In adult women on hormone therapy, does progesterone (including synthetic progestins) cause more anxiety and depressive symptoms than estrogen?

Progesterone and Synthetic Progestins Cause More Mood Disturbances Than Estrogen in Hormone Therapy

Synthetic progestins, particularly medroxyprogesterone acetate (MPA), are more likely to cause anxiety and depressive symptoms than estrogen, especially when combined with higher estrogen doses or in women with pre-existing mood sensitivity. 1

Key Evidence on Progestins and Mood

Synthetic Progestins Show Clear Mood Effects

• Depression was reported in 19% of women taking progesterone capsules 200mg with conjugated estrogens versus 12% on placebo in a large 3-year trial of 875 postmenopausal women. 2

• Higher estrogen doses (3mg vs 2mg estradiol) significantly worsen negative mood symptoms during the progestin phase, with increased tension, irritability, and depressed mood (P < 0.001). 1

• The combination of elevated estrogen with progestin creates a synergistic negative effect on mood that exceeds either hormone alone. 1

Type of Progestin Matters Critically

• Natural micronized progesterone (MP) has a more favorable safety profile than synthetic progestins like MPA, which negatively impacts cardiovascular risk, lipid profiles, and vasomotion. 3

• Synthetic progestins suppress ovulation and disturb ovarian endocrine function in the luteal phase, preventing metabolism to neuroactive, mood-improving derivatives like allopregnanolone. 4

• MPA specifically has been associated with worse metabolic and cardiovascular profiles compared to natural progesterone alternatives. 3

Estrogen's Relationship to Mood

Estrogen Effects Are Context-Dependent

• Mood disturbances with estrogen are primarily associated with sudden withdrawal, fluctuations, and sustained deficiencies—not stable estrogen administration itself. 5

• Women show differential sensitivity to mood-destabilizing effects of gonadal steroid changes, with vulnerability determined by individual factors rather than absolute hormone levels. 5

• Estrogen-only therapy in the Women's Health Initiative did not show significant mood disturbances as a primary adverse effect, though urinary incontinence and thromboembolic events were increased. 3

Individual Vulnerability Is Key

• Women with a history of postpartum depression demonstrate particular sensitivity to estrogen withdrawal, while those without such history do not show the same vulnerability. 5

• The critical factor is hormonal stability rather than absolute levels—rapid fluctuations or withdrawal after sustained elevation may worsen mood. 5

• Progesterone theoretically has anxiolytic and anesthetic properties through serotonergic receptor modulation, yet absolute progesterone levels do not correlate with depression symptoms. 6, 5

Clinical Algorithm for Hormone Selection

First-Line Approach

1. For women without mood disorder history: Use natural micronized progesterone (MP) rather than synthetic progestins like MPA, as recommended by the European Society for Human Reproduction and Embryology (ESHRE). 3

2. For women with pre-existing mood disorders or premenstrual dysphoric disorder: Avoid synthetic progestins entirely; consider estrogen-only therapy if hysterectomy has been performed, or use MP with the lowest effective estrogen dose. 6, 5, 1

3. Estrogen dosing: Use 2mg estradiol rather than 3mg when progestin must be added, as higher estrogen doses significantly amplify progestin-induced negative mood symptoms. 1

Monitoring Strategy

• Monitor patients with pre-existing mood disorders closely during the first weeks of treatment, particularly watching for mood destabilization. 5

• Measure serum progesterone at symptom onset with documentation of cycle day to differentiate between normal luteal phase elevation versus pathological hyperprogesteronemia. 6

• Perform thyroid function tests (TSH, free T4) to rule out thyroid dysfunction, which can overlap with hormonal mood symptoms. 6

Critical Pitfalls to Avoid

Common Errors in Clinical Practice

• Do not assume all progestins have equivalent mood effects—synthetic progestins like MPA have distinctly worse mood profiles than natural micronized progesterone. 3, 4

• Do not combine high-dose estrogen (3mg) with any progestin in mood-sensitive women—this combination significantly worsens tension, irritability, and depressed mood. 1

• Do not attribute anxiety/mood symptoms directly to progesterone elevation without considering cycle timing and individual sensitivity to hormonal fluctuations. 6

• Avoid oophorectomy or hysterectomy for cyclic mood symptoms unless another indication exists. 6

Special Considerations

• Brief treatment (14 days) with MPA after estradiol discontinuation does not appear to disrupt mood in either depressed or non-depressed women, suggesting short-term exposure may be tolerated. 7

• The literature does not support a universal association between exogenous progesterone and negative mood in the general population, but a vulnerable subset of women clearly exists. 8

• Progestin-only contraceptives may have different effects than combined hormone therapy, with sparse evidence suggesting potential mood and stress effects. 9