Chapter 11 - Progesterone Matters More (continued)

Perimenopause isn’t “all in your head”, and it’s not solved by throwing a single hormone at a dozen symptoms. We tell two case stories, Emma (42) and Claire (53), to show what happens when care gets split into silos: pain over here, mood over there, gut issues somewhere else, and no one stepping back to connect the pattern across hormones, metabolism and medication burden.

Emma’s history of endometriosis and PICOS sets up years of oestrogen dominance and progesterone deficiency, then perimenopause turns the volume up. We unpack a detail that changes everything: a pill-induced withdrawal bleed can look like a normal monthly cycle while ovulation is actually suppressed, meaning natural progesterone stays low. From there we dig into the yin-yang relationship between oestrogen and progesterone, why progesterone is often overlooked in perimenopause hormone therapy, and how side effects from multiple pharmaceuticals can mimic or amplify the very symptoms you’re trying to treat.

Claire’s story is the cautionary tale: years past her final period, still trapped in a hormonal storm, numbed by sedatives and misread as a psychiatric case when the root drivers include hormone disruption, gut dysfunction, nutrient depletion, thyroid slowdown and a chronically overactivated stress response. We walk through a practical, stepwise approach focused on foundations, testing, and rebuilding balance so women can actually feel calm, clear and energised again.

If any part of this sounds familiar, share this with a friend, subscribe, and leave a review so more women find it. What’s one question you want to feel confident asking your GP at your next appointment?

Transcript

Emma Wants Whole-Person Care

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Chapter eleven continued Chapter eleven point five Emma Why progesterone does matter more Emma was a stunning woman who came to see me at the age of forty two, reporting perimenopausal symptoms. She was a woman with a complex medical history and a set of chronic conditions. She was desperate to find a solution that would support her body and her unique biochemistry, both of which she felt were out of alignment. For reasons that you will soon learn, Emma felt caught in the middle of different medical specialists, their varying diagnoses and their numerous potential solutions, none of which seemed to be serving Emma on her health journey. Very quickly after Emma sat down in my office, she said, I know I have a complicated case. I know I see a lot of different doctors, and I'm on a long list of pharmaceuticals. But I feel like no one is looking at me as a whole human being. No one is tying together my pain, my symptoms, and my chronic conditions. I was already familiar with some of Emma's medical history. Due to a horrific car crash, she endured eight corrective surgeries within ten years, during which she worked with a host of specialists and had developed long-standing relationships with each of them. I had no doubt that every doctor involved in her case was doing their very best to help Emma heal. However, what I heard Emma say was that each specialist seemed to be operating in their own silo of medical expertise, both in their diagnosis and therapy protocols to treat her symptoms and conditions. I suspect that none of her specialists had talked to each other, so they weren't connecting the dots between her different medical issues. I sensed that over time Emma had internalized these symptoms and issues as her fault, as her personal and unchangeable brokenness. I could hear the frustration in her words as she spoke. Then Emma asked me a critical question. Can you help me tie everything together? Can you treat me as a whole person, looking from a bird's eye view with all of the symptoms and conditions collectively? I told her that I would absolutely try. Since I practice precision medicine, I see every patient and their biochemistry as unique, and therefore in need of a customized treatment protocol tailored to each woman's specific issues and presenting symptoms. I approached Emma's case in the same way. I understood that her case was going to be a bit more complex because in addition to the accident and her current perimenopausal challenges, she was diagnosed at 18 with Picos and endometriosis. Her treatment in her youth for these two conditions had already set up a unique set of challenges to find the most effective supportive therapy for her during this transitional phase of

Mapping Emma’s Symptoms And Meds

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life. But before I go any deeper into Emma's Picos and endometriosis, first let's go over the issues and symptoms Emma reported when we began our work together. Chronic pain from eight surgeries after the accident, severe breast tenderness to the point that the touch of her t-shirt against her skin was intolerable, migraines, mood swings and insomnia, most likely exacerbated by potential PTSD from the accident, low libido, weight loss resistance, most likely due to existing insulin resistance, debilitating fatigue and brain fog, hair loss, nausea, food addiction, with her favourite binge, blocks of Cadbury chocolate. Emma also listed her current medications, and as I listened, I began to recognize that at least some of the symptoms she presented with were most likely due to side effects from the pharmaceuticals she was taking. More on that

Endometriosis And PICOS Basics

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later. But I want to look more closely at the health conditions Emma faced at 18. Endometriosis and picos. How Emma's endometriosis and picos set the stage for perimenopause. As a quick reminder, endometriosis is a condition in which tissue, similar to the lining of the uterus, begins to grow in places it shouldn't, outside of the uterus. For example, the tissue might grow on the ovaries, the fallopian tubes, or other areas in the pelvis. Endometriosis is considered an estrogen-dependent inflammatory condition, often associated with too much estrogen on board, with a corresponding progesterone deficiency. This hormonal imbalance can cause significant pain, inflammation, and, in some cases, challenges with fertility. But that is only one condition young Emma faced. She also suffered from PICOS. We've talked about Picos multiple times in the book, but here's a quick reminder should you need it. Women with PICOS often ovulate irregularly or sometimes not at all. This can lead to significant hormonal imbalances or estrogen dominance, without enough progesterone on board to modulate the estrogen or the levels of androgens like testosterone. These imbalances can affect everything from mood to metabolism to skin to menstrual cycles and even fertility. Now let's connect the dots for this young woman who suffered both conditions, Picos and endometriosis.

How Estrogen Dominance Builds

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Both conditions can involve estrogen dominance and a deficiency in progesterone. And, as I know from my own medical history, both can result in weight loss resistance, sometimes obesity, and are often closely related to insulin resistance, elevated insulin and glucose levels, so the body is more likely to store fat than burn it. Additionally, the inflammation caused by endometriosis can disrupt ovarian function, causing anovulatory cycles when no ovulation occurs. Further worsening Picos and perimenopausal type symptoms, which include irregular periods, hot flushes, anxiety and depression. In order to treat her endometriosis and Picos, at 18 Emma's doctors prescribed primulate, norethterone, which is a synthetic progesterone. You are already familiar with some of the concerns about progesterone versus bioidentical progesterone from our previous case studies, but basically the primulate suppressed Emma's body's natural production of progesterone, effectively shutting down her reproductive system. Yes, the primulate was used to treat Emma's endometriosis and stop some of her symptoms. Yet, when you stop a woman's body from ovulating successfully, there can be chronic side effects such as bone density loss, weight gain, risk of diabetes, mood issues, fertility challenges, disruption to the gut microbiome and ongoing fatigue. Do any of these symptoms sound familiar to what Emma was experiencing? Yes. To make matters worse, Emma's POS itself created issues with ovulation, making it more difficult for her body to produce enough progesterone. And then, from ages 18 to 42, the primulate largely halted Emma's body's natural production of progesterone, putting her at risk for the long-term health challenges we touched on above.

Pill Bleeds Versus Real Cycles

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Before we talk more about Emma's possible solution, we need to introduce an important issue, the difference between a monthly bleed that is pill induced and a woman's natural menstrual cycle based bleed, and what this looked like in Emma's situation. A pill induced bleed versus a natural menstrual cycle. I want to speak to the differences between a pill induced bleed and a natural menstrual cycle because this distinction was especially important in Emma's case. The primulate effect on her menstrual cycles was similar to the oral contraceptive pill. She experienced a bleed each month, but it was a pill induced bleed, something entirely different from a natural menstrual cycle. This difference is something I believe every woman, every mum, and every daughter who is taking or considering taking the pill deserves to understand. You see, a pill-induced bleed is chemically orchestrated. It happens simply because of the progestin present in the oral contraceptive pill, or for Emma the primulate. And this results in a withdrawal bleed. This kind of bleed is not the same as a natural menstrual cycle that happens within a successful ovulation cycle. As you recall, ovulation, as Dr. Bryden puts it, is the standing ovation in a woman's body, meaning it's the critical event when your body produces progesterone, the goddess hormone that is essential for brain, bone, cardiovascular, and breast health. The withdrawal bleed, in essence, skips over the body's natural hormone production and rhythm, artificially shedding the uterine lining, and it typically reflects what's known as an anovulatory cycle. No ovulation occurs. Thus, this happens with minimal or no natural production of progesterone. For many women, including Emma, this long-term suppression of hormones, particularly progesterone, may lead to significant challenges as they transition into perimenopause. I recognize that hindsight gives us 2020 vision, but had I treated Emma at 18 or 24, my approach would have been to prescribe cyclical progesterone therapy, meaning supplementing natural progesterone during her cycle, instead of putting her on a progesterone. As Professor Pryor's research has shown, cyclical progesterone could have supported Emma's natural ovulation and helped modulate her endometriosis, while it also regulated the longer, irregular cycles that can come with Picos. It may have also eased the burden of her androgen excess, those dominant male hormones like testosterone that contributed to her hair loss. Again, I want to honor the fact that Emma's doctors at the time were doing the best they could with the tools they had. But looking back, it's clear her young body needed a bigger toolbox that could have smoothed her entry into perimenopause years later.

The Estrogen Progesterone Balance

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Why progesterone does matter more for Emma? Fast forward to the 42-year-old Emma sitting in my clinic, suffering from a myriad of perimenopausal symptoms and other chronic issues. With the worsening of her symptoms, Emma went to see her GP, seeking a solution or mitigation to her suffering. This is how Emma found herself in what I call a hormonal paradox. You see, at age 24, her doctors didn't hesitate in prescribing primulate, shutting down her ovulation. But now, at 42, her doctors seem concerned about her estrogen and bone health. Emma's case was a perfect example of the current echo chamber among health practitioners in the orthodox medical model, where the message is often that women simply need hormones as they transition into perimenopause. As a result, Emma's GP then prescribed estrogen for her without ever considering her 18 years of progesterone deficiency. No progesterone was prescribed. For Emma, progesterone's absence was problematic. What many doctors forget, and what I want to shout from the mountaintops, is the yin and the yang of the working relationship between estrogen and progesterone, especially when it comes to preserving bone health in women. Think of estrogen as yin. She's protective, slowing the rate of bone breakdown, keeping your skeletal structure strong and steady. Then progesterone is like the yang. She renews and stimulates new bone growth and regeneration. We know that the yin and the yang work together to create balance and harmony. Similarly, as a woman's body shifts into perimenopause, in order to rebalance and restore harmony in her systems, where there is estrogen, there must also always be progesterone. What I see so often in the women who come into my clinic, including Emma, is that estrogen gets all the attention, while progesterone is often overlooked. Yet, as I've said many times, when it comes to perimenopause, progesterone does matter more. It helps modulate estrogen, the diva of the hormone world, but it also plays a vital role in brain, bone and breast health. That's why it upsets me when I see a woman like Emma presenting with breast tenderness, migraines, fatigue, and heavy bleeds, all classic signs of higher estrogen levels, and yet no one thinks to bring progesterone on board. However, the lack of attention to Emma's progesterone deficiency is just part of the complexity of her case. We also need to discuss the role that the list of her medications played in the symptoms she was experiencing.

Side Effects That Mimic Illness

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Side effects mistaken as Emma's primary conditions. When Emma came to see me, she wasn't only experiencing the signs and symptoms of her picos and endometriosis, or the biochemical shifts of perimenopause. She was also suffering from the side effects of the pharmaceuticals she had been prescribed. Take primulate, for example, the synthetic progestin. Possible side effects include nausea, migraines, changes in libido and breast tenderness. Then there's celebrex, which help manage Emma's chronic pain following the accident. While it's an anti-inflammatory, it can also bring side effects including headaches, abdominal pain and diarrhoea. And finally, one more on her list, Norgesic, which was prescribed to ease her musculoskeletal pain and muscle spasms. This combination medication contains a muscle relaxant alongside a pain reliever, and one of its major side effects can be gastrointestinal disruption. Basically, it can punch holes in the gut. This is just a partial list of Emma's medications and their possible side effects. So the question for me became, were we treating the side effects from Emma's medications, or were we actually addressing the symptoms of her underlying health conditions? With each specialist prescribing their own drug therapy, often without talking to the other doctors, I knew we had to consider another possibility that the side effects of one pharmaceutical might be making the side effects of another worse. Is it any wonder why Emma felt a bit lost, stuck in the confusion created by the different silos of medical expertise she'd been handed? My answer to that was no.

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Her confusion was not surprising. Now, let me share the protocol I developed to help Emma.

Repair Rebalance And Progesterone

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My functional medicine approach. I started by recognizing that Emma needed someone to take her through triage, to establish what needed to be addressed first, and then respond in a way that integrated her overall medical treatment. That meant we started with her foundational health. We healed, sealed, and repaired her gut health and eliminated any of her inflammatory trigger foods. We identified and treated her hypothyroidism, which had gone undiagnosed for years, to better support her metabolism and return her energy while making it easier for her to maintain a healthy weight and better mood. We addressed and corrected her insulin resistance, which allowed her body to respond to insulin more effectively and use glucose properly for energy, helping her fatigue and weight fluctuations. We reintroduced bioidentical oral micronized progesterone to address the high levels of estrogen and androgens Emma had. Using this protocol, Emma began to feel real relief. Her inflammation decreased, she was sleeping better, and her breast tenderness and anxiety both subsided. She even experienced steady weight loss. She told me, I feel like I have a waste again. Her migraines subsided and her gut became calmer too. By focusing on two key phases of the hierarchy of healing, repair and rebalance, we could guide Emma's biochemistry back into alignment in a way that finally made sense for both Emma and her body.

Claire’s Missed Perimenopause Window

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Chapter 11.6 Claire, an unsuccessful graduation to the calm of menopause. There are several reasons I chose Claire as our final case study to close the rebalance chapter. But the most important is this. Her story is a cautionary tale of what can happen to a woman's health when the window for treating perimenopause and rebalancing her hormones properly is missed. Parts of Claire's health journey will sound familiar, especially if you've listened to Emma's story. Both Emma and Claire received well-intentioned but in some ways misguided treatment as young women that later disrupted their transition into perimenopause, and for Claire in particular, into menopause itself. As you will see, Claire never received proper support during the stormy hormonal season of perimenopause, and as a result, she never truly arrived in the more stable and peaceful hormonal state of menopause. Instead, she spent years suffering with unresolved symptoms, misdiagnoses, and missed opportunities to heal. This beautiful mum of three came to see me at age 53. Claire was just 45 when she had her last period, which is considered fairly young. By now, I don't need to tell you that the definition of when a woman officially graduates to menopause is 12 months and one day after her final bleed. However, in Claire's case, at 53, despite being eight years into menopause, she was still experiencing debilitating perimenopausal symptoms. Her health journey will reveal the long-term consequences to a woman's biochemistry that are possible from suppressing ovulation, and therefore her natural production of progesterone during her reproductive years. Receiving the wrong treatment during perimenopause, Claire was then later misdiagnosed as a psychiatric case, when in truth her symptoms were rooted in her hormonal imbalance. Claire's hormonal storm.

Sedatives And The Grey Numbzone

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From the moment Claire came into the clinic, she recognized what a blessed life she'd been given. She was a mum, she loved her husband, they lived comfortably in a beautiful house, and she enjoyed the privilege to stay home to raise her children. And yet, as I dug deeper into her story and into how she truly spent her days at home, I discovered that beneath the surface she lived a quiet nightmare. As we began sorting through Claire's intake form, what caught my immediate attention was her listed medications. This beautiful mum with children still living at home took a sedative and a hypnotic at night to help her sleep. She was also on five milligrams of diazepan during the day, which she took once or twice depending on the severity of her anxiety. As she spoke, I worried that perhaps she was simply being numbed, dulling her spark rather than addressing the root cause. Before we delve into Claire's physical symptoms and her medical history of a long-term prescription of a combined oral contraceptive pill containing both synthetic estrogen and synthetic progestin, I want to look more closely at these drug therapies. What concerned me was the hypnotic sedative and the diazepan kept Claire emotionally numb, meaning she was unable to access the joy that existed in her life. You can't selectively numb emotion. Human beings are meant to experience the emotional highs of highs, the day your child is born, the day you get married, and the lows of lows, the day your partner leaves or the day you lose a dear friend. That's just the beautiful messiness of life. However, the Dalai Lama speaks about the importance of being able to return to an emotional equilibrium, coming back to the mean, that place where you simply feel content, where life is happening, some good, some bad, but there is balance. For Claire, like so many women who take antidepressants, she was trapped in what I call this grey numbzone. She could neither feel the highs, the lows, nor the mean of contentment. As she sat across from me, Claire looked exhausted, pale and absent, as if she were experiencing life by looking at everything through a grey lens. I thought to myself, this beautiful soul has a twenty one-year-old, a seventeen-year-old, and a twelve-year-old who live busy, dynamic lives. Yet, at fifty-three, she was missing out on everything in her children's lives. Every soccer game, birthday party, and carpool, because she spent all day, every day, in her bedroom. Yet I could hear in her words that Claire was desperate to feel happy again. She also missed feeling calm, relaxed, and vital. Her main goal of treatment was to reclaim that vibrancy she once had, to get out of her bedroom, to engage with her children and her husband, with life. Beyond her anxiety and the effects of her medications, Claire's physical symptoms also played a major role in confining her at home. She experienced the following No libido, diarrhea and other gut disruptions, a history of fibrocystic tender breasts presenting as lumps, strongly indicating a higher estrogen state, debilitating back and joint pain, weight loss resistance, she was 10 kilograms overweight, severe mood swings, excessive sweating and constant cold hands and feet, chronic fatigue where she felt both wired and tired so she couldn't sleep. Insomnia. Claire checked 23 out of the 30 symptoms on the perimenopausal self-assessment, and yet, her last menstrual bleed was eight years earlier. So why was she still riding the hormonal roller coaster of perimenopause? To answer that, we have to look more closely, just as we did with Emma at Claire's earlier medical history.

Trauma History And Symptom Intensity

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First, I want to bring to your attention that Claire also had a high ACE adverse childhood experiences score. This test is a screening tool used to identify traumatic events experienced before the age of 18. Although not a physical symptom, higher ACE scores are not uncommon to the women I see in my clinic. This reality supports compelling research that shows a strong connection between higher ACE scores and more intense perimenopausal symptoms. Although in Claire's case study, I won't focus on the relationship between her ACE score and her symptoms, I want to touch on this briefly to create a sort of on-ramp to what we will explore more deeply in chapters 12 and 13. Why trauma so often taps a woman on the shoulder during this powerful transition phase of her life. I believe a woman's body carries these early adverse experiences forward. And from what I've seen in the hormonal disruption of perimenopause, unresolved trauma often resurfaces both emotionally and biochemically. For now, let's take a closer look at Claire's earlier medical history. The

Years Without Ovulation On The Pill

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shutting down of Claire's hormones. At the age of 16, Claire was put on a combined oral contraceptive pill, containing both synthetic estrogen and progestin. She remained on the pill until she fell pregnant with her first child when Claire was 30. So for 14 years, Claire didn't ovulate naturally. As you learned earlier, this early suppression of a woman's natural production of progesterone can have devastating effects later in life, particularly in perimenopause. During a time in Claire's life when she should have been ovulating robustly, when her natural production of progesterone, the goddess in her hormonal world, should have been sky high, the oral contraceptive, in essence, shut her hormones down. The natural production of progesterone should have been positively impacting her heart, brain, bones, and fertility, but the goddess progesterone was missing in action. During her fertile years, Claire was very lucky that even with a severe hormonal disruption from the contraceptive, she was able to produce enough progesterone to fall pregnant three times. Research into the oral contraceptive pill has revealed various issues connected with this therapeutic approach. The research has linked the pill to depression, bone mineral issues, osteoporosis, depletion of magnesium, disruption of the gut microbiome, as well as increased anxiety because of the suppression of natural progesterone production.

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Now, let's return to Claire's health journey.

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The missed

Hormones Misread As Psychiatry

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window of treatment. As Claire began to experience perimenopausal symptoms due to the natural changes in her biochemistry, she never received proper treatment or support from her GP. Instead of being offered perimenopausal hormone therapy, her case was diagnosed as psychiatric instead of hormonal due to her issues with anxiety. So she was treated with sedatives and anti-anxiety medications. At one point, Claire was actually admitted to a psychiatric hospital and given timazepan, a powerful sedative, along with additional SSRIs, selective serotonin reuptake inhibitors, a class of medications commonly prescribed to treat depression and anxiety disorders. During that critical phase in her life, no one thought to test Claire's hormonal levels, no one considered her chronic sleep issues, the disruptions in her gut, or her overactivated nervous system. When Claire was young and her hormone levels should have been at their peak, most critically her progesterone, they were shut down with the pill. Later, when she most needed perimenopausal hormone therapy to bring her biochemistry back into alignment, she was given antidepressants instead. In my opinion, this is precisely why, eight years later, she found herself in my clinic, still presenting with debilitating symptoms of an unsuccessful graduation to menopause. What further broke my heart for Claire was that for the three years prior to coming to see me, she had been in and out of hospitals. She reported that her doctors had done the tests they thought necessary, including gastroscopies, endoscopies, and full blood panels. After each one, they told her that everything looked normal, that there was nothing wrong with her. She was instructed to keep taking the diazepan and the sedatives. For Claire's treatment protocol, we needed to go back to the drawing board, and by that I mean we had to go back to restoring her foundational health. Her symptoms had nothing to do with psychiatric issues. They had everything to do with the disruptions in her gut health and the chronic dysregulation in her nervous system that had gone unaddressed for years. I believe she had been in a sympathetic dominant nervous system state for so long, meaning that her body was stuck in constant fight or flight, that her adrenals were exhausted. Yet no GP had ever looked at the issues caused by the long-standing dysregulation of her nervous system. I don't believe any doctor ever truly listened to Claire when she repeatedly insisted that her issues were not psychological. When she described her anxiety to me, she said, I feel the anxiety in my body. I feel its pressure and fire. When I begin to worry, my mind starts racing. I feel it in my head and my chest. I get so anxious I can't fall asleep. I'm wired and tired, and eventually my body will crash, but only for a short time before that same cycle begins again. I was determined to listen to Claire as we began my treatment protocol to heal her body. Claire's Treatment

Gut Thyroid HPA And Hormone Support

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Protocol. While I believe many of Claire's issues were directly correlated to her long-term use of the combined contraceptive pill, the lack of proper care during perimenopause played an equally critical role. It was the missing piece of support that left this beautiful woman, now 53 years of age, stuck in a state of hormonal turmoil when she should have already gracefully graduated into the calm of menopause. And that's the very reason my protocol for Claire began with repair and doing the work to heal and seal her gut. Claire began my heal, seal and repair protocol. After she completed the four weeks of eating ideal foods, including delicious power cuppers, we identified her food triggers. We reestablished the integrity of her gut lining so her ability to absorb nutrients came back online. The protocol also successfully reduced a lot of her inflammation. With a healed and sealed gut, we could shift our focus to Claire's over-activated nervous system, more specifically to calming her HPA axis. We ran some full blood panels, including a comprehensive thyroid panel, and we also checked her B12, magnesium and zinc nutrient levels, all of which could have been exacerbating her anxiety. For Claire, an essential part of repairing her adrenal burnout included a full assessment of her thyroid function. Like Claire, when your stress response has been chronically activated, your body prioritizes survival. To conserve resources, it will often downregulate thyroid function, slowing your metabolism and energy production in the process. This is the reason Claire experienced relentless fatigue, cold hands and feet, and a constant struggle to lose weight. The next step to bring Claire's biochemistry back online was to prescribe her bioidentical progesterone, because this goddess hormone promotes sleep. If you remember, progesterone is calm, cool, and collected. She nourishes your bones, your skin, your breasts, and your brain. Progesterone had been the missing piece for Claire, both as a young girl when her body didn't produce it naturally, and also during her perimenopausal treatment. Progesterone is what her body had been asking for. With Claire's gut now healed, sealed and repaired, and her overactivated adrenals finally receiving the support they needed, her hormones were back into balance. Most importantly, her progesterone was at the optimal level for a woman in menopause. As a result, Claire's symptoms subsided. She is once again finding the joy in her life and cherishing time with her children and husband. She now spends her days doing the things she loves and finds meaningful. Claire has truly reclaimed her vitality.

Ask Better Questions And Persist

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As we close out Rebalance, the second phase of the hierarchy of healing and prepare to step into the third and final phase reclaim, I want to leave you with a few closing thoughts. You've met six beautiful women and followed their health journeys as they navigated the hormonal storminess of perimenopause. Each woman's path was uniquely her own, just like her biochemistry. And yet, what shines through every story is this. No matter what challenges or chronic symptoms you may be facing today, when you're empowered with the right knowledge about this natural and critical transitional phase of life, you can find the treatment and support your body needs to feel vibrant again. Be bold.

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Ask your GP the right questions. Request the proper testing.

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And if you're told everything looks normal, but your body is saying otherwise, trust your instinct. Insist on better answers.

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You deserve to feel vibrant, radiant, and full of zest for life.