Alvin Pettle, M.D., FRCS(C) (OBS & GYN)


During the mid to late 40's, patients usually develop irregular periods and many symptoms that are secondary to the loss of progesterone. They develop cramps, migraines, mood swings and fibrocystic breasts, all secondary to the fact that they have unopposed estrogen and very often during those cycles they do not have enough progesterone to counter-balance that estrogen.


In fact, nature works always in balance. It always balances having estrogen in the first half of the cycle and the progesterone along the second half of the cycle, after the receptor sites have been prepared by the estrogen. Many patients suffer untoward symptoms because during the mid and late 40's of their age, they simply do not have enough progesterone to counter-balance their own estrogen.



This also happens at different ages when patients suffer from PMS, for in truth PMS starts off as a physiological event whereby estrogen stimulation causes a panic in the adrenals and the adrenals pour out more adrenaline and noradrenaline, which causes the patients to have irritability, anxiety and water retention symptoms of PMS.


It is the use of natural progesterone that was first suggested by Dr. Katherine Dalton that is the true beginning of the treatment of PMS. I have been successfully treating PMS with the use of natural progesterone cream using it as a transdermal cream, rather than the vaginal applications that were first suggested by Dr. Katherine Dalton. I feel, as Dr. John Lee feels, that natural progesterone is best provided to the body using the transdermal route. Certainly one does not have to swallow progesterone to be effective, and as a matter of fact, swallowing progesterone usually produces a first pass through the liver and the liver does indeed take 77-80% of the progesterone out of the system. This is why patients have to take large doses of progesterone in order to get an effective amount of progesterone in the blood stream. This is good therapy since, it usually is natural progesterone that we're using orally, but it does have to be provided in higher doses and therefore the patient usually has to take oral progesterone at night, since high doses of oral progesterone are usually sedative. This is not always a bad thing if the patient has insomnia, so you do have two choices; one to give the natural progesterone orally or you can use a transdermal progesterone.


One of the biggest debates about natural progesterone and perhaps one of the downfalls of natural progesterone has been the debate between whether or not wild yam, which is the usual precursor source of the natural progesterone, is truly enough -- or do we need to give progesterone produced from wild yam. Many patients do take wild yam by allopathic physicians and have not been found to provide the amount of progesterone in the blood stream that is usually necessary to protect the patient physiologically. I personally found that using the actual progesterone is far more effective than using wild yam cream. In fact, I now write prescriptions for natural progesterone that is made in the pharmacy. However, this natural progesterone does have its source from wild yam and certainly we have two advantages of having the prescription written through the pharmacy, in that: one, you know exactly the amount of the progesterone in the written prescription, and two, you can adjust the amounts of progesterone both up and down depending on the patient's symptoms. (York Downs Pharmacy, Toronto (1-800-564-5020)


I have found that using a 3% progesterone cream ΒΌ tsp. twice a day has been the most effective method of starting therapy, both for PMS and for menopausal symptoms. I realize this is a higher dose than first suggested by Dr. Lee in the United States, but I've found that the 3% progesterone cream has served me very well in my practice. The 3% progesterone cream provides approximately 30 mg. of progesterone transdermally on each application, provided that you give 1/4 tsp. of cream at each given dose. Some pharmacies have used syringes; in this case, they allocate the amount of 30 mg. into the dose and give instructions to the patient to use one or two given lines on the syringe, and many patients have found that to be a very effective method of application, rather than using a jar of cream.


PMS patients do very well if the progesterone is given to them before the rise of estrogen. I usually ask them to apply the 3% progesterone twice a day starting approximately day 10 to 12 of their cycle and using the progesterone cream up until the day of menstruation commencement. Some people who suffer from severe migraines with the PMS do very well if they use the progesterone cream right into the first day of the menses. Patients who are trying to conceive, but feel that they would benefit from the natural progesterone cream, are usually asked to take the progesterone cream later in the cycle, approximately day 14 or day 15 of the cycle.


Menopausal patients who do not have a menstrual flow are asked to use the progesterone cream every day of the calendar month except for the first 5 days of the calendar month, allowing them the time to clean off their receptor sites and the progesterone seems to be more effective once they do take the 5 days off. Some patients, however, enjoy the use of the cream so much that they are very reluctant to stop during those 5 days. In fact, the progesterone cream helps them sleep at night. It improves their libido, and it certainly makes the menopausal flushes a thing of the past.


I do agree with Dr. John Lee's statement that approximately 2 out of 3 patients can be treated for their menopausal flushes with progesterone alone. The other third of the patients who require added estrogen are best served if they use a natural estrogen from a soy base, and one of the ones that we'll talk about in another morning session will be the use of Tri-Est as a natural hormonal replacement for estrogen. Tri-Est is 80% estriol, by far the safest estrogen and perhaps the most protective estrogen from breast cancer, and this estrogen is placed together with 10% estradiol and 10% estrone, which are the two most potent estrogens that are used in allopathic medications in 100% concentrations.


The fascinating thing about natural progesterone is that it has been forgotten by gynecologists for many years. In fact, when I carried out hysterectomies on patients, 15 to 20 years ago, I would place patients on estrogen alone and forget about the fact that progesterone had always protected not only the uterus but also it protected the breasts and the bones of the patient. I now have every patient who has had a hysterectomy on not only just natural estrogen, but they certainly are given natural progesterone, and in some cases, they are given only natural progesterone, especially patients who have a contraindication to estrogen, such as a past history of breast cancer or a family history of breast cancer.

"There are so many advantages of using natural progesterone in the ability to manage the patients peri-menopausal symptoms that, as a gynecologist for 25 years, I now have found over the last five years that there is not a gynecological condition that does not improve with the proper use of natural progesterone. "


I am now documenting cases of patients who are on progesterone alone, whose bone densities have improved dramatically during the use of natural progesterone. It has not worked in every case, but certainly allopathic medication hasn't worked in every case for osteoporosis as well. I hope to publish the results of the use of natural progesterone and the prevention and treatment of osteoporosis.


The other major issue regarding the use of natural progesterone is whether it is safe to use in patients with previous histories of breast cancer. I now have patients who are taking natural progesterone and have had tremendous relief of the symptoms of menopause, such as dry vagina, dyspareunia and insomnia, and these patients are extremely thankful for the use of natural progesterone. I do follow their blood levels of estradiol and estrone to make certain that these levels are not increasing with the use of natural progesterone. Natural progesterone is a 21 carbon steroid and, theoretically, could be transformed into natural estrogen within the body cascade of hormones. This is a very new field of endeavor. To say the patient is fully aware of the pros and cons of the use of the hormonal substance, I have found that the decision that is made between patient and physician is usually a well thought out decision and that both the physician and the patient should feel comfortable with the final decision.


Another one of the fascinating uses of natural progesterone is to help benefit the libido. As you may know, the libido seems to be driven by testosterone in women far more than we ever thought in the past. The progesterone being a 21carbon product, can provide a precursor to make the 19-carbon product of testosterone within the body's mechanism. However, if the progesterone does not provide enough of an increase in libido, the patients are now very comfortable with the use of transsexual testosterone and perhaps that will be the topic of our third session.


The mechanism of action of the progesterone is, basically, once the transdermal cream is placed onto the skin, the progesterone then usually peaks between two to three hours and is worn off by twelve hours. That is why progesterone is used twice a day and allows for the patient to have the full effect of the progesterone throughout those 12 hours.


During future diaries, I will elaborate even more on the use of natural progesterone and how it combines with the use of natural Tri-Est and the use of natural testosterone. I do, at this time, have to reiterate that we are not talking about synthetic progesterone here. We are talking about natural progesterone.


Allopathic physicians have continued to use drugs such as Provera, Medroxy-Progesterone, which are synthetic and certainly foreign to the human body. Although they are necessary to be used when given an allopathic drug such as hormonal replacement therapy, the patients are still not receiving natural progesterone. The only effects that Provera truly provides are to counterbalance the estrogenic effect on the uterus.


The synthetic progesterone does not provide a protection for the bone, and in fact, decreases the lipid protection of the estrogen therapy, as was seen in the P.E.P.I. trial. At the present time, I am trying to convince my medical colleagues to use more natural progesterone when they are using their hormonal replacement therapy. If the physiology is truly understood, then natural progesterone would certainly be better received by the patient's body than a synthetic progesterone.


There are so many advantages of using natural progesterone in the ability to manage the patients peri-menopausal symptoms that, as a gynecologist for 25 years, I now have found over the last five years that there is not a gynecological condition that does not improve with the proper use of natural progesterone.


My hope is to put out a short letter like this one each and every month on topics that will be both relevant and interesting to patients throughout the world. Next month, we will talk about the use of natural estrogen in the form of Tri-Est.


During this time, as always, please take care of each other.