Questions About Progesterone for Perimenopause? Here's What to Know, from Benefits to Timing

When you think of the classic perimenopause symptoms—trouble sleeping, mood changes, irregular periods, the like—you might assume they’re caused solely by the estrogen fluctuations you’re experiencing. But while estrogen may have a key role in these changes, these symptoms can also be triggered by low levels of another hormone: progesterone. 

Taking progesterone for perimenopause may play a part in reducing your symptoms and helping you feel like your old self. Beyond providing some symptom relief, progesterone is crucial for people who have a uterus and take estrogen, as progesterone protects your uterus from a dangerous thickening of the uterine lining (aka endometrial hyperplasia) that can happen when estrogen is taken alone. Left untreated, this thickening can sometimes progress to endometrial cancer—which is exactly why progesterone is usually considered essential for anyone with a uterus who's taking estrogen.

Whether progesterone is old news to you or a totally new concept, read on to learn more about what the hormone does in your body, signs your levels are getting low, and when to ask a healthcare professional, such as a Midi clinician, about if you should take progesterone for perimenopause. 

What Does Progesterone Do in Perimenopause?

Ever since you started getting your period, progesterone has been working quietly in the background. Along with estrogen, progesterone prepares your uterine lining each month to help with fertility and keeps your cycle regular. It also can improve your mood and sleep (progesterone can target receptors in the brain to help feel calm), support your thyroid, balance out levels of estrogen, and more. 

But here’s the thing: Progesterone is produced when you ovulate. “It typically rises in order to help support the uterine lining in case a pregnancy occurs,” says Amanda Rosales, DNP, a clinical leader at Midi. As a result, going through perimenopause can mess with levels of the hormone. “Ovulation becomes less predictable and less frequent, so progesterone won’t rise as much,” says Rosales. “This can lead to irregular bleeding, more PMS symptoms, and sleep issues.”

One quick note: While they sound similar, progesterone and progestin aren’t the same thing. Progesterone is the natural hormone, while progestins are synthetic versions found in many forms of birth control. They have different chemical structures and behave differently in your body.

Why Progesterone Drops First in Perimenopause

A key reason your hormones change during perimenopause is because ovulation becomes a lot less regular (until it ultimately stops completely). This sets off a domino effect in your body. First, fewer ovulation phases means you don’t get the routine monthly bumps in progesterone that you used to. Because this tends to happen before your estrogen declines, you may have higher levels of estrogen compared to progesterone during perimenopause—the hormones are out of balance. 

This leads to something called unopposed estrogen, also known as estrogen dominance. The progesterone isn’t there to keep the estrogen in check, so the estrogen can have an outsized impact on your body. You may notice that your breasts feel tender, you’re tired, you have a lower libido, and your mood is worse, among other symptoms. 

Hearing that something is out of balance in your body may make you feel worried, but this is an entirely natural part of perimenopause. And not only does this not really need a diagnosis, there’s also no good way to test for low progesterone levels. They can fluctuate all the time, so a single blood test won’t tell the whole story.

Signs of Low Progesterone in Perimenopause

You may not experience all of these, but here are some of the main symptoms of low progesterone during perimenopause:

• Irregular periods: Your cycles may be shorter, your bleeding may be lighter or heavier, and you may have spotting between periods
• Headaches
• Anxiety, depression, irritability, and other mood changes
• Poor sleep
• Hot flashes

These symptoms can be caused by things other than low progesterone, so make sure you talk about anything new or concerning with a healthcare professional, such as a Midi clinician. They can do a deep dive on your symptoms and come up with the right treatment for you.

Benefits of Progesterone for Perimenopause Symptoms

Many women going through perimenopause consider hormone replacement therapy (HRT, now commonly referred to as menopause hormone therapy or MHT). HRT can include estrogen, progesterone, or a combo of the two, depending on your health history. Here are some of the ways taking progesterone during perimenopause may improve your symptoms:

• It can protect your uterus: When you take estrogen, your uterine lining can grow too thick, raising your risk for uterine cancer. Progesterone can stop that from happening and bring your risk back down. (This is the main reason why progesterone may be part of your treatment.)
• It can improve your sleep: Studies show that taking oral micronized progesterone (a bioidentical form of the progesterone your body makes—more on this below) in the evening can help you fall asleep faster and sleep better. This is likely because progesterone affects what’s known as GABA-A receptors in the brain, which can have sedative effects.
• It could help your mood and anxiety: The same calming actions that can make you feel sleepy could also help you feel less anxious, but it doesn’t work this way for everyone. In some people who are more sensitive to hormones, progesterone could actually have the opposite effect, raising anxiety.
• It can make your periods less annoying: Estrogen dominance during perimenopause can cause your cycles to be irregular with heavy bleeding. Taking progesterone can help you get back to regular.

Types of Progesterone: Micronized, Progestins, and Creams

The progesterone most often recommended for HRT is something called oral micronized progesterone. This is a form of the hormone that is “bioidentical” to what the body makes. This means that it has increased bioavailability, a fancy way of saying that more of the medication is absorbed and used by your body. “Micronized progesterone also appears to be associated with a lower breast cancer risk than synthetic progestins,” says Rosales.

That doesn’t mean synthetic progestins don’t have a place—they are often used in oral birth control to stop the body from releasing an egg and protect against pregnancy. But they do have different side effects from micronized progesterone, including, as mentioned above, an increased risk for certain cancers. Progestin is also what you’ll find in hormonal IUDs, which can be helpful for birth control, thinning the lining of the uterus, and reducing bleeding each month (or even stopping it completely).

There’s another form of progesterone you might hear about: topical progesterone. These creams or gels are rubbed on to the skin to improve elasticity and firmness. Some users may also notice an improvement in other symptoms like sleep and mood, but don’t rely on these forms to protect your uterus. When applied to the skin, not enough of the progesterone reaches the blood, so the creams and gels won’t protect your uterine lining from getting too thick.

You don’t need to try to remember all of this yourself. A healthcare professional, such as a Midi clinician, will go over your health history, symptoms, and goals and recommend the right form of progesterone for you.

Progesterone Dosage and When to Take It

There is no single right progesterone dosage for perimenopause. Rather, your clinician will individualize your prescription based on your unique needs. 

They will also determine if you should take cyclical progesterone or continuous progesterone. Cyclical progesterone, which is often recommended if you’re still getting your period, is when you only take the medication for half of your 28-day cycle. Continuous progesterone, on the other hand, involves taking progesterone every day. This method is typically for postmenopausal people  who have not had a period for more than a year.

But there is one thing you’ll probably do: take it at night. “At Midi, we typically prescribe micronized progesterone at bedtime because it can make you drowsy,” says Rosales. This can be a good thing, as perimenopause can often mess with your sleep.

Progesterone With or Without Estrogen

Progesterone can be taken alongside estrogen or by itself; the right path will depend on your symptoms, health history, and goals. “While patients tend to benefit the most from combining it with estrogen, some who have irregular bleeding and sleep issues could benefit from just progesterone,” says Rosales.

But if you have other symptoms related to low estrogen, like hot flashes and vaginal dryness, doing a combination of estrogen and progesterone may give more relief. Just know that if you are taking estrogen and have a uterus, you generally also need to take progesterone to protect against uterine cancer.

A healthcare professional, such as a Midi clinician, will help determine the right path forward for you. They can go over your symptoms, what your cycle is like, and personal risk factors to determine which is right for you.

Side Effects and Safety Considerations

Like all medications, progesterones and synthetic progestins can come with certain side effects. Here are a few to know about:

• Drowsiness
• Stomach issues/pain
• Breast tenderness/pain
• Headaches
• Irritability or mood swings
• Vaginal discharge

There are some rare but more serious side effects to know as well. If you experience any of the following, let your clinician know right away:

• Swelling in your arms or legs
• Lumps in your breast
• Signs of a stroke (confusion, dizziness, difficulty speaking) or heart attack (chest pain, arm pain)
• Intense headaches
• Double vision
• Allergic reactions like hives or difficulty breathing

Certain people should likely not take hormones like progesterone, including those who have had hormone-sensitive breast cancer, a stroke, heart attack, blood clots, or liver disease in the past. 

This is why going over your complete health history with a clinician is so important, as is following up about any side effects you’re experiencing. If needed, they can work with you to adjust your dose or form of progesterone to help you feel better. 

How Midi Health Can Help

Making a decision on whether or not to take progesterone for perimenopause can be complicated—Midi can help clear things up. Midi offers virtual, insurance-covered care from clinicians who specialize in perimenopause and menopause. You’ll meet one-on-one with your clinician to go over your symptoms, talk about any recommended testing, and determine if HRT is a good fit for you. 

If your clinician thinks that progesterone could help you with your symptoms or is needed to protect your uterus alongside estrogen, they will prescribe you a personalized dose and monitor your symptoms and side effects.

Book a visit with a Midi clinician to learn more and get the care you deserve. 

Key Takeaways

• During perimenopause, progesterone often drops before estrogen, leading to symptoms like heavy bleeding, sleep issues, and anxiety.
• Supplementing your progesterone levels as part of hormone therapy may be able to help with certain symptoms.
• If you are taking estrogen and have a uterus, you generally also need to take progesterone to keep your uterine lining from getting too thick (something that can raise your risk for uterine cancer).
• Unlike progestin, a synthetic form of the hormone, micronized progesterone is bioidentical to the hormone your body produces, which helps it get absorbed more easily.

Frequently Asked Questions (FAQs)

What are the downsides of taking progesterone?

Taking progesterone can come with some side effects, like drowsiness, mood changes, tender breasts, and stomach pain. It may also increase your risk for stroke or heart attack in some people, so make sure to go over your health history with your clinician before starting on progesterone.

What happens if you take progesterone without estrogen in perimenopause?

There is generally no danger to taking progesterone without estrogen during perimenopause. Progesterone may not improve all of your menopause symptoms, but when taken alone it can help with sleep, mood, heavy bleeding, and more. The only downside is that progesterone may not improve all of your menopause symptoms; that’s why your clinician may recommend taking it alongside estrogen for the most impact, depending on your health history.

What happens when a woman first starts taking progesterone?

Most women start noticing an improvement in sleep soon after starting progesterone. Mood changes and cycle changes will follow, with maximum improvement seen after a few months. 

Can I take progesterone continuously in perimenopause, or only part of the month?

In perimenopause, you will likely only take progesterone part of the month (14 days during each cycle). That said, it can also be taken daily. Once you reach menopause, which is when you’ve gone a year without a period, you can take progesterone continuously.

How long does it take for progesterone to start working in perimenopause?

You may start to notice that the progesterone is working within a week or two, but keep in mind that everyone can react differently to hormone therapy. If you’ve been taking progesterone for more than 4 weeks and haven’t noticed any symptom improvements, talk about it with your clinician to see you're on the right dose and formulation.