
that may accompany progesterone and progestin use.
In addition, there is evidence that some progesterone, or progestin regimens may interfere with the beneficial
effects of estrogen.
Will I definitely have unpleasant symptoms while using a progestogen?
No, the majority of women may not experience significant symptoms while
using a progestogen. However, those women who do are often discouraged from continuing their HRT program.
What unpleasant symptoms can accompany progestogen use?
Unpleasant symptoms may include irritability, fatigue, depression, diminished
libido, emotional volatility, breast tenderness, muscle aches, fluid retention, constipation, uterine cramping,
changes in appetite, headaches and insomnia. Some women may experience none of these symptoms while others may
experience all of them.
What kind of problems can "unopposed" estrogen stimulation cause?
"Unopposed" estrogen administration may result in irregular and
excessive vaginal bleeding and abnormal changes of the uterine lining, including estrogen-induced endometrial cancer.
Progestogens downgrade the sensitivity of the estrogen receptors in the uterine lining and reduce the frequency
of these problems. It is so effective in preventing excessive stimulation of the uterine lining, that appropriate
administration of progestogen, lowers the incidence of endometrial cancer to below that of non-users of HRT.
How do I include a progestagen in my HRT regimen?
There are 2 basic regimens, along with some variations.
In the first the estrogen is given continuously and the progestogens are taken for 10-12 days each month. In this
method, after finishing the progestogen, women using this regimen will usually have what is referred to as "scheduled
withdrawal bleeding," beginning 1-7 days after the final progestogen dose each month. This is referred to
as "sequential therapy." Some women find the bleeding unacceptable and are less likely to continue HRT.
In the second method, estrogen and a smaller dose of a progestogen are combined and taken daily. This is often
referred to as "continuous-combined therapy." The rationale for this regimen is to prevent any vaginal
bleeding, but some women experience persistent spotting, or bleeding. This regimen is available in both oral and
transdermal formulations. It is recommended by many experts and has gained wide patient and physician acceptance
in the United States.
Which method do you recommend?
I almost always suggest sequential HRT regimens. On the surface it might
seem more attractive to use continuous-combined therapy and avoid any withdrawal bleeding, but this method may
be less optimal than using a progestogen for 10-12 days each month.
Why?
There are many women who are users of continuous combined-therapy and are
happy with this regimen. They have good control of menopausal symptoms, are not bothered by the daily progestogen
dose and are able to avoid any withdrawal bleeding. For women who consider scheduled vaginal bleeding unacceptable
and would not use HRT if it necessitated bleeding, continuous combined therapy is likely the best option.
Nevertheless, there is preliminary research evidence that suggests that a commonly used oral continuous-combined
HRT formulation containing conjugated equine estrogen and medroxyprogesterone may interfere with the cardioprotective
benefits of estrogen.
In addition, studies funded by the National Cancer Institute demonstrated an increase in the incidence of lobular
carcinoma, a relatively uncommon form of breast cancer in patients using this formulation. The over all increase
in cancer risk appears to be small and further studies are needed to define the issue, however for the moment,
it might be more prudent to use either sequential therapy, or a non oral formulation of continuous-combined therapy.
There are alternate oral continuous-combined formulations and the status
of these preparations relative to the aforementioned studies will be addressed in ongoing and future research.
If a woman has had a hysterectomy does she need to take a progestogen?
If the uterus is not present, there is no need for a progestogen, natural,
or synthetic. Some make the argument that progesterone should be used "for balance," in women without
a uterus, as it more closely resembles a woman's natural cycle. I do not recommend this as a premenopausal woman's
progesterone level is for practical purposes nearly undetectable for most of the ovulatory cycle and there is no
reason to unnecessarily expose her to any potential negative consequences of progestogen use.
There is one subset of women who have had a hysterectomy where progestogen replacement would be a consideration.
Those women who have had a surgical menopause because of endometriosis and residual endometrial tissue is known,
or suspected to remain in the body. There have been a few cases reported in the medical literature where residual
endometrial tissue has undergone malignant transformation. This is rare, but if residual endometriosis is a consideration,
10-12 days of a progestogen at 1-3 month intervals would be reasonable.
I suffer from a number of the symptoms you mention while using a progestin, is
there any way to lessen the problem?
In some, but not all cases, it is possible to diminish the impact of these
problems by changing the type, dose, schedule, or route of administration of the progestogen, but ultimately the
symptoms are a direct effect of the progestogen, whether synthetic or natural. Many women have fewer symptoms when
using a product such as micronized progesterone, either from a compounding pharmacy, or from the local pharmacy,
where it is sold under the name of Prometrium. Women who are allergic to peanuts should not use this compound,
as it contains peanut oil. Some women find they experience fewer symptoms when using a progestogen by the vaginal
route, either in suppositories, or in cream form.
One strategy that is useful is to increase the progesterone free interval
to 2, 3, or 4 months taking care to monitor for signs of endometrial overstimulation. Some doctors have had good
results with the use of a progestin-releasing intrauterine device, which some research indicates is capable providing
endometrial protection. However, in some women it is virtually impossible to include a progestogen in their HRT
regimen due to the severity of the negative effects. In this extreme situation, it may be necessary to leave the
progestogen out of the program entirely. However, users of unopposed estrogen who have a uterus should be monitored
carefully, without exception, for the development of abnormal changes of the uterine lining.
I have heard a lot about natural progesterone skin creams, including one that
contains Yam progesterone. Is this a good thing for me to use?
I do not believe there is any benefit to using progesterone skin creams,
as they do not provide any protection from the long-term negative health consequences of hormone deprivation. Yam
and other plant progesterones, cannot be metabolized in the human body, unless they are modified pharmaceutically
and any suggestion that they provide benefit, other than skin lubrication, is without basis. Progesterone skin
creams that purport to be "natural," often contain micronized progesterone as the active ingredient.
There is one study that suggested that a progesterone skin cream was mildly beneficial in reducing the severity
of hot flashes.
There are those that recommend the use of progesterone skin cream as it is "natural" and counteracts
any "estrogen dominance." However, the defining feature of menopause is ovarian failure and its accompanying
estrogen deficiency. As such, by definition, all menopausal women are estrogen deficient and the concept that they
are suffering from "estrogen dominance," is not plausible. These products are very effectively marketed
and I believe that careful scrutiny will reveal that a significant number of those who advocate their use profit
by their sale.
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Dr Nosanchuk is currently in practice in Southeastern Michigan
and is accepting new patients. His office is located in Bingham Farms, a suburb of the Detroit Metropolitan Area.
Dr N specializes in the care and treatment of menopausal women and has a special interest providing treatment to
women whose lives have been altered by their menopause, hysterectomy, or both. This includes strategies to restore
quality of life, by resolving problems, such as persistent symptoms, loss of libido and disturbances of sexual
function.
Appointments with Dr Nosanchuk can be scheduled by calling (248) 644-7200
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IMPORTANT
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