Progesterone for Reducing Uterine Bleeding
Yes, progesterone therapy is highly effective for reducing uterine bleeding in women with hormonal imbalances including PCOS, with the levonorgestrel-releasing intrauterine device (LNG-IUD) being the most effective option (reducing menstrual blood loss by 71-95%), followed by oral progesterone 200 mg daily for 21 days per month as an alternative. 1
First-Line Treatment Approach
For women with heavy menstrual bleeding and desire for contraception, place a levonorgestrel-releasing IUD as first-line therapy. 1 This provides the highest efficacy with menstrual blood loss reduction of 71-95% and has comparable efficacy to endometrial ablation 1. The LNG-IUD is particularly effective for women on antiplatelet or anticoagulation therapy who develop abnormal uterine bleeding 1.
For women declining IUD placement or requiring oral therapy, prescribe oral micronized progesterone 200 mg daily for 21 days per month 1. This regimen effectively reduces menstrual blood loss in women with cyclic heavy bleeding 1. Cyclic progestogen therapy for 21 days results in significant reduction in menstrual blood loss 2.
Treatment Algorithm for PCOS-Related Bleeding
Before initiating progesterone therapy, rule out pregnancy, structural causes (fibroids, polyps), and malignancy 1. In women with PCOS, oral micronized progesterone (100 mg morning, 200 mg bedtime for 7 days) can be used to induce withdrawal bleeding without significantly altering circulating androgen levels 3. This makes it safe for timing blood sampling and managing irregular bleeding in PCOS patients 3.
For PCOS patients with irregular dysfunctional uterine bleeding, either oral dydrogesterone or vaginal micronized progesterone can be used with similar efficacy over a three-month treatment period. 4 Vaginal micronized progesterone represents an alternative to oral preparations in treating dysfunctional uterine bleeding 4.
Specific Regimens by Clinical Context
For Abnormal Uterine Bleeding with Ovulatory Dysfunction
First-line medical management includes progestin-only contraception and combined hormonal contraception, which reduce bleeding symptoms 5. Progestogens are used to regulate intermenstrual bleeding and decrease heavy menstrual bleeding in women of reproductive age or who are perimenopausal 6.
For Perimenopausal Women with Endometrial Hyperplasia
Initiate LNG-IUD for optimal bleeding control and potential regression of non-atypical hyperplasia 1. In perimenopausal women, progesterones prevent endometrial hyperplasia and aim to reduce the development of endometrial cancer 6.
For Postmenopausal Women on Estrogen Therapy
A postmenopausal woman with a uterus taking estrogens should take a single daily dose of 200 mg progesterone capsules at bedtime for 12 continuous days per 28-day cycle 7. This prevents endometrial hyperplasia, which occurred in 64% of women on estrogen alone versus only 6% in women receiving combination therapy over 36 months 7.
Important Contraindications and Safety Considerations
Do not prescribe progesterone in women with: 1
- Known or suspected pregnancy
- Peanut allergy (progesterone capsules contain peanut oil) 7
- Current or history of thromboembolism
- Undiagnosed vaginal bleeding
- Active liver disease
- Known or suspected breast or uterine cancer
Critical Pitfalls to Avoid
Progesterone has NO role as primary therapy for uterine fibroid-related bleeding, as oral contraceptives or GnRH agonists are preferred 1. For fibroids, first-line medical management includes estrogen-progestin oral contraceptive pills and progestin-containing IUDs 5. Progesterone receptor modulators such as ulipristal acetate show efficacy for fibroid-related bleeding but face hepatotoxicity concerns limiting U.S. approval 5.
Progesterone is not appropriate for acute hemorrhagic bleeding requiring immediate hemostasis or bleeding from structural lesions without addressing the underlying pathology 1.
Some women experience drowsiness, dizziness, blurred vision, difficulty speaking, or difficulty walking after taking progesterone capsules 7. Take the daily dose at bedtime with a glass of water while standing to minimize these effects 7.
Monitoring and Duration
Annual clinical review focusing on compliance, bleeding patterns, and symptom control is necessary 8. No routine laboratory monitoring is required unless specific symptoms arise 8. The treatment should be regularly reassessed to determine if continued therapy remains necessary 7.
Using progestins with estrogens may increase the chance of heart attacks, strokes, breast cancer, blood clots, and dementia (particularly in women age 65 and older) 7. These risks must be weighed against benefits when prescribing combination therapy 7.