Bio-identical progesterone isn’t without risk
By: Marika Geis, ND
Ask anyone suffering from extreme PMS or early menopause if they’ve benefited from bio-identical hormones and they’ll tell you that along with B vitamins, Fish oil, Chaste-tree, seed rotations, calcium/magnesium, liver and adrenal support, bio-identical progesterone was a game-changer. The benefits of bio-identical progesterone don’t stop there. In women with PCOS, progesterone can lower the male type hormones responsible for some of their symptoms along with balancing the pituitary hormones that help regulate their cycle. While the processes that contribute to the above conditions are complex, the one common denominator is the relative excess of estrogen. Estrogen is a hormone which, if left unopposed, can have a significant impact on our health. Nowhere was this made clearer than with the Women’s Health Initiative in 1991. Of the 3 interventions, one sought to determine which would have a greater benefit on reducing cardiovascular risk, cancer and osteoporosis: estrogen-only therapy or estrogen in combination with progesterone. Women with intact uteruses given ‘estrogen-only’ therapy were at significantly greater risk of developing uterine cancer, a risk that was reduced when estrogen was given in combination with progesterone. As a result, the study ended in 2004, two and a half years early.
In a world that seems determined to ensure that we are swimming in vast amounts of estrogen, both from the environment: plastics and their petrochemical cousins, pesticides and herbicides etc…and internally: lack of ovulation (a process that produces progesterone), compromised liver function (which will hold onto estrogen as opposed to eliminating it) and excessive stress (a process that sequesters progesterone to make more stress hormone), progesterone might seem a likely antidote for all this exposure given its role in balancing the effects of estrogen. This of course, after the liver function has been corrected and balance has been restored to the nervous system, right? For the most part, this is true but what happens when we’re given too much of a good thing? What might present as a baffling array of symptoms apparently implicating the thyroid gland, the nervous system and cardiovascular system, could actually have their roots in supra-physiologic amounts of progesterone as we shall soon see.
Lucy, a 47 year-old mother of 3 children, experiencing increasingly irritable episodes prior to her cycle along with night sweats that leave her sleepless and drained of energy went to her doctor’s office asking for advice on how to handle this new development. She has a good rapport with her physician and reports that she has also been experiencing frequent headaches, some flushing during the day and increasingly irregular periods that are quite heavy and painful. Her intrepid doctor, resisting the urge to recommend antidepressants and/or birth control pills, and having just read Dr. John Lee’s ‘What Your Doctor May Not Tell You About Menopause’, correctly sees this as the relative imbalance of estrogen and progesterone that occurs in early menopause and goes about prescribing her the standard dose of bioidentical progesterone to be taken during the last 2 weeks of her cycle. Lucy left relieved and began taking her medication at the appropriate time. Well, she was astonished. Most of her symptoms had disappeared, she felt more like her old self and life went back to normal. After about 6 months or so she found herself back in the doctor’s office with the same symptoms. What happened? More progesterone is prescribed except this time the symptoms aren’t getting any better. In fact, Lucy is now experiencing heart palpitations, hair loss, extreme fatigue, depression, low libido, cravings and weight gain. Some preliminary blood work by her doctor showed a normal value for thyroid function but a high fasting blood sugar along with a cholesterol profile that increased her risk of having a cardiovascular event in the future. Perhaps Diabetes? Maybe.
Lucy decided to take matters into her own hands unwilling to accept the fact that within 6 months she went from a healthy 47-year-old woman to one that could potentially be taking 4-5 different medications to mitigate the cardiovascular risks associated with Type 2 Diabetes. She had some brave friends that had seen Naturopathic Doctors with some encouraging results and decided to make an appointment. During the course of the interview, her naturopath suggested something called ‘salivary hormone testing’ to see where her levels of estrogen and progesterone were at given that her decline started with common peri-menopausal symptoms. They decided on a hormone panel that included the hormones in question in addition to assessing the status of her nervous system. The results clearly indicated where the problem was. Estrogen was within the normal range for a woman her age but her progesterone was clearly out of balance. And not by a little. The normal reference range for this particular test for progesterone is 0-50. Her result came back as
Lucy decided to take matters into her own hands unwilling to accept the fact that within 6 months she went from a healthy 47-year-old woman to one that could potentially be taking 4-5 different medications to mitigate the cardiovascular risks associated with Type 2 Diabetes. She had some brave friends that had seen Naturopathic Doctors with some encouraging results and decided to make an appointment. During the course of the interview, her naturopath suggested something called ‘salivary hormone testing’ to see where her levels of estrogen and progesterone were at given that her decline started with common peri-menopausal symptoms. They decided on a hormone panel that included the hormones in question in addition to assessing the status of her nervous system. The results clearly indicated where the problem was. Estrogen was within the normal range for a woman her age but her progesterone was clearly out of balance. And not by a little. The normal reference range for this particular test for progesterone is 0-50. Her result came back as 3200!!
When the body encounters an agent that is in excess of what it needs, it will attempt to protect itself from its effects by down-regulating the number of receptors on the target organs that respond to the agent in question.
Take adult-onset Diabetes as an example. In response to chronically high blood sugar, the pancreas makes more and more insulin in an attempt to keep levels with range. However, when the body registers that too much is being made, the number of receptors to insulin is reduced and the body secretes even more insulin to achieve the same blood sugar lowering effect. This is what is known as insulin resistance – the precursor to Type II Diabetes. Progesterone receptors will act in much the same way in that once the body is flooded with progesterone and all receptors are saturated, the body will make fewer receptors available because it no longer needs to maintain sensitivity. Since the target tissues no longer need progesterone it is often repurposed to other systems.
One common fate of excess progesterone is cortisol. Anyone with a history of PMS that was improved by including adrenal support to their health regimen can attest to this. When the body is under chronic stress, it will sequester progesterone to make more cortisol leaving the patient with a relative excess of estrogen. But what happens when there’s a relative excess of progesterone? The same thing, although the stimulus won’t be excessively long term stress. Excess progesterone will be shunted to making additional cortisol. Excess cortisol can have a suppressive effect on the thyroid gland – the metabolic powerhouse of the body. The end result is a spectrum of symptoms that involve the pancreas, adrenals, thyroid and ovaries: extreme fatigue, depression, low libido, hair loss, weight gain, palpitations, insomnia, cravings and perhaps more troublesome is the potential to precipitate progesterone receptor-positive cancers.
So what’s the bottom line? As a naturopath, I can’t say that bio-identical progesterone is my first choice when it comes to treating things like PMS, peri-menopause, PCOS or some other kind of estrogen-dependent condition. I usually try and support the systems whose dysfunction is lending the body to manifest those particular symptoms. This can go a very long way! However, when my patients are doing their very best to support healthy blood sugar levels, manage their stress and take their supplements and things are still just not quite right, I have no qualms about recommending bio-identical hormones. But, and a very BIG but, it is usually done with appropriate testing to ensure that the recommended dosage actually reflects what their body needs. A good rule of thumb is to start low and go slow. Test every 2-3 months for the first 12 months to ensure that your levels are within range and make corrections accordingly. A good compounding pharmacist is a crucial ally when a patient’s needs go beyond the standard available dose. Avoid unintended consequences… test don’t guess!