hello Ruba Health it's Dr Lisha your integrative gynecologist hormone specialist speaker bestselling author of the other PMS your Survival Guide for Perry menopause and menopause and I'm back as I promis to talk about part two of progesterone as I said at the end of the last lecture we do need to have a conversation that is talking about how all progesterone is not created equal so as usual I like to kind of give you the lecture outline for today just so you know where we're going so we know you know where we're going for the conversation
we're going to talk about what is causing all the confusion we're going to talk about progestins bioidentical progesterone progesterone how should I prescribe it what tests should I run to follow up after I prescribe it and then how do I adjust a patient's dosing remember I always love to give you some takeaways some things that I really want you to make sure that you take away from this lecture that paradigm shift of progesterone even when my patient has had a hysterctomy so remember progesterone is still in the conversation I want you to help your patients
understand that there are different types of progesterone that's your job you are the medical interpreter here this is where you give your patient information so that they can make an informed decision they can either make an informed refusal or an informed consent all right and and both of those are equally just as important I want you to remember to accept that progesterone has benefits other than uterine protection so when it comes to that section of how should I prescribe it we're going to talk about remembering the benefits that's what's going to play in your brain
as you're talking about okay how am I going to prescribe this and I want you to remember to bring progesterone into the conversation sooner rather than later with your per menopausal women let's talk about what is causing all the confusion I think everybody wants to point their finger at the Whi init or the Women's Health Initiative the hormone arm of the Whi study and I don't think that that is all the the right thing to do like that's the end all be all so I'm going to make a statement here that is probably not going
to be popular I'm going to say it's not the Whi studies fault not their total fault is not on them and I think the discussion comes from us wanting to say well remember when that study came out it looked at um some of the end points came out that were showing us that there was an increased risk in breast cancer and that increased risk in breast cancer was due to the progesterone side of things that when you added progesterone to your estrogen there appeared to be an increased risk of 8% 10,000 women that developed breast
cancer subsequently have found out here recently that one it was not statistically significant the P value did not translate into the wild into our general population I'm not saying that you know there wasn't any significance for breast cancer any breast cancer is significant what I am saying is that it did not translate out into the population what we also found is that it was the project ttin and so this is where we need to help clear up the conversation there is a misuse of terminology so in the world of studies and Science and data and
all um and when we get into the minutia if a molecule has a certain molecular makeup and it gets to have the label of progesterone it is then lumped under this umbrella we have have to be mindful that there are progestogens or progestogen and there is progestin progestogen is a substance that's naturally occurring or it is synthetic it is made and it does have effect on the progesterone receptor on the cell membrane progestins are a synthetic version along alone they also have the ability to stimulate the progesterone receptor on the membrane here is where things
get where we need to really peel back the layers and help everybody understand so let's talk about progestins here is the molecular makeup of a progestin and a progestin can come in the form of mroy progesterone acetate Leon nestal or eth androne acetate so the the names that our patients will recognize Moren Deo pra or the mini pill or birth control pills this is what our patients will recognize right and I will say in some situations this is what is what is an option for your patient so if I could be a little transparent I'm
I am going to share my own story I have uterine fire fibroids I've actually had to have a myomectomy cuz I had one that was sitting on the fundus of my uterus that was twisting and running and outgrowing its blood supply and then I had some that were inside the myometrium that tend to grow when I had pregnancies I also was very symptomatic with my uterine fibroids I had severe significant menaga matter of fact there was one time in Residence see I have this vivid memory of standing in surgery for a long period of time
doing a hysterctomy and I remember recognizing the feeling that I had messed up my scrubs and so after my pregnancies I I had utilized birth control in the past to help to calm down the the the menaja and it was it was helpful but what I did was I made the decision after we had our children to utilize the morina IUD because my fibroids were not located inside the uterine cavity it significantly impacted the way that I was able to move throughout life after putting in the marina because we know that if it's a progestin
or a progestogen it does have significant influence on the uterine lining it has antiproliferative type of property so this is why this can be an option for women at certain points and phases in their lives now when it comes to your per menopausal and menopausal women this is not an option because for one we're going to learn that it is the dosage is not correct and it's about the metabolites okay so let's move on bioidentical progesterone here is the molecular structure of progesterone that is naturally occurring in our in our body we'll call this biological
progesterone okay this can go sit on the progesterone receptor on the cell membrane stimulate a progesterone response this is called dydrogesterone it is a bioidentical type of progesterone it too can go and sit on the cell progesterone receptor on the cell membrane and cause an a response and turn on that progesterone receptor the difference between these types of progesterone and the progestins are the metabolites how your body breaks these things down how your body then what metabolite what molecule it then spits out on the other end okay so this is really significant the way that
progesterone bioid iCal progesterone can be can be seen is an oral micronized progesterone or dydrogesterone so when you go to your Pharmacy or you you deal with a compounding pharmacy this is how you explain to your patients there are different types of progesterone there's the oral micronized progesterone it can come in the formulation of prometrium that you can find at your local pharmacy tell them though I can only prescribe in certain incremental amounts when I can prescribe even if it's oral micronized progesterone through a compounding pharmacy I can be very specific and tailor the dosing
for you all right so how should you prescribe progesterone there's oral progesterone we talked about that just briefly for a second there's oral micronized progesterone there's progesterone suppositories and there's the trans dermal progesterone cream okay in thinking about what form you're going to use progesterone suppositories are mainly used to support a pregnancy through the first trimester now oral progesterone or the micronized progesterone this can come in various form forms or formulations like I briefly just stated there is the prometrium form that a lot of us know about and your patients can get this at their
local pharmacy so what I tend to tell patients is that particular dose that particular formulation will only come in 100 200 300 millgram and so if I want to make sure that I am customizing this dose for you I would prefer to go to a compounding pharmacy because this is how I prescribe my progesterone for per menopausal women I can do a low do continuous oral micronized progesterone depending on the symptoms that they come in with let's say for instance they're coming to us and they're saying the big issue is my sleep I cannot get
to sleep and stay asleep like I used to so I will give them about 25 mg of progesterone and I'll tell them to actually tit trate that up until their symptoms resolve what does that mean so I'll tell them the first night take 25 if you noticed maybe it it helped me a little bit but I still didn't get the best sleep the next night do 50 Mig and if you still see that there can be some adjustment made the following night do 75 milligram and go up by 25 Mig until you can get to
sleep stay asleep and you wake up feeling rested and not groggy the next day that's the first gold post that we're looking at the first mile marker and so I'll have patients come back to me and say you know what oh my gosh I got a to maybe 50 and I was great that was excellent great no problems I didn't need anything else I'll have some patients that say wow I had to get all the way up to 100 so this way you put them in the driver's seat you give them the ability to see
what works for their physiology at that point now the next thing I'll do for some param menopausal women is do this low dose cycling through the ltil phase okay where I'll do a low dose continuous and even cycle through the ludal phase and where I'll start them at a low dose and the only reason I will do this is if they come in say yes sleep is an issue but I also have PMS so I'll say let's just do the 12 milligram 12.5 milligrams start there and the first month see if that will help with
both if it seems that it did not help with both symptoms then let's do that second half of your cycle add on that 25 and see if that will help as as well for some women that even have started having heavier cycles for this hay menopausal phase they tend to see that this type of approach can really even help with minimizing how heavy their Cycles are okay now I am also very mindful to check in with them and see hey how is this in with you waking up the next day are you feeling okay is
it are you too groggy because sometimes they have to go up more than 255 they may have to go up to 50 during that week okay so we're always checking in for my menopausal women I can start around 75 maybe even go up to 100 and I'll do a continuous dose of the oral micronized progesterone I can also do a continuous dose with cyclically increasing that you know for 7 to 14 days of um that micronized dosing where I go up a little bit so when I do this and and I've shared this with others
they've asked me oh so do you give your menopausal women a period And I said actually no because I'm not taking them completely off of progesterone so I may start them at a low dose maybe 75 and if they need a little extra help I'll say hey go up by that 25 for like how you used to have a period so we'll do that for about 7 to 14 days maybe just seven maybe 10 days go up bump that up come back down and let's see because for some women when they start on that progesterone
it was good for a little while remember and they were doing well and then maybe something happened and and they're not and it's not helping as as much as it was so maybe we need to go up a little bit but I don't want to just leave them on that higher dose because then they may not be able to metabolize that higher dose and clear things as fast so they may wake up groggy they may not feel as good you know as sharp they may even start feeling a little puffy getting that wak in cuz
remember they may start metabolizing and shunting towards the mineral corticoid steroid pathway and that then becomes a problem so you have some leeway you have some way to be able to adjust dosing and we're going to get into how you follow that up now if you have some women that for some reason are like you know what I just don't want to take another pill or I'm already taking some I'm already doing creams can I just do everything as a cream and this is where you can offer them transdermal cream for progesterone I can start
out at 75 milligrams for your menopausal women if they are per menopausal women you can start out at that low dose that 25 at night whatever dosing you were doing orally you can do that for the cream and you can even adjust um dosing for the cream if need be and have them increase their clicks or have them do it multiple times throughout the day cuz remember progesterone can help with that anxious feeling can help with mood too so remember when it comes to choosing the form of which you're going to give your patients the
progesterone transdermal is an option and it can still protect the uterine lining because know this is part of the conversation and I wanted to put this in this section so that we can have this discussion about it protecting the uterine lining most people what they do is we will look at and the gold standard we've been told is serum serum testing make sure that they have certain levels we want them to be at about five nanograms per deciliter because that's where we have been that's that's the magic number that we've captured Ed from being in
the reproductive phase when the Corpus ludum is there after ovulation and we're like oh that's the number that we can see that is an anti-proliferative phase there's that secretory phase that must be the magic number for all women that must be where we're looking for remember everybody is different now what the Studies have shown is that when you use transdermal formulation there may not be that spike in the bloodstream they have not shown that to be consistent and the reasoning is that they feel that because of the preparation of the cream that there may be
some lipophilic components to that cream and when you put it in on when you put it on the skin it kind of gets hung up in the microcirculation of the epidermis and the dermal layer mainly that dermal layer and it takes a while for it to then disperse into the systemic circulation there's also thought that the red blood cells kind of suck up the progesterone and are like a carrier just like albumin or just like shbg and so because it's in the red blood cell we can't measure it in the serum okay so those are
some of the conversations that we're having now what some people are saying or actually what we found in studies is that when when they looked at the uterine lining and did endometrial biopsies when there was a transdermal application of progesterone even when the serum levels were not at the air at not within the the range that we were used to seeing when you were given oral progesterone there was still this anti-proliferative effect of the uterine lining so with your patients that have a uterus you can be confident that you can still have protection of the
uterine lining in using transdermal preparation okay now remember I also wanted to have this discussion in this section micronized progesterone with transdermal estradiol can be helpful for mood depression in particular we have looked at studies that have shown us that there has been some sign significant impact on a woman's mood when you add that progesterone component remember progesterone and remember that bioidentical progesterone it's the metabolites it can break down to those neurosteroids that pregnane steroid that can sit on the Gaba a and the nmda receptor and can help stimulate and have have influence on the
serotonergic pathway can have influence on the dopaminergic pathway so we want to remember that progesterone has influence in the body in other places other than just the uterine lining so people ask okay so then what test do I run to follow up remember you can do serum testing not all serum tests will show you the numbers that you want to see we know that even with oral micronized progesterone and I'll talk about that in a second but you can do that serum testing because we are so familiar with that you're looking for a certain level
between from between 3 to 5 nanograms per deciliter you're also looking you can look at urine you can do the Dutch test for instance you can look at the urine testing look at the metabolites that are being formed because remember our bioidentical progesterones can break down into certain metabolites that we can look for saliva is also a way to follow up because saliva testing will look at what is bioavailable it will look at that free floating form of progesterone it won't look at what's all bound up okay and what we did see in the study
I wanted to point out was that the saliva testing when you use transdermal progesterone did show an increase in the saliva concentration of progesterone so maybe when you're using transdermal application you can decide on the modality that you're going to use for followup so that you can match that and know okay this is what I'm looking for now I have a tool I have the right measuring stick for the right form of progesterone that I'm using the other way that you can follow up you can actually do an endometrial biopsy that is invasive I know
that's a little invasive but what they showed in the study was that when they did the endometrial biopsy there was no proliferation of the endometrial lining they saw that they saw that secretory type of of endometrium they saw that anti-proliferative type of endometrium even though the serum levels did not show where they thought that they should be all right the other thing you can do is use an ultrasound to measure the endometrial stripe you could just follow your patients and do seral and that's that's less invasive than an endometrial biopsy so how do you adjust
the dosing when it comes to you know you know decide especially if you're going to do that that transdermal formulation where you're not going to use serum or you're you're going to use a different a different tool to assess you know or maybe you are using serum and you're using oral that oral micronized progesterone how are you going to make the adjustments in your patients dosing how about you simply ask your patients how they're doing how they're feeling if they're feeling better on the dose that you've given them and and even if the serum levels
are not showing what you believe should be the target number their body's physiology is telling you something so simply ask ask if because if you continue to push and push and push and you're chasing a number they can come back to you and say I feel awful I do not feel good on this remember the metab AB olism of the hormones are just as important as when you put that hormone in the system and remember remember remember hey takeaway points that Paradigm Shift progesterone even when my patient has had a hysterctomy remember you are the
medical interpreter it is your job to help your patient remember or not remember but even learn that there are different types of progesterone and progesterone comes in different forms it is different Delivery Systems and help them understand the different types of progesterone and why you are recommending a certain formulation of progesterone for them at this stage in their lives remember in prescribing progesterone all the other benefits that progesterone has other than protection of the uterine lining and bring progesterone into the conversation sooner rather than later with your per menopausal women it has been my pleasure
to be here again with you at Rupa Health remember you can follow me on all social media platforms at Dr leesa MD that's d r l a k e i s c h a m d
