Women’s health, hormone therapies, Estrogens, Progesterone/excess and deficiencies, Breast ptosis, Menstruation, Dysmennorrhea, Ovulatory pain, Migraine/premenstrual, Vaginal dryness, Dyspareunia, PCOS, Endometriosis, Ovarian cysts

BIO in January and February 2018

Hormone Therapies to Cure Female-Related Disorders: Practical Tips

By Thierry Hertoghe, MD

Prevention and cure of breast cysts, under- and overdeveloped breasts, breast ptosis, amenorrhea, hypomenorrhea, and menorrhagia, poly- and spaniomenorrhea, irregular menstrual cycles, ovulatory pains, spasmodic and constant dysmenorrhea, premenstrual and menstrual migraines, ovarian cysts and polycystic ovarian syndrome, vaginal dryness, dyspareunia, endometriosis, lichen sclerosis, hirsutism, etc.

Most female-related disorders are caused by deficiencies, excesses, or imbalances of the two important types of female hormones—estrogens and progesterone. In this article, we will review the most typical female-related disorders and suggest how to correct them with hormone supplements.

To determine which female hormone deficiencies and excesses are causing female-related disorders, and which hormone supplements to provide as a treatment, I recommend physicians train their skills in recognizing the differences in actions and deficiency signs and symptoms between estrogens and progesterone.

Estrogens

increase progesterone production by stimulating ovulation through the production of a high preovulatory peak that stimulates a peak secretion of LH, the pituitary hormone that triggers ovulation.

• Estrogens stimulate the (ortho)sympathetic nervous system directly and through conversion into catechol estrogens, making women

  excited and enthusiastic

  , but excess estrogens render women nervous, aggressive, and anxious.

• Estrogens also cause a person to

  retain fluid

  and benefit from adequate hydration of the skin and mucosa, but in excess they lead to painful swelling of breasts and lower abdomen.

• Estrogens also stimulate

  healthy epithelial cell proliferation

  , particularly in the genital areas (breasts, ovaries, and endometrium), however, at excessive levels, they stimulate excessive cell proliferation in these areas producing enlarged breasts or breast cysts, ovarian cysts, endometrial glandulocystic hyperplasia, and fibroids.

Progesterone

has in these domains opposite actions that protect against estrogen excess. Progesterone reduces estrogen activity by reducing the levels of estradiol, the most potent estrogen, through a stimulation of the conversion of estradiol into the three to 10 times less active estrone.

• Progesterone stimulates the parasympathetic nervous system, making women

  calm and in control

  .

• Progesterone is

  diuretic

  , increases water excretion through urine, protecting in this manner against excessive fluid retention. This diuretic action is not shared by all progestogens. High doses of synthetic derivatives of bioidentical progesterone can cause fluid retention, particularly when they derive from androgens.

• Progesterone also stops estrogen-induced epithelial cell proliferation and

  differentiates epithelial cells

  into more functional cells. For example, progesterone stops estrogen-induced anarchic proliferation in the endometrium, differentiating these cells so that the endometrium of the uterus can accept implantation of a fertilized egg cell and nourish it.

Table 1 shows the differences in actions of the two types of female hormones.

Excesses (predominance) in these female hormones will accentuate these effects.

Estrogen predominance

produces nervousness, water retention, and excessive cell-proliferation. Estrogen predominance is frequently encountered in premenopausal women who are not supplemented with female hormones. In contrast, postmenopausal women usually show estrogen predominance only when taking an imbalanced female hormone treatment (e.g., the medically unsafe, treatment with estrogen alone (without progesterone) usually prescribed to women after hysterectomy

.

Progesterone supplementation is necessary to keep not only the uterus tissues but also the ovarian, breast, and brain tissues well-balanced and safe.

Progesterone dominance

with depression and dehydration is rarely encountered, generally only when excessive doses of progesterone or progestogen derivatives are given.

Deficiencies in female hormones will provide opposite effects to their actions. In

estrogen deficiency

, low mood and energy, dehydration, and atrophy prevails. In cases of

progesterone deficiency

associated to adequate estrogen levels, nervousness predominates; and, in the genital areas, swelling and excessive epithelial cell proliferation. Table 2 reviews the most typical and pathognomonic signs and symptoms of each female hormone deficiency, enabling physicians to quickly detect which female hormone deficit(s) a patient is suffering from.

At what time of the day are female hormone deficiency complaints the worst? Contrary to hypothyroidism and cortisol deficiencies where symptoms are more severe at specific times in the day (upon awakening for hypothyroidism and in stressful moments for adrenal deficiency), women with estrogen and progesterone deficiencies find that most complaints appear at the same intensity at any time of the day, with the exception of vasomotor disorders (hot flushes and sweats), which tend to occur more at night and in stressful conditions. In premenopausal women, estrogen deficiency symptoms are worse during menstruation and in the follicular phase, whereas progesterone deficiency symptoms predominate in the luteal phase, during the 5 to 14 days before the period.

What are the most efficient and safest female hormone treatments? The

most efficient and safest

treatment

consists, in my experience, of transdermal estradiol and oral or vaginal progesterone, in accordance with the current scientific literature. Estriol is interesting as an estrogen but does not absorb well through the transdermal route and has insufficient effects for the brain, bones, and cardiovascular system. The data are not all conclusive about its cancer safety or protection (the risk of endometrial cancer is several times higher in women taking estriol alone without progesterone). It is efficient for the vaginal mucosa and reduces ocular dryness. For this reason, I consider 1-2 mg/day oral estriol as a worthwhile adjuvant estrogen, but it does not replace the essential estradiol.

From what age do women need female hormone supplements? As soon as female hormone deficiency is diagnosed. Some women with weak ovaries may already need female hormones

at the end of puberty

because their ovaries never succeed in producing sufficient amounts of female hormones to be fully healthy. In most women, however, the need for estrogen and progesterone supplementation starts

between 30 and 35 years old

, as confirmed by research that shows that the levels of both hormones start progressively and significantly to decline at these ages.^1-2

Which conditions can accelerate the natural age-related decline in female hormone production long before menopause? Pregnancies also weaken the ovaries. Research demonstrates that women who have been pregnant have significantly lower serum levels and urinary excretion rates of estrogen metabolites than women of the same age who have never been pregnant.³ In my experience, most women after pregnancy show premature signs of estrogen and progesterone deficiencies and look like older mothers rather than the energetic and young-looking ladies they were before. To keep their health and good looks, they need small doses of estrogen and progesterone. Practice of intensive sport (reduced estrogen and progesterone metabolites),^4-5 stress (estrogen and progesterone deficits),⁵ malnutrition,⁵ overweight (decreased progesterone and its metabolites), smoking (decreased estradiol),⁶ a history of induced abortion,³ uterine tubal ligation^7-8 also reduce production of female hormones and their metabolites. These deficits make it necessary for women to get additional estrogen and progesterone therapies to correct the hormone deficits long before menopause.

Female-Related Disorders That Can Quickly Be Corrected in Days or Weeks

Droopy breasts

(breast ptosis) are signs of significant estrogen deficiency. For this reason, in

premenopausal women

add estrogen daily during most of the menstrual cycle (follicular and luteal phases) but administer the protective progesterone only in the second half of the cycle, the luteal phase. In

postmenopausal women

, I usually prescribe both transdermal estradiol and oral or vaginal progesterone on the same days: from the 1^st to the 25^th day of the month. This usually and safely blocks menstruation, a relief for most older women.

The estradiol should be taken upon awakening because it increases energy, and progesterone at bedtime because of it induces sleep. An efficient dose to bring back the breast volume and tone is 1.5 to 3 mg/day of transdermal estradiol (upon awakening) and 100 mg/day of oral or vaginal progesterone (at bedtime). If the breasts remain droopy, increase the estradiol dose further until the breasts regain their normal tone and volume.

Tip: The patient should

avoid consuming (unsprouted) whole grains

as the fiber contained in grains prevents intestinal reabsorption of female hormones. About 60% of the female hormones are attached (conjugated) by the liver to a glucuronate or a sulfate. These glucuron- and sulfo- hormone conjugates are secreted then by the liver into the bile, which flows into the small intestine. In the gut, bacteria break off the bonds between the glucuronates and sulfates and the estrogen and progesterone, permitting reabsorption of the latter through the intestinal wall and reutilization as hormones. This enterohepatic cycle is interrupted by the non-absorbable cereal fiber that strongly binds to the hormones and drags them into the stools, almost tripling the net loss of these hormones in the stools and lowering the female hormone levels 20 to 40% in the serum.

Amenorrhea and hypomenorrhea

in

premenopausal women

who are not yet menopausal (FSH is still well below the 30 mIU/ml threshold for menopause) and still have healthy egg cells result from severe estrogen deficiency. Normal menstruation is restored by adding estradiol and progesterone as mentioned above (usually 2 to 3 mg/day of transdermal estradiol gel from the 5^th to the 25^th day of the menstrual cycle) and 100 mg (usually not more) progesterone from the 15^th to the 25^th day of the cycle. In

postmenopausal women

treated with both estradiol and progesterone on the same days (typically from the 1^st to the 25^th day of the month), amenorrhea is generally the rule and is safe because the progesterone blocks the proliferation of endometrium by estradiol and the possibility of having periods. I recommend stopping the treatment during 3-5 days at the end of the month as the interruption decreases the breast cancer risk and permits an abnormal endometrial cell that might have developed to die during the estrogen-free interval.

Tip: Amenorrhea and estrogen deficiency may be caused by low-protein and low-fat intakes as in low-calorie diets, for example. Recommend the patient eat at least 200 g/day (a little less than a half pound/day) of meat or fish and take a daily soupspoon of butter (preferably ghee, butter that has been clarified (cleaned) from its proteins) or an egg yolk. Eating more animal protein and fat boosts female hormone production.

Menorrhagia:

How to reduce heavy menstrual bleeding by adding progesterone. Progesterone deficiency allows excessive menstrual bleeding by permitting an excessive proliferation of the endometrium under impulse of estrogens. Once progesterone treatment is administered at a sufficient dose, it stops any further production of endometrium. By this inhibition, it reduces the material for bleeding as endometrium is what bleeds away during periods. In case of mild menorrhagia, 100 to 150 mg/day from the 18^th to the 25^th day of the cycle should be sufficient to reduce the bleeding back to normal. In case of heavier bleeding, 150 mg to 200 mg/day from the 15^th to the 25^th day of the cycle may be necessary. In extreme cases of severe menorrhagia, 50 mg/day from the 5^th or the 10^th day to the 14th day and then 150 mg to 200 mg/day from the 15^th to the 25^th day of the menstrual cycle can be required.

Tip: Check for hypothyroidism or adrenal (cortisol) deficiency as they both can cause insufficient ovulation, which results in progesterone deficiency. Check also for vitamin K, B3, etc., as well as thyroid (again), as these deficiencies are associated with insufficient production of coagulation factors and treat those deficits whenever they are confirmed.

Polymenorrhea, spaniomenorrhea, and irregular menstrual cycles

: How to restore a 28-day menstrual cycle. Short (26 or less days), prolonged (30 or more days), and irregular (mixing of short and long) menstrual cycles are mainly due to estrogen deficiency. To treat them, a higher estrogen dose is useful (e.g., 2-4 mg/day of transdermal estradiol with a moderate 100 mg/day dose of progesterone given in premenopausal and postmenopausal women on the same days of the menstrual cycle or month, respectively) as suggested above.

In some premenopausal women with short menstrual cycles, progesterone deficiency symptoms, and not symptoms of estrogen deficit, predominate with severe premenstrual syndrome and tension, mastalgia, etc. In this case, I recommend treating with slightly lower doses of transdermal estradiol (1.5 – 3 mg/day) and higher doses of progesterone 150 to 200 mg/day.

Tip: Recommend the patient eat

sufficient animal protein-rich foods (> 200 g/day)

to support female hormone production and

avoid whole grain foods

to avoid hormone loss in the stools. There is a fivefold higher risk of irregular menstrual cycles in women regularly eating whole grain bread.

Spasmodic dysmenorrhea, menstrual migraine,

and

hot flushes:

How to get rid of severe cramps, hot flushes and migraines. Heavy cramps in the lower abdomen alternated with pain-free periods during the day and hot flushes in premenopausal women occur generally during menstruation when estrogen levels are at their lowest levels. As for menstrual migraine, these menstrual abdominal cramps are due to estrogen deficiency and relieved by estrogen supplementation. In case one of these three complaints is the only bothersome complaint, the estrogen deficiency is probably only present during menstruation and 0.75 to 1 mg/day of transdermal estradiol during the first four days of the menstrual cycle may be sufficient as a therapy.

When a patient suffers from other estrogen deficiency complaints appearing at other times of the menstrual cycle, then a typical premenopausal female hormone treatment is required to relieve the patient from all her symptoms. It typically consists of 2-4 mg/day of transdermal estradiol gel from the 5^th to the 25^th day of the menstrual cycle with progesterone from the 15^th or 18^th day to the 25^th day. If some spasmodic dysmenorrhea would persist, add a smaller (0.75 to 1 mg/day) dose of transdermal estradiol during the first 4 days of the menstrual cycle.

Tip: Avoid smoking and caffeinated beverages because even if they may help relieve some of the spasmodic dysmenorrhea or migraine, they usually accelerate the upcoming next painful period and increase its intensity. Note that for migraines, thyroid therapy may help, too, as it eliminates the myxedema, which compresses brain structures inside the non-extendable skull. Thyroid therapy also increases estrogen production, another way by which it can reduce migraine.

Ovulatory pains

,

constant dysmenorrhea

, and

premenstrual migraine

: All three symptoms are due to progesterone deficiency and require progesterone for treatment during the luteal phase, the second part of the menstrual cycle. To prevent

ovulatory pains

, progesterone treatment should start at a smaller dose of 50 mg/day before the normal time of ovulation (from the 10^th to the 14^th day of the cycle), usually from the 10^th to the 14^th day of the menstrual cycle, and then continue at higher doses of 100 to 200 mg/day from the 15^th or 18^th day to the 25^th day of the cycle as there are usually many other complaints of progesterone deficiency when ovulatory pains occur.

When a patient suffers from

permanent lower abdominal pain

and

recurrent migraine

in the premenstrual period, starting progesterone from the 15^th or 18^th day of the menstrual cycle to the 25^th day of the cycle may suffice and deliver the patient from her pain. However, frequently estrogen deficiency complaints may also be found in these premenopausal women and require small (not high) doses of 0.75-2 mg transdermal estradiol from the 5^th to the 25^th day of the menstrual cycle. Whatever the cases, a relatively higher progesterone dose than the estrogen dose should be given when constant dysmenorrhea and premenstrual migraine are the predominant complaints, otherwise there is a risk of aggravating these stressful complaints with estrogen supplementation.

Tip: Check for

hypothyroidism

whenever progesterone deficiency complaints predominate, particularly in young women (below age 30). The ovaries in hypothyroid women produce insufficient amounts of progesterone because of a lack of thyroid hormone stimulation. In young women, thyroid therapy usually restores ovulation and progesterone levels and may make the complaints of progesterone deficiency disappear on their own without exogenous female hormone supplements. In hypothyroid women above age 35-40, the number of functional oocytes has dropped to levels that are too low, and progesterone supplementation is almost always necessary next to thyroid therapy.

Vaginal dryness and dyspareunia:

The dryness and atrophy of the vaginal mucosa and its almost inevitable consequence of pain at penis penetration during intercourse are due to estrogen deficiency.

In most women, correcting the underlying estrogen deficiency with a typical pre- or postmenopausal treatment consisting of

transdermal estradiol and oral or vaginal progesterone

such as explained above is efficient. In some women, the vagina has remained in estrogen deficiency for too long a time and addition of

a vaginal gel or tablets of estriol

is necessary the first six months to make the symptoms completely disappear. In rare cases, the adjuvant vaginal estriol treatment should be continued for a longer time, perhaps indefinitely.

Female-Related Disorders That Need Months and (for some) 1-2 Years for Correction

Breast cysts:

How to make breast cysts disappear naturally. It takes approximately six to 15 months to make cysts totally disappear in women, regardless of the age or severity of the breast cyst, even in Reclus disease. The main treatment here is not hormonal but nutritional: iodine. One to three drops per breast of a 5% iodine-containing

Lugol’s solution

daily applied (no interruption) on the area overlapping the breast cysts permits 12% penetration of the iodine into the skin and cysts. The solution stains the skin yellow-brown, but this is transitory. After 20 to 30 minutes almost all iodine that has remained on the skin has outgassed into the atmosphere. Iodine blocks proliferation of tumor cells so that in the cysts drenched with iodine no new cells appear while the old cells die and disappear one after the other. In severe fibrocystic breast disease, I recommend reinforcing the efficacy of the topical iodine treatment by having the patient take an additional 3-5 drops/day orally of the same Lugol’s solution mixed with water to reach cystic areas within the breast that are poorly accessible topically. As progesterone also helps to prevent and reduce breast cysts, I also prescribe the patient a

progesterone gel 1%

to apply daily on the breast before placing the iodine solution.

Tip: Recommend the patient

avoid drinking coffee, tea, and alcohol

as the caffeine or ethanol these drinks contain promotes breast cysts formation. Make them also take progesterone orally or vaginally in the second phase of the menstrual cycle in case the breasts swell painfully.

Small breasts:

How to stimulate underdeveloped breasts (micromastia) to grow to a normal adult size. In

young women

using female hormone treatment, it takes about 12 to 15 months to fully develop breasts from one of the lower Tanner puberty stages (stages 2 to 4) to a full adult stage 5 breast development. The typical treatment consists of administering upon awakening 2 to 4 mg/day of a transdermal estradiol gel from the 5^th to the 25^th day of the menstrual cycle and at bedtime 100 to 150 mg/day of progesterone from the 15^th to the 25^th day of the cycle. The higher the estradiol levels are, the bigger the breasts become.

In

older peri- and postmenopausal women

, growth hormone therapy may be necessary in addition to estrogens (and progesterone) to make the breasts grow.

Tip: Breast enlargement requires sufficient animal protein intake. Suggest the patient eat at least 200 grams/day of meat, fish, or chicken.

Enlarged breasts:

How to prevent and treat over-sized breasts. Prevention of over-sized breasts is simple: Treat any progesterone deficiency as soon as possible as it is long-term progesterone deficiency that allows excessive mammary cell proliferation to make the breasts too big. In general, the treatment consists of administering 100 to 200 mg/day of micronized progesterone from the 15^th or 18^th day to the 25^th day of the menstrual cycle.

Once the breasts have become excessively enlarged (macromastia), further enlargement can be hindered by administering progesterone alone in the same manner and at the same doses used for prevention of breast enlargement. Reduction of breast size is usually not very efficient with progesterone or other hormone therapies without surgery, and if so, it results in breast ptosis rather than breast reduction.

Tip:

Avoid coffee, tea and alcohol

as they increase breast epithelial cell proliferation.

Ovarian cysts, polycystic ovarian syndrome, and hirsutism:

How to make ovarian cysts disappear.

Ovarian cysts

are facilitated by one of the following deficiencies: iodine, thyroid, cortisol, or progesterone deficiencies. Toxins (chlorine, etc.) may facilitate the development of cysts, but it is usually by producing one or more of these four deficiencies. Correction of one or two of these deficits is generally sufficient to correct the problem.

In case of iodine deficiency, 3 to 5 drops a day of a

5% Lugol’s solution

may be sufficient to make the ovarian cysts disappear in 3-6 months. Hypothyroidism is, in my experience, best corrected with 30 to 150 mg/day of

desiccated thyroid extracts

from pork origin as they contain not only T4 (thyroxine, four iodine atoms), but also T3 (three iodine atoms, by far the most active thyroid hormone), T2 (two iodine atoms), T1 (one iodine atom), and T0 (zero iodine atoms), which all may have some additional benefit. These different T0 to T4 hormones are delivered by thyroid extracts imbedded in a big thyroglobulin protein. Absorption and digestion of this protein is slow and progressive, permitting progressive release of the different thyroid hormones out of this long protein. In this way, a more persistent 24-hour thyroid activity is achieved and, thus, better correction of the hypothyroidism than treatments containing only purified T4 or T3.

Cortisol deficiency is best corrected by hydrocortisone (bioidentical cortisol) 10 to 15 mg in the morning and 10 mg at midday. Remember to always supplement DHEA in equivalent doses (15 to 25 mg/day) whenever cortisol is given as the DHEA protects against any excessive catabolic effects of cortisol.

In

polycystic ovarian syndrome

with typical hyperandrogenism and hirsutism, the treatment is more complex as, in my experience, all of the aforementioned thyroid, cortisol, and progesterone deficiencies exist simultaneously with some degree of estrogen deficiency. These deficits trigger a compensatory increase in production of testosterone and adrenal androgens. Correction of these aforementioned deficiencies usually reduces and normalizes the androgen excesses and associated hirsutism, although slowly. After confirmation of the deficiencies by laboratory tests, administer to your patient hydrocortisone, desiccated thyroid, and a combination of 2-4 mg/day of transdermal estradiol from the 5^th to the 25^th day of the menstrual cycle and a maximum of 100 mg/day (not too high) of oral progesterone from the 15^th to the 25^th day of the cycle.

How do these hormones reduce

hirsutism

? The

hydrocortisone

reduces the secretion of ACTH, the pituitary hormone that stimulates the adrenal cortex to produce cortisol and adrenal androgens, thereby reducing the secretion of DHEA, androstenedione, and other adrenal androgens. In case of severe adrenal hyperandrogenism with important hirsutism, correct in the first six to nine months the cortisol deficiency with a potent synthetic derivative such as 0.25 to 0.35 mg/day of dexamethasone, which lowers the adrenal androgen levels more than the bioidentical cortisol. However, it is important not to lower the adrenal androgens too much, so regular control of the 17-ketosteroids, the metabolites of the adrenal androgens, in a 24-hour urine collection is recommended every six months. If a hirsute patient wishes only to take bioidentical hormones, then provide hydrocortisone in four divided doses of 5 mg taken at regular four-to-five-hour intervals: upon awakening, at lunch, at 4 PM, and before bedtime. The spreading of the dose permits better suppression of excessive adrenal androgen production.

Thyroid therapy

increases the conversion of testosterone into estradiol rather than into the masculinizing dihydrotestosterone.

Estradiol

blocks the masculinizing effects of androgens and progesterone amongst others by inhibiting the conversion of the harmless testosterone into the body hair-promoting dihydrotestosterone.

Without aesthetic hair removal, it takes 2-4 years after normalization of androgen levels for slow disappearance of the excessive body hair. For this reason, I suggest women with hirsutism get their excess body hair removed. After hair removal, the hirsutism should not grow back if all hormone levels are in the meantime normalized.

Endometriosis:

Can a patient get rid of endometriosis without surgery? The development of endometrial mucosa inside the abdominal cavity is also, in my experience, due to a multiple hormone deficiency syndrome with thyroid, cortisol, and progesterone deficiencies. Hypothyroidism and cortisol deficiency do not allow good ovulation, resulting in progesterone deficiency. One of progesterone’s roles is to relax the uterine wall and prevent unwanted uterine contractions. It is very useful during a pregnancy, for example, as otherwise excessive contractions could lead to a miscarriage. It is also useful to avoid endometriosis. With progesterone deficiency, the uterine body and tubes contract too frequently and anarchically so that islets of endometrium detach from the inner wall of the uterus, penetrate the fallopian tubes, and from there enter into the abdomen and implant themselves in places where they do not belong. Additionally, cortisol deficiency increases the inflammation around the endometrial islets inside the abdominal cavity, increasing pain and suffering.

In my experience, the best treatment is to correct the hormone deficiencies in the same way as for polycystic ovarian syndrome by using hydrocortisone, desiccated thyroid, and progesterone. If pain and inflammation predominate, I prefer using a synthetic cortisol derivative such as prednisolone (5 mg/day) with 15-20 mg/day of DHEA for the first six to nine months of treatment and then later switch to bioidentical hydrocortisone.

Tip: Insist that the patient follow a healthy diet that makes her have a flat belly free of bloating and inflammation and does not irritate the gastrointestinal system. A bloating abdomen is sick, inflamed, and aggravates the endometriosis. Suggest that the patient eat boiled vegetables and ripe fruits. Make her eat fruits in the first half of the day at a distance from the meals (1/2 an hour before or 3 hours after meals). Suggest she consume protein-rich foods such as meat and fish as early as possible in the day so that with gravity and movement the foods go down in the gut quicker and get digested in the different parts of the gastrointestinal system. Proteins should not be consumed in the evening as they then unnecessarily stagnate the whole night in the stomach, overloading the gastrointestinal system and causing inflammation in the same abdominal cavity were the islets of endometriosis are located. The patient should also avoid junk foods: not only fast foods, sweets and soft drinks, but also unsprouted grains (bread, muesli, porridge, pasta, and rice) and dairy products (milk, yoghurt, and cheese) that are too irritating for the human digestive tract.

Fibroids

are mainly due to progesterone deficiency, although iodine deficiency by allowing excessive tumor cell proliferation and hypothyroidism by causing progesterone deficiency may contribute to fibroid formation. The best treatment is to

prevent fibroid

development by correcting progesterone deficiency on time (100 to 200 mg/day from the 15^th or 18^th day to the 25^th day of the menstrual cycle).

What to do when

major fibroids

are already developed? Prevent further aggravation. In premenopausal women, further aggravation can be prevented by providing 50 (to rarely 100) mg/day of micronized progesterone from the 5th to the 14^th day of the menstrual cycle, and then 100 to often 200 mg/day from the 15^th to the 25^th day of the cycle. If a patient needs estradiol, too, then do not exceed 1.5 mg/day of transdermal estradiol. In postmenopausal women, a smaller dose of estradiol is recommended such as 0.75 to 1.5 mg/day and a relatively higher progesterone dose such as 150 mg/day. It works better with synthetic derivatives of progesterone because of their more prolonged 24-hour action (whereas bioidentical progesterone has an average 16-hour action). Dydrogesterone (Duphaston®) is the only safe one I know of, but is, to my knowledge, not available in North America.

An alternative is to apply transdermally a 10% progesterone liposomal cream in the morning and evening on the skin areas with the highest hormone absorption such as the zones rich in blood vessels where we flush—the upper chest and the face. One gram of a 10% liposomal cream corresponds to progesterone caps of 100 mg. Liposomal creams are better absorbed than other forms. High-dosed progesterone treatments may also partially reduce the fibroids, but a near-total cure is generally only obtained by using gonadotropin agonists for six months, which put the ovaries in menopause. This artificial menopause can be partially compensated by adding the synthetic tibolone, which relieves menopausal symptoms and does not stimulate fibroid development.

Vulvar lichen sclerosis:

This type of inflammation of the vulvar lips is very painful and can lead to a fusion of the vulvar lips and an impossibility of having intercourse. It is mainly due to androgen deficiency. If it is in a not too advanced stage, then the lichen sclerosis may be cured by applying on the vulvar lips a topical testosterone cream. Avoid using gels as the alcohol may irritate the skin of the vulvar lips. Testosterone is a potent anti-inflammatory hormone for genital, muscular, and tendon tissues, not in other areas. A 0.5% testosterone cream twice a day applied in a very thin layer on the vulvar lips may suffice. If the inflammation is very active, addition of a 1% hydrocortisone cream may be necessary. Ideal is even to use the more potent dihydrotestosterone creams, but they are to my knowledge no longer on the market. Studies have also shown that progesterone creams may help improve lichen sclerosis to a lesser degree than androgens, but this is likely due to its conversion into testosterone, and from the testosterone to dihydrotestosterone. After curing the lichen sclerosis, a systemic testosterone treatment should be continued to avoid recurrence (of course, combined with female hormone treatment to avoid virilization)

Tip: Recommend the patient wear

lose underwear made of natural fiber

such as cotton. She should avoid wearing underwear made of synthetic fiber to avoid excessive sweating and irritation that would aggravate the vulvar inflammation. Daily application of a

topical vitamin A solution

(e.g., the patient can open and use high-dosed 25,000 IU caps) may help, too, as it reduces lichen sclerosis.

Table 3 reviews the sex hormone treatments of the most important female-related disorders.

References

1. MacNaughton J, et al. Age related changes in follicle stimulating hormone, luteinizing hormone, oestradiol and immunoreactive inhibin in women of reproductive age. Clin Endocrinol (Oxf). 1992 Apr;36(4):339-45.

2. Lau WN, et al. The effect of ageing on female fertility in an assisted reproduction programme in Hong Kong: retrospective study. Hong Kong Med J. 2000 Jun;6(2):147-52.

3. Windham GC, et al. Ovarian hormones in premenopausal women: variation by demographic, reproductive and menstrual cycle characteristics. Epidemiology. 2002 Nov;13(6):675-84.

4. De Souza MJ, et al. High frequency of luteal phase deficiency and anovulation in recreational women runners: blunted elevation in follicle-stimulating hormone observed during luteal-follicular transition. J Clin Endocrinol Metab. 1998 Dec;83(12):4220-32.

5. Kaplan JR, Manuck SB. Ovarian dysfunction, stress, and disease: a primate continuum. ILAR J. 2004;45(2):89-115.

6. Westhoff C, et al. Predictors of ovarian steroid secretion in reproductive-age women. Am J Epidemiol. 1996 Aug 15;144(4):381-8

7. Rojansky N, Halbreich U. Prevalence and severity of premenstrual changes after tubal sterilization. J Reprod Med. 1991 Aug;36(8):551-5

8. Alvarez-Sanchez F, et al. Pituitary-ovarian function after tubal ligation. Fertil Steril. 1981 Nov;36(5)