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Natural Progesterone and Oestrogen

by Dr Shirley Bond(more info)

listed in symposium - menopause, originally published in issue 27 - April 1998

 

A Transcript     Contents     Introduction: Dr Goodman     Dr Bond (Intro)     Dr Lee

Dr Bond     Q&A: Drs Lee and Bond     Dr Smallbone     Dr Griffin     Beth MacEoin

Q&A: Smallbone, Griffin & MacEoin     Leslie Kenton     Q&A: All     Exhibitors & Speakers

 

 

Oestrogen and Progesterone Balance
 From puberty to the grave, our general health and well being or lack of it, is a reflection of our hormonal balance. I think all of us at sometime become very cross when someone, usually a male, makes the comment 'it must be her hormones' and that happens when we behave out of character or irrationally and I think most of us get very cross because we know it is probably true.

The two hormones that have the most important effect on us and we are considering this morning are oestrogen and progesterone. We have heard from Dr John Lee about the effects of imbalance of these hormones, and how progesterone can balance things, but I want to concentrate now on women who do need some extra oestrogen as well.

These hormones change in their balance throughout our lives. At puberty some mechanism – I have to confess we don't know what it is – triggers the hypothalamus which is part of the brain, to secrete a hormone which in turn stimulates the pituitary which in turn stimulates the ovaries. The ovaries then start producing oestrogen and progesterone in a balance that continues throughout our lives until we reach the menopause.

At the time of menstruation the oestrogen and progesterone levels are normally both very low. The oestrogen rises until you get to the middle of your cycle, when ovulation occurs. After ovulation the ovary has a small area which is know as the corpus luteum or the yellow body which is in fact the egg shell, what is left of the egg after the egg has left the ovary, and this part of the ovary then starts to excrete large quantities of progesterone which in the second half of your cycle will balance out the oestrogen. If the egg is fertilised and you become pregnant these high levels continue because they maintain the lining of the uterus so the egg can implant. If the egg isn't fertilised there is some mechanism, and we don't know what is, which comes back from the egg to tell the ovary it can stop making progesterone, and the levels of both the oestrogen and the progesterone will drop and a period occurs.

This changing balance of oestrogen and progesterone repeats itself from month to month throughout our lives unless we become pregnant or unless as frequently happens nowadays, in the mid to late thirties something occurs and we don't ovulate properly. At the menopause this cycling stops and we are led to believe that our oestrogens drop to rock bottom. This isn't true. The levels of oestrogen change, the ovary produces less but the adrenals secrete a hormone which can be converted in the fat to a form of oestrogen; in fact, some fat post-menopausal women make more oestrogen than thin pre-menopausal women.

Types of Oestrogen
As Dr Lee has explained to us, because we are not ovulating the levels of progesterone drop, and our oestrogen is not balanced out by the progesterone. Up to this point we have tended to refer to oestrogen as if it were a single hormone, and in fact it is not. Progesterone is a single hormone, but there are a number of oestrogens and the human female has three main oestrogens. They are oestradiol, oestriol and oestrone. In our fertile non pregnant years the main two we secrete are oestradiol and oestrone. These are produced by the ovary. During pregnancy however the balance changes, and the main oestrogen is oestriol which tends to be known as safe oestrogen. Then, later in life, after the menopause, the main oestrogen we have is oestrone which is the one that is made in the fatty tissue from the adrenal steroid androstenedione.

When your blood is measured by your doctor to see what your oestrogen levels are doing, they measure oestradiol, they don't measure oestrone, so it is not surprising you are always told it is rock bottom because they are not measuring the oestrogen that a post menopausal woman has.

That is if they even bother to measure oestrogen; most of them frequently just measure the pituitary hormone, the FSH which is the one which stimulates the ovary and the body knows perfectly well that the ovary doesn't want to be stimulated once one has reached the menopause, so of course it is high. Now you can see from this that the balance of these oestrogens is quite complex and changes at different times of life, so who in fact does need supplemented oestrogen?

I agree completely with Dr Lee that the majority of menopausal and pre-menopausal women have symptoms that are due to oestrogen dominance and are in need of progesterone. The majority or large numbers do not need oestrogen, but there are women who do show symptoms of lack of oestrogen and again one has to be very careful because if you give these people oestrogen, if you don't balance it out with progesterone, you will give them symptoms of oestrogen dominance long before they get rid of the symptoms that are due to the lack of oestrogen. That may sound very complicated but what it means is that the oestrogen has a rather nasty knack of causing its unpleasant effects before it deals with what you hoped it was going to deal with.

Who Needs Oestrogen?
NowWomen who need oestrogen supplementation fall into five main groups:

If the ovaries have been removed surgically, unless a woman is quite plump and making a lot of her own oestrogen, then she probably will need supplementing with oestrogen and sadly, healthy ovaries are being removed all the time as part of a hysterectomy. This happens because the surgeon will say, as I am sure some of you have heard "You don't need your ovaries any more, do you, you are not going to have any children, you not going to have a uterus anyway. In any case you might develop cancer and we can give you some nice hormones much more easily if you haven't got ovaries, you don't need these ovaries". They never say the same about the testicles of the husbands of these menopausal ladies. [audience laughter] When I make any comments like that, I'm told that that's different.

Now ovaries may sometimes be removed for other reasons: as a result of cysts or they can become twisted or infected or they can be removed or damaged as a result some other abdominal surgery and if that's the case then quite often one does need to replace an oestrogen, but again it must be done with progesterone. You can sometimes get women who seem to have malfunctioning ovaries. This may occur following an hysterectomy because the blood supplies to the ovaries and the uterus are very close, they are very interconnected, they are slightly different in everybody. So it is no slight upon a surgeon if the blood supply to the ovary does get damaged. If it does, then this ovarian failure seems to occur about a year to eighteen months after hysterectomy. I think it is very important to remember that this doesn't always happen, there are many women around with ovaries having had an hysterectomy, and these ovaries function perfectly normally until they reach their menopause.

Unless, of course, the surgeon has gone and stuck an implant of oestrogen into you while you were under the anaesthetic and then those ovaries will be suppressed by that massive dose of oestrogen.

You can also have some women who need oestrogen because they have malfunction of the ovaries for some unexplained reason in their twenties or in their thirties. I am always very reluctant to call this an early menopause which is what many doctors call it, because it isn't. Strictly speaking, it is an ovarian failure and it can be due to all sorts of things, dietary problems, severe health problems, sometimes even over-exercising and upsetting the balance of things.

If women have been anorexic, sometimes if they have been on the contraceptive pill and come off it. I have a lot of patients who have come to me who have been on the contraceptive pill for many years, they come off if, their ovaries don't start to ovulate very quickly, their GP does a blood test. "Ah, the menopause, you've got an early menopause." If only they'd wait, those ovaries usually recover.

Also you may need to use some oestrogen when a woman is being weaned off traditional HRT. There frequently comes a time either as a result of hearing the sort of information you are getting today, reading an article or just becoming fed up with HRT or having a problem when your doctor says you mustn't take it any more and you have got to come off it. Stopping traditional HRT suddenly, cold turkey you might say, some women do it and some get away with it. They have no problem. Others would have a very unpleasant time with hot flushes and feeling very unwell if they did that, and so one has to wean them off. This is often done when you are taking women off traditional HRT and putting them onto natural progesterone and you can do this in many ways. You can reduce the dosage of the actual oestrogen they are taking, remove the progestogen, the artificial progesterone from their HRT and give them natural progesterone in a higher dose than you get from Pro-Gest. You would give it as a 200 mg capsule and you have then got exactly the same sort of pattern of hormone giving as with traditional HRT except you are using natural progesterone. I always prefer to change the oestrogen as well because as I explained to you earlier, most traditional HRT is either Premarin or oestradiol on its own.

So I would normally change somebody over onto a tri-oestrogen and then start reducing that because that reflects the natural balance and in the first stage if it is an highish dose, which it might have to be, then you would give natural progesterone for 10 days of the cycle to produce a bleed to protect the uterus from the effect of the oestrogen. Gradually as you bring the oestrogen down, the bleeding stops and you can switch over and use the progesterone throughout the cycle. It is something which has to be worked out for the individual.

Then there are some people who have symptoms of oestrogen dominance, they have the bloating, they have the tender breasts, they feel awful and who obviously need progesterone and they start on the natural progesterone, and a lot of these symptoms dissolve very quickly. But they still get left with sometimes some uncontrollable hot flushes which the progesterone hasn't dealt with, although in my experience it usually does eventually. Herbal things they'd tried don't help or they may have very dry problems with their vaginas or an excessive bone loss which isn't compensated by using progesterone or looking at all the other factors that Dr Lee mentioned. Sometimes then you do have to give a little oestrogen to deal with those specific symptoms, and again it is important to select the right one. For example the vagina, if it doesn't respond to any of the other things, will respond particularly well to oestriol which is in fact prescribable, it's in the doctor's little bible as Ovestin and that is a very good one for the vagina.

Hormonin as I said, which is a tri-oestrogen tablet, is also in that book and the high levels of progesterone that you might need to balance that are also available. The thing regarding this business of using oestrogen with progesterone, I think the important factor is that you do not use oestrogen on its own, ever. You always balance with progesterone. It is so often said by doctors to women who have had hysterectomies, you don't need progesterone, but what they really mean is, you don't need progestogen because you haven't got a uterus that needs protecting. They have forgotten all the other balancing effects of the progesterone with the oestrogen.

It is very complicated; I could go on for a very long time discussing all the various aspects of how you can use progesterone with oestrogen and still not cover many of the points that would be of interest to you.

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