On Monday, I met my new therapist. She is awesome. Her son is transmasculine, so she understands our struggle for gender-affirming care.
Yesterday, Tuesday, I had an appointment with the Endocrinology Clinic at the Rocky Mountain Regional VA Center in Aurora. It is a very nice campus; very modern, with other medical centers next door, such as the University of Colorado Children's Hospital. The VA Staff were friendly, but I am not impressed with the care so far.
My appointment was for 11:00 am, and I arrived early enough to wander around and find where I needed to go because the place is HUGE. I checked in at 10:50, and within minutes was called back by the nurse to get my vitals. Then I was returned to the waiting room to wait for my provider.
I waited, and waited, and waited. At 11:40, I spoke with the receptionist to ensure they had not forgotten me. He assured me that the doctors were running late due to many morning appointments where the patients arrived late due to the pouring rain.
At 11:45 am, my provider called me in. He said that he could not access my medical records yet, so he wanted to review my current meds and medical history. When we finished, he excused himself to consult with his attending physician (the woman I was scheduled to see in the first place). After a bit, both of them returned, and she announced that my progesterone dosage was too high.
Excuse me?
You don't know me. You don't know the number of experts that I have consulted over the years, the published studies I have read, or even the reason my doctors in South Dakota prescribed that dose. And you want to arbitrarily change that? Um, no. You have not even looked at my records, nor have you ordered any lab tests to support that decision. No. No. No.
I tried to educate this woman by explaining what I know, how I know it, and how she can verify it for her own knowledge. She said that "high" progesterone levels are "believed" to cause breast cancer. I told her that I am aware of those outdated studies, and they do not apply to me. I told her to go to Wikipedia and search for "pharmacokinetics of progesterone," go to the footnotes, and read the study that explains the reason progesterone should be given three times a day and not once per day. She dismissed that and said she would consult with her superior, who is up on all the latest studies, and get back to me. Then she ordered lab tests to actually see where my hormone levels are currently.
I told her to think logically about this. If "high progesterone" causes cancer, then that would mean that women would be getting cancer every time they get pregnant, because progesterone and estrogen levels soar very high during pregnancy. She said that pregnant women do get breast cancer often and they believe the cause is high progesterone levels.
What she is referring to is PABC (Pregnancy Associated Breast Cancer), which is the most common cancer in pregnant women.
However, the risk factor is 1 out of 3,000 pregnancies, and is considered "rare". There is no conclusive proof that it is caused by high progesterone levels yet, but there are ongoing studies that may suggest it.
The problem is that there is great difficulty isolating a single cause from all of the various other things that could be the cause: high estrogen levels, increased IGF-1, Human Growth Hormone, medical history of breast cancers, obesity, and other risk factors.
So, what is she calling "high" progesterone levels?
Progesterone levels rise rapidly after conception, reaching 11-44 ng/mL.
In the second trimester, levels continue to increase, reaching 17-146 ng/mL.
In the third trimester, levels reach their peak, ranging from 49-300 ng/mL.
Since I am not pregnant, let's assume that a "high" progesterone level for me would be at the upper end of the first trimester range: 11-44 ng/mL. For safety's sake, let's say that anything over 40 would be considered "high". If my ovaries were producing that much progesterone, I would agree that this is something we need to check.
Oh, wait.
I don't have ovaries, so they are obviously not dumping huge amounts of progesterone into my bloodstream. I am not taking any synthetic progestins (like are found in birth control pills). I am taking bioidentical progesterone pills. That means that what I am taking is chemically identical to what is produced by human ovaries.
Now we get to the question of her concern that my "dose is too high". We have established what we will assume is "too high," so now the question is, how many pills do I need to take to reach those levels in my blood?
The thing about oral medications is that they first get processed through the liver, which is known as "first pass". The medication is mostly removed from the system before it gets into the bloodstream, which means that higher doses are necessary to achieve higher levels.
So, how much progesterone is eliminated during the first pass?
"... a study using LC–MS found that the bioavailability of oral progesterone was only 2.4% relative to vaginal progesterone gel...The very low bioavailability of oral progesterone is due to the fact that it is poorly absorbed from the gastrointestinal tract and undergoes massive metabolism, resulting in almost complete inactivation during the first pass through the liver."
The article also has a chart that shows the various routes, their effects on serum levels, and duration:
Capsule 200 mg 4.3 – 11.7ng/mL 2 – 2.5 hours
In order to maintain the 11.7ng/mL level, you would need to take 200mg six times a day for 24-hour coverage because the duration is only 2 - 2.5 hours.
In order to hit our "high dose" level of over 40ng/mL, we would need to take 800mg (4 x 200mg dose), and take that much six times per day.
I take 100mg three times per day. She thinks that is too high, and I think that is too low. I would need to take 8 capsules six times per day to reach a risky level. And once I reach that level and stay there for months, my risk is almost 1 out of 3,000 (rare).
The problem is further compounded because I can't write my own prescriptions, so I have to go through healthcare providers who do not even understand basic human reproduction biology. It also appears they are not interested in reading something as commonplace as a Wikipedia article that quotes established studies and provides links to them as references. 🤡
So now, I am waiting for them to get my lab results and consult their "experts". I expected this, so I made arrangements to keep my gynecologist as a provider, and she can renew my prescriptions through TeleHealth appointments. We will see if I need to play that ace.
Tomorrow, I get to meet my new Primary Care physician. I have heard she is a wonderful person, and my new therapist's mother is one of her patients. Can't get a better review than that. I am looking forward to meeting a helpful and sane person. 😀
