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PROGESTERONE AND HIGH-RISK PREGNANCY

Q. I am the Mother of a beautiful and healthy 3 year old daughter. However, I am currently having my third miscarriage (in a row). After my first miscarriage (blighted ovum), my Dr. checked my progesterone levels and found them to be entirely too low. He immediately put me on a 400 mg per day dose of Prometrium. My second miscarriage (I saw an actual heartbeat, but after 7 weeks, the baby stopped growing and died.) The third, didn't even make it passed week 5. I trusted my Dr, although after being charged for the 1st two, and still owing him money, he has basically told me to go home and call him if I need to.

Anyway, back to the point, in reading the Patient Insert in the sample pack of Prometrium, I had noticed something strange.  It says, specifically, not to take if you think you are pregnant. (I assumed that didn't apply to those of us who were producing little progesterone.)

What I am having trouble understanding, is if after 3 consecutive miscarriages, why continue to use it? Am I just not taking it soon enough? If that is the case, why not take it daily for preventative measures?


A. In the "normal" course of events, progesterone levels begin to rise at the time of ovulation. The egg is released from an sack, called the corpus luteum. This emptied sack stimulates the production of progesterone. Progesterone is made from the words PRO (meaning "for" or "in favor of") and Gestation (pregnancy). Progesterone levels are quite high during pregnancy.

The corpus luteum can stimulate the production of progesterone for about 2 weeks. If there is a pregnancy the new baby takes over the stimulation of progesterone. If there is not a pregnancy the lining of the uterus is lost and the period begins. It is the falling levels of progesterone that stimulates the beginning of a period.

Progesterone is absolutely necessary for maintaining a pregnancy.

Prometrium® is a commercial brand of progesterone. It seems to be an adequate source for some women. However, there are a number of things about it I don't like. For one, it contains peanut oil. Many people are sensitive to all peanut products. Second, the presence of the oil causes a dramatic spike in progesterone level shortly after the capsule is swallowed. This is followed by a fairly sharp fall in levels. This is not the kind of progesterone levels one would see in a normal cycle. The falling levels look like the END of a cycle (in some situations) and the woman's body reacts just as it would in a normal period, clearing the uterus with a period. I believe the dramatic rising and falling levels of progesterone caused by Prometrium is one of the reasons "they" say not to use if you're pregnant. If the falling levels of progesterone trigger a period, the same falling levels could stimulate clearing of the uterus even when a baby is present. Another reason for the warning is that most drug companies fear allowing their products to be used during pregnancy (if you recall, thalidomide was once consider safe for all people, but caused serious birth defects).

The idea of using progesterone to maintain a pregnancy is an excellent one (See http://en.wikipedia.org/wiki/17-Hydroxyprogesterone about the use of an injection of progesterone that helps maintain pregnancy. I also think other methods of administration would work as well - without the need for an injection). It is providing the mother's body with the hormone she is lacking. However, the progesterone ought to be used differently (much different from the dosing of Prometrium). If the normal rise and fall or progesterone follows a cycle then using it as a supplement should also follow a cycle.

Progesterone Levels

When women suffer from low progesterone we usually suggest a progesterone cream. The dose is 20mg daily for the first couple of weeks of a cycle. This is increased to twice daily during the last half of a cycle, then the dose is stopped until a period begins. This mimics the normal cycling of progesterone. (NOTE: the amount of progesterone used topically is considerably less than the oral dose. WHen used by mouth the progesterone is acted upon in the gut and right away in the liver. This reduces the amopunt of available progesterone and offers an increased amount of progesterone metabolites. This is usually harmless, but it does uses a lot more progesterone and subjects the woman to other chemical substances that are not commonly found in the body. An oral dose of 100 to 200mg is often replaced by a topical dose of around 20mg).

Progesterone levels are usually very high during pregnancy so it seems reasonable to use a quality natural progesterone (we like the cream.) This is used according to a cycle (as above) until pregnancy begins. Then the dose is maintained at 20mg (or more) twice daily. The absolute levels are less important than the results being obtained. The usual dose is around 20mg twice a day but it is not uncommon for some women to use 100mg or more. When these levels are needed the doctor usually recommends a suppository instead of the cream. It can get pretty messy slathering the progesterone cream in those doses.

Safety

Progesterone is very safe for the baby. In fact each of us literally swam in a sea of progesterone before we were born. The doctors who specialize in high risk pregnancies always insist on fairly substantial doses of natural progesterone, usually by suppository.

After a baby is born the mother's progesterone levels fall rapidly (there is no longer a baby stimulating the production of progesterone). Some women do not start making their own progesterone in sufficient amounts. I believe this lack of progesterone is what is sometimes referred to as "post partum blues." Instead of prescribing all sorts of chemical antidepressants I think a balanced dose of progesterone would be more helpful. However, few doctors would agree with me.

I hope this give you an idea of the importance of using natural progesterone AND using it correctly. I do not think Prometrium® is an effective alternative.