Guest Post by Jerilynn C. Prior, Centre for Menstrual Cycle and Ovulation Research

I just read “The Estrogen Dilemma” in Sunday’s New York Times Magazine,  and I feel like weeping—in sorrow and deep sadness. This article by Cynthia Gorney is about energetic, intelligent women who feel they must take estrogen in order to survive perimenopause yet have deep worries about its risks. I know personally the anguishing changes that erupt during perimenopause. “The Estrogen Dilemma” also evoked my frustration and even rage. It is wrong that symptomatic women in the midst of the long and stormy midlife transition have to face a conundrum—to take estrogen or not. It arises from a Nixonian-style cover-up of three proven and important-for-women truths: 1)    Perimenopause causes higher and not lower estrogen levels. (By perimenopause I mean the transition from fertile menstrual cycles to menopause, or the life phase beginning one year beyond the final menstrual flow.) 2)    Progesterone, estrogen’s essential partner hormone, in contrast to estrogen, truly is lower in perimenopause. 3)    Women survive perimenopause and “graduate” into a less symptomatic menopause.

Are estrogen levels low in perimenopause? No. Taking all perimenopausal women together (a meta-analysis of published levels comparing within-center young with perimenopausal women) estrogen levels are 26 percent higher (1). For symptomatic perimenopausal women like Cynthia Gormley and myself, estrogen swings to Everest-like peaks and may intermittently be a 1000-fold greater. Perimenopause, for some of us, is estrogen’s storm season (2).

Despite that, ever since estrogen was first discovered in 1926, anything ailing women has been deemed “estrogen deficiency.” And often inappropriately so treated. Thus, estrogen levels must be dropping and low in perimenopause when women become symptomatic—it makes sense because we know that perimenopausal women are running out of their store of ovarian follicles that, after all, make estrogen. That perimenopause-dropping-estrogen idea fits with the fact that perimenopausal women begin to have night sweats. But it doesn’t fit with the reality that night sweats begin while women are still having regular menstrual cycles (3) and thus still have adequate estrogen levels (but the misunderstanding of what causes hot flushes is yet another story).

The evidence that perimenopausal estrogen levels are higher than in the sexiest 20-something is strong and consistent (1;4-9). Why are media articles, consensus documents and authorized definitions still talking about dropping estrogen levels? A cover-up. The first clear evidence for higher estrogen was published from a Melbourne epidemiology study in 1995 (10). The back-story here is telling—the authors measured estrogen levels that were variable but at least a quarter of them were much higher than expected. However, their interpretation was that estrogen levels were dropping. That’s because levels in the 45-55 year old women with regular cycles (whom they wrongly called premenopausal) were higher than in those who’d been without flow for three to 12 months (10). That illustrates the power of what I call “the estrogen myth.” I, who at the time was suffering with puzzling sore breasts, heavy but regular flow and mood swings, was ecstatic to see data that explained my experiences. However, I was horrified at the erroneous interpretation—my colleagues and I wrote an impassioned letter to the editor demanding that the authors “let the data speak” (11).

Now to the second cover-up—lower perimenopausal progesterone. If this were a world where women’s health was guided by science rather than by power-over-women, we would all know that perimenopause, besides being a time of higher estrogen, is a life phase in which progesterone is too low. You ask, “Why are lower progesterone levels important? I thought it causes PMS and breast cancer.” This ignoring or blaming of progesterone is the second major cover-up, and not just for 15 years, but since estrogen’s discovery in the 1920s. Framing women’s reproduction only in terms of estrogen creates the postulate that “Estrogen’s what makes a girl, a girl.” The estrogen myth further asserts that estrogen is the female hormone, much as testosterone is the only important male hormone.

Progesterone, however, is the second essential hormone for women, one that makes egg implantation and pregnancy possible. But progesterone’s job is much bigger than that—progesterone halts the exuberant growth that estrogen stimulates (12), and counterbalances and complements estrogen’s actions in every tissue of our bodies. If women’s health is a jetliner and one wing is estrogen, progesterone is the other wing. Women’s health literally doesn’t fly without both estrogen and progesterone.

You haven’t heard about progesterone’s essential role in women’s health because of the power-driven “estrogen myth.” As Susan Baxter and I wrote in The Estrogen Errors—Why Progesterone is Better for Women’s Health (13), there is a broad and consistent conspiracy to frame estrogen as the source of women’s allure and youthful health. The manufacturers of Premarin (the popular conjugated horse estrogen prescribed for and taken by millions of women) have cleverly crafted this erroneous notion by slogans such as  “estrogen deficiency” and “hormone replacement therapy,” and by their support for North American academic gynecology. It isn’t rational, but gynecologists love estrogen (14); their backlash after the Women’s Health Initiative results is further evidence of both the love affair and its illogic.

There is increasing evidence that, in order to be well, women need both progesterone and estrogen throughout most of 30-40 years of menstruating life. With enough estrogen but not enough progesterone, there is increased risk for rapid bone loss and risk for osteoporosis and fractures, breast and endometrial cancer as well as heart disease. So I say, “If estrogen’s what makes a girl, a girl, then, Progesterone with estrogen is what makes a girl, a woman.”

But are there practical reasons for symptomatic women in perimenopause to be aware that their progesterone levels are low? I think so. When I began jolting awake every night in a wringing sweat, taking oral micronized progesterone (bio-identical and sold as FDA-approved, Prometrium®) saved me. It made sense—if estrogen’s too high and progesterone’s too low—take what’s deficient. It is now proven that 300 mg of oral micronized progesterone at bedtime decreases sleep disruption, improves refreshing rapid eye movement sleep and doesn’t cause a foggy mind the next morning (15). There is also reason to believe that progesterone, like medroxyprogesterone (16) will help hot flushes and night sweats. It is important, however, to realize that no drug has been proven effective for perimenopausal vasomotor symptoms in randomized controlled trials. Oral contraceptives were not effective (17) and no study has shown that estrogen works.

Progesterone, based on my clinical and personal experience (2), helps sore breasts, clots and flooding cycles, irritability and also the risk for endometrial cancer (18). Furthermore, I believe it will help women currently using estrogen who wish to stop.

Which brings us to the final cover-up—the fact that we recover from perimenopause. This reality is lost on women when the powers that be blend and conflate the terms “perimenopause” and “menopause,” as did the call-out definition in this article. Furthermore menopause is equated with a supposedly dreadful “estrogen deficiency” when, in reality, low estrogen and progesterone levels are normal for that part of our lives (19). Gail Greendale, a Californian scientist like Roberta Brinton whom Cynthia Gormley interviewed, has shown that we even recover from the mind-muddle of perimenopause (20). Not that I don’t believe the women in this story felt better while taking estrogen—we all get better from perimenopause.

Over and over, women report that they are relieved to become menopausal. For most of us, life following a year after our last flow is kinder and gentler. And, if like me, you are having bad hot flushes and night sweats in menopause, at least medroxyprogesterone, by itself and without estrogen, has been proven highly effective and equivalent to estrogen (16), the hot flush gold standard. Or you, like me, could take progesterone for wicked hot flushes and night sweats, stopping once a year to see whether you still need it.

So—the “Estrogen Dilemma” poses a devil-or-deep-blue-sea kind of impossible choice for women—take estrogen (and its risks) or suffer. This is a false dichotomy. Shame on those who deny good science and perpetuate the erroneous ideas that estrogen levels are dropping in perimenopause, who ignore or blame progesterone and who “forget” to tell women that we survive perimenopause and often live many healthy, happy years in menopause. My wish is that all symptomatic perimenopausal women have access to accurate information, supportive family and friends and strong faith that you, too, will survive estrogen’s storm season (2).

Cross-posted at The Estrogen Errors blog.

Reference List

1. Prior JC. Perimenopause: The complex endocrinology of the menopausal transition. Endocr.Rev. 1998;19:397-428.
2. Prior JC. Estrogen’s Storm Season- Stories of Perimenopause. reprinted 2007ed. Vancouver, BC: CeMCOR; 2005.
3. Hale GE, Hitchcock CL, Williams LA, Vigna YM, Prior JC. Cyclicity of breast tenderness and night-time vasomotor symptoms in mid-life women: information collected using the Daily Perimenopause Diary. Climacteric. 2003;6(2):128-39.
4. Santoro N, Rosenberg J, Adel T, Skurnick JH. Characterization  of reproductive hormonal dynamics in the perimenopause. J Clin Endocrinol Metab 1996;81:4,1495-501.
5. Klein NA, Illingworth PJ, Groome NP, McNeilly AS, Battaglia AS, Soules MR. Decreased inhibin B secretion is associated with the monotropic FSH rise in older, ovulatory women: A study of serum and follicular fluid levels of dimeric inhibin A and B in spontaneous menstrual cycles. J Clin Endocrinol Metab 1996;81:7:2742-5.
6. Hale GE, Zhao X, Hughes CL, Burger HG, Robertson DM, Fraser IS. Endocrine features of menstrual cycles in middle and late reproductive age and the menopausal transition classified according to the Staging of Reproductive Aging Workshop (STRAW) staging system. J Clin.Endocrinol.Metab 2007;92(8):3060-7.
7. Seifert-Klauss V, link TM, heumann C, Luppa P, Haseitl M, Rattenhuber J et al. Influence of pattern on menopausal transition on the amount of trabecular bone loss. Results from a 6-year prospective longitudinal study. Maturitas 2006;55:317-24.
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9. O’Connor KA, Ferrell RJ, Brindle E, Shofer J, Holman DJ, Miller RC et al. Total and Unopposed Estrogen Exposure across Stages of the Transition to Menopause. Cancer Epidemiol.Biomarkers Prev. 2009;18(3):828-36.
10. Burger HG, Dudley EC, Hopper JL, Shelley JM, Green A, Smith A et al. The endocrinology of the menopausal transition: a cross-sectional study of a population-based sample. J Clin Endocrinol Metab 1995;80:3537-45.
11. Prior JC, Barr SI, Vigna YM. The controversial endocrinology of the menopausal transition (letter). J Clin Endocrinol Metab 1996;81:3127-8.
12. Clarke CL, Sutherland RL. Progestin regulation of cellular proliferation. Endocr.Rev. 1990;11:266-301.
13. Baxter S, Prior JC. The Estrogen Errors: Why Progesterone is Better For Women’s Health. Westport: Praeger Publishers; 2009.
14. Fugh-Berman A, Scialli AR. Gynecologists and estrogen: an affair of the heart. Perspect.Biol.Med 2006;49(1):115-30.
15. Schussler P, Kluge M, Yassouridis A, Dresler M, Held K, Zihl J et al. Progesterone reduces wakefulness in sleep EEG and has no effect on cognition in healthy postmenopausal women. Psychoneuroendocr. 2008;33(8):1124-31.
16. Prior JC, Nielsen JD, Hitchcock CL, Williams LA, Vigna YM, Dean CB. Medroxyprogesterone and conjugated oestrogen are equivalent for hot flushes: a 1-year randomized double-blind trial following premenopausal ovariectomy. Clin.Sci.(Lond) 2007;112(10):517-25.
17. Casper RF, Dodin S, Reid RL, Study Investigators. The effect of 20 ug ethinyl estradiol/1 mg norethindrone acetate (MinestrinTM), a low-dose oral contraceptive, on vaginal bleeding patterns, hot flashes, and quality of life in symptomatic perimenopausal women. Menopause 1997;4:139-47.
18. Hale GE, Hughes CL, Cline JM. Endometrial cancer: hormonal factors, the perimenopausal “window of risk”, and isoflavones. J Clin Endocrinol Metab 2002;87:3-15.
19. Prior JC. One voice on menopause. J.Am.Med.Women Assoc. 1994;49:27-9.
20. Greendale GA, Huang MH, Wight RG, Seeman T, Luetters C, Avis NE et al. Effects of the menopause transition and hormone use on cognitive performance in midlife women. Neurology 2009;72(21):1850-7.