Can I prescribe Pro Era (progesterone) 10 mg daily to a patient with hypertension on amlodipine (calcium channel blocker) 10 mg, telmesartan (angiotensin II receptor antagonist) 40 mg daily to stop abnormal uterine bleeding?

Can Oral Progesterone 10 mg Daily Be Prescribed for This Patient?

No, oral progesterone 10 mg daily is an insufficient dose for treating abnormal uterine bleeding, and the patient's hypertension requires careful consideration of contraceptive safety—however, progesterone-only therapy is appropriate for this clinical scenario when dosed correctly.

Correct Dosing for Abnormal Uterine Bleeding

The FDA-approved dosing for oral progesterone (Pro Era/Prometrium) differs significantly from what you've proposed:

• For secondary amenorrhea and abnormal bleeding: 400 mg daily at bedtime for 10 days 1
• For endometrial protection in postmenopausal women on estrogen: 200 mg daily for 12 continuous days per 28-day cycle 1
• Your proposed 10 mg daily dose has no evidence base and will be therapeutically ineffective 1

Safety Profile with Hypertension

Progesterone-only therapy is safe and appropriate for women with hypertension, unlike combined hormonal contraceptives which are contraindicated:

• The American College of Obstetricians and Gynecologists recommends progestin-only contraceptives as the first-line hormonal option for women with hypertension 2, 3
• Combined hormonal contraceptives are absolutely contraindicated in hypertensive women, even when blood pressure is well-controlled, due to 6-9 fold increased risk of myocardial infarction and 8-15 fold increased risk of stroke 3
• Progestin-only methods show no increased cardiovascular risk in hypertensive women 3

Drug Interactions with Current Antihypertensive Regimen

There are no significant interactions between oral progesterone and amlodipine or telmisartan 2, 3. The patient can safely continue her current blood pressure medications while taking progesterone therapy.

Recommended Treatment Approach

For Acute Heavy Bleeding:

• Oral progesterone 400 mg daily at bedtime for 10 days to induce withdrawal bleeding and reset the cycle 1, 4
• This regimen achieves 73-77% success rate for inducing withdrawal bleeding 1

For Chronic Heavy Menstrual Bleeding:

Consider these evidence-based options in order of preference:

1. Levonorgestrel intrauterine device (20 μg/day): Most effective option with 71-95% reduction in menstrual blood loss, safe in hypertension, and provides contraception 5, 4, 6

2. Cyclic oral progesterone: 400 mg daily for 10-14 days per month can reduce bleeding by 87%, though may cause irregular spotting 5, 7

3. Continuous oral progestins: Norethindrone 5-10 mg daily provides sustained endometrial suppression 4, 6

Duration of Treatment

• Acute treatment: 10 days for immediate cycle control 1, 4
• Chronic management: Can be continued for 3-6 months, then reassess 5, 4
• Long-term: If using levonorgestrel IUD, effective for up to 5 years 5

Monitoring Requirements

Blood pressure must be checked every 6 months while on any hormonal therapy, even progestin-only methods 2, 3. At age 43 with existing hypertension, baseline cardiovascular risk assessment should include evaluation for additional risk factors (smoking, obesity, family history) 2, 3.

Critical Contraindications to Exclude

Before prescribing, ensure the patient does not have 1:

• Undiagnosed abnormal genital bleeding (requires endometrial sampling if >45 years or risk factors present) 5
• Known or suspected breast cancer
• Active or history of venous thromboembolism
• Known liver dysfunction
• Pregnancy (must be excluded)
• Peanut allergy (oral progesterone capsules contain peanut oil) 1

Common Pitfalls to Avoid

• Do not underdose: 10 mg is ineffective; use 400 mg for acute treatment 1
• Do not prescribe combined hormonal contraceptives: These are absolutely contraindicated with hypertension 2, 3
• Do not use tranexamic acid or NSAIDs as monotherapy in cardiovascular disease: These carry thrombotic risks 5
• Take at bedtime: Progesterone causes significant drowsiness, dizziness, and rarely ataxia in 5-10% of patients 1

Alternative if Progesterone Fails

If medical management with appropriate progesterone dosing fails after 3-6 months, consider 5, 6:

• Endometrial ablation (second-generation techniques have >90% success)
• Hysterectomy for definitive management
• These surgical options avoid hormonal exposure entirely while providing contraception through reduced fertility 5