June 11

Progesterone – Q&A with Prof. Jerilynn Prior


Editor’s note: At MenoClarity Live, there were lots of questions for one of our founders, Professor Jerilynn Prior, about progesterone. In many places, progesterone is only prescribed to accompany estrogen for women who still have a womb to protect against endometrial cancer. Professor Prior’s research shows progesterone has a much greater role to play in the management of perimenopause symptoms.

Answers from Professor Jerilynn C. Prior BA, MD, FRCPC

Q What are your thoughts about progesterone intolerance? I have this.

There are very few people who are actually unable to use progesterone as a therapy. In most situations progesterone seemed to be causing problem because it was started when the person was already on full or high dose estrogen. Progesterone, in its first cycle may increase what are really estrogen-related symptoms. That experience goes away with either dropping the estrogen dose (if taking that) or with continuing with the progesterone.

Q The role of progesterone is often underestimated. I’m in the UK with this being off license in terms of indication. How do we go about discussing this with patients – explain the off license nature? And prescribe alone without oestrogen? UK BMS guidance doesn’t advocate this? But rather start combined HRT (if womb present) rather than one alone.

Thank you for your question. I’m not part of the culture of medicine in the UK so I’m not sure I can totally answer this.

However, I would first explain that for treating with progesterone in perimenopause we are using it as a kind of “physiological replacement therapy”. In other words, we’re replacing or augmenting progesterone since the higher estrogen levels are way out of balance with naturally lower progesterone levels.

In using progesterone in menopause as a solo therapy, we are treating it like any other therapy for hot flushes, night sweats and sleep problems.      

Q What is the view on taking progesterone after a hysterectomy?  My sister does not currently take it due to her hysterectomy; however, I feel convinced her symptoms would ease if she could take progesterone. She is on oestrogen.

Great question! 

It is a very important concept that women who have a uterus and take estrogen must always also take progesterone. But it isn’t a logical extension of that concept that women who don’t have a uterus don’t need progesterone. That would imply that progesterone is only helpful for preventing uterine cancer. We know that is not true. Progesterone works with or counterbalances estrogen in every part of our bodies. Said another way, a woman who has had a hysterectomy (and thus has no uterus) still has breasts, brain, bones and heart that need progesterone also. 

Q When would progesterone therapy optimally start?

Any treatment starts when the person needs it. We use progesterone to treat problematic perimenopausal night sweats and sleep problems. If women are waking more than twice a week with night sweats, that is a reason to start progesterone therapy.

Q When taking progesterone or hormone therapy, why do we not reflect the natural cycle ie. only take progesterone for 7-14 days  of a month to reflect the second half of the cycle (luteal)?

Good question. In most situations the problem we are trying to treat isn’t limited to 14 days each cycle.  

Usually for perimenopausal women who are having trouble coping with life, not sleeping well and waking with night sweats, those problems are irregular or extend beyond two weeks each cycle.  However, if as happens in Very Early Perimenopause when cycles are still regular, night sweats are only around menstruation, you can start progesterone about 10 days before you expect your period and continue taking it for a full 14 days. 

Finally, when estrogen in menopause is prescribed in higher doses (more than 1 pump of estrogen/day, a 100-microgram patch changed twice a week or other high doses) you need to take progesterone in a dose of 300 mg every day to be able to prevent uterine cancer. 

Q I had a total hysterectomy 12 years ago, was never prescribed progesterone and I’ve just been on estrogen and now for the last 2 years on testosterone as well. Do I have to take progesterone? My menopause specialist says no.

I’m sorry that you find yourself caught between different points of view. Here’s what I would say to your physician, “I still have breasts, brain, bones and heart that I have learned need progesterone as well as estrogen. Please prescribe me progesterone 300 mg each day at bedtime. Thank you.”  

If your menopause specialist declines to do as you respectfully ask, then ask your family doctor to prescribe your hormones.

I would also re-examine the testosterone since there are few strong reasons for women to take it.  And it is metabolized into estrogen . . . .

Q Can progesterone be taken all month long for perimenopause symptoms? My client only has it for half the month and has a very hard time when she doesn’t take it. She is prescribed estrogen all month.

If your client is in perimenopause, evidence says to me she would be more effectively treated with daily 300 mg of progesterone alone. There is no evidence that estrogen helps with perimenopausal hot flushes and night sweats, it doesn’t improve deep sleep and it may cause harm when women’s own estrogen levels may still become very high. 

Q I am in perimenopause (48 years, irregular cycle). I am on 200 mg progesterone (utrogestan). I take it for two weeks a month. Would it be possible to take it continually? All throughout the month? I use oestrogen patches as well (50 mg).

If you are taking oestrogen daily (which is NOT a safe or evidence-based thing to do in perimenopause), you need to also be taking progesterone daily.

If you were not taking oestrogen, then the decision to go to daily therapy would depend on whether night sweats and sleep problems bother you more than the last two weeks of your cycle or of a month. In other words, we use progesterone to treat problematic symptoms. 

Q Progesterone is just for perimenopause or for post menopause too?

Thanks for this good question. There are randomized controlled trial studies showing that 300 mg of oral micronized progesterone is effective for hot flushes, night and sleep problems in (post) menopausal women (more than a year past their final flow) as well as for treating night sweats and sleep problems in perimenopause.  

Q There seem to be a lot of progesterone creams on the market as well. What are your thoughts on these instead of the oral form?

I think that progesterone should always be prescribed by a healthcare provider and not be otherwise available. The progesterone creams are largely a way to make money since the evidence that they are effective for problematic perimenopause or for menopause is currently lacking. However, they are also very safe. I would not trust them to protect against endometrial cancer in women taking estrogen therapy. Nor do I think they are adequately effective in perimenopause but may help in menopause.

Q Does it make a difference / better or worse to take oral micronised progesterone vs in gel form?

I am unclear about what you are asking. I think that the gel form of progesterone is only available for taking through the vagina. Evidence says that progesterone orally is the only form that clearly improves sleep problems. 

Q I have been asked about progesterone only.  Do you have the link to the report that Jerilynn spoke about and had on her slide?  

Here is the link to the open-access controlled trial of progesterone for perimenopausal night sweats.

Q Recommendation of 300mg oral dose for what phases of menopause or all?

Oral micronized progesterone 300 mg at bedtime is effective for perimenopause as well as for menopause – in both life phases it should be used to treat problematic things like night sweats waking you more than twice a week, or for sleep problems leading to tiredness and fatigue.

Q If you have a Mirena coil/ progestin for heavy periods, can oral progesterone act in the same way to reduce heavy bleeding (in adenomyosis for example).

Good question! The progestin-releasing IUD is effective for heavy vaginal bleeding. Progesterone by mouth is less effective (because it is not at high levels right at the lining of the uterus).  However, my clinical experience is that if 300 mg are taken every day by a woman with adenomyosis or flooding menstruation, it will decrease the frequency of periods and also the amount of flow, usually without stopping flow totally until very late in perimenopause.

Q What about progesterone creams? Can you get them in the UK or only in the US?

I don’t know. They are compounded in Canada, and not available without a prescription; in the USA they are freely available over the counter.

Q I know you won’t be able to give specific advice, however, do you suggest that women who are perimenopausal should take progesterone continuously?  I currently take 200mg days 15 – 28.  I am also on the mini pill ceresette.  I don’t have periods, because the mini pill stops them for me; however I have tried coming off the pill and periods returns, so I know I am not menopausal (I am 46). I ask because I know I feel much better the 2 weeks I am taking progesterone than the 2 weeks I am not.  Wondering if I should take this up with my GP.

Certainly, ask your GP for daily progesterone 300 mg at bedtime. Progesterone, however, does not prevent pregnancy, so either keep the mini-pill or stop it and use condoms and vaginal spermicide for contraception. 

Read about the difference between progesterone and progestin.


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