What is the role of progesterone supplementation in managing perimenopausal symptoms?

From the Guidelines

Progesterone supplementation can be an effective treatment for managing perimenopausal symptoms, particularly those related to estrogen dominance, and should be considered for women experiencing heavy or irregular periods, mood swings, sleep disturbances, or anxiety during perimenopause. For women experiencing these symptoms, bioidentical progesterone (such as Prometrium) at doses of 100-200mg taken orally at bedtime is typically recommended 1. Topical progesterone creams (20-40mg daily) are also available but may have less consistent absorption. Treatment is usually cyclic (10-14 days per month) for women still having periods or continuous for those with more advanced perimenopausal symptoms. Some key points to consider when using progesterone supplementation include:

• Progesterone works by balancing estrogen effects, which often become erratic during perimenopause when progesterone levels naturally decline before estrogen.
• This supplementation helps regulate menstrual cycles, improves sleep quality through its mild sedative effect, reduces anxiety, and may decrease hot flashes in some women.
• Unlike synthetic progestins, bioidentical progesterone typically causes fewer side effects, though some women may experience drowsiness, dizziness, or breast tenderness.
• Progesterone supplementation should be medically supervised and may be particularly beneficial for women with estrogen dominance symptoms who are not yet candidates for full hormone replacement therapy. It's also important to note that the use of hormone replacement therapy (HRT) for the prevention of chronic conditions in postmenopausal women is not recommended, as the harms are likely to outweigh the benefits 1. However, for women experiencing menopausal symptoms, the decision to initiate or continue HRT should be made on the basis of discussions between a woman and her clinician, taking into account individual risk factors and preferences 1.

From the FDA Drug Label

Progesterone capsules are used for the treatment of secondary amenorrhea (absence of menstrual periods in women who have previously had a menstrual period) due to a decrease in progesterone Progesterone capsules are used in combination with estrogen-containing medications in a postmenopausal woman with a uterus (womb). The addition of a progestin is generally recommended for a woman with a uterus to reduce the chance of getting cancer of the uterus (womb)

The role of progesterone supplementation in managing perimenopausal symptoms is to treat secondary amenorrhea and to protect the endometrium when used in combination with estrogen-containing medications.

• Key benefits of progesterone supplementation include:
  • Treatment of menstrual irregularities
  • Protection of the endometrium
• Important considerations:
  • Progesterone capsules should be taken as directed by a healthcare provider
  • Regular check-ups with a healthcare provider are necessary to monitor for potential side effects and to determine if treatment should continue 2, 2

From the Research

Role of Progesterone Supplementation

• Progesterone supplementation plays a crucial role in managing perimenopausal symptoms, particularly in combination with estrogen therapy 3, 4.
• The addition of progestogen to estrogen therapy helps prevent the development of endometrial hyperplasia and improves adherence to therapy 3.
• Progesterone acts physiologically to counteract the proliferative effects of estradiol during the menstrual cycle, and in menopausal hormone therapy, progestogens protect the endometrium against the proliferative effects of estrogens in women with a uterus 4.

Management of Perimenopausal Symptoms

• Estrogen-based hormonal therapies are the most effective treatments for many perimenopausal symptoms, including hot flashes, night sweats, and genitourinary discomfort 5, 6.
• Non-hormonal treatment options are also available for women who are not candidates for hormonal therapies, such as selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) 6.
• Progesterone supplementation may be used in combination with estrogen therapy to manage perimenopausal symptoms, particularly in women with a uterus 3, 4.

Benefits and Risks of Progesterone Supplementation

• The benefits of progesterone supplementation include the prevention of endometrial hyperplasia and the improvement of adherence to estrogen therapy 3.
• The risks of progesterone supplementation include the potential for irregular bleeding and non-adherence to treatment, particularly with continuous combined estrogen-progestogen regimens 3.
• Recent data suggest that micronized progesterone may be safer for the breast than synthetic progestin, but less efficient on the endometrium 4.

Clinical Considerations

• The management of perimenopausal symptoms requires an individualized approach, taking into account the woman's medical history, symptoms, and preferences 5, 7.
• Healthcare providers should evaluate and manage women in the perimenopausal transition with evidence-based treatments, including hormonal and non-hormonal options 5, 7.
• Progesterone supplementation should be used in combination with estrogen therapy, if necessary, to manage perimenopausal symptoms and prevent endometrial hyperplasia in women with a uterus 3, 4.