Endometriosis and Perimenopause: Can You Use HRT? | Hormone Doctor's Warning

0:00Welcome back to another AMA of the Dr. Brighten Show. I'm your host, Dr. Jolene Brighten, board certified in naturopathic endocrinology, nutrition scientist, and the author of the new book, ADHD and Women. Today, I am joined by my friend and assistant, Angela, and she's going to be asking me all of your questions. Now, as always, if you can like, comment, subscribe, share, join the community, hang out with me weekly, I would love that. Today's episode is a whole lot of questions about endometriosis, adenomyosis, or adenomyosis, wherever you roll in this world. I think we're going to talk fibroids too.

0:32So this is the kind of information you need in on. Make sure that you join us for the full episode. And as we near the 200th episode of the Dr. Brighton Show, I need to hear from you. What do you like most? You like the AMAs? You like the panels? You like the guests? You like just sometime you and me? Just let me know. Because the only way I can continue to show up and serve you and us have a good time is if I get your feedback. So drop a comment wherever you're listening and let me know what do you want more of so that the Dr. Brighton Show team can deliver that just to you. And with that said, I'll let you be the boss.

1:04And you'll be the one asking the questions today. Okay, let's get right into it. We received several versions of this question. Why can endometriosis and adenomyosis symptoms get worse during perimenopause? Is it because estrogen is spiking, progesterone is falling, or is the explanation more complicated? it is all of the above. But it does get complicated because it's not just about hormone stimulation of the lesions. It's also about immune system dysregulation, dysbiosis developing, changing nervous systems. So estrogen, well, we know that estrogen can drive and feed endometriosis. We also know the answer is not just to take it away.

1:47Because endometriosis lesions have aromatase. And aromatase takes your testosterone, makes estrogen, and then allows itself to grow. That's what the endometriosis lesion is doing. Progesterone should be challenging that estrogen. The problem is the endometriosis lesion. It upregulates the estrogen receptors, downregulates the progesterone receptors, and now we have basically progesterone resistance. Progesterone can't dock on the receptor even though the receptors are there. So this is where we often have to use more progesterone, or we might need to use progestins, just depending on the individual.

2:20Now, we've got the estrogen rocking and rolling like crazy. We've got the progesterone not challenging it. And then we've got immune system dysregulation. So as we age and we lose our estrogen, there's a phenomenon called inflammation. So as you age, you get more inflammation. And part of that is the decline of estrogen. So estrogen is actually protective. Endometriosis lesions, they produce prostaglandins, histamine, inflammatory cytokines. So that is also why it can get a lot worse. And then there's the fact that as estrogen declines, so does the microbial diversity of the gut. There's a system called the estrobilome in the gut.

2:57These are the organisms that recycle or move out estrogen, and that can become disrupted. And then you can recycle estrogen, have more than your body planned on. It's a great mechanism when we don't make enough estrogen to keep estrogen around, but unfortunately we can get that disruption. Women with endometriosis have been shown to have a propensity towards insulin dysregulation. They have a propensity towards intestinal hyperpermeability. All of these things are also hormone-related. And then there's sleep. And if you don't sleep, you're going to be in more pain. And sleep is very, very restorative time.

3:31Melatonin is incredibly, incredibly potent antioxidant protecting us against the oxidative stress of endometriosis. So it is a lot more complicated, but yeah, it's hormones. Okay. Why does PERI make endo and adeno even worse? Is it the high spikes of estrogen that happen? Yes. So there can be high spikes of estrogen or there can be prolonged exposure to estrogen in the absence of progesterone challenging it. Is progesterone resistance a real phenomenon in endometriosis? And are women with endometriosis or adenomyosis more likely to experience low progesterone or relative androgen symptoms during perimenopause?

4:08So androgens are tricky. We're talking about primarily testosterone. And you might have a decline happening at 25 and bottoming out by 40. You might be someone whose androgens stay fine, but the absence of estrogen, and now you're plucking hairs in the parking lot, right? So it really just depends on the individual. And that's not really endometriosis specific as far as we can tell that like in perimenopause, there's something specific to that. What I will say is there can be androgen abnormalities throughout the lifetime of an endometriosis patient. And certain androgens can be elevated. And that might be a biomarker we could look for to predict if someone has endometriosis, but not necessarily diagnose it.

4:54We're going to change our minds about androgens, perimenopause, and endometriosis, and how are we going to change them? However, the research determines what is actually going on. It's a huge gap right now. So you might have low progesterone. You could have concomitant PCOS, now called PMOS. You know, there can be a variety of reasons that you have low progesterone, but you can have normal progesterone and low progesterone symptoms because of the progesterone resistance. Now, the lesions can make estrogen. And at the same time, the lesions are so inflammatory that I think progesterone has a really hard time docking on it.

5:32Some of the research says that like, oh, you don't make enough progesterone receptors. I've talked about this in an episode I'll link to. What I think might happen is that the lesions are making inflammation. Anytime there's inflammation, it's harder to dock hormones onto a receptor. So they upregulate estrogen receptors and they just like don't do anything with progesterone. And that makes it so that they can thrive. So absolutely, we know that if you don't have progesterone to challenge estrogen, you can see growth of these lesions more symptoms. Progesterone also helps with mast cells and helps with histamine.

6:09Estrogen is gonna cause you to make more histamine. It's also going, well, not make more histamine, but dump more histamine. Those are going to downregulate DAO enzymes so you don't clear your histamine. And then histamine is going to tell your ovaries to make more estrogen. They work together in that way. Progesterone can help with mitigating all of that as well. So this is why typically women with endometriosis, even when they're not in perimenopause, we're like, maybe we should do cyclical progesterone half the cycle. If someone has adenomyosis, I will do that. Or they might go with a progestin IUD because we want to be flooding these receptors and trying to block so much estrogen stimulation.

6:47Not getting rid of estrogen. The rest of your body needs it for sure. And this is why sometimes women can't use progesterone. They have to use progestin. Progestin grabs onto those receptors so much more tightly. There was an interesting study on endometrial cancer. Endometrial cancer does something similar to endometriosis in terms of its resistance to progesterone so that it can grow and thrive. These cells literally working against you. They initiated GLP-1s and found progestins. This study wasn't on progesterone. GLP-1s with progestins made the progestins dock on the receptors better. The receptors were more responsive.

7:24Hypothesis is that it decreases inflammation. So that improves that. We do not have any clinical trials on endometriosis, but this could be one mechanism of action in which women with endometriosis say, I use GLP-1, my symptoms get better. It's still like very preliminary. And this is all anecdotal. And then, you know, people's clinical observations that we need clinical trials on. Can someone with endometriosis safely use HRT during perimenopause and menopause? And how do you approach HRT when someone has severe endometriosis, but also feels intolerant of progesterone. Yes. So absolutely, women can use HRT if they have endometriosis, but you have to be with someone experienced and it has to be done right.

8:10It's not uncommon for a woman with endometriosis to lose her uterus, have a hysterectomy, and a doctor to say, well, we just have to give you estrogen because the guidelines say no uterus, no progesterone, which is really like I've been seriously criticized for like 15 years for giving progesterone to everyone is it has so many more benefits, but absolutely a woman with endometriosis, we can never say for certain that we cut out every lesion if you've had excision surgery. And because of that, if I give you just estrogen, which is literally gasoline on the fire of endometriosis, then I could do harm.

8:42We need to have progesterone. In addition, research has shown with endometriomas, if you give just estrogen, so sometimes if you have a hysterectomy, you retain your ovaries. If you've had endometriomas, you're at higher risk of ovarian cancer if I just give you estrogen. I have to also give you progesterone. Now, progesterone intolerance is real. Women have paradoxical effects. They take oral progesterone instead of feeling chilled out, calm, getting good sleep, feeling less anxious, the opposite. Raging, totally up all night wondering why I can't get to sleep, feeling like I'm losing my mind, being incredibly depressed, weeping, crying all the time.

9:20Those kinds of things shouldn't just be tolerated. We need to look at what's going on there and see if we can go a different route. Sometimes what you need is instead of 100 and 200 milligrams of progesterone, you need 300 milligrams. Or sometimes we need to start you on 25 and 50 milligrams and go really slow and bring you up over time. Other times, we just go the vaginal route. There's women who go the rectal route. I never start there as an alternative. I don't think anybody likes to start anything rectally. It's not a good time. Um, so, you know, but women do administer it rectally. So what's the theory there?

9:53So when you take it orally, you might be a rapid metabolizer who pushes it into allopregnenolone really quick. It's a huge bolus on the brain of this neurosteroine metabolite. So if we go vaginal route, you're still going to get allopregnenolone, but never the amount that you're going to get orally. Like, you know, not all at once for sure. So that may be your rapid metabolizer. We have to go a different route. So in the United States, the menopause society says, if you have a uterus, it must be oral progesterone. The British menopause society is like, we understand you might not be able to tolerate oral progesterone.

10:31So you still deserve estrogen. Go a different route, but don't drop below the dosage of what you would use in oral. What that means is if you have vaginal route, don't go like, oh, well, I was going to give you 200 milligrams, but we'll just do 100 milligrams. No, same dose vaginally. Now, a lot of people will say, there's no way it's affecting the endometrial lining because we have known evidence of that. Like you shouldn't be using it. Look at the fertility studies. What do we use? Vaginal progesterone, why? Because that readies the uterus. It steps in and it does its job and it counters the effect of estrogen on the uterus and starts to change those cells.

11:09So we can look at the fertility studies and say absolutely 100 % vaginal progesterone is changing the uterine environment and the uterine lining. And from that, you know, that is why practitioners are like, we can go an opposite route, you know, from oral to downstairs in the vaginal route and it be effective. In patients, when we do this, if they're ever concerned, we can monitor with a transvaginal ultrasound. And I have found you can use topical estradiol, you use vaginal progesterone and I don't see endometrial hyperplasia. occurring. And so, you know, when we're concerned, there's ways to monitor that.

11:46So it always happens endometrial hyperplasia comes first. We build up a bunch of endometrial lining and then comes endometrial cancer like years later down the road. If your ADHD feels different across your cycle, postpartum or in perimenopause, ADHD in Women explains why hormones can change your brain and what you can do about it. Pre-order now and for a limited time, get the first chapter audio read by me, Dr. Jolene Brighton, for free. Plus a bunch of other bonuses like a free recipe guide and a PMDD workshop. Claim your bonuses at drbrighton.com slash ADHD and women. That's D-R-B-R-I-G-H-T-E-N dot com slash ADHD and women.

12:32For someone using progestins or progesterone to control endometriosis or adenomyosis pain, what are the options if the medication works but they really want to stop taking it yes so you know I have the endometriosis reset course and there's there's literally so the course has like I'm just laughing because there's like an hour and a half video I think that I do on all of this just teaching progesterone versus progestin so you understand this you understand your options you know the question is always like why do you want to come off of it sometimes coming off progestin is because they're like I don't know who I am on this I don't feel like myself my mood is completely tanking.

13:08Well, then we might want to try progesterone instead. It might be using vaginal progesterone and they're like, I'm getting yeast infections all the time. Like, this is horrible. You know, a route we haven't talked about yet. There's also injectable progesterone. There haven't been studies on IM or subcutaneous progesterone outside of fertility. So we can't say 100%. Oh, yes, this is going to work for endometriosis. But I have tried it in endometriosis patients and have seen positive responses. Now, does that mean that everyone's going to be like these women? No. And this is something that in the absence of evidence that this is when doctors start going with off-label use and we start to get creative.

13:47It's also why like in the endometriosis community, you see people taking oral progesterone, oral progestin, also having an IUD. Like people are getting really creative on how do we manage this disease because we're not getting a lot of help in the research and we're not getting innovations in the pharmaceutical industry. So if you want to come off of it, the question is always why. And then, you know, we have to look at like, well, should you maybe consider excision surgery with a qualified specialist? And I should also say, because we're talking about perimenopause and menopause, it's always ideal if we can have excision surgery before we go into menopause hormone therapy.

14:22And the reason is, is because we know we got most of the lesions. Just because you go into menopause doesn't mean endometriosis will go away. I think that's important to know. And just because I don't give you estrogen doesn't mean your endometriosis will get better at all. I mean, sometimes this is deep infiltrating endometriosis. It's in organs. It's tethering organs. It's, you know, strangling your bowels. I mean, it can be that dramatic of a disease. And just saying, like, just go through menopause and then you won't have estrogen, that's not enough. Because those lesions will continue to progress in some people.

14:55Several people asked about trying to increase progesterone naturally. Can supplements such as Vitex, topical USP progesterone cream, or Saw Palmetto actually change progesterone in a meaningful way? So Saw Palmetto, no. Saw Palmetto is going to affect 5-alpha reductase. And in doing that, it can affect allopregnenolone, the neurosteroid metabolite. So this is why, you know, I'm glad this is coming up now because sometimes with progesterone intolerance, we're using Saw Palmetto so that you don't go so heavy. into allopregnenolins so quickly. The other thing is it'll keep you from the hair loss DHT causes.

15:37So the hair follicle becoming very, very thin, the chin, chest, abdomen having proliferation of hair growth. So that's more how saw palmetto is used. When we're talking about, so there was the saw palmetto question. When we're talking about Vitex, it will help you for as long as your ovaries are able to make progesterone. If you're, you know, perimenopausal, your ovaries are calling it quits, it's not going to help you with that. We don't have like tons of studies about what's the best dose, but it's pretty universally accepted that 200 milligrams orally is the best dose for Vitex. Vitamin B6 and vitamin C are also incredibly important for progesterone production and going to stop stressing so much because the body will actually prioritize stress hormones over reproductive hormones when the environment's not safe.

16:30It's about survival and procreation is very expensive, right? So we've got to survive first. Okay. When does endometriosis or adenomyosis need surgical care rather than hormonal management alone? So adenomyosis is a tricky one because if you have diffuse adenomyosis, we can't excise that. it's a hysterectomy. There is a treatment called HIFU, high intensity frequency ultrasound. I think that's what it stands for. I'm like, let me double check that because I always say HIFU that may be able to shrink those lesions. If it is a focal lesion of adenomyosis, that can be excised. If it's very, very large, that might be a hysterectomy.

17:13When it comes to excision, we look at quality of life and we look at more than just pain. What is your fatigue like? What are the symptoms that you're having? You know, we see ADHD women are twice as likely to have endometriosis. Eilish-Danlos syndrome, seven times more likely. Like we see these co-occurring conditions. If they're being exacerbated by the endometriosis, it might be worth removing those lesions altogether. When it comes to excision surgery, though, Dr. Melissa McHale said this, and I echo it so much. No surgery is better than bad surgery. so without a doubt if you do not have access to a qualified excision surgeon and no a general OB-GYN and no a MIG certified OB-GYN is not qualified for endometriosis they're going to come for me but I don't care because I care more about the people who are listening right now they need to be doing at least 50 to 100 if not more surgeries every single year it needs to be their focus if they're delivering babies the majority of time and doing like a little bit of endo here and there, you don't want them in your body.

18:13We want a full excision surgery. And I will also say it's a red flag if they don't do imaging first. Imaging is how you actually understand who needs to be in the room for the surgery. And as Dr. Ron Cabrera has said on the Dr. Brighton Show, it is not a suggestion. Imaging is mandatory before excision surgery. And anyone who's not doing imaging first is not someone I would let operate on your body. I would also say someone who has that excision surgery, I met with three surgeons before I picked mine. Shop around. It's like dating. Don't let them put a ring on it until you're sure. And if you have an endometrioma, they better be the best because if they're not the best, they might excise too much tissue.

18:55They might take out your ovary. I don't like any of that. So why do I say they gotta be the best? Because your ovaries matter. They matter for your brain, your heart, your bones, so much of your life. Can fibroids actually be made to disappear naturally? And when might a medication such as Lupron be used before surgery for a very large fibroid? I hate Lupron so very much. But just prior to an embryo transfer, if you have adenomyosis, sometimes with fibroids too, two months of Lupron might be helpful. But I hate it. I know you do. I hate it so much. Castrating women is not cool. And that's what it does.

19:35It's a chemical castration. Why I hate it is because there are women who never recover their hormones again. And I find that incredibly problematic. There are women who are given it for more than six months. Pharmaceutical companies like don't do that. It's dangerous. It's bad for women's health. Doctors are like me. What else am I going to do? And she doesn't eat her hormones because so much of gynecology is taught that our hormones are completely expendable. and what is crazy to me is all through our 20s and 30s and even before that we're told just take the pill you don't need your hormones use lupron you don't need your hormones get an iud your hormones don't matter holy shit you're 40 your hormones are everything they matter so much i'm like the cognitive dissonance of this like you know my brain it cannot handle a contradiction it cannot handle a contradiction like that so um when it comes so with fibroids sometimes people can shrink them, have a consult.

20:31Depending on the size, you may not be able to. And it might be better just to have surgery and have those removed, especially depending on your fertility goals. With fibroids, with adenomyosis and pregnancy, time is of the essence, right? And so you might need to have a procedure. HIFU may also help with fibroids. That's a natural way. I will say there was a study that showed that with adenomyosis, 25 % of cases, it came back. But I'm like, well, what if we did something else? What if we helped with estrogen metabolism? What if we use progesterone? What if there was a progestin IUD? Like, what if we did other things?

21:07So with fibroids, there are medications, there are, you know, there are surgeries, but you know, if they get too large, there's really nothing natural that's going to take care of it except for surgery. And I would rather have surgery, honestly, than do Lupron. And the reason is, is because Lupron demands that you have no hormones for two months. Women become suicidal. Women have severe depression. It is horrible to have the vaginal dryness, the hot flashes, the night sweats, to go to brain fog, all of that. And I think that, you know, if they're large enough, just having surgery, it's the recovery.

21:46As someone who did Lupron for two months, I'm like, I would do surgery before I lived through Luf-Bron and I actually did ad-back therapy. And because like, you know, I'm trained in endocrinology, I can do that. They did ad-back therapy of estrogen and progesterone because I was like, I cannot survive. I cannot survive another day in the absence of hormones. It is just so horrific for my brain. Well, if you guys enjoy having Angela here with me, let me know. As always, like we love spending time with you. Thank you for being part of the Dr. Brighton Show community. If you can, leave us a comment, let us know what was helpful, what you'd like to hear more of, and of course, share this with everyone so that people can get the information they need.

22:27And together, we all can change women's health for the better. Thank you. Thank you.