Find out when and why you should be taking progesterone when taking postmenopausal hormone therapy replacement. It’s more complicated than you might think!
Well hello to everyone and welcome back to my youtube channel health by heather hirsch where here we discuss all things menopause and midlife today i wanted to talk about progesterone i actually did this over on my instagram i got so many comments and questions and in my dms that i thought let’s turn this also into a youtube channel video so that’s what we’re
Going to be talking about today if you guys don’t already follow me over on instagram it’s certainly a fun time i’m at hormone.health.doc and i’m on twitter at heatherhershmd you can also check out my podcast women’s health by heather hearst and i will link that in the description bar below including my course and my ebook and just tons of resources on all
Things menopause really good evidence-based information and that is the whole reason actually i dedicated my entire career to midlife and menopause is because women are led so astray during this time but also i want to make sure that you know you are doing things safely and that you’re living your best life at the same time so let’s talk about progesterone so i
Use progesterone a lot when i am prescribing post-menopausal hormone therapy now you must take progesterone if you have an intact uterus that is numero uno because the main role of the progesterone component is to prevent pre-cancer in your uterus or uterine cancer that is its main main role and it is one of the big reasons i strongly recommend fda only approved
Hormone therapy because it has been scientifically studied to perfectly balance the estrogen that you are taking so that you will not wind up with uterine pre-cancer or cancer it is such a huge statement to make but that is the main reason you want to take fda-approved hormone therapy has been scientifically studied unlike non-fda approved or compounded medications
Which really should only be used quite sparingly or in the case that there are severe severe severe reactions or allergies to almost everything that is commercially available and even then i still worry a little bit and i do follow my patients up with routine ultrasounds okay so you need progesterone if you have an intact uterus what if you don’t have an intact
Uterus well you don’t need to take progesterone yep i said it a lot of people messaged me and said i don’t have a uterus and do i really need to take progesterone you don’t there are some small benefits from progesterone that we’re going to get into but otherwise you really do not need to take a progestin now i want to walk backwards when we talk about the safety
Of a post-menopausal hormone therapy the big study that we know of is called the women’s health initiative and that study came out in the early 2000s now i did a whole video on that which i will link as well and all about what we’ve learned from women’s health initiative but the big thing that we learned is that unopposed estrogen ie estrogen alone can increase
Your risk substantially for uterine cancer and so you must take a progesterone if you have an intact uterus and you’re also taking estrogen they then took that uh and they broke the women up into two arms women who had um in in a hysterectomy and they did not have an intact uterus so they only took estrogen and women with an intact uterus who they gave estrogen
And progesterone now namely these medications were prem pro or conjugated equine estrogen and uh prem pro and mba or conjugated equine estrogen and medoxy progesterone acetate and those just make a little bit of a difference it was an oral combination because that is certainly not the only way that you can take postmenopausal hormone therapy but in the long-term
Analyses of these they found that the women who did particularly well were those who who had had a hysterectomy and were taking estrogen alone in fact those women had substantially uh statistically significant reductions in breast cancer and did extremely well and actually so did the women in the estrogen progesterone arm but there was a slight increased risk
In breast cancer which actually turns out to be two to four women in a thousand over five years who took oral prem pro and again there’s different progesterones that we have now and so what that all sort of means is for those of us who are menopause experts hmm so the music estrogen only had less breast cancer but those who took estrogen plus progesterone had a
Slight increased risk so maybe it’s not the estrogen maybe it’s the progesterone component there’s still a lot that we’re learning about different types of progestins now when they haven’t studied different types of progestins not the middoxy progesterone acetate that was used in the whi they do even see lower risks of breast cancer so there’s a lot to the story
But the reason i go through all of that is because if you do not have an intake uterus you don’t need to take progesterone and that might even be better for you now if you have an intact uterus you must take a progestin it’s just that simple because we do not want you to get uterine cancer we know that risk is elevated without balancing the estrogen now all the
Good stuff really comes from the estrogen replacement the reduction in vasomotor symptoms ability to go back to sleep or sleeping issues mood issues vaginal atrophy or genital urination syndrome of menopause bone health brain heart health heart health especially if you’re within 10 years of menopause significantly improve with the estrogen so the good stuff kind
Of comes from the estrogen the progesterone is really there to protect your intact uterus there’s a couple different ways that you can take progesterone my favorite way actually there’s there’s a few actually is to take micronized natural progesterone at a bedtime and that has a little added benefit of sometimes causing some sleepiness so that if you have trouble
Falling asleep during midlife and menopause that certainly is a good reason to add that progesterone at bedtime and some women love this side effect because if they have trouble falling asleep this makes a huge a bill impact in their ability to get a good night’s rest that’s pretty much his other main benefit so the other ways i like to use progestin is in a
Progesterone releasing iud because that kind of progestin really doesn’t go systemically it mainly has effects right in the uterus right where you need it so that is one of my other preferred methods and progestins also come in um a combination tabs with estrogen so sometimes it’s north syndrome sometimes it’s not natural progesterone um sometimes the patches
Have libra and gestural those are all different types of progestins that one can use and those actually are a little bit have even lower rates of breast cancer than the medoxy progesterone acetate which again overall was so was really actually quite low and it’s a complex story especially when you’re thinking about all the different ways and types and kinds of
Progestins that you can do so for my patients who do not have an intact uterus i don’t routinely give them progestin and unless they find that there is some little benefit from taking that progesterone at nighttime i.e falling asleep that’s really the other main reason to use a progestin sometimes i also if my patients have had severe endometriosis and they’re early
In their um menopause it’s sort of the early menopause the first part of that transition i don’t want the estrogen to cause cyclic pain reminiscent of their endometriosis so i might give them a progesterone even though they have had their uterus removed there may still be some endometrial implants in the pelvic bowl also if my patients have had really early um
Uterine cancers but now have had a hysterectomy and no signs of metastases and their g1 oncologist is okay with using estrogen in menopause i might also give them a progestin just because they have that diagnosis and i just want to give a little bit of extra protection in the pelvic bowl and as long as my patients can tolerate it then those are two other kind of
Rare reasons i’ll use progesterone in a patient who’s had a hysterectomy all right so say you still have your intact uterus you guys are still good friends you need to take that progesterone there’s actually two ways you can do this if you’re doing it in a separate pill from your estrogen i know just add another layer and this is a good reason to have a menopause
Expert or specialist if you have one so there’s two ways to take that separate progesterone you can take it cyclically meaning just 12 days of the month or you can take it continuously meaning every single night so why do one or the other well there’s definitely some reasons some of it is science some of it is art so if you you know let’s go with continuous
Some of the main reasons my patients will take continuous is because it does help them with that benefit of feeling sleepy before bed and helps them with sleep that is just a miracle and so why not if they benefit and they notice a difference without it it certainly makes more sense to take it every single night some of my patients also find that they simply go
Bonkers trying to remember if it’s day 1-12 of the calendar month or if they’ve taken it 12 days and it really messes them up and it just kind of makes them worried and anxious that they’re going to forget it so for those patients they just prefer taking it every single night it’s kind of just a no-brainer they brush their teeth they take their estrogen they take
Their progesterone or what have you and boom they’re off and running so why do my patients do it cyclically well there is a couple reasons the biggest one is actually for my patients who are in very late perimenopause early menopause transition and i know this by your period history maybe some of your lab work and your symptomatology but for those patients when
I’m using postmenopausal estrogen it is a very likely that they are still going to have a bleed or a period yes i know and it’s also more likely that they’ll know when they’re going to get it if i use the progesterone in a cyclic manner typically i do that days 1 through 12 of the calendar month and then typically as that progesterone withdrawals usually on day
10 11 12 13 14 they will get a bleed or they won’t but it’s usually if it’s going to come going to be at that time that also helps me know yes i was expecting that type of bleeding or you know it just really kind of can help from the clinician standpoint as well as for the patient so to know when you might have your period can certainly make a big difference so
That’s reason number one the other reason is that just women prefer to have like less exposure to the progestin and that’s fine again a lot of that might go back to what they feel about the women’s health study now again those were different progesterones right micronized natural progesterone versus npr medoxy progesterone acetate but still some women like the
Idea of having less exposure so they only take it 12 days of the month and if i forgot to mention that is the minimum amount of progesterone needed to keep the uterus healthy yeah i have heard some or sometimes i will see progesterone given once every three months but i still prefer the lowest dose to be at least 12 days of the month that’s kind of mimicking
What your body kind of did pre-menopausally and studies have shown that that dose that um at least 12 days of the month is going to keep the uterus nice and healthy so if you’re taking an oral separate progesterone you can do it cyclic which is a days 1-12 or continuous every single night now you obviously can’t do that if your estrogen progesterone are
Combined and again a lot of this has to do with patient preference the way that they live their lives their top symptoms and my brain kind of beep bop boops tries to figure out what is going to be the best regimen for my patients so that is a lot about progesterone and certainly i did that in a very quick uh episode here but i wanted to help break this mystery
Of the progesterone down for you before i go let’s not gloss over the most important point which is the use of fda approved progesterone now there are plenty of people who do get compounded per when you are taking a compounded medication each dose can be a very different and each the combinations of medications can be different they can’t be studied in large
Term studies because it’s not the same medication in every single batch that’s why it’s unregulated and that’s why and that is why or it is compounded and that makes me worry i have seen many cases of uterine cancer from compounded non-fda approved progesterone and to the point where i certainly really really encourage my patients to almost always use fta
Approved progesterone products i know this is a point of controversy especially here on youtube and that’s okay my position will always be that and again there is extremely extremely extremely rare cases when it is okay to compound progesterone a severe allergy to almost everything commercially available or if you’re not taking an estrogen yeah if you’re taking
Dust progesterone but no estrogen post menopausally which you know i don’t think it would have as many benefits but certainly for some women that’s what they choose to do you’re not going to have unopposed estrogen and progesterone because you’re not really making any estrogen although i would still want to make sure you weren’t making some of your own estrogen
From adipose tissue post menopausally and the very few handful of cases i’ve had in my career i’ve had to compound progesterone i almost routinely check an ultrasound every three to six months to make sure my patient’s lining is not getting to the point where i need to consider a diagnosis or a workup of pre-cancer or uterine cancer so that is why i sincerely
Recommend fda approved products i promise for almost all of my patients except for those that fit on one hand i can really find a progestin that works for you i have had a also of the same number on my hand the same amount of people actually undergo hysterectomy because they could not tolerate progesterone now that’s a little extreme and certainly not something
I recommend and is a very lengthy conversation and personal choice um but there are other ways that you can do this one last medication that i didn’t talk about is a medication called duave and duovas conjugated equine estrogen and basadoxethane and that is another or different type of progesterone there is also certainly a lot of other things that hopefully
We’re studying so there is more things in the repertoire that we have to fit exactly what a patient needs for example a more targeted type of progesterone would be really helpful as well as maybe also or we know actually in the in the pipes are some other non-hormonal agents that also might help with symptoms so certainly it’s a lengthy conversation it really
Comes down to your safety and your personal decision and what fits your lifestyle the best like all these videos i always feel like i talk and talk and talk and it’s not until i rewatch them that i’m pretty confident i hit all of the talking points so i hope that i have at least broken down for you why to take a progesterone who needs it who doesn’t why to take
It continuously versus cyclic and just kind of discuss that there is lots of different options out there for you especially those that are fda approved wow guys thank you so much for watching my youtube channel please go ahead and give this video a like and subscribe to my channel if you’ve been watching for some time and you haven’t yet hit that little a special
Red button because it really helps other women see this podcast and it helps me know that you guys want to hear more of this content and i can make time to film it in this really hot room so thank you to all of you for subscribing and following let me know your questions or comments comment below how do you take your progesterone do you take it do you not um
What are your other remaining questions till next time i’ll see you guys next week
Transcribed from video
Why to take progesterone at menopause. By Heather Hirsch MD MS NCMP
