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.