Ep 35: Understanding Progestogens in Menopause Hormone Therapy

In this episode of Reset Recharge, Dr. Komal Patil-Sisodia, a triple board-certified endocrinologist and women's health expert, delves into the complexities of progestogens, a crucial hormone in menopause hormone therapy (MHT). Dr. Patil-Sisodia explains the importance of progestogens in protecting the uterus, the different types available, and their unique effects. She also clarifies common myths and provides guidance on choosing the right progestogen based on individual health factors and preferences. This episode aims to empower women with the knowledge to make informed decisions about their MHT.

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Audio Stamps:

00:00 Introduction to Reset Recharge

00:53 Understanding Progestogens

03:13 Types of Progestogens

04:25 Clinical Use of Progestogens

06:00 Methods of Administration

08:48 Choosing the Right Progestogen

09:42 Debunking Progestogen Myths

10:25 Case Studies and Practical Examples

11:29 Recap and Final Thoughts

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Transcript

Dr. Komal Patil-Sisodia 0:00

Welcome to Reset Recharge, the podcast where women's health takes center stage. I'm your host, Dr. Komal Patil-Sisodia, a triple board certified endocrinologist and women's health expert. This show is all about empowering you with the knowledge to understand your metabolic health, navigate hormonal changes, and feel confident in the conversations you're having with your healthcare provider. Whether you're managing symptoms, exploring treatment options, or just want to feel more in tune with your body, you're in the right place. As a physician, my goal is to educate on this podcast. The content shared here is for informational purposes only and should not replace personalized medical advice. If something we discuss resonates with you, please talk to your healthcare provider at your next visit. Now let's dive in and help you reset, recharge, and take control of your health. Hi everyone. Welcome back to Reset Recharge. Today we are going to talk about a class of hormones that is one of the most important pieces of menopause, hormone therapy, and also one of the most confusing progestogen. And here's what I want you to feel by the end of the episode, I want you to be clear on the vocabulary, on why Progestogen matter, on what kinds exist and how they're used differently for different people. This is about understanding the tools in the toolbox so you and your clinician can make choices that are actually aligned with your body and your risk profile. I wanted to start with the basic, why do we even need progesterone? This question comes up a lot in my clinic. In menopause hormone therapy, MHT Estrogen will often take center stage because estrogen is the hormone that is most linked to classic symptoms like hot flashes, night sweats, sleep disruption, vaginal dryness, mood shifts, brain fog, joint aches, and that"my body feels unfamiliar" feeling. Estrogen helps a lot of people feel like themselves again. But estrogen has a very specific effect on one part of our body that we have to pay attention to, and that's the uterus. If you still have your uterus, meaning you haven't had a hysterectomy, estrogen alone can stimulate the uterine lining called the endometrium to keep growing. Think of estrogen as a signal preparing your uterine lining for a potential pregnancy, and when you are not pregnant, it sheds in a menstrual cycle, but in menopause, without ovulation and without enough progesterone to balance it, that lining can become too thick. Over time, unopposed estrogen will raise the risk of endometrial hyperplasia and potentially endometrial cancer. A lot of women ask me if they've had a uterine ablation, whether this risk still holds true. Yes, because you still have your uterus intact. So if you still have your uterus and you're taking systemic estrogen, you need endometrial protection. And that's what progestogen do. They come in and help stabilize and. Safely shed the lining. The easiest way to remember this is that estrogen is for symptom relief and progestogen is a uterine safety net. But I do have a lot of women who have improvement in their symptoms on, progestogen alone. For a long time we told women that if you don't have a uterus, you don't need a progestogen. And I think we are finding that is not always necessarily the case. Before we dive in, I want to make sure that we sort out all of the different names that Progestogen are called. There is progesterone, progestin, progestogen. These are all terms you may have heard and sometimes we use them interchangeably, but that's not always correct. It's important to understand the difference, and once you do it makes it kind of easy to understand. Progesterone is a natural hormone that your body makes. It's produced mostly after ovulation when you are still having menstrual cycles, and it helps balance estrogen in the menstrual cycle. A progestin is a synthetic lab made version designed to act like progesterone in the body, but can have some different effects as well. It will attach to progesterone receptors, and protects the endometrium but because it's structurally different, it can have different side effects and risk patterns. It's most commonly used in birth control pills, but also used for menopause hormone therapy. Progestogen is an umbrella term. It means any compound that activates progesterone receptors. So that is progesterone, which is the natural, or progestin, which is the synthetic. Now that the language is clear, let's talk about what's actually used clinically. There are two main groups of progestogen and menopause hormone therapy. The first one is micronized progesterone. This is bioidentical progesterone, and if you've listened to this podcast before, you know that I hate the term bioidentical because it is a marketing term. It just means that it is chemically identical to what your body naturally makes, micronized means it's. Been processed into smaller particles so that your body can absorb it. It's often preferred because it tends to have a better side effect profile in terms of breast cancer risk and cardiovascular health compared to a lot of the synthetic options. The synthetic progestins are also very effective for endometrial protection, but they vary more in how they behave because their chemical structures are different than what your body makes. The main types that we use here in the United States, for menopause hormone therapy are medroxyprogesterone acetate, norethindrone acetate, levonorgestrel, And drosperinone. Outside of the United States. You can also get two additional progestogens called Dydrogesterone and trimegestone. This list matters when someone says progestin and doesn't tell you which one. The important thing to know about all of these different progestins is that they will have different effects on things like breast cancer risk, blood clot risk, metabolic health, and cardiovascular health. And that's why you'll hear a lot of clinicians say that not all progestogen are equal, and they aren't. And that's based purely on the chemistry. So let's talk a little bit about how you take Progestogen. They can be taken in several different ways. Oral, which means by a pill can be taken either daily or two weeks out of the month. Transdermal means absorbed through the skin often as a patch or a gel preparation In my opinion, these don't work quite as well as the other roots. You have vaginal, where you can have either local or systemic absorption depending on the dose in the formulation. And then intrauterine, and this is most commonly known as the levono gestural IUD, which is local progestin therapy to the uterus. To help break down the uterine lining and it gives very strong protection of the uterus and can minimize whole body exposure of having to take a progestogen for most women. If somebody is having trouble tolerating, Progestogen by mouth or has risk factors that make systemic exposure less appealing, the IUD can be a smart alternative. So let's talk a little bit about how you take these. we talk about either taking hormone therapy continuous, or what we call sequential. A continuous regimen is where a progestogen is taken every day alongside estrogen. The pros are that you get more consistent protection of your uterine lining. It can often lead to no withdrawal bleeding. Once you get adjusted and are on the right dose and can feel simpler to manage this regimen is most common for post-menopausal women or anybody who wants to avoid having a period and bleeding. The next on the list is what we call sequential or, cyclic regimen, and this is where progestogen are taken for part of the month, often 10 to 14 days within a 28 day cycle. The pros of this is that it mimics the rhythm of a natural menstrual cycle. It can be easier to do it this way in early perimenopause where the bleeding is already irregular and some women feel better emotionally or physically on a cyclic pattern compared to continuous. It takes a little bit of trial and error to figure out what's right for you. Another way to think about it is by perimenopause versus post menopause. In early perimenopause, your ovaries are still fluctuating in their function, and the cyclic regimens are often a better fit because your body is still doing some cycling. In post menopause. The ovaries have pretty much quieted down and the continuous regimens are often preferred because they reduce withdrawal bleeding and keep the protection of the uterine lining steady. A lot of this depends on patient preference, what their cycles and bleeding patterns are like, and how they tolerate the progestogen they're taking. So how do you choose a progestogen? Let's talk a little bit about the decision process. There's no universal best progestogen. There's only best for you. And so when you're choosing a progestogen with your. Clinician, it's important to talk about the status of your uterus, whether you have one or not. Whether you've gone through a uterine ablation, what your bleeding cycle is like. Your symptom profile, your personal and family history, your risk factors, and how well you tolerate something. Some people will prioritize sleep support, mood stability, minimal breast tenderness, minimal bleeding, cardiovascular safety or clot reduction, and because different progestogen behave differently, clinicians will tailor these choices. Your right option might change over time from perimenopause to post menopause. It's not going to be a very stable landscape for everybody. Next. I want to transition to clearing up a few myths that I hear constantly about progestogens. Myth number one is if it says progesterone, it's all the same. A progestogen is a category and there are multiple types, structures, and effects. Myth number two is that progestogen are just an annoying add-on. Actually, they are critical for safety. If you have a uterus, you have to be taking this to prevent endometrial cancer and they're doing important protective work. Myth number three, if I feel bad on one progestogen, I'll feel bad on all of them. This is not necessarily true, and sometimes changing the type, the dose or the route can make a world of difference for you. So let's talk about a simplified example. This is just a way to picture how you would tailor a regimen to somebody. Imagine there are two women both in their early fifties, so we'll say 52, both using estrogen for hot flashes. The first woman has a uterus. She prefers not to have any bleeding. She has some cardiovascular risk factors, and a clinician might lean towards something like micronized progesterone in a continuous regimen because it gives steady protection and has a better safety profile. If you think about the second woman in my example, she is an early perimenopause. She's still occasionally having cycles and is bothered by the irregular bleeding already. She might do better on the sequential regimen where she takes the progesterone for the first half of her cycle. And if that doesn't work well for her, even considering a levonorgestrel IUD for local control. Up to 21% of women can stop having their periods with the levonorgestrel IUD. For both women, it's The same goal for protection, but just a completely different landscape for how menopause is playing out in their bodies. So let's pull this all together. Here's your recap. Number one, progestogen are required with estrogen therapy if you have a uterus to prevent endometrial overgrowth and decrease endometrial cancer risk. Number two, progesterone is chemically identical to what your body makes. Progestins are synthetic and different, and progestogen means both all under one umbrella number three. The main progestogen used in menopause hormone therapy are micronized, progesterone, and synthetic progestins. Number four, they can be taken orally, transdermally vaginally, or via IUD. Number five, continuous regimens give consistent protection and usually avoid withdrawal bleeding. Sequential regimens will mimic natural cycling and may fit better in early perimenopause. And lastly number six, your choice is individualized based on symptoms, risk factors, and preference. So if you've been handed a prescription and told, here's your progesterone with no other context, I hope today I gave you language and clarity. You deserve to understand what's going into your body and why. If this episode helped, share it with someone who needs it and bring these terms to your next appointment. The quality of your care often rises with the quality of your questions. Next week on Reset Recharge, we'll keep talking about hormone therapy, literacy, and practical, evidence-based information Thank you all for tuning in and I hope I'll see you all on the next episode.