For this episode, we wanted to answer another reader question.  We love answering reader and listener questions. Also, we understand that you might not be getting answers from your docs and feel frustrated. Honestly, we really try to go into depth on answering these reader/listener questions as we want to be as thorough as possible on conditions, symptoms, dosing, and options.  

With that said, this is meant to be educational only and not meant for medical advice (there, my attorney will be very happy to have said that!).  But as mentioned above, we want to be as thorough as possible in all aspects. This question is from Nickie. We love this question and really think others can relate to Nickie’s situation.  She has been told she has Polycystic Ovarian Syndrome and has been prescribed oral progesterone.

She has concerns with taking progesterone, its side effects and the topical cream versus the oral.  Nickie also has concerns with her symptoms such as trouble losing weight and thinning hair. So we are going to do our best to answer Nickie’s questions as well as go into depth on forms, dosing, testing and options for PCOS.

Nickie’s Question: 
Hi, I was prescribed 200mg of Prometrium a couple of weeks ago to take on day 20-30 of my 32-day cycle. I ovulate around day 16. Day 20 was the night before our vacation, and after reading some potential side effects, I decided to wait until this next cycle to take them for the ten days.

They think I have PCOS, so I’m hoping it’ll make it easier to lose weight. My main concern are the potential side effects of the pills. Do you think using the cream is significantly better/less side effects than taking the two pills at night? I’ll also have a few drinks on the weekend and didn’t know how that would interact with the medicine as well. I have about two weeks to decide which I want to do, so I’m looking for advice.  

Also a history I have many symptoms of low progesterone. Anxiety, thinning hair, inability to lose weight no matter what I do, and after having a miscarriage at 12 weeks last year, I had to take oral progesterone to stop the bleeding. Thank you!

Dr. Davidson’s Response: 
First, we want to explain what PCOS is.  PCOS stands for Polycystic Ovarian Syndrome.  Which is exactly as it is described, being there are multiple cysts on the ovaries.  In many cases of PCOS, the ovaries are likened to a string of pearls. Because there are so many cysts in the ovaries that it looks like pearls.  However, there is so much more to it than just multiple cysts in the ovaries.

Typically there are very high androgens, being testosterone and DHEA.  These androgens can cause hair growth on the body is called hirsutism. Being that hair is growing on the face, around the nipple and lower abdomen.  I have even seen women that have hair growth on their necks. Not only is there unwanted hair growth, but there is also hair loss on the head. Hair can be very thin, especially the temples, hairline and top of the head.  Also included in PCOS is infertility because of the multiple cysts and lack of ovulation.

Missing periods is common in PCOS.  Some women can miss anywhere from 3 to 6 months of their menses.  High blood pressure and elevated cholesterol, in particular triglycerides, can occur in PCOS.  Weight gain is common in PCOS. This weight gain is not because these women are eating poorly or not exercising.  It is because women with PCOS have an easier tendency to gain weight, especially in the stomach. This unwanted weight gain is partly due to the increased levels of insulin that are common in PCOS.  

One important aspect we want to point out is, PCOS is not black or white.  Many doctors will say, either you have it, or you do not. However, we have found that PCOS is more like a spectrum where some women will have the majority of the symptoms and others just a few.  This could very well be the case in Nickie. Nickie has been pregnant but sadly miscarried. Also, she is having regular monthly periods. Although, Nickie does have the thinning hair and trouble with weight loss.  

With this said, Nickie does not have all the usual symptoms of PCOS, but she does have some.  First, it would be important to test Nickie’s blood work. Looking for the levels of androgens such as testosterone and DHEA-sulfate.  Also testing her LH (luteinizing hormone) and FSH (follicle stimulating hormone) would be good. Typically in PCOS, there is a 2:1 ratio of FSH to LH.  For example, an LH of 16 and an FSH of 8 would cause suspect for having PCOS or on the spectrum of PCOS. Also for Nickie, testing her thyroid function would be helpful.  

I am sure she has had her thyroid tested, such as the TSH.  However, actually testing the Free T4 and Free T3 would be extremely important in Nickie’s case.  We have written articles and recorded podcasts on the importance of thyroid function. We believe it is not proper to rely on a TSH (thyroid stimulating hormone) alone to determine if a person has a thyroid issue.  The TSH is just a signal from the brain monitoring overall thyroid status in the body.

The thyroid makes T4 which then travels in the body converting to T3.  A free hormone is the bioactive hormone, which is why we like to test the free T4 and free T3.  If Nickie’s thyroid function is low that can affect her female hormones, especially progesterone. Low thyroid function usually has the consequence of lower progesterone levels in women.  Not to mention it can also be part of the culprit of weight gain, infertility, higher risk of miscarriage and fatigue.

To further answer Nickie’s question, Prometrium is bioidentical progesterone.  If you are taking progesterone, make sure you are taking bioidentical and not any type of progestin.  However, Prometrium has its own drawbacks. Prometrium has many fillers that people can be allergic to.  In particular, it has peanut oil that many people are allergic or sensitive to. Prometrium only comes in 100 mg and 200 mg oral doses.  

Sometimes 100 mg might be too high for some women.  Or 100 mg might be too low, and 200 mg Prometrium is too high.  Also, Prometrium is an instant release progesterone. Meaning as soon as you ingest it, the levels immediately rise and then can quickly fall.  Other options to Prometrium is to use a compounded bioidentical progesterone. This would have to come from a compounding pharmacy, which are very common throughout the United States.  Compounding gives more versatility in dosing being able to tailor any milligram of progesterone to the unique individual.

Also, a compounding pharmacy can make the bioidentical progesterone as a sustained release.  Sustained release stays in the system longer and can help with mood and improved sleep through the night. Progesterone can come in many forms.  It can come in capsules, creams, gels, vaginal suppositories, sublingual troches.

We find that oral progesterone is more helpful for protecting the uterus when a woman is taking estrogen.  Oral can be more helpful for thinning the lining of the uterus reducing heavy periods. And we find the oral to be more helpful for women that have trouble staying asleep through the night.  Transdermal progesterone such as creams can also be helpful for mood and can be taken during the day as it does not make you as tired as the oral forms can. Oral progesterone seems to be more helpful in low progesterone during the first nine weeks of pregnancy.  

Low progesterone level in early pregnancy can have a higher risk of miscarriage.  Although as mentioned taking oral progesterone in the day can make you sleepy. Often in the first nine weeks of pregnancy, for a woman with low progesterone, taking oral at night and cream or transvaginal during the day can be helpful in raising the level to prevent miscarriage.

But to further answer Nickie’s question. Depending on the health goals, personal and family history of the individual, progesterone is quite safe.  She should not experience any side effects from taking the progesterone. However, keep in mind if Nickie is allergic to peanuts or the fillers in Prometrium.  Also, keep in mind her dose and whether instant or sustained release works best for her.

Nickie is going to cycle the progesterone, taking it from day 16 to her period.  This is common, as menstruating women make progesterone the last half of her cycle.  I have many women that take progesterone all month long. It really depends on what our goals are.  Taking progesterone all month long can help with periods, mood and sleep to name a few. However, taking progesterone all month long can inhibit ovulation.  It might be that Nickie is working on conceiving. In that case, taking progesterone for half of her cycle is appropriate.

Back to the rest of Nickie’s question.  She was concerned about having alcohol and taking progesterone.  There are no contraindications to taking alcohol and progesterone.  Just keep in mind that progesterone can make you tired and alcohol is a sedative.  Be aware of that when taking the combination at the same time might make you feel quite drowsy.      
      
I would like to go back and talk about the stubborn weight gain that Nickie was working on.  Other tests that might help Nickie, in this case, would be to check her fasting insulin levels.  Remember when I mentioned in PCOS higher levels of insulin can contribute to easy weight gain? So working on reducing the insulin burden in the body would be a key aspect to losing weight.  Progesterone can help to an extent. But honestly, taking progesterone is not going to make Nickie miraculously lose weight.

There is a connection between insulin and cortisol that can contribute to gaining weight easily and having an impossible time trying to lose it.  Both cortisol and insulin manage blood sugar/glucose. When cortisol is elevated, it can raise glucose levels. And when glucose levels rise, that will cause the pancreas to secrete elevated levels of insulin.  Cortisol levels rise with stress, mental and physical.

High intense cardiovascular exercise can raise cortisol.  Life stressors can also raise cortisol. This all has an impact on causing weight gain, especially in the abdomen.  One aspect of reducing insulin and cortisol is to reduce stress. I know this is easy said, but not easily done. However, switching your exercise to weights and walking over intense cardio is a great first step.  Also changing your diet can remarkable reduce your insulin.

High glycemic foods such as sugar and processed, refined carbohydrates cause your insulin to soar which in turn causes your weight to soar.  We have a program that we wrote called, The Keto-Carb-Cycling-Program (or KCCP as we abbreviate it). The KCCP is a free download on our website and can help you reduce cortisol and insulin.   

I really want to thank Nickie for reaching out and asking about her situation.  Reader and listener questions can be so helpful to others. And it also helps you understand that you are not alone in your hormonal concerns. If you have any questions, leave a comment below, or send an email to [email protected].