Can progesterone stop or reduce menstrual bleeding?

Can Progesterone Stop Menstrual Bleeding?

Yes, progesterone can effectively reduce and stop menstrual bleeding, with the levonorgestrel-releasing intrauterine device (LNG-IUS) being the most effective option (reducing menstrual blood loss by 71-95%), while oral cyclic progestins reduce bleeding by approximately 87%, though they are less effective than the LNG-IUS. 1

Most Effective Progesterone-Based Options

Levonorgestrel-Releasing Intrauterine Device (LNG-IUS)

• The LNG-IUS (20 μg/day) is the single most effective progesterone-based treatment for heavy menstrual bleeding, achieving 71-95% reduction in menstrual blood loss 1
• This is the only progestin intrauterine device that has been formally evaluated for treatment of abnormal uterine bleeding 1
• Efficacy is comparable to endometrial ablation procedures 1
• Works primarily at the endometrial level with minimal systemic progesterone absorption 1
• 22% of users experience complete amenorrhea (cessation of bleeding) 1

Oral Cyclic Progestin Treatment

• Cyclic oral progestin reduces bleeding by 87% and typically results in irregular bleeding with eventual reduction to light bleeding only 1
• Standard dosing for secondary amenorrhea: 400 mg progesterone capsules daily at bedtime for 10 days 2
• For endometrial protection in postmenopausal women on estrogen: 200 mg progesterone capsules daily at bedtime for 12 continuous days per 28-day cycle 2
• Recent evidence shows adding 5 mg norethisterone acetate to progesterone-only pills significantly reduces breakthrough bleeding after 2,4, and 6 weeks 3

Comparative Effectiveness

Oral Progestins vs. Other Medical Therapies

• Short-cycle progestins (7-10 days during luteal phase) are inferior to tranexamic acid, danazol, and the LNG-IUS for reducing menstrual blood loss 4
• Long-cycle progestins (day 5-26 of cycle) are also inferior to LNG-IUS, tranexamic acid, and ormeloxifene 4
• However, oral progestins may be similar in effectiveness to combined vaginal ring therapy 4

LNG-IUS vs. Surgical Options

• The LNG-IUS is more effective than oral medications but less effective than hysterectomy for complete bleeding control 5
• When compared to endometrial ablation, the LNG-IUS shows similar satisfaction rates and quality of life improvements, though evidence quality is low 5
• The LNG-IUS is more cost-effective than both endometrial ablation (within 2 years) and hysterectomy (up to 10 years) 5

Clinical Application Algorithm

For Acute Heavy Menstrual Bleeding

• High-dose oral or injectable progestin-only medications may be considered short-term in hemodynamically unstable women when bleeding is not controlled 1
• Rule out pregnancy first in all reproductive-age women with abnormal bleeding 1
• Assess for hemodynamic instability (bleeding saturating large pad/tampon hourly for ≥4 hours warrants urgent evaluation) 1

For Chronic Heavy Menstrual Bleeding

1. First-line: Consider LNG-IUS for maximum effectiveness (71-95% reduction) 1, 6
2. Second-line: Cyclic oral progestins if LNG-IUS is unacceptable or contraindicated (87% reduction) 1, 6
3. For breakthrough bleeding on progesterone-only pills: Add norethisterone acetate 5 mg 3

For Secondary Amenorrhea (Inducing Withdrawal Bleeding)

• Progesterone capsules 400 mg daily at bedtime for 10 days results in 80% of women experiencing withdrawal bleeding within 7 days 2
• Alternative dosing: 300 mg daily for 10 days achieves 73.8% withdrawal bleeding rate 2

Important Caveats and Contraindications

Special Population: Women with Cardiovascular Disease

• In women with spontaneous coronary artery dissection (SCAD), hormonal therapy including progesterone is relatively contraindicated and requires careful clinical judgment 1
• The LNG-IUS may still be considered in SCAD patients due to minimal systemic absorption, though theoretical safety concerns exist 1
• Hormone replacement therapy should not be used for secondary prevention in women with established coronary artery disease 7

Common Side Effects

• Minor adverse effects are more common with LNG-IUS: pelvic pain, breast tenderness, ovarian cysts, and intermenstrual bleeding/spotting (especially first 3-6 months) 5
• Oral progesterone capsules may cause drowsiness, dizziness, blurred vision, difficulty speaking, or difficulty walking—should be taken at bedtime in standing position with water 2
• Unscheduled bleeding or amenorrhea with progestin therapy is generally not harmful 1

Absolute Contraindications to Progesterone

• Allergy to peanuts (progesterone capsules contain peanut oil) 2
• Current unusual vaginal bleeding of unknown cause 2
• Current or history of certain cancers (breast, uterus) 2
• Active or history of blood clots, stroke, or heart attack 2
• Current liver problems 2
• Pregnancy 2

Counseling Points

• Enhanced counseling about expected bleeding patterns reduces discontinuation rates 1, 6
• With LNG-IUS: 22% experience amenorrhea, 34% infrequent spotting, but 7% have frequent bleeding and 18% prolonged bleeding 1
• Reassure patients that irregular bleeding patterns are generally not harmful 1, 6
• If bleeding persists despite treatment and is unacceptable to the patient, counsel on alternative methods 1, 6