Oral Micronized Progesterone

Micronized progesterone is the progestogen most menopause specialists prefer, and for good reason: it is bioidentical, it may carry lower breast cancer risk than the synthetic progestin the WHI studied, and it has a sedative effect that turns a side effect into a sleep aid. Take it at bedtime. The drowsiness that would be a problem at 8 AM becomes a benefit at 10 PM. For women struggling with both endometrial protection requirements and menopause-related insomnia, this is one of the more elegant solutions in the HRT toolkit.

Brand name: Prometrium. Generics widely available at $15 to 50 per month.

Any woman on systemic estrogen who has a uterus. Without progestogen opposition, estrogen stimulates the endometrial lining and increases the risk of hyperplasia and cancer. This is non-negotiable.

Prometrium (brand) contains peanut oil. If you have a peanut allergy, tell your clinician immediately. Options: compounded micronized progesterone without peanut oil, or a different progestogen (norethindrone, or a levonorgestrel IUD for local endometrial protection).

Continuous (for women in confirmed menopause on continuous HRT): 100 mg at bedtime every night. No cycling, no withdrawal bleed. Breakthrough spotting is common in the first 3 to 6 months.

Cyclic (for perimenopausal women or early postmenopause): 200 mg at bedtime for calendar days 1 to 12 (or 1 to 14) each month. Expect a withdrawal bleed within a few days after the last dose. This bleed is by design, not a problem. If you miss one day, take it the next evening and continue. Missing several consecutive days may reduce endometrial protection for that cycle - tell your clinician.

Some women experience irritability, depressed mood, anxiety, or emotional flatness on progesterone. This is more common during the cyclic high-dose phase and can feel like severe PMS returning. If this happens, your clinician has options: switch from cyclic to continuous (lower daily dose may be better tolerated), try a different progestogen (some women tolerate norethindrone better), use a Mirena IUD for endometrial protection instead (local delivery minimizes systemic mood effects), or reduce the dose if adequate endometrial protection can be maintained.

Do not simply stop progesterone without discussing alternatives. If you have a uterus, you need endometrial protection. The solution is changing the approach, not eliminating it.

Drowsiness (take at bedtime - feature, not bug). Dizziness. Headache. Bloating. Mood changes - some women feel calmer (allopregnanolone metabolite has anxiolytic properties), others feel worse. If mood effects are negative and persistent, discuss alternatives.

Generic: $15 to 50 per month. Walmart: $10-15. Widely covered by insurance.

The Cycling Schedule In Practice

For cyclic regimens: take progesterone 200mg at bedtime for days 1 to 12 (or 1 to 14) of each calendar month. Expect a withdrawal bleed within a few days after the last progesterone dose. This bleed is not a menstrual period - it is a progestogen-withdrawal bleed that sheds the endometrial lining as a protective mechanism. If you miss a day, take it the next evening and continue the schedule. Missing one day is not dangerous. Missing several consecutive days may result in inadequate endometrial protection for that cycle - tell your clinician.

For continuous regimens: take 100mg at bedtime every night. No cycling, no withdrawal bleed (though breakthrough spotting in the first 3 to 6 months is common and expected).