Why Is No One Talking About Progesterone?
Perimenopause has been a hot topic for the past few years, but the conversation is always
centred around oestrogen. When in fact the first hormone we lose in perimenopause is actually
progesterone, not oestrogen! Dr Ruqia Zafar, GP and medical director of FUTURE WOMAN‘s
bHRT clinic tells us why progesterone needs more attention.
For decades, the narrative around women’s hormone health has been largely dominated by
oestrogen. We’ve been conditioned to believe that just as men have testosterone, women
primarily have oestrogen. This neat, albeit simplistic, view, partly stemming from oestrogen’s
earlier discovery, has profoundly shaped research priorities and clinical understanding.
Shockingly, three times as much research is undertaken on oestrogen compared to
progesterone. But as we look closer, especially when it comes to the complex transition of
perimenopause, a different hormonal hero emerges: progesterone.
So, why is no one talking enough about this crucial hormone?
The historical focus on oestrogen has created a significant imbalance in our understanding of
women’s physiology. While oestrogen undoubtedly plays vital roles, progesterone is equally
important for women’s health. In fact, during a healthy menstrual cycle, women typically
produce 100 times more progesterone than oestrogen.
This powerful hormone, primarily made as a result of ovulation, is not just about sustaining a
healthy pregnancy. Recent research is increasingly revealing that progesterone is critical for
bone health, breast health, mood, and sleep as it interacts with the GABAergic system in
the central nervous system to promote calm. It also has calming effects on the body and
brain, acts as a natural antihistamine, reduces inflammation, supports the thyroid, and promotes
a healthy menstrual cycle.
Progesterone’s vital role in women’s health
The underappreciation of progesterone becomes particularly evident during perimenopause,
the lengthy transition leading up to menopause. While many assume the fluctuating and
declining oestrogen levels are the primary drivers of perimenopausal symptoms, it’s often the
loss of progesterone that marks the initial hormonal shift. As our ovarian follicles age,
ovulation becomes more sporadic, leading to a decrease in progesterone production. Even
when ovulation still occurs, progesterone levels may be lower than before. Particularly in the
early stages of perimenopause, the main event is the decline of progesterone as well as
ovulating less frequently. Progesterone is a vital hormone and it’s responsible for many of the
telltale signs of perimenopause – from anxiety to poor sleep and worsened PMS and periods.
This is why, at FUTURE WOMAN we never prescribe oestrogen without progesterone (whether
you have had a hysterectomy or not) and often in early perimenopause we may prescribe
progesterone alone. However, it is always a balancing act and requires regular monitoring as
you progress through the stages of perimenopause and oestrogen starts to drop. When this
happens we may need to adjust progesterone doses to reduce its impact on the body’s
sensitivity to oestrogen.
Prioritising progesterone in early HRT
As Director of BHRT at FUTURE WOMAN and a practicing GP specialising in perimenopause,
through my extensive clinical experience I see the importance of prioritising progesterone
hormone therapy (HRT) at the very start of perimenopause. Addressing the declining
progesterone levels early on can effectively alleviate many of the initial symptoms women
experience during this transition, such as poor sleep, anxiety, and heavy, painful periods.
Furthermore, you should never go on oestrogen HRT without real progesterone to balance
it out. In the early stages of perimenopause, oestrogen levels can fluctuate wildly and even rise
higher than before the transition. Introducing oestrogen-only HRT or oestrogen balanced with a
synthetic progestin in this scenario can lead to oestrogen dominance or unopposed
oestrogen, potentially worsening symptoms.
Progesterone vs. progestins: Understanding the difference
It’s crucial to understand that progestins, the synthetic hormones found in most hormonal
contraception and some HRT, are NOT the same as progesterone. While progestins may
have a localised effect in the uterus, they do not offer the same wide-ranging benefits as natural
progesterone and can even have contrasting side effects, such as hair loss, weight gain,
mood changes, and worsening insulin resistance. Therefore, balancing oestrogen in HRT
requires body-identical or bioidentical progesterone, which has the same molecular
structure as the progesterone produced by your body.
The implications of overlooking progesterone are significant. Many women in their 40s and 50s
experiencing mood changes like low mood, anxiety, and irritability during perimenopause are
sometimes wrongly prescribed anti-depressants instead of treatments related to their changing
hormone levels. Addressing the underlying progesterone deficiency could be a more effective
approach for many.
While oestrogen has long held the spotlight in women’s health, it’s time to give progesterone
the recognition it deserves. Especially during perimenopause, progesterone plays a pivotal
role, often being the first hormone to decline and significantly impacting a woman’s
experience. By shifting our focus and understanding the power of progesterone, we can
provide women with more effective and targeted support throughout their hormonal journey.
Key takeaway
Dr. Ruqia Zafar’s clinical insights underscore the importance of prioritising progesterone in early
perimenopausal HRT and always ensuring that oestrogen HRT is balanced with real, body-identical progesterone, not synthetic progestins
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