PMDD Wars: Progesterone vs. Progestins: Part 1, Progestins

There are many controversies surrounding PMDD, and one of the biggest is the use of progestins and progesterone to help mitigate the symptoms.  I think someone out there must be marketing progesterone for PMDD pretty heavily, because of all of the questions I'm getting on the subject.  So I'm going to back up and start at the very beginning, assuming you know nothing about progesterone and progestins, like I did when I first started researching this topic. 

First of all, we are talking about two different things.  Progesterone and progestins are not the same.  Progesterone is produced naturally in your body; progestins are synthesized to mimic what progesterone does for your body.  It's important that you do not confuse the two, and when reading articles or advertisements or results of clinical studies on hormones, it's important that you know which one they are talking about--natural progesterone, plant-based progesterone, or synthetic progestins, also called progestogens.  

Somehow it all gets lumped into being called "progesterone", and I think this is a big part of where our confusion as consumers comes from.

So:

Progesterone is what your body makes naturally

Bio-identical progesterone - a synthetic progesterone made from plant sources that is biochemically similar to those produced by the body

Progestins  - synthetic progesterone-like chemicals structurally different from what your body makes

Progestogens - synthetic progesterone-like chemicals structurally different from what your body makes

If you read nothing else of this post, please make sure you learn the above distinctions.

Because of the enormous amount of information on progestins alone, I will not get to the information on what is termed bio-identical progesterone today.  If that's all you want to read about, you will have to wait for a different post, but in the meantime I do encourage you to keep reading, as what follows may answer some of your questions, and may help to explain why you feel the way you do.  

Now, back to the basics:

Progesterone is a hormone naturally secreted by the ovary in the second two weeks of a woman's menstrual cycle.  Both bio-identical progesterone (synthesized from plant sources) and progestins (synthesized from chemicals) can also be taken in pill form, the latter by women taking birth control pills and hormone replacement therapy pills.  Progestins can also be used to induce a menstrual period in the case of stopped menstrual periods, or to regulate abnormal bleeding in the case of heavy blood flow problems.  Progesterone is also used in high doses for women with infertility problems and to prevent miscarriages.

There are several different kinds of progesterone being marketed today.  Today's post is about  progestins, the synthetic progesterone-like chemicals (also called progestogens) which bind to the body's progesterone receptors and function, for the most part, just like progesterone.  But because they are chemically different from our own natural progesterone, they have side effects.

Progestins were originally developed because they could be absorbed into the blood when ingested in pill form--this was before the development of micronized progesterone capsules. 

Progestins are only available via a prescription. You find progestins in birth control pills, also called oral contraceptives.  There are two main types of birth control pills: combination pills and progestin-only pills.  Most pills are available in both a 21-day or a 28-day pack, with the 28-day pack containing 7 placebos, or inactive pills, taken on the days you would normally have a menstrual period.  Combination pills are the most popular, due to the well-published side effects of synthesized estrogen-only therapies, and contain both synthesized estrogen and progestin. 

However, all combination pills raise the risk of heart attacks, stroke, and blood clots.  That risk rises if you are either smoker or over the age of 35.  Other factors, such as being obese or having a family history of heart disease make these blood clots more likely, therefore the FDA advises women against taking any combination birth control pills if you have a history of blood clots, heart attack, or stroke. 

One type of birth control pills carries a higher risk of deep vein thrombosis or pulmonary embolism (blood clots that start in a leg vein and travel to the lungs) than others.  Those are the pills that contain the ingredient drospireone and include Beyaz, Gianvi, Lornay Ocella Safyral, Yasmin, Yaz, and Zarah.  According to a post in the blog re: Cycling, as of April, 2012, pharmaceutical giant Bayer (makers of Beyaz, Yasmin, and Yaz) faced 11,300 lawsuits from women who have been seriously injured and family members of women who have died after taking Yaz or Yasmin.  In December of 2012 the company reported they settled the first 3500 cases with a total of $750 million in payouts.  As of this date, the latest case filed, November 28, 2012, is from a woman in Oklahoma who took Yaz for only two months, ten years ago, and developed deep vein thrombosis.

That said, the following side effects, usually severe or sudden, may be caused by blood clots:

Headache or migraine

Loss of or change in speech, coordination, or vision

Numbness or pain in chest, arm, or leg

Unexplained shortness of breath

 More common side effects of progestins include:

Changes in vaginal bleeding

Light bleeding or spotting between withdrawal bleeds

Symptoms of blood sugar problems (Dry mouth, frequent urination, loss of appetite, or unusual thirst)

Mental depression

Nausea

Skin rash

Unexpected or increased flow of breast milk

Abdominal pain or cramping

Breast tenderness

Bloating or swelling of ankles or feet

Blood pressure increase

Dizziness

Headache

Mood changes

Nervousness

Unusual or rapid weight gain

Acne

Brown spots on exposed skin

Hot flashes

Loss or gain of body, facial, or scalp hair

Loss of sexual desire

Trouble sleeping

Certain doses of progestins may also cause a temporary thinning of your bones, which is a factor in developing osteoporosis, but on the other hand, it has been found that progestins *may* offer some protection against osteoporosis in postmenopausal women.  Smoking, drinking alcohol, and taking or drinking caffeine can also thin your bones, so be aware of the added stress you may be placing on your bones by taking progestins.

Progestin-only pills (also called the mini-pill) are most commonly used by nursing mothers, women at risk for blood clots, and other conditions that prevent them from taking estrogen.

Combination birth control pills come in different phases, depending on whether the level of hormones in the pills changes throughout the month.  Monophasic (one phase) pills contain the same amount of estrogen and progestin in all of the active pills.  Two-phase pills change the level of hormones once during the menstrual cycle.  Three-phase pills change the levels of hormones every seven days during the first three weeks of pills.  Then you have the inactive pills for the fourth week, which is when you get what is called a withdrawal bleed.  It's not to be confused with a period.  You bleed, but you don't have a true period.  You can't, because you didn't ovulate.  Four-phase pills change their hormone levels four times per cycle. 

Is it safe or healthy to skip periods?  If you aren't taking oral contraceptives, you need a period after ovulation to shed the lining that's built up in  your uterus in preparation to receive a fertilized egg.  But when you're taking birth control pills, they suppress ovulation, so no eggs are released, and therefore your uterine lining doesn't build up.  The reason you bleed is because of the week of inactive pills in your birth control packet.  And sometimes you might not bleed at all. 

I am of the opinion that it's not a good thing to chemically suppress any natural body functions, but every woman has to decide for herself.  More information on this (so that you can make your own informed decision) can be found at the blog, Sweetening the Pill.

So, in addition to regulating your menstrual cycle by suppressing ovulation, and treating women with no period (amenorrhea) in an effort to bring about a period if possible, progestins are used:

To prevent estrogen from thickening the lining of your uterus

To treat pain related to endometriosis

To help treat cancer of the breast, kidney, or uterus—as progestins can stop the growth of an estrogen-fed tumor

To help prevent anemia (low iron in blood)

and, in high doses:

To stop heavy menstrual bleeding

To help a pregnancy occur during egg donor or infertility procedures

and

To help maintain a pregnancy when not enough progesterone is made by the body to do so.

So both progesterone and progestins are tricky things:  High doses can either start or stop menstrual bleeding, and can be used to help support pregnancy, while low doses can prevent pregnancy from occurring.

However, there have been some reports that high doses of progestins during pregnancy may cause birth defects in the sex organs of a male fetus, and some progestins may cause male-like changes in a female fetus and female-like changes in a male fetus. 

Hormones are powerful things, ladies, so buyer beware.

Before taking progestins, you should also tell your doctor if you have or have had any medical issues with the following, either through your family history, or having experienced these issues yourself, as progestins may make these conditions worse:

Allergies (to medicines, food dyes, preservatives, or animals)

Asthma

Epilepsy

Heart or circulation problems

Kidney disease

Migraines

Bleeding problems

Blood clots

Breast cancer

Deep vein thrombosis

Heart attack

Liver disease

Pulmonary embolism

Stroke

Blood clots in the veins

Breast lumps or cysts

Diabetes

Memory loss

Vision changes

Note:  Just as each woman is individual in her hormonal makeup, each synthetic progestin has a different side effect profile, due to the various formulations, so it is hard to pinpoint which progestins will cause which symptoms in which women.  I'm just trying to cover all the possibilities here so that you can see where, if at all, you fit in. 

Proposed off-label uses for progestins include treating hot flashes (interesting, since they can apparently also cause hot flashes) and polycystic ovary syndrome (PCOS).  An off-label use is one that has not been approved by the FDA, but once a drug has been approved by the FDA (in this case, birth control or hormone replacement therapy) to treat a specific condition or disorder, doctors may then prescribe it as they see fit.  Much marketing is done in the area of off-label use for many drugs touted as PMDD symptom relievers, and several drug companies have been reprimanded and fined by the FDA for promoting non-approved uses of their drugs to treat these symptoms.

We'll talk more about that next time. 

The Other Side of PMDD, continued

Since I wrote that last post, and since I was PMDD-ing this week, I really paid attention to what was going on inside my head.   Thursday I was overwhelmed and angry.  Normally I love to feed people, take care of them, give them a hot meal and some home comforts.  But my partner, my son, and I had agreed it would be "fend for yourself" night on Thursday, due to different commitments.  I was therefore "supposed" to worry only about myself. 

But then they both showed up at dinnertime, hungry and neither one of them cooks.  So instead of just worrying about myself, I was suddenly in charge of a meal, and in no mood to graciously pull one together.  Instead I became like a drill sergeant...you, go set the table, you...chop those vegetables....you're in charge of the microwave....you, get us something to drink. 

Not my usual self at all, but I rose to the occasion and kept a lid on my resentments.

Even so, later on in the evening, after we'd come and gone to the Christmas show we were all trying to get to on time, I apologized to my partner for being so...well...bossy. 

He didn't mind.  He said, "You hardly ever get like that.  It's nice to see you're human."

Which got me to really thinking about PMDD and what's going on inside our heads when it happens.  Are we really screwing up, or is it our brain telling us we're screwing up when we are not, and that's what kicks off all the fights and relationship issues? 

Because you know when you're screwing up.  Everyone does.  We don't need people to tell us when we mess up.  Because we know it, inside, when we make a genuine mistake.  Pointing it out to us only makes things worse.  (And I am talking about humans here, not just PMDD women.)  We all get hurt and defensive and either go into withdrawal or denial--or come out fighting.

So here's my thought:  What if we're not really screwing up--we just think we are, and so we act accordingly...by coming out fighting?  The best defense is a good offense...that sort of thinking.

It's something to consider.  Because while I thought I was being overly bossy...he just thought I was trying to get everyone fed and out the door in time.

Fast forward to Saturday afternoon.  I am in a rage.  I know I am in a rage.  Thank goodness I am alone.  I think that is part of why I am in a rage.  I don't want to be alone.  I'm tired of working, and I want to take a break, do something fun.

But at the same time I know that if someone shows up...my partner or my son...that's not going to make me happy, either.  I know this, because in that moment, nothing can make me happy. 

So it was best that they each had something else to do for most of the day.

But meanwhile I stewed.  And anything and everything that didn't normally bother me, suddenly bothered me, big time.

By the time my partner arrived to go to church, I was angry and I. Just. Didn't. Care.

But I had spent the day "watching" myself, or practicing awareness, so I knew I was angry, and I knew there was no reason (aside from my hormones) for me to be angry, and I knew I was being irrational, and I knew I didn't want a fight.

So I asked him...Do you ever feel like you Just. Don't. Care?  You don't care whose feelings you hurt, or who you piss off, or what people think?  You've just had it, and you're just going to say and do what you want to say and do?

He said yes, he had felt like that.

I said, "Well, that's the way I feel right now."  Like I am going to say and do what I want to, and nobody better get in my way.

"I see," he said.

"I'm just warning you," I said.  "So that if I do or say something totally irrational, you don't sit there wondering 'What just happened?'"  I'm in that kind of mood."

Oh.  Okay.

And that was the extent of it.  There was no incident.  We had no argument.  We went to church, and then we rented a movie.  We had a perfectly pleasant evening. 

But I felt better letting him know what was going on inside of me, so that should I snap, he wasn't taken by surprise.

He appreciated knowing I was on the edge.  We settled into a quiet evening together.

"So you can control it?" he asked at one point.

Well...yes, and no.

I can control it up to a point.  But when the dam bursts, it bursts.  And at that point, I can't control it. 

My goal is to keep that dam from bursting.  To keep from snapping out on those closest to me. 

Because it is my goal, I am getting more and more successful at accomplishing it.

But I can tell you of a thousand times where I failed.

Try to imagine walking around with a totally irrational "Don't fuck with me" attitude going on inside your head.  Try to imagine this happening several days a month, like clockwork.  It switches on, it shuts off.  You have no control over when it does either.  All you can do is hang on and hope you (and your relationships) survive the ride.

For instance...take a totally normal exchange at the deli counter when you're in one of these moods. 

The clerk asks what I would like.  The clerk asks "sliced or shaved?".  This question totally pisses me off inside...I'm there every frigging week (not true) ordering the same damn thing (close, but also not true) so why can't they effing remember what I like?  (unreasonable expectation).    

Are you seeing how a PMDD mind works?

Meanwhile, I am smiling and politely answering, "sliced" like I do every time, and feeling like I want to punch the next person who crosses my path.

It's really not about you.  (Although it can be, so don't think you're completely off the hook).  It's about doing battle with thoughts that come out of nowhere and are sometimes voiced before you can stop them.  It's about hearing or seeing or doing something and placing the most negative context on it that you can possibly imagine.  It's about not knowing what you want or how to make it better. 

As I told my partner..."Don't even try to make me feel better right now because you literally can't.  You will not be able to win, no matter what you do."

But there are things we can do to keep it from getting worse.  Sit quietly together, watching a movie or maybe listening to music or napping or reading books.  Hug without talking.  Go for a walk.  Just be together in silence, or at least a peaceful atmosphere. 

For me, silence is best, so that I can concentrate on doing battle with the misperceptions going on inside my head.  So that I don't say something I will regret.

In short, when I am PMDD-ing, don't confuse me by asking questions, or by wanting something from me.  This is a time you either need to give to me (your love and understanding) or get the hell out of my way.

There's really no in-between.

The Other Side of PMDD

"My wife has PMDD 2 weeks each month. I can now track it on a calendar. The meanness, sharp tongue, irritability, over-sensitivity to the slightest comment...it's all there each month, like clockwork. I used to make the mistake of reacting to her negativity, which results in a showdown at the OK Corral with talks of divorce, etc., etc. Now, I just keep my mouth shut, offer my help, not reacting to the negativity. It's not easy at all. My only escape is to go to the gym when it seems everything I do is wrong in her eyes. But I bear it each month because I love my wife and I know it's not her. I say she becomes Mr. Hyde once a month for 2 weeks, and I just learn to keep my mouth shut. A big exercise in tolerance and patience. If you love your wife or special someone, tolerance and patience are vital. If you don't have them, you will suffer."

This is my most recent comment.  I thank God for Anonymous, because it allows me to print this comment in full--and use it as the subject of this post. 

This man is suffering.  My heart goes out to him.  My admiration and respect go out to him as well, because he loves his wife and refuses to let her PMDD ruin, end, or dissolve their marriage. 

What he says is true.  "If you love your wife or special someone, tolerance and patience are vital.  If you don't have them, you will suffer." 

I suspect he is talking about himself, here, but he could just as easily be talking about the both of them.  Much is made over the suffering of the non-PMDD partner in a relationship.  But let me say this -  as much as you are suffering by being the brunt of her emotions, she is suffering at least twice as much inside.  She doesn't want to be doing what she is doing.  She is often as horrified as you are by what comes out of her mouth.  Perhaps in that moment a part of her malfunctioning brain wants you to suffer as she is suffering, but overall, none of us wants to have PMDD, much less every month.

To partners like the man above, I am grateful beyond measure.  One, because you treat your PMDD woman with love and respect, and two, because writing that comment allows me to see where you are coming from, and to respond to what you see from the outside with what is happening to me on the inside.

Notice I didn't say what is happening to your PMDD woman.  That, I can not know for sure...but by explaining what happens to me, I might be able to open the door to a conversation between the two of you about what happens to her.

I'm going through an episode right now.  It started about two days ago.  I'd like to say I can pinpoint when the slide began, but I can not.  It seems like a gradual shift, a slow sinking into the darkness, as opposed to coming out of an episode, which I have literally felt in my head when my "brain" snapped back into place.  The return to sanity can be instantaneous.  The gradual slide into anger, despair, and hopelessness can take what feels like forever. 

So...while this is what you are seeing on the outside--a moody, irrational, unreasonable, emotional, maybe even rude or strangely acting woman--I'm going to tell you what's happening on the inside.  My head hurts, my body hurts, I didn't want to wake up this morning.  I feel like I have been drugged.  My mouth is dry and there is a tightness behind my eyes reminiscent of a hangover, but I have not had any alcohol.  I feel fat and smelly and ugly.  Yesterday, in the hopes of cheering myself up, I decided to organize the photos from my Trip of a Lifetime six months ago.  In every single photo I was in, I hated how I looked. 

Normally, my looks do not bother me.  At all, as I know I am loved just the way I am.  Yesterday, I was obsessed with my body image.  Couldn't find enough flaws to point out to myself. 

Okay, so that project didn't turn out.  Yesterday, I also went to a funeral.  It might not have been the best of ideas, but really, you have no choice when these things happen.  You either go or you don't go.  I felt that paying my respects was more important than hiding in my cave.  I waited until the last half hour of the viewing, so that if anything went awry, I had a natural exit.  As it turned out, there were several people there I would have loved to have stayed and talked with.  Sad circumstances, but I enjoyed seeing them all again just the same. 

The funeral itself was lovely and poignant...one of the most beautiful services I have ever attended...

But it sparked thoughts of death and dying for the rest of the day.  Who's going to go next?  How long do I have?  How many of us will be here next year?  What do I want to do with the time I have left?

This very question nearly devolved into an argument between myself and my partner last night.  Normally I am happy to let life unfold as it will.  Last night there was an urgency, an almost desperation behind my thoughts and words.  We need to do this, and we need to do that, and we need to do it NOW. 

I will feel very foolish when that feeling goes away next week.  I know this already. 

If he had argued with me instead of  patiently "listened" to me, I would have (at least mentally) declared the relationship hopeless and over.  There would have been harsh words and an explosion of tears. 

I suppose I should be happy that I'm only going to feel foolish.  Especially if he takes my dark words to heart....while I've blissfully gone back to my "It's all good" mode.

If you were my partner, wouldn't you be confused?

Another example:  Our church music minister plays guitar, has a beautiful voice, and chooses upbeat songs.  Normally I love to sing along with her.  Last night her music irritated the hell out of me.  She didn't do anything different.  I was the one who was different.

Inside.  Inside I was different.  But I never let on, not on the outside.  If I had, I'd only come off as crazy.

When we got back to the car, after a very uplifting service, I told my partner, "Right now, I could tell you what is wrong with anything.  You just name it, and I will tell you what is wrong with it."

This is where the "I can't do anything right" sentiment comes from in partners of PMDD women.

I spent most of yesterday alone, as my partner was busy elsewhere.  Even while my PMDD self was irritated beyond words at that, I was glad that he was not here, having to bear the brunt of my irrationality.  I knew, as he would have known had he been here, that there was absolutely nothing he could do right yesterday.

So it was best that he was elsewhere.  The same went for my son.  He walked in the door, aiming for a quick change of clothes, and within two minutes I was not speaking to him.  It was best for him, and for myself.  He left after giving me a big hug and telling me he loves me.  As I shut the door behind him my thoughts were, "Yeah, right."

I adore my son, and we get along great.  Anybody who knows us knows he loves me, too.  He can get manipulative, like kids do, and I let him, like Moms do, but the love is always there. 

Not yesterday.  Even though it was being freely offered, I wasn't feeling it.

Yesterday I was feeling my most unloveable.  Old, dumb, lazy, overwhelmed, uncertain, weepy, morbid, incompetent, uncaring and unkind.  In real life, I am none of those things.  If anyone had been around me yesterday...if I had not spent the day alone (except for the funeral)...I would have snapped and snarled all day.  Why? 

Because I was feeling extremely vulnerable.  I was feeling worthless, useless, and like every decision I'd ever made in my life had been wrong.

Hello?

For one, that's not even possible.  But there you go.  PMDD doesn't make sense. 

So you're walking around, feeling gross physically, mentally, and emotionally, and you just...well, you're miserable inside.  Nothing can make you happy, and nobody better try...because if they try they will fail, you'll see to that...and if they don't try....well, you'll have something to say about that, too.

It's no wonder I get letters from PMDD women who fear they will spend the rest of their lives alone.  Who can deal with someone like that?  Where nothing you do is right for days, sometimes weeks, on end.

Yesterday I could have gone on a rant like you wouldn't believe about what was wrong in my life.

Funny, I was perfectly happy with my life three days ago.  Feeling rather blessed, actually.

Okay, so this personality change is bewildering enough to watch from the outside.  Try to imagine what it feels like from the inside.  Try to imagine what it feels like when your brain feeds you lies all day long.  Nobody likes you, everybody hates you, you're nothing but a big screw-up, a slob, a loser, a bad (mom, sister, daughter, friend, wife, girlfriend - fill in the blank), you're fat, you're ugly, you're disorganized and uncoordinated and talentless, your life is a mess, even your own (fill in the blank here) doesn't like you....

You spend all your energy fighting off these lies in your head.  Another blogger, Laura, put it really well.  PMDD is a bully.  So here you are, being bullied by your PMDD.  You're feeling your worst, and at your weakest.  Someone says something to you.  Something that in your PMDD state, your brain twists around to the most negative implication possible.

What are you going to do...fight or flight?

The primitive brain has us fighting.  That's where I think my brain goes during an episode of PMDD.  Into primitive, reptilian, survival mode.  It's fight or flight, survival of the fittest, baby, and I'm going to see to it that you go down in flames.

The opposite of fighting is withdrawal.  Withdrawal into ourselves--where we let the PMDD bully run rampant inside us--and withdrawal into depression--where we accept what the PMDD bully says, and beat ourselves up even after he or she is long gone.

Try living with a bully inside your head for two weeks a month and see how long you last before you lose it one way or another.  Either through anger or tears, or both.

So yes, while it is undoubtedly hard on our partners and the friends and family who love us, keep in mind that PMDD is no picnic for the woman herself, either. 

She's doing the best she can with a temporarily malfunctioning brain.  She doesn't want to ruin your party, your weekend, your vacation, relationship, or marriage.

She just wants to feel safe, from demons neither of you can see.