By: Joseph Feste, M.D., MD, FACOG, AACS, AACG, Medical Director and Mike Clark, Director of Education and Research, NBH Lifetime Health.
Low levels of the female hormone progesterone can cause a condition referred to as estrogen dominance. It is the ratio between progesterone and estrogen that determines whether you are deficient in progesterone and are in a state of estrogen dominance. At NBH Lifetime Health, we have seen ratios of up to 1000:1. A healthy ratio for non-pregnant women is generally 10:1.
Why is this important? An imbalance between these two essential hormones can increase a woman’s risk of breast cancer, make it difficult to lose weight and easy to gain weight, increase the risk of miscarriages and infertility, cause skin breakouts, cause PMS symptoms, cause heavy bleeding, cramping and headaches or cause a woman not to have periods or to have irregular periods. PCOS (polycystic ovary syndrome) generally includes low levels of progesterone and insulin resistance. Hysterectomies are often the end result of low levels of progesterone because of possible compromise of the blood supply to the ovaries.
PeriMenopausal Women: As women enter the perimenopausal years, usually in their 30’s or 40’s, hormone changes can create one or more of the following symptoms: hot flashes, night sweats, insomnia, loss of libido, weight gain, hair loss, depression, anxiety, and more, that become more severe around ages fifty to fifty-five when estrogen, progesterone, and testosterone permanently diminish and the metabolic system slows down (thyroid).
One recent client, age 42, represents a more extreme example of estrogen dominance in her perimenopause years. She had a history of 13 miscarriages, heavy bleeding, cramping and excess weight that she found almost impossible to lose. Her difficulties with her periods had started with puberty. Her sister and mother both had hysterectomies and both had breast cancer. She expected to follow the same path. Her lab tests verified estrogen dominance. Our physician placed her on progesterone and natural thyroid booster and she has lost 32 lbs. on the diet program. If she continues her regimen, she should greatly reduce her risk of breast cancer and avoid a hysterectomy. She will also reduce her risk of diabetes and heart disease.
A more common example of a perimenopausal woman (or even a teenager) with estrogen dominance is one who has issues with her period which may include heavy or moderate bleeding, headaches, cramping or irregular or no periods. She may or may not be on some type of birth control. She may have skin eruptions. Often, weight is a serious issue and she may have bouts of irritability and moodiness, particularly during the week or two before her period. Her sleep may also be erratic and she may wake up tired.
Postmenopausal women are often prescribed some form of estrogen, usually synthetic. This places them in a state of estrogen dominance. A typical result is weight gain (particularly around the middle), sleep difficulties, low sex drive and an overall lower quality of life. If a postmenopausal woman is not on estrogen, she is likely deficient in all hormones. This also applies to surgical menopause (hysterectomy with ovaries removed).
“The Teen Weight-Loss Solution” by Erika Schwartz, M.D.
Many teenage females suffer from estrogen dominance (low progesterone). The following symptoms in a female teen (or young woman) are ones that should be considered for treatment
with natural progesterone.
• Mood swings
• Weight gain
• Irregular periods
• Painful periods
“These symptoms can occur together or alone. There are no contraindications to trying natural progesterone, so even trying it to treat one of the symptoms is reasonable. Before embarking on birth control pills or antidepressants for your teen, we would recommend that the teen try a three-month course of natural progesterone so she can see the benefits of this treatment.”
Estrogen Dominance and Hormonal Birth Control
The term Hormonal Contraception refers to birth control methods that act on the endocrine system. With most types of hormonal birth control, a woman takes hormones to prevent ovulation. When there is no egg to be fertilized, pregnancy cannot occur. Hormones also cause other changes in the cervical mucus and uterine lining that help prevent pregnancy.
There is no question that hormonal forms of contraception are effective and convenient. However, it is important to understand that using these methods suppresses the female’s own production of progesterone and estradiol, and sometimes testosterone levels depending upon which birth control pill one is taking.
The suppression of progesterone leaves a woman in a state of estrogen dominance, which puts her at greater risk for developing breast cancer, and prone to bothersome symptoms such as premenstrual tension, water retention, breast tenderness, foggy thinking, tearfulness, sadness and mood swings.
It is essential to understand that when we test our clients that are currently using a hormonal form of birth control, the progesterone level will likely be below range and the estradiol level may be as well. When synthetic progestins are being used, endogenous production of progesterone is blocked. It is also important to note that the suppression of natural progesterone by the progestin and estrogen will negate the beneficial effects of progesterone produced by the ovary. Progestin blocks the progesterone receptor sites.
In spite of this concern, we and others have found it beneficial to supplement the BCP’s with bioidentical progesterone. This can help with weight loss, PMS, headaches or other symptoms that may be occurring and may help overcome some of the potential health risks caused by BCP.
Weight Gain, Reduced Libido, Other Side Effects of Birth Control Pills
Estrogen dominance refers to an imbalance between estrogen and progesterone. This imbalance can lead to weight gain, PMS (irritability, moodiness), insulin resistance, water retention, bloating, headaches and other symptoms including reduced sex drive. The most common reason for the reduced sex drive is that the lack of optimal levels of progesterone can result in the binding of free testosterone. This can also interfere with building lean muscle mass, strength and energy.
These conditions can occur without BCP if progesterone is low. PCOS (Polycystic Ovary Syndrome) is also associated with low progesterone. An individual may just have one of the conditions/symptoms or all of them.
Unfortunately, BCP are often prescribed for heavy bleeding, cramping, headaches, etc. when a woman (or teenager) does not need birth control protection and would do much better on bioidentical progesterone and possibly other hormones that can be identified in an analysis of the blood. Further, our disease oriented medical system is not generally aware of the need for and use of progesterone except for uterine cancer protection, support of the uterine lining for infertility and for pregnancy support.
Birth Control Pills (BCP):
The most established form of hormonal birth control is an oral contraceptive made from synthetic hormones. The pill is considered to be 97-99% effective if used properly, and is fully reversible.
There are two types of birth control pills available: the combination pill and the mini-pill. The combination pill contains the hormones estrogen and progestin, a synthetic form of progesterone. It is not progesterone! It is taken once a day, most commonly for 21 days followed by a 7-day break. When a woman uses the combination pill, the eggs in her ovaries do not mature and she does not ovulate. Without ovulation, there is no egg available for the sperm to fertilize.
The mini-pill only contains progestin. Progestin thickens the cervical mucus, making it more difficult for sperm to pass through the cervix. It also makes the lining of the uterus less receptive to the implantation of a fertilized egg. The progestin only pill is sometimes recommended for women who have medical reasons for which they must avoid estrogen.
The minipill is taken every day – there are no on or off days with the minipill.
The theoretical efficacy of the minipill is similar to that of the combined pill (97-99%); however they are taken on a strict timing schedule. The pills must be taken within 3 hours of the same time of day every day. Therefore, real-life efficacy is dependent upon user compliance.
Birth Control Pills Of Special Note:
Injected contraceptive (trade name Depo Provera): Depot medroxyprogesterone acetate (DMPA) is a synthetic long-acting form of the hormone progesterone. DMPA is similar to the birth-control minipill in that it does not contain estrogen.
Its effectiveness in preventing pregnancy is close to 100%. DMPA must be injected by a health-care professional every three months. The injection must be administered within the first five days of a woman’s menstrual period. She is then protected from pregnancy within 24 hours of receiving the injection. A woman may stop having periods altogether after using DMPA for one year. A woman’s menstrual periods should begin again within 6 to 18 months after she stops taking the injections. A woman can also become pregnant, usually within 12 to 18 months, once she stops using DMPA.
In addition to the estrogen dominance issues and side effects, another important side effect of Depo Provera use is osteoporosis. According to Pfizer, the maker of Depo Provera, “Use of Depo Provera may cause you to lose calcium stored in your bones. The longer you use Depo Provera, the more calcium you are likely to lose. The calcium may not return completely once depo injections are stopped.
IUD (trade name Mirena): Intrauterine contraceptives are known as IUDs (intrauterine devices). The Mirena is an IUD that secretes the progestin levonorgestrel. Made of soft, flexible plastic, it is put in place by a healthcare provider during an office visit. Mirena should be placed within 7 days of the start of the period. When properly placed, Mirena prevents pregnancy
for as long as your patient wants, for up to 5 years. Periods may become shorter, lighter, or even stop with Mirena use. The Mirena is 99% effective in preventing pregnancy, and fertility returns after removing the IUD.
Lab Tests When On Birth Control for Estradiol and Progesterone. It is important to understand that we generally do not test for estradiol and progesterone levels when a woman is using a hormonal form of birth control. Also, LH and FSH will be markedly suppressed on birth control pills. Her progesterone level will likely be below range, and her estradiol level may be as well. If we believe it necessary to test, we will ask the client to go off birth control for at least thirty days and then test mid-cycle.
Many physicians give birth control pills pre and post menopause so the hormone tests for estradiol and progesterone are not helpful if the testing is done while on the birth control pill. When synthetic progestins are being used, endogenous production of progesterone slows considerably. It is also important to note that there is competition between the progestins found in these birth control methods and bioidentical progesterone that may negate some of the beneficial effects of progesterone supplementation.
If not on birth control and still having regular periods, labs should be done on days 11 or 12 of the cycle to test the highest levels of estradiol. If postmenopausal, then labs can be done at any time. Generally, low progesterone is treated by symptoms.
Our physicians encourage women over the age of 45 to stop the birth control pills so we can test their hormones. The same is true for those younger women whom we suspect have PCOS. That said, you must consider the likelihood of pregnancy, especially in the younger women. At NBH Lifetime Health, we encourage those couples who don’t want to have any more children to have the husband get a vasectomy so we can treat the ladies with the proper hormones.
If you have any questions about estrogen dominance, your BCP or about progesterone, please call for a complimentary consultation with our Austin hormone doctor or Nurse Practitioners.
Hormone Replacement and Cancer Risks By Labrix Labs
“Patients often have questions regarding hormone replacement and cancer risks. While not all cancers are influenced by hormone levels, malignancies that arise from hormone sensitive tissues often are. These hormone sensitive cancers include ovarian, endometrial, breast and prostate cancers.
One of the primary risk factors for endometrial cancer is unopposed estrogen