Low Progesterone Symptoms in Perimenopause and Beyond

You tend to hear a lot about estrogen and its starring role during the menopause years, but low progesterone symptoms are often some of the earliest signs of perimenopause for many women. Levels of estrogen and progesterone both start to fluctuate in midlife, yet progesterone typically takes the lead, declining a little earlier in the menopause transition.

Progesterone plays a critical role in menstruation, and when levels of the hormone begin to shift in early perimenopause, it’s common to start noticing irregular periods—one of the classic signs of low progesterone. Even if your cycles were consistent as a clock for decades, they now may become shorter, then longer. As time goes on, you may skip periods entirely or experience episodes of heavy, unpredictable bleeding.

Low progesterone can have other effects on your body, too. While these symptoms can be frustrating, they’re real and treatable with the right support. Read on for more about what causes low progesterone, and how a Midi clinician can talk with you about available treatments for low progesterone that can help you feel more like yourself again.

What Is Progesterone, and What Does It Do?

Along with estrogen, progesterone is the other major hormone that your ovaries make. Estrogen may be the household name, but progesterone does just as much heavy lifting. 

Progesterone is a progestogen, a class of hormones that includes the progesterone your body makes, lab-made versions that are chemically identical to it, and synthetic progestins that have a different structure. (If your clinician prescribes a progesterone treatment to you, it may be in either of those last two forms.)

Progesterone is a busy hormone. Throughout your lifetime, it’s responsible for a number of important roles in your body:

• Protects your uterus: This may be progesterone’s most critical job. After ovulation each month, progesterone helps thicken the lining of the uterus, preparing it for a possible pregnancy. And should you become pregnant, the hormone makes it possible for a fertilized egg to successfully attach to the uterus wall.
• Regulates your menstrual cycle: After progesterone has prepped your uterine lining for pregnancy and that doesn’t happen, levels of the hormone drop, the lining sheds, and—voilà—you get your period. 
• May help your mood: Progesterone can have a calming influence in your brain and has a role in how your body handles stress, which is why changes in your levels may affect your mood. 

In midlife, the balance of your reproductive hormones shifts, and that includes progesterone: As the ovaries release eggs less regularly, estrogen levels fluctuate and progesterone levels decline, and you may start experiencing a number of possible signs of low progesterone.

Low Progesterone Symptoms: What to Watch For

So what are the possible low progesterone symptoms in perimenopause to keep an eye out for?

• Periods that look different than usual: During perimenopause, at first your cycle may be shorter—for example, if you reliably had a 28- to 30-day cycle for years, it may become every 24 to 26 days. Then, as estrogen fluctuates and progesterone levels continue to decline, your cycles may become further and further apart. Your period may ghost you completely for a month, or you may have episodes of heavy, prolonged, unpredictable bleeding. 
• Trouble sleeping: Progesterone has natural snooze-promoting effects, and as your body adjusts to lower levels, you might experience insomnia, wake up frequently (possibly compounded by night sweats), and have lousy sleep in general. 
• Mood changes: Declining progesterone levels can spur heightened anxiety, feelings of tension, crying spells, and low mood. You might also feel like your PMS symptoms are way more extreme than they used to be.

That’s not all: With less progesterone to balance estrogen’s effects on your body, it’s possible to experience something that’s popularly called estrogen dominance, which may result in breast tenderness, uterine cramps, bloating, or fluid retention.

Why Does Progesterone Fall First in Perimenopause?

Shifting levels of reproductive hormones are the primary reason why you start to experience symptoms of perimenopause. Along with the possible signs of low progesterone above, they can include hot flashes, night sweats, vaginal dryness, painful sex, and more. 

Here’s why progesterone declines first: Since ovulation becomes less regular in perimenopause, the body isn’t getting that monthly signal to make progesterone, so levels drop. Estrogen, on the other hand, is produced throughout the cycle, although levels do start to fluctuate (and then eventually decline). 

That means estrogen levels can still spike and drop during this time, while progesterone tends to be low and unpredictable. The shift in the balance of the two hormones reflects irregular ovulation, and it’s behind many of the changes to your period. 

What Causes Low Progesterone Besides Perimenopause?

Perimenopause is the major moment in a woman’s life when hormone levels start to fluctuate, but other possible factors can also result in low progesterone. Dysfunction in the ovaries can occur due to medical and lifestyle causes, which then have an effect on progesterone production.

• Chronic stress: Prolonged emotional or physical stress can raise cortisol (also known as the stress hormone). Over time, this can interfere with the brain signals that trigger ovulation, causing it to be delayed or skipped.
• Extreme diets or nutritional deficiencies: Not getting enough critical nutrients can affect your body in countless ways, and that includes your hormones. Restricting calories or following a super limited diet can eventually trigger something called hypothalamic amenorrhea—basically, when your period stops due to a problem in the hypothalamus.
• Polyendocrine metabolic ovarian syndrome (PMOS, formerly known as polycystic ovary syndrome, or PCOS): This condition is characterized by a hormonal imbalance that can affect your periods and cause low progesterone.
• Thyroid disorders: Both hypothyroidism and hyperthyroidism can interfere with the delicate feedback loop in the reproductive system, disrupting normal ovulation.
• Hyperprolactinemia: Women with this condition produce elevated levels of the hormone prolactin, which can affect the ovulatory cycle and affect progesterone.
• Premature ovarian insufficiency (POI): If your ovarian function decreases before age 40, POI is a possible culprit. This condition can cause unpredictable ovulation, low estrogen, and low progesterone.

How Is Low Progesterone Diagnosed? Testing, Explained

The most likely time you would be tested for low progesterone is as part of a fertility workup when you’re trying to conceive, since it can help show when ovulation is happening. It can also be used to evaluate irregular periods.

Low progesterone can be diagnosed via a blood test, such as a PGSN or progesterone test. The challenge, though, is that your body produces varying levels of progesterone at different times throughout the month and even by the hour—so “normal” ranges depend a lot on where you are in your menstrual cycle. This also means a single point-in-time test can be misleading and may not accurately reflect your overall hormonal situation.

For this reason, a healthcare professional may use a number of tools to diagnose low progesterone, such as a blood test along with your menstrual cycle history (have you had lots of irregular periods the last few months, and is your cycle getting shorter?) and other symptoms you’ve been experiencing. Your clinician may also request additional blood work, especially if your symptoms are unusual, you’re under age 35, or you’re experiencing postmenopausal bleeding to also rule out specific conditions.

You may have also heard that at-home hormone tests can be a helpful tool in diagnosing issues like low progesterone or figuring out whether you’re in perimenopause. These tests may look at follicle-stimulating hormone (FSH), estradiol, progesterone, luteinizing hormone (LH), and thyroid markers—but they only tell part of the story, and the findings may not be reliable.

If you do choose to use one of these tests, make sure to book a follow-up visit with a clinician, such as one at Midi, so they can help you interpret the results accurately.

Treatment for Low Progesterone: What Actually Helps

If your clinician determines that you do have low progesterone, you can discuss whether it makes sense for you to start taking progesterone. Note: For women who have a uterus and are prescribed hormone therapy that includes estrogen, their clinician will generally prescribe progesterone along with it; this protects the uterine lining from overgrowth of endometrial tissue, which raises the risk of endometrial cancer. 

Progesterone hormone replacement therapy (HRT, now commonly referred to as menopause hormone therapy, or MHT) is available in a few different forms, depending on your symptoms and overall health: 

• Micronized (bioidentical) progesterone: This comes in the form of oral pills, typically taken at bedtime, since it supports sleep as well. Midi clinicians consider micronized progesterone the first-line treatment option because it’s chemically similar to the progesterone that the body makes. 
• Progestin: This synthetic form of progesterone is designed to work like the progesterone the body makes. It’s available as pills, injections, or part of combined hormone products. 
• IUD, such as Mirena or Liletta: Yes, IUDs are best known as a form of contraception, but they can also be an effective option that delivers progesterone, along with providing birth control for up to 5 years. 

As with any medication, progesterone can cause side effects, such as breast tenderness, headaches, mood shifts, sleepiness, or an upset stomach. Let your clinician know about side effects that you experience, especially if they don’t go away.

How to Increase Progesterone Naturally: What the Evidence Says

Some women wonder how to increase progesterone naturally. The truth is that no supplement or lifestyle tweak is known to bring progesterone levels back to their normal range. That said, some approaches that support overall health may be worth trying. 

Lifestyle changes that support ovulation may be beneficial for progesterone production, including eating enough and getting a balanced mix of nutrients, managing stress, and prioritizing sleep. 

There’s mixed and very limited evidence on the effectiveness of supplements to increase progesterone naturally. Your clinician might recommend taking vitamin D or zinc supplements if you have a deficiency in these nutrients. And if your clinician thinks you’d benefit from a supplement to reduce cortisol, they might recommend adaptogens like ashwagandha or amino acids like L-theanine (which are combined in Midi's Daily Cortisol Support supplement). Stress-reduction techniques, such as yoga and mindful breathing, can also help.

Before you add a supplement to your routine, talk with your clinician. And before buying one, check the label to confirm that it’s third-party tested, which helps you know that what’s stated on the label is actually in the bottle.

When to Seek Care—and How Midi Can Help

Hormone fluctuations are a normal and expected part of the menopause transition. And yes, they can be disruptive. But know that many treatments are available to help manage low progesterone symptoms that interfere with your life or just really bug you. 

Before your visit with a clinician, it can help to gather some information, such as the dates of your most recent menstrual cycles, changes and patterns in your sleep, mood changes you’ve noticed, and any other symptoms.

Midi clinicians can be especially helpful during this time. During a virtual Midi visit, a clinician can review your symptoms and health history, order labs when needed, and come up with a personalized treatment plan.

Yet some symptoms that you might develop during perimenopause or beyond warrant urgent medical care. Reach out to a healthcare professional right away if you notice:

• Heavy vaginal bleeding: such as soaking through a pad or tampon per hour
• Irregular or frequent bleeding: such as cycles that occur more than every 21 days or persistent spotting for more than 3 months
• Any vaginal bleeding at all postmenopause: which can be a sign of a serious health condition 
• Severe pelvic pain: which might feel sharp and warrants evaluation

Key Takeaways

• Progesterone is a reproductive hormone produced in the ovaries. It has a number of important roles in the body, including regulating your menstrual cycle, protecting your uterus, supporting your mood, and facilitating a healthy pregnancy.
• Both progesterone and estrogen levels shift during perimenopause, but progesterone typically starts declining a little earlier in the menopause transition.
• Irregular periods and a shorter menstrual cycle are some of the first signs of low progesterone that women often notice. Other low progesterone symptoms can include trouble sleeping, mood changes, breast tenderness, uterine cramps, bloating, or fluid retention; these symptoms may also reflect a shift in the balance between estrogen and progesterone during perimenopause. 
• Testing for low progesterone is usually done for women who are trying to conceive or have irregular bleeding. Because levels vary throughout your monthly cycle and even by the hour, a single reading isn’t super helpful. 
• If you do have low progesterone, your clinician might recommend supplementation, such as micronized (bioidentical) progesterone or progestin.

Frequently Asked Questions (FAQs)

What happens when a woman has low progesterone?

If you have low progesterone, you might initially notice irregular periods and a menstrual cycle that’s shorter than usual for you. As time goes on, your cycle might become longer, and you may skip periods altogether. You might also experience trouble sleeping and mood changes. These are normal changes during the menopause transition.

How do I know if I need progesterone?

Your clinician can assess your symptoms and figure out whether testing and treatment are warranted, and then discuss your various options with you to find the best one for your health.

What are the differences in symptoms between low and high progesterone levels?

Low progesterone can cause your periods to become irregular or occur more frequently, along with trouble sleeping and mood changes. Too-high levels of progesterone may not have any noticeable symptoms at all and in most cases have no impact on health. However, taking progesterone can cause mood changes or leave you feeling sleepy.

Does low progesterone cause weight gain?

No, not directly. Weight gain in midlife is a real thing and has many potential causes. Hormonal shifts certainly come into play, as do aging and changing lifestyle.