Amanda’s Question: I’m 41. I have regular periods every 35 days. I have some anxiety, tiredness, stress, but I do work a lot. I don’t have trouble sleeping, but my doctor checked my serum progesterone level, and at day 21, it was .5. She said it was low. She had prescribed me oral 200 milligrams a day of compounded progesterone. I work at a job that requires 24-hour shifts twice a week. I’m trying to verse myself in information about this replacement therapy and if this is the right way for me to take progesterone therapy. She told me to just not take it on the days that I work, but I’m concerned with things that I read about replacement therapy and increased mood issues and anxiety. I don’t think I could deal with those any worse than I have than what I have. Can you please tell me if I’m on the right path as I’m scared to begin this therapy? Thanks, Amanda.
Short Answer: When women enter their early to mid 40’s, they typically stop ovulating, but continue to have periods. This lack of ovulation usually causes a significant drop in progesterone levels and can lead to many unwanted symptoms of perimenopause. Taking oral, bioidentical, sustained-release progesterone is a simple, but effective way to help deal with many of the unwanted symptoms. We typically start a patient on 100 mg of sustained-release Progesterone and they can increase to 200 mg later if needed. Some women may even need to cycle the progesterone dose. For example, taking 100 mg (1 capsule) from Day 1 to Day 13 of the cycle and then increase to 200 mg (2 capsules), from Day 14 back to the period.
PYHP 111 Full Transcript:
Dr. Maki: Hello everyone. Thank you for joining us for another episode of the Progress You Health podcast. I’m Dr. Maki.
Dr. Davidson: And I’m Dr. Davidson.
Dr. Maki: We mentioned in the last couple of times on the podcast, you actually have a book coming out, The Perimenopause Plan. It should be out probably within the next, I would say, probably the next couple of weeks to the next month or so.
Dr. Davidson: Depending on when we post this podcast. It’s all written. It’s just having a little bit of issue trying to make it look pretty- the design process.
Dr. Maki: Yeah. It should be fun. We’re excited about. It’s going to be published in Amazon as an e-book. Perimenopause is something that we deal with all the time and it was definitely a- I know you like to write. You’ve always been the writer. That’s always been your forte for the most part so we’re definitely excited about that. We’ll keep you up to date on that. Now, diving in, we have again more questions. We just have lots and lots of them. So, hopefully, if everyone keeps sending us emails with their questions that I’m assuming that the questions that we’re answering, people are finding some value or enjoying the questions because we just keep getting more of those. So, hopefully, it’s not getting stale or we don’t want to be boring anybody with what we’re talking about. It is very specific. You definitely have to be having some hormonal challenges. This is certainly not a podcast for men by any means. But we know that this kind of information is really hard to find on the internet which is the whole genesis behind the podcast in the first place. So, this is Amanda. I want you to go ahead and read the question.
Dr. Davidson: Okay. So, this question is from “Amanda” because like we always say we change everybody’s names just to try to keep the personal stuff and all that jazz to a minimum. So, this is from “Amanda”. So, Amanda says, “I’m 41. I have regular periods every 35 days. I have some anxiety, tiredness, stress, but I do work a lot. I don’t have trouble sleeping, but my doctor checked my serum progesterone level, and at day 21, it was .5. She said it was low. She had prescribed me oral 200 milligrams a day of compounded progesterone. I work at a job that requires 24-hour shifts twice a week. I’m trying to verse myself in information about this replacement therapy and if this is the right way for me to take progesterone therapy. She told me to just not take it on the days that I work, but I’m concerned with things that I read about replacement therapy and increased mood issues and anxiety. I don’t think I could deal with those any worse than I have than what I have. Can you please tell me if I’m on the right path as I’m scared to begin this therapy? Thanks, Amanda.”
Dr. Maki: A couple of things. So, she works two 24-hour shifts a week. I’m not sure what that is, but that sounds awful.
Dr. Davidson: Well, depends on what it is.
Dr. Maki: Yeah well, it certainly depends on what it is but two 24-hour shifts a week? I mean maybe two 24-hour shifts a month, but the week? That seems very taxing on her body in some respects, right? Maybe she’s a firefighter. Maybe I’m assuming in a 24-hour shift she can probably sleep, but I’ve known people- when I was in college, I used to work at a hospital and people were on call and stuff, and you’re sleeping, but you have one eye open waiting for the phone to ring. I think it was pagers back then because no one had cell phones yet because it was in the early to mid-90s. So, you’re sleeping, but you’re not really sleeping because you’re waiting to be called to something because- so I don’t know. So, you’re not sleeping all that well, plus you have the stress of a middle-of-the-night response that you have to go to just adds to the stress. I’m not sure what she’s doing for a 24-hour shift, but from my experience, I did a lot of overnight shifts. I was a little bit of a night owl back. I couldn’t sleep ever. Working the graveyard shifts in a hospital is brutal after a while.
Dr. Davidson: I couldn’t imagine a 24-hour shift, but you know me. I like my sleep. But if Amanda is, obviously, she’s on call if she’s doing a 24-hour shift, and my goodness. If she’s a firefighter, thank you for your service. We we need you, we need you. And we also need you to be healthy and happy and have energy.
Dr. Maki: And awake.
Dr. Davidson: And yes, and be awake and not have anxiety. So, we really wanted to answer this question. I’m sure a lot of you listening, may not have a 24-hour shift twice a week and being on call like Amanda, but at the same time, I really think that this question can relate to a lot of women because she’s in her early 40s and I would say I’m in my late 40s, hence the Perimenopausal Plan book is very close to my heart near and dear because I’m right in it. But Amanda very well could be in that perimenopausal phase at 41 because it can happen anywhere between the late 30s to the early 50s is that time before menopause, which is almost like a completely different aspect for menopause. Because like Amanda said, and her doctor is spot, on day 21 of her cycle is- Did you hear that little sneeze? That was Bob, our little copilot dog, that goes with us everywhere.
Dr. Maki: He’ll sleep all day, but the minute we sit down and do a podcast, of course, he has to start moving around and making a bunch of noise.
Dr. Davidson: Yeah, he wants some attention, but sorry. Just to get back to Amanda. She’s 41. Her doctor is spot on doing her blood work on day 21, which is that luteal phase of the cycle when that progesterone really should be starting to surge and it is only at .5. So, it definitely is low which is one of the first signs you see in perimenopause is that progesterone drops. The estrogen doesn’t necessarily drop which is why she’s having regular periods, but the progesterone does. And low progesterone symptoms do cause anxiety, do cause trouble- She doesn’t have any trouble sleeping but a lot of perimenopausal women have trouble staying asleep. They either wake up for hours or they wake up multiple times. So, there are other symptoms. I do think taking some progesterone might be a great deal. It might help her a lot, help Amanda a lot especially with that anxiety or if she’s feeling that negative, irritable mood or snarky and grumpy. I think it would truly help. But 200 milligrams might be a little bit much.
Dr. Maki: Especially right out of the gate. Like her first prescription, we usually start for a situation like this, based on her age, based on her lab work, based on her symptoms, we would probably start out at a hundred milligrams, maybe even depending on the woman. Maybe even 50 milligrams, and then work our way up from there. We usually don’t go any higher than 200 just like this case, 200 is about as high as you need to go, but to start a woman on 200 milligrams, this is the kind of response you would expect. You expect them to be a little bit tired.
Dr. Davidson: Wow, that’s a lot, or it’s going to make you tired which is why the doc doesn’t want her to take it on her days off.
Dr. Maki: Which I think is- When you and I are talking about this prepping, I said well, just don’t take it the days you work. I mean, that’s a reasonable explanation, but the 200-milligram component I think is a little bit- That could be easily reduced. Also to whether it’s instant release or sustained release, we always prefer to use sustained release. It doesn’t specify whether it is or isn’t. I’d like to think that it’s sustained release but we’re not really sure about that part.
Dr. Davidson: But you think about in a female cycle, the estrogen is, when you’re having your period, your estrogen and progesterone or low. The estrogen comes up the first part of your cycle. Usually, it spikes around day 12 to day 14, so you have ovulation, and we really don’t make much progesterone until post ovulation. Once you hit that day 14 and you have that ovulation, you’re going to make progesterone thereafter. So, we really only make progesterone for a half of our “monthly cycle”. Now, Amanda has a little bit longer cycles. She’s not the perfect 28-day cycle, but who is. She’s a little bit longer, day 35. So, she might be ovulating a little bit later like around day 18. But on day 21, she should have had some progesterone present. So, I would probably- Usually, what I start with menstruating females, in the beginning, is I’ll start with just having them take that progesterone. I do like the oral. I love the oral in perimenopause. Capsule is for just half of the cycle, just mimicking what would naturally when that progesterone should come up because I find that sometimes when you give a menstruating female progesterone right off the bat all month long, it tends to shorten their cycles because sometimes progesterone can cause a period. So, if you try to give Amanda progesterone all month long, she might find that her cycles get shortened to 21 to 25 days, and then, not everybody wants to have a period every 3 weeks. So, I usually start that last tap. And since she’s only 41, it’s so much easier to start low and work your way up. There is no problem with that. But when you start a little bit too high and then you start to have issues with being tired or puffy or bloated or hungry, it’s really hard to back out of that. So, I would even start her at 50 and then work up to 75, work up to a hundred, see how she’s doing.
Dr. Maki: Now, you mentioned with a menstruating female, for a menopausal female, obviously, they’re in menopause so they’re their bodies are not producing any estrogen or progesterone. The definition of perimenopause is that like you said, that lack of progesterone production usually happens after they stop ovulating which is ovulation is what instigates the release of progesterone. If the progesterone goes down, that usually means that there’s no more ovulation which is going to happen somewhere between the early-to-mid 40s in most cases. Some women maybe a little bit longer than that, but usually, that’s the time frame. The other option for a situation like this to like I said, starting it initially getting them used to the progesterone, or if you started them early and then you cycle it. So, you start them on, not early but on a lower dose, and then they can-What we’ll typically do is we’ll use a lower dose in the first half of the month, and then a higher dose the second half of the month because technically, a woman does not make any progesterone for the first 2 weeks of their cycle. That’s actually true physiology. So, giving a woman progesterone all month long in some ways is going against the grain, but women just typically seem to respond pretty well when they have progesterone the entire cycle.
Dr. Davidson: That is absolutely true. Like I said, start off with half of the cycle and then maybe work up. Like I was saying, I’m 47. Yeah, I’m perimenopause. I sure am.
Dr. Maki: Oh God.
Dr. Davidson: Stop. And just for transparency, I take progesterone all month long. I stop on my period because you don’t want to necessarily take progesterone or any hormones on your period because you want that entire uterine lining to slough off and sometimes progesterone can inhibit that if you’re taking that during your period. But I take it from day 5 to my next period.
Dr. Maki: Are you taking it today?
Dr. Davidson: I took it last night because you want to take progesterone at night. So, that’s where you work into that. Like I was saying, less is best and then you just work your way to that particular individual. I know you think I probably need more progesterone, but I find I’m a little more sensitive to it that I probably take a little bit less on average when you’re comparing other women.
Dr. Maki: I’m just teasing. I’m just teasing. Yeah, so definitely taking progesterone at night. Now, she’s working the 24-hour shifts so I’m assuming on those shifts- I’m not sure what that what her job duties entail. Hopefully, she gets to sleep because that puts a lot of strain on the adrenals and your cortisol and your insulin. Shift work like that is really, really challenging, and especially the older you get. You can do it in your teens and 20s, but you’re in your 40s trying to do shift work like that. That’s really, really, really tough, putting an extra burden on you. Now, she mentions a couple of the negative mood impacts. Now, the things that we typically use progesterone for is exactly those mood issues: anxiety, anxiousness, irritability. I know you’re irritable with me all the time.
Dr. Davidson: That’s not because of my progesterone. [laughs]
Dr. Maki: Well, no, not because of the progesterone, but we know, and we talk to patients all the time and they even say it. I’m just so irritable all the time. And it’s simple things. It’s the way their husbands breathe, and the way they chew, and just those really subtle little things.
Dr. Davidson: Now you’re really embarrassing me. [laughs]
Dr. Maki: Well, I’m not saying you. I have first-hand experience. I talk to just as many people as you do. And they all, I wouldn’t say complain. Complain is not the right word. I’m complaining about them complaining. I’m just relaying the verbiage they use and it’s all very similar from one woman to the next as far as how they feel like they have this internal, one minute, they’re fine. And then their husband or their children will do something, and they’re in a fit of rage in a second, and they feel bad about it because they can’t help this little emotional explosion they have. Progesterone helps to calm all that down. It mellows everything out. It reduces the volatility in their emotions because really when you look at the physiology- This is the interesting part. When you look at the physiology of progesterone, really, when you’re giving a woman progesterone in a case like this- Usually, let’s be honest. Women, when they’re in their 40s and 50s, they got kids, they are working. They got their big kid, the husband. They got lots of stress to deal with. So, when you give a woman progesterone, you’re really helping her adrenals catch up a little bit because there’s a pathway- We’ve talked about this on another podcast, but there’s a pathway called the pregnenolone steal where your body will divert depending on your stress level. Not sleeping at night two 24 hour shifts a week is just like increasing your stress. Your body will divert hormonal attention away from progesterone and divert it directly to cortisol because your body can’t live without cortisol, but your body can certainly function without progesterone at least, maybe not optimally, but at least can function. So automatically, your body’s not making any of it anyways, and then your body’s going to divert what little hormonal energy there is leftover to direct to cortisol, and that’s where some of the insomnia comes from. That’s where some of the midsection weight gain comes from, all because of- I wouldn’t say all because of a lack of progesterone, but that’s really where it starts.
Dr. Davidson: Exactly. So, just to back up a little bit with Amanda taking that progesterone- because progesterone will make you tired. That’s why when Dr. Maki asked me, “Did you take your progesterone?” Yes, today.
Dr. Maki: I was teasing.
Dr. Davidson: No, I didn’t take it today because we take it at night and you know that. You’re just teasing me. [laughs] But now we take the progesterone at night because it does make you a little tired. It does raise up GABA, it helps balance out cortisol, and raise up GABA for the next day, but you take it at night. So, I can understand Amanda. Taking 200 milligrams of oral progesterone, that would make you very tired.
Dr. Maki: For you, you would sleep for 2 days if you took 200 milligrams.
Dr. Davidson: I think for 2 weeks.
Dr. Maki: You are, I will say, you are fairly sensitive to progesterone because that’s where it is. It’s a very individualized thing. And the fact that she’s so tired from taking 200 milligrams, that’s a clear example that the dose needs to go down. You know, honestly, if she’s that tired from 200 milligrams, she might be fine with 50 or even 75 because she’s having such a significant response to a higher dose. Now granted, let’s be honest. 200 milligrams is pretty high, but that tends to be more of a menopausal dose as opposed to an early stage perimenopausal dose, and for a woman that has her period, typically, 200 milligrams is way too much for women that still have their period.
Dr. Davidson: So like what Amanda had written here that she did some research and found that this replacement therapy could cause more increased negative moods and more anxiety, and that’s not necessarily true, I would say, with progesterone. Hey, Google is a rabbit’s hole. We all go down it. But if anything, doing this therapy would help with the mood, would help with the anxiety, but there is a small caveat like I said, progesterone makes you tired. If you take too much of it, it can make you feel almost, like in some ways, not motivated, kind of lethargic. Sounds good, but don’t want to do it. I’m comfy right here. So that’s where you don’t want to do too much. And like Dr. Maki had mentioned, that would be maybe more, even with menopausal women, I don’t necessarily have many on that high of a dose, but maybe that’s just my patient population. Every practitioner has a different patient population. But I would say for Amanda that if she took 200 milligrams every day and then skipped it twice a week, she probably would have out of order bleeding because when you take that much progesterone and you’re not being consistent with it, it can create just like some spotting, some irregular bleeding.
Dr. Maki: Yeah. She gets a little bit of withdrawal bleeding from stopping it and now she’s setting up a whole nother issue for herself. So, yeah. I think progesterone is good. I wouldn’t be too nervous about the mood impact because we use it for positive beneficial mood impact. That’s one of the main reasons. Why we use capsules versus the cream. The creams do not have that brain effect that women seem to respond well to. So, I wouldn’t be worried about her. And if you have any anxiety, it’s going to also help to tone that down certainly. So, I wouldn’t be too afraid about that. I would just, maybe go back to your practitioner and have them adjust the dose just to get acclimated like you said. Maybe just start with 50 milligrams.
Dr. Davidson: Start with 50 milligrams. It’s a great way and work your way up. And for Amanda, because I can understand if she’s on call and she has to drive a truck or a car, or have to be like in all her brain cells or working on par, on point if she was on a 50 milligram progesterone, she could skip that a couple of days of the week and not get any withdrawal bleeding.
Dr. Maki: Yeah, because it’s definitely more of an appropriate range. So, yeah. This was a good one. I’m a little bit empathetic for Amanda’s 24-hour shifts. Hopefully, she does get to sleep. Hopefully, it’s not too crazy. I can’t imagine what that is. But I can only think of either working in a hospital or being a firefighter. I’m sure there’s lots of other shift work that are out there. I actually had one patient a long time ago that used to work at an oil refinery. And the people that make- This is just a segue, a little tangent. But the people that determine the schedules for these jobs- This guy worked at an oil refinery in Southern California. I think Carson or something like that. He worked from 3 o’clock in the morning till 3 o’clock in the afternoon. That was the morning shift. And then they had a 3 o’clock in the afternoon till 3 o’clock in the morning. Those are- You couldn’t have designed a worse schedule for somebody because no matter what, whatever shift he’s on he’s up during the middle of the night, no matter what shift he’s on. Of course, his main complaint when he came to see me was fatigue. He was tired. He was like, you’ve been doing it for like 25 years, and he was just literally exhausted all the time. But literally, you could not pick any worse of a schedule. Maybe you could tweak that a little bit, but 3 o’clock in the morning till 3 o’clock in the afternoon, 3 o’clock in the afternoon till 3 o’clock in the morning, he’s never getting a night’s sleep from dark till dawn ever for 25 years. All right. Honestly, some of these companies, they should be consulting with people that understand circadian rhythm, and a way to understand that you’re not going against the hormonal grain, because honestly, there is research to show people that do shift work, their life expectancy goes down. It’s not necessarily great from a cortisol perspective to be going against that hormonal grain all the time. A little bit, once in a while, no problem, but on a schedule like what he had, oh God, I just felt bad for that guy. And I think that we moved and drifted apart, and I think eventually he retired shortly thereafter. Thank God.
I had another, gentleman patient that worked at a children’s detention center, and his was night shift. And he did that for probably 20 years. I’m not sure if he’s a counselor, a security guard or exactly what he was but his shift for literally, for 2 decades, was to work at night. He finally retired this last March right before the pandemic started. And without doing anything different except sleeping, he lost like 14 pounds from just starting to sleep. That’s why when we’re working with someone, the first month that we were working with a new patient, the first thing we focus on is getting them to sleep better, not partially for that reason, but just for making sure those hormones are heading in the right direction. Just a little tangent there…
Dr. Davidson: We love your tangents.
Dr. Maki: Well, maybe not, but hopefully…
Dr. Davidson: Your tangents are fun.
Dr. Maki: …hopefully you’re not too irritated with me right now.
Dr. Davison: Never. You’re the biggest sweetie pie there ever was.
Dr. Maki: Oh, you don’t say that when we’re not being recorded, that’s for sure. So again, if you have any more questions, please reach, firstname.lastname@example.org. Dr. Davidson, do you have any more comments or anything to say about Amanda?
Dr. Davidson: No. Thank you for writing, Amanda, and we appreciate whatever shifts you’re doing because we know it’s probably important.
Dr. Maki: I’m sure it’s very important. So, until next time. I’m Dr. Maki.
Dr. Davidson: And I’m Dr. Davidson.
Dr. Maki: Take care. Bye bye.