Endometriosis and Your Hormones: Progesterone 101 - a podcast by Jessica Duffin

So last week we talked about oestrogen, and so today, clearly I’m going to move onto the other predominant hormone in the menstrual cycle, progesterone 

So, let’s get started.

Progesterone is famous for ‘fluffing’ up the uterine lining in the second half of your menstrual cycle, which occurs after ovulation, and this phase is called the luteal phase. 

When we say fluffing up, progesterone is essentially further preparing the uterine lining to allow for implantation of a fertilised egg, whilst halting oestrogen’s effects of  cell-proliferation which thickens the uterine lining.  If the egg is fertilised, it will begin stimulating a steady blood supply to the lining to nourish the egg, via the formation of new blood vessels and additionally will trigger the release of nutrients from glands hidden in the endometrial lining (which is just another fancy word for uterine lining). It will also prevent uterine cramping so the egg can stay nice and secure and plays an absolutely essential role in maintaining the endometrial lining and pregnancy throughout. 

Progesterone is a muscle relaxant, which is to further support pregnancy by allowing the muscles of our pelvis to open and stretch as the abdomen begins to expand with pregnancy. However, because it is a muscle relaxant, it also relaxes the intestines, which slows down intestinal motility, leading to fewer bowel movements. In people who already have gut health issues (which let’s face it, is most of us with endo) this can then lead to constipation in the second half of the cycle.

Progesterone is also immune suppressing, and this is so the immune system doesn’t reject a potential implanted egg by seeing it as a foreign invader. Coupled with elevated levels of inflammation that build from ovulation to menstruation, we might end up feeling like we have the flu if we don’t keep our immune system strong and inflammation down. This is what you may have heard of as the ‘period flu’ or ‘PMS flu’.

But, that’s not all. Progesterone plays a huge role in brain and nervous system health.

Firstly, it actually protects and repairs the fatty layer that wraps around the end of nerve fibres – these are called myelin sheaths, though remembering the name is not what’s important. What’s important is the progesterone allows these to stay intact and functioning, and these myelin sheaths support proper communication between brain neurons (otherwise known as nerve cells) which allows for healthy cognitive function and communication between the brain and nervous system. Think about these myelin sheaths like a sheath on a long sword, the nerve fibre is the sword, the sheath is the fatty layer, and if that sheath starts to get worn down, the sword will be exposed in places and may start to get blunted or rusty.

The next way that progesterone supports brain and nervous system health is through its effect on GABA, the calming neurotransmitter. When progesterone is used up in the body, it produces a metabolite, which is just a by-product of progesterone being used – it’s sort of what progesterone is transformed into once it’s done its job. So, this metabolite is called allopregnanolone and  allopregnanolone binds to GABA receptors. Think of receptors as a lock and key, the receptor is a lock on a cell, whilst the keys are GABA or allopregnanolone. The binding of allopregnanolone to a GABA receptor actually enhances the soothing effects of GABA, creating a sedative like response which can improve sleep, calm anxiety, and generally soothe both body and mind.

Progesterone also helps protect us from breast and uterine cancer, supports bone density and heart health. Aaand plays a star role in ovulation, the production of progesterone is essential to kicking off the last hormonal change that aids in ovulation.

Finally, progesterone raises our temperature, which is why when using the fertility awareness method for tracking your cycle, you’ll use a basal body thermometer to take your temperature upon waking. Before ovulation, your temperature will be 36.11 to 36.50 degrees Celsius, after ovulation, it should rise 36.55-8. to If your temperature jumps up and stays there for three days in a row, you’ve ovulated and this temp change should be sustained and then drop just before your period as your progesterone levels drop.

So just like oestrogen, it’s actually an integral hormone to overall health. 

 

Progesterone and the Menstrual Cycle

Now you know the benefits, let’s look at how it’s made and its patterns during the menstrual cycle.

Progesterone is made in something called the corpus luteum. The corpus luteum is a short-term gland made from the follicle which the chosen egg ovulates from, and this transformation occurs as ovulation takes place, so mid-way through your cycle.

If the chosen eggs becomes fertilised, the corpus luteum will continue to make progesterone to sustain the pregnancy for the first three months of the cycle, if levels aren’t high enough, this is when miscarriage can occur. It’s why whenever my clients are having trouble conceiving or have miscarried, I like to keep checking their progesterone levels, because shockingly this is not something that is standardly done by doctors in relation to this, not until at least, recurrent miscarriages have occurred. After the first trimester, the progesterone supply comes from the umbilical cord. 

Now, if fertilisation doesn’t occur, progesterone will be made for between 11 to 17 days post-ovulation, and then drop sharply just before your period, triggering the shedding of the uterine lining.

Progesterone goes on to stay low during the menstrual and follicular phase of the menstrual cycle, with oestrogen dominating during this time, and then progesterone dominates after ovulation.

So, what happens if there’s a problem with progesterone – and why would that occur?

The biggest imbalance we see with progesterone is low levels of progesterone. Like oestrogen dominance, there can be two ways that low progesterone occurs. 

So the first would be that your progesterone levels are actually normal but are low in contrast to oestrogen, creating an oestrogen dominance affect. Remember, this would only occur in the second half of your cycle, when progesterone is supposed to be higher than oestrogen.

Or you actually have low levels of progesterone itself.

So, let’s look at the first scenario briefly. This would of course occur from elevated levels of oestrogen, in which case, we need to look at what could be affecting that and we covered those points last week. 

So what if you actually have low levels of progesterone?

The key culprit would be because of lack of ovulation. If we’re not ovulating, the main follicle doesn’t get a chance to turn into the corpus luteum and produce progesterone.

The number one cause of lack of ovulation is some kind of physical or emotional stressor. This occurs because stress hormones like cortisol actually suppress the release of GnRH (which is short for Gonadotropin Releasing Hormone). GnRH is essential to get the menstrual cycle moving, it essentially tells the pituitary glands to make follicle stimulating hormone and lutenising hormone, and follicle stimulating hormone is essential for the growth of the chosen follicle whilst luteinsing hormone is vital to ovulation. When GnRH is suppressed, so are these, and so of course is ovulation and the resulting progesterone levels. 

Additionally, cortisol also further prevents ovulation by making the ovaries resistant to the effects of FSH and LH.

Now even if ovulation still manages to occur, the downstream suppression of LH and FSH can still lower progesterone production and finally, cortisol actually binds to progesterone receptors, meaning even if progesterone is made, it then can’t go on and do its job in the body and is essentially just floating around with nowhere to go and nothing to do.

Now remember, a stressor doesn’t have to be an actual stressor in your life, it could be inflammation from SIBO, or lack of nutrients from undereating or having SIBO, or over exercising, or living in chronic pain.

Now if you have managed to ovulate, and stress isn’t an issue, but you have low levels of progesterone, you may have something called luteal phase insufficiency, which is essentially where the corpus luteum is unable to make enough progesterone. Whilst there may be numerous causes and it’s always best to work with a practitioner if you are struggling with this, I commonly see this to be a problem in my clients who are unable to absorb enough nutrients from their food due to SIBO, or who have a lot of diarrhoea from SIBO so are underweight. They basically aren’t taking in enough nutrients to create healthy follicles. 

Another cause would be thyroid issues, whether that’s hyperthyroidism or hypothyroidism, but can affect ovulation and progesterone output. Other conditions can affect ovulation and ultimately progesterone production too, like PCOS and high levels of the hormone prolactin. 

Finally, progestin IUDs can also create low progesterone overall. Progestin is not progesterone and therefore works differently in the body, and whilst you may have been told the IUD doesn’t stop ovulation, it does for many in at least the first year of use. 

Symptoms of low progesterone may sound familiar, because of course, once we have low progesterone, we also have oestrogen dominance, so here are some of the signs:

·      Heavy periods

·      PMS

·      Tender breasts, especially before your period

·      Missing periods

·      Shorter cycles (indicating that progesterone wasn’t around long enough to have a full luteal phase)

·      Irregular cycles

·      Miscarriages or fertility struggles

·      Low moods – especially anxiety, anger and irritability in the second half of your cycle

·      Breakthrough bleeding in the luteal phase

 

Now, when it comes to progesterone, low progesterone is the most common issue we see, so much so, that going through all of my courses, I realised we don’t even cover high progesterone levels!

However, Dr. Jolene Brighten briefly covers the symptoms of high progesterone in her blog post on hormonal imbalances, so here are the symptoms from her:

·      Irritability

·      Feeling tearful

·      Sore breasts

·      Headaches

·      Tiredness

 

High progesterone levels can be caused by:

·      Progesterone cream, which is a common treatment used by many people with endometriosis.

And according to an article by Clue app., high progesterone can also be caused by:

·      Congenital adrenal hyperplasia (CAH)

·      Some ovarian cysts 

·      Certain ovarian tumours 

·      Pregnancy complications

Because this is not my area of expertise, I’ve linked to a couple of evidence-based articles on high progesterone in the show notes. 

So, how does progesterone affect endometriosis?

Firstly, we have the obvious issue that progesterone counteracts the proliferating effects of oestrogen, so without enough progesterone, there is the risk that oestrogen will go unchecked and could encourage endometriosis growth. However, this is a slightly simplistic view because some endometriosis cells are resistant to the effects of progesterone and some do not even have progesterone receptors at all, so progesterone literally cannot act on those specific cells. 

The other benefit of progesterone is that it is immunosuppressive and we know there is significant immune dysfunction in endometriosis, where certain immune cells are creating excessive levels of inflammation but are doing a poor job of cleaning the endometriosis up. Having sufficient progesterone levels can potentially help quiet some of that excessive inflammation in the second half of the cycle. 

Finally, progesterone can inhibit the formation of new blood vessels to the endo lesions, which are essential to their growth and development.

Now of course, indirectly, if you already have gut issues related to your endometriosis, because of SIBO or adhesions or gut dysbiosis, then the natural rise of progesterone in the second half of the cycle can cause constipation. The answer isn’t to supress progesterone, as I hope you can already see the benefits, but it’s more so to support your gut, and this could look like different things depending on what is going on with your body. If you have adhesions affecting the transition of food through the gut, daily massage like the I Love You massage or Arvigo can make a huge difference and I see this work so well with many of my constipated clients. I’ve linked to resources for both of these in my show notes.

If it’s SIBO related or gut dysbiosis related, obviously taking the necessary steps to heal the gut is essential, but in the short-term, in the second phase of your cycle, you can use some symptomatic relief strategies, which I outline in episode 169 and I’ve linked to that in the show notes.

Another issue you may have with endo is a tight pelvic floor, which when coupled with sluggish intestines, may result in constipation, so any form of pelvic floor relaxation or movement that helps gut motility like yoga, or rebounding or simply walking, is going to help.

Of course, we also have the issue that endometriosis can cause anxiety and depression, so if we have low levels of progesterone in the second half of the cycle, those conditions may feel even worse.

The answer is of course, to work to balance your oestrogen and progesterone levels with good hormonal practices, including blood sugar balancing, stress management, supporting the detoxification pathways, etc. Everything I cover in this podcast, in my nutrition masterclasses, courses and coaching. As I said last week, one of the most powerful ways to transform your hormones is with blood sugar balancing, so I would begin there. But if your biggest problem is lack of sleep, maybe that’s where you start – or if its stress, maybe you bring in meditation. The key is, we want to make sure you’re ovulating.

Now there are a few key nutrients and some hacks for raising progesterone, and I’m going to keep that for another episode because this podcast is pretty long already! But initially, we really want to get those foundations in place rather than chasing supplements and shiny hacks that are short-lived. 

If you’re not sure about what your progesterone is doing, you can get a simple blood test. This blood test should be taken five to seven days after ovulation, if you’re not sure when you ovulated, then you can do days 19-22 of an average 28-day cycle (remember, this is just an average, 28 is not the ‘perfect’ cycle length). If your cycle is much longer, then check with the test provider. 

And a great way to actually be sure you’re ovulating is to use the Fertility Awareness Method, which uses three different markers you can track daily, to actually know for sure whether you’ve ovulated or not. I’ve linked to a couple of resources and episodes on this in the show notes. 

So that’s it! I hope you now feel confident that you understand how progesterone is made, how it affects endo and how it might be impacting you personally! If you’ve found this episode helpful, please remember to share with others and let me know what you thought! 

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 Show Notes

Progesterone menstrual cycle/imbalances:

https://www.ncbi.nlm.nih.gov/books/NBK279054/#female_the-normal-menstrual-cycle-and-the-control-of-ovulation._1

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4653859/

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4436586/

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5689497/

https://pubmed.ncbi.nlm.nih.gov/20595939/

https://pubmed.ncbi.nlm.nih.gov/11994369/

https://onlinelibrary.wiley.com/doi/abs/10.1111/jne.12179

Episode 169: https://www.thisendolife.com/this-endolife-podcast-episodes/symptom-management-supplements-for-the-endo-belly

Prolactin

https://academic.oup.com/mend/article/4/1/13/2713978

High progesterone

https://www.verywellhealth.com/high-progesterone-symptoms-5185751

https://helloclue.com/articles/cycle-a-z/progesterone-101

https://drbrighten.com/hormone-imbalance-symtpoms/

IUD

https://nicolejardim.com/how-does-the-mirena-iud-work-is-it-right-for-me/

Fertility Awareness Method

https://nicolejardim.com/how-to-track-your-cycle-to-know-if-when-youre-ovulating-when-your-period-will-arrive/

https://www.freebirthsociety.com/blogs/the-free-birth-podcast/fam-understanding-the-basics-of-the-fertility-awareness-method

Endo and progesterone

https://www.frontiersin.org/articles/10.3389/fnint.2020.00026/full

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5077092/

https://pubmed.ncbi.nlm.nih.gov/8671374/

Hormone testing

https://nicolejardim.com/hormone-testing-cheat-sheet/

https://nicolejardim.com/the-best-way-to-test-hormones/

https://drbrighten.com/when-is-the-best-time-to-test-hormone-levels/ 

Further episodes of This EndoLife

Further podcasts by Jessica Duffin

Website of Jessica Duffin