Am I taking enough progesterone in my menopause hormone therapy?

The Dodge

I get a lot of questions about progesterone, so I thought this question was worth a bit of a deeper dive. 

I’m in my late 60’s and I’ve been on HRT (currently 0.05 estradiol patch and micronized progesterone) since my menopause transition began in my early 50’s. I have found that progesterone does help a lot with sleep issues. However, in the last few years taking even a small amount of progesterone (100 mg) on a daily basis causes breakthrough bleeding that can last for days.

The only way I’ve been able to take progesterone and protect my uterus is to cycle with it. I take 200 mg of micronized progesterone for 12 days until I have a “period.” I do this every 2-3 months to avoid having a monthly bleed. Is this safe?

If someone is taking estrogen therapy and has a uterus, they need a progestogen (which means either progesterone or a progestin, which is a synthetic hormone with progesterone-like properties). A progestogen is needed because over time estrogen can cause cancer of the lining of the uterus. So-called “bioidentical” estrogen isn’t safer in this regard, the cancer risk is a property of estrogen. 

Before moving any further, there are several key basics to know regarding menopausal hormone therapy:

• Unlike estrogens, there is currently no formulation that allows the hormone progesterone to be absorbed across the skin. This means that topical progesterone, such as a patch, cream to rub into the skin, or spray, isn’t an option. However, topical progestogens are (I know, the names can be tricky). So, the patch and the vaginal ring that contain both estrogen and a progestogen are fine options. 

• A standard dose of pharmaceutical vaginal estrogen (meaning not compounded) doesn’t require a progestogen as there isn’t enough estrogen to stimulate the lining of the uterus. 

• Compounded hormones result in unreliable dosing and are unstudied from a uterine safety standpoint, meaning we have no idea how much progestogen (either progesterone or progestin) to give to counteract the estrogen. Blood levels of hormones cannot help here. If you are using a compounded product, including pellets, and your provider is guiding your progestogen therapy based on hormone levels, they may as well be consulting a book of spells. 

If someone is using pharmaceutical estrogen, like the person asking the question, we know how much progesterone/progestin is needed to protect the uterus.