Consider Progesterone / by Dr. Natalia P Zhikhareva

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When I educate and advise my patients on considering adding progesterone as an important part of their HRT regiment, I am often told, “My doctor doesn’t think it’s a good idea and says it may lead to breast cancer” (read cited article on the contrary to the latter).  Sadly, I have to inform the patient that most providers overseeing medical treatment of gender dysphoria are not as knowledgeable in the field of transgender medicine as one would hope, unless of course your endocrinologist happens to be specializing in this area (Dr. Vierregger or Dr. Olson-Kennedy just to name a few).  

This is primarily due to providers adhering to 2017 Endocrine Society Guidelines for gender dysphoria stipulating that the protocol for cross-sex therapy, or HRT, for trans women is estradiol and anti-androgen (https://academic.oup.com/jcem/article/102/11/3869/4157558). Unless the medical provider either specializes in transgender care or is curious enough to think outside the box and do additional research, chances are they will continue to adhere to these guidelines. This leaves many tans women uninformed and without a potentially important addition to their HRT treatment.  

Dr. Jerilynn Prior, a Professor of Endocrinology and Metabolism at the University of British Columbia and a Scientific Director of the Centre for Menstrual Cycle and Ovulation Research, in her recent article “Progesterone is Important for Transwomen’s Therapy - Applying Evidence for the Benefits of Progesterone in Ciswomen,” emphasizes the importance of progesterone regimen for trans women.  Citing research on the importance of progesterone as well as physiological estradiol levels as necessary during ciswomen’s premenopausal menstrual cycles for current fertility and long-term health, she argues are of equal importance for transwomen potential physiological benefits.  Dr. Prior summarizes six clinical benefits of oral micronized progesterone molecularly identical to the natural hormone (NOT: SYNTHETIC PROGESTINS) in her article that I briefly summarize below.

1. Progesterone Leads to More Rapid Feminization

Progesterone helps decrease the masculinizing effects on unwanted male-pattern hair.  This is essentially due to the progesterone competing with an enzyme that converts testosterone into DHT, the hormone that is masculinizing skin and hair follicles. 

2. Progesterone Helps Suppression of Gonadal Androgen (Testosterone) Production 

While progesterone helps decrease gonadal testosterone production, note it may not be sufficent enough to act as a complete anti-androgen.  However, the additional help in suppression should further aid in feminization of secondary sex characteristics.

3. Progesterone Combined With E2 Leads to Increased Breast Size

Apart from Dr. Prior’s article, the mutual consensus in the trans community that most providers become aware of, is the accelerated breast growth when adding progesterone to the HRT regimen.  

4. Progesterone Helps Increase Areal Bone Mineral Density

Progesterone helps increase bone formation by activating receptors causing them to increase the number of mature osteoblasts and to increase the process of creating collagen bone matrix.

5. Progesterone Helps Improve Sleep

Many factors such as stress and anxiety related to gender dysphoria interfere with one’s sleep.  Progesterone (300mg at bedtime), Dr. Prior writes, significantly improves deep sleep, decreases the time to fall asleep and decreases mid-sleep wakening.  

6. Progesterone Improves Cardiovascular Physiology

Progesterone may assist in preventing the cardiovascular disease seen in some long term HRT treated trans women.

It is important to consider and discuss with your medical provider whether progesterone should be added to your HRT regimen.  I encourage you to read Dr. Prior’s full article to expand your knowledge of your medical treatment. https://academic.oup.com/jcem/article/104/4/1181/5270376

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