Should progesterone levels be checked in a postmenopausal female?

Progesterone Testing in Postmenopausal Women

Progesterone levels should not be routinely checked in postmenopausal women, as progesterone naturally falls to very low levels after menopause and measurement provides no clinically useful information for diagnosis or management.

Physiological Context

• After menopause, progesterone levels drop to baseline low levels due to cessation of ovarian follicular activity and corpus luteum formation 1
• Progesterone measurement during mid-luteal phase (7 days after suspected ovulation) is only useful for confirming ovulation in reproductive-age women, with levels <6 nmol/L indicating anovulation 1
• In postmenopausal women, progesterone levels are expected to remain consistently low, making measurement diagnostically meaningless 1

Clinical Applications Where Progesterone is Relevant (But Not Measured)

Hormone Replacement Therapy Context

• Progesterone's primary role in postmenopausal women is endometrial protection when estrogen therapy is prescribed, not as a diagnostic marker 2
• Women with an intact uterus receiving estrogen therapy must have progestogen added to prevent estrogen-induced endometrial hyperplasia and adenocarcinoma 2
• The clinical goal is providing endometrial protection while maintaining estrogen benefits and minimizing side effects, particularly uterine bleeding 2

Therapeutic Use (Not Diagnostic Testing)

• Progesterone therapy may improve vasomotor symptoms and sleep quality in symptomatic postmenopausal women, but this is based on clinical symptoms, not serum levels 3, 4
• Transdermal progesterone at 20 mg/day significantly relieves menopausal symptoms without adversely affecting prothrombotic potential 5
• Oral micronized progesterone (200-400 mg daily) combined with estradiol results in symptomatic improvement and amenorrhea without endometrial proliferation 6

Key Clinical Pitfall

• Do not order progesterone levels to "confirm menopause" or evaluate menopausal symptoms - this provides no actionable information and wastes resources 1
• Menopause is a clinical diagnosis based on age and amenorrhea duration (12 months of absent menses in women >45 years), not hormone levels 7
• If hormonal assessment is needed for unclear menopausal status, FSH >35 IU/L and LH >11 IU/L suggest ovarian failure, but progesterone measurement adds nothing 1

When Progesterone Measurement Might Be Considered (Rare Exceptions)

• Anti-Müllerian hormone (AMH) is preferred over progesterone for assessing ovarian reserve in perimenopausal women with irregular cycles, as AMH does not vary by menstrual day and is unaffected by exogenous hormones 1, 7
• For women with irregular bleeding patterns in perimenopause who may still be ovulating intermittently, mid-luteal progesterone could theoretically confirm ovulation, but this rarely changes management 1

Contraindications to Hormone Therapy

• Postmenopausal women should not receive combination estrogen and progestin therapy for primary or secondary prevention of coronary heart disease 8
• Women who experience ST-elevation myocardial infarction should discontinue hormone therapy and not initiate it de novo 8