Hormone Therapy and Perimenopause: Do I need Progesterone if I'm Still Having a Period?

Ask Dr. Jen

I’m in perimenopause and still having periods. I’m on estrogen, but my doctor says I don’t need progesterone yet because I’m still having periods. is that okay?

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Short take

This is not a recommended approach. Whenever we give estrogen for any length of time it needs to be paired with progesterone or a progestin to protect the uterus from the estrogen.

Tell Me More

When someone has a uterus and they want to take estrogen to treat symptoms of menopause, be it in the menopause transition (aka perimenopause) or after their period stops (menopause), they also need progesterone or a progestin, which is a progesterone-like synthetic hormone. This is because over time, estrogen will eventually cause precancer and even cancer of the endometrium (uterine lining). You can read more about that risk here.

But what if someone is still having periods? After all, isn’t a period a sign of ovulation and ovulation means progesterone? Is it necessary to take additional progesterone or can you just take the estrogen because your menstrual cycle has you covered?

You still need progesterone or a progestin. Here’s why…

Hormone levels become erratic during the menopause transition. During some cycles, estrogen levels may be lower or normal and during others they may even be higher than typical. Progesterone levels may be normal or they may be lower. And during some cycles you may not make any progesterone at all.

Menstruation is not a reliable sign of ovulation in the menopause transition, even when it seems regular. It’s not uncommon in the menopause transition for a follicle to develop and produce estrogen, as it typically does, but then ovulation doesn’t happen and no progesterone is produced. But this follicle can’t keep churning out estrogen forever, and it eventually dies off. When this happens, the estrogen is withdrawn and this can trigger menstrual bleeding. And it can seem just like a period.

If you are having symptoms that warrant estrogen, there is already something going on at the hormone level with your ovaries. And these hormone changes will only progress the closer you get to menopause. It can take just six months of estrogen without sufficient progesterone or a progestin to overstimulate the lining of the uterus and cause precancerous changes.

Also, giving estrogen without a progesterone/progestin in the menopause transition has not been studied adequately for safety.

Ok, so what are the hormonal options for people who are having hot flashes or night sweats and are still having periods? They are the same as for people who have stopped having periods! Here are some strategies to consider:

• Use estrogen as you normally would, preferably transdermally, and a levonorgestrel IUD. The IUD will likely stop your period, or dramatically reduce bleeding, and will definitely protect your uterus from the estrogen and can provide contraception if needed. As menstrual irregularities are very common in the menopause transition, the IUD can essentially prevent these irregularities for many people.

• Take estrogen as you normally would and then oral progesterone, which can either be taken in a higher dose for 12-14 days a month or a lower dose daily. We usually try to start the progesterone mid cycle to mimic the normal release of progesterone (we think this minimizes abnormal bleeding). However, sometimes no matter which option you choose there can be some irregular bleeding.

• Use estrogen as you normally would and then oral progestin instead of a progesterone. We prefer progesterone as we believe it has the lowest risk of breast cancer, but progestins tend to be better at preventing irregular bleeding as they are stronger as far as the endometrium is concerned. So I might consider a progestin when there is bothersome bleeding with the progesterone and a hormonal IUD is not an option. Progestins can be taken in the same way as described for progesterone, a higher dose for 12-14 days a months or a lower daily dose.

• Take the estrogen containing birth control pill, which also has progestin. This will provide cycle control and more than enough estrogen for the menopause transition. This also provides the benefit of preventing the irregular bleeding of the menopause transition.

If someone needs estrogen for symptoms of the menopause transition there is almost certainly menstrual irregularity at the hormonal level, even if it’s not readily apparent with irregular periods. And those hormone changes will only progress over time. The menstrual cycle can’t be relied upon to produce enough progesterone to counteract additional estradiol given by prescription and so we still recommend a progesterone or progestin to prevent cancer, even when you are still getting a period.

Coming Up…

Given all the questions about hormone therapy and the ins and outs of prescribing, I am starting a weekly series dedicated to hormone therapy. It will start with posts about some basics and build on that knowledge each week. If you have specific questions, please leave them below!