When adding transdermal natural progesterone for a woman already on estrogen (ERT) or on estrogen plus a progestin (HRT):
I. Perimenopausal woman whose doctor is prescribing estrogen
There is no reason to give estrogen of any sort to a woman who is still having menstrual bleeding. The fact of menstrual bleeding means she is not deficient in estrogen. However, her periods may be irregular due to progesterone deficiency. She should taper down her doctor's estrogen and start using progesterone cream (like Pro-Gest, etc.), one ounce used up from day 12 to day 26, counting day 1 as the first day of her previous period.
If bleeding starts before day 26, she should stop the progesterone and start counting up to day 12 again, and then start the progesterone again as directed above. It may take three cycles before she achieves synchrony with her normal cycle.
II. Postmenopausal woman on ERT
Since progesterone replacement in women deficient in progesterone may initially (and temporarily) increase the sensitivity of estrogen receptors, she should immediately reduce her estrogen dose by one-half (50%) when starting with progesterone.. She can do this several ways. If the estrogen dose is a pill that can be broken in half, the process is simple. If the estrogen prescription is a capsule not easily broken in halves (such as Premarin), she can take one every other day. That will achieve the same reduction goal.
Estrogen and progesterone can be used together during a three-week or 24-25 day time period each month, leaving 5-7 days each month without either hormone . The estrogen dose should be low enough so monthly bleeding does not occur but it should be high enough to prevent vaginal dryness and/or hot flashes. The usual dose of progesterone is one-half of a jar (one ounce) each month, the cream being applied to the palms of the hands, the face and neck, the upper chest and breasts, the inside of the arms, and behind the knees. Rotating among the various sites will maximize absorption. The size of the "gob" to use will become apparent as one proceeds through each monthly cycle.
Every 2-3 months, the woman can experiment with lowering the estrogen dosage even further until she finds the lowest dose the prevents vaginal dryness and/or hot flashes. Since postmenopausal women continue to make estrogen (primarily in their body fat), many women find that estrogen supplementation can be eliminated altogether 5-6 months after starting the progesterone. The presence of the progesterone makes estrogen receptors more sensitive such that her own (endogenous) estrogen is sufficient. In this process of lowering her estrogen dose, the patient may have to request her doctor to prescribe smaller dose pills or capsules since some are difficult or impossible to break into halves or quarters.
If the woman is using Estraderm patches, she should know they come in two dosages. Generally, both dosages are too high; my patients experienced breast fullness and tenderness, and water retention, even when using the lower dose patch. Some of my patients cut a hole (slightly smaller than a dime) in a broad piece of tape which they applied to the skin under the patch. This reduced the skin area exposed to the estrogen in the patch but some of the patients developed skin irritation from the tape they had used. In those cases, I changed their prescription to an oral estrogen such as Estrace (oral estradiol coming in a variety of dosage strengths) while they proceeded with decreasing doses over time.
III. Postmenopausal woman on HRT (estrogen plus progestin such as Provera)
In these cases, I recommend that the Provera be immediately stopped when transdermal natural progesterone is added. I have found no ill effects in stopping Provera abruptly. Here again, the eventual progesterone dose will usually be found to be one-half of a 2-oz jar used up during a 3-week or 24-25 day time period. However, since such women have usually been deficient in progesterone for many years, and since the progesterone she is absorbing is fat-soluble, much of it will be initially "lost" into her body fat. For these women, I usually recommend using a full 2-oz jar each month for the first 1-2 months to compensate for the progesterone being stored in body fat. By the third month, she can usually reduce to one ounce per month since her fat-stored progesterone has reached phsiologic equilibrium and will not be storing more progesterone as it did the first several months.
As in situation II above, estrogen should be tapered more slowly. An abrupt reduction in estrogen can trigger resumption of hot flashes or vaginal dryness. These symptoms can be prevented by lowering the dose more gradually. I usually recommend reducing the dose by 50% when starting with the progesterone. Then, every 2-3 months, she can try reducing that dose by 50% again. This process can be continued until she has arrived at the lowest estrogen dose that prevents vaginal dryness and/or hot flashes. As above, she may discover that her own (endogenous) estrogen production is sufficient for the need, and supplemental estrogen may then be discontinued.
In general, postmenopausal estrogen production is about 40-50% of pre-menopausal production. When estrogen receptor sensitivity is returned to normal by the presence of progesterone, the postmenopausal estrogen production is often found to be sufficient. As time goes on, the endogenous estrogen production may continue to decrease slowly and the woman will find that vaginal dryness may eventually occur. This would indicate a need for low-dose estrogen supplementation such as vaginal Premarin or estriol (which is especially good for vaginal dryness).
IV. Benefit of phytoestrogens.
Plant-based diets and certain herbs are rich with phytoestrogens (compounds in plants with estrogenic effects) that often suffice for prevention of vaginal dryness or hot flashes in postmenopausal woman. Thus, proper diet or herb supplements often make prescription estrogen unnecessary.