What Is The Lowest Dose of Progesterone For HRT?

If there’s one thing we know about menopause, it’s that you want to put an end to persistent, frustrating symptoms—and fast. We get how critical it is to find treatments that can make a real difference in how you feel and, quite frankly, help you get your life back. You no longer want to erupt in sweat as a hot flash washes over you in the middle of the work day. You don’t want to feel as irritated as you do about, well, everything. You don’t want constant headaches to disrupt your plans with friends. You’re ready for a decent night’s sleep.

So, if your clinician told you that your symptoms were likely related to menopause, it may have been a relief knowing that treatment—hormone replacement therapy (HRT) in particular—could help you feel a lot more like you again.

Progesterone is a hormone often used in hormone replacement therapy, alongside estrogen. And it’s completely understandable to have questions about it—what it is, what it does, and how much of it you actually need. 

At Midi Health, we often hear from women who have questions about dosing, including if they should take the lowest dose of progesterone for HRT. That question often stems from old, outdated information about hormone replacement therapy from 2002 data that linked taking estrogen plus progesterone hormone replacement therapy to an increased risk of breast cancer and heart disease. The study in question was widely misinterpreted and the risks exaggerated, says Midi’s medical advisor and certified menopause practitioner Lauren Streicher, MD, a clinical professor of obstetrics and gynecology at Northwestern University’s Feinberg School of Medicine and the founding medical director of the Northwestern Medicine Center for Sexual Medicine and Menopause.

"Some women are aware that in that old study from 2002, it was not the estrogen that caused the increased risk of breast cancer—it was the progesterone," explains Dr. Streicher. "And the progesterone that was used then was not a natural progesterone, it was a synthetic progesterone. The progesterone that we prescribe today is a natural progesterone, which has not been shown to increase the risk of breast cancer. But it’s still one of the reasons that women might say, well, I want to take the lowest dose of progesterone. It’s important to realize that’s not necessary."

Another situation where dosing might be of interest: Some women simply don’t tolerate progesterone well for a variety of reasons, including moodiness, bloating, and irregular bleeding. In those cases, you can work with your healthcare professional, like a Midi clinician, to find a better dose or alternative treatment.

Read on to learn about the important role progesterone plays in hormone replacement therapy, plus info on dosing and safety.

Got Questions about progesterone?

What Is the Lowest Dose of Progesterone for HRT?

First, let's address the question you came here for. At Midi, the lowest dosage of progesterone for HRT that we start many women on is usually 100 mg daily. But, like all menopause treatments, progesterone dosing is highly personal. Whether it’s recommended to take progesterone, how much, and in what form differs from person to person, and you’ll want to work with your clinician to figure out what’s best for you and your goals.

"The lowest dose of progesterone for HRT is really dependent on how much estrogen you're taking because the purpose of the progesterone is to protect the lining of the uterus. When you use estrogen alone, you can get a buildup of that lining, which over time can increase the risk of uterine cancer," explains Dr. Streicher. "We have typical doses that people use based on standard doses of estrogen, but it's very individual. And if someone is not tolerating progesterone well, we have alternatives."

To get personalized recommendations based on your symptoms and health history, you can book a virtual visit with a menopause specialist through a platform like Midi.

Hormone Replacement Therapy (HRT) 101

Symptoms that emerge during perimenopause and menopause can make life downright miserable—sleep loss, hot flashes and night sweats, foggy thinking, among others. It’s natural and positive that many women seek relief and choose to go on hormone replacement therapy, or HRT, which includes progesterone. To understand progesterone’s role in HRT, also known as menopausal hormone therapy or MHT, you first have to understand the treatment more broadly. Let’s break it down:

What Is Hormone Replacement Therapy?

What it is: Hormone replacement therapy, also referred to as hormone therapy or menopause hormone therapy, is a treatment for perimenopause and menopause that replenishes hormones that naturally decline as you age. The name is a bit misleading—you’re not replacing any hormones in your body as much as you’re supplementing them as they decline. 

How it works: Hormone replacement therapy works by releasing estrogen into the bloodstream or vaginal tissue, and is available in many forms, including pills, patches, vaginal rings, and topical creams, and gels. 

When to consider it: Hormone replacement therapy is often recommended by clinicians for women with menopause symptoms that are disrupting their lives.

What it's proven to help with: It’s the most effective treatment for relieving menopausal hot flashes, night sweats, vaginal dryness, and recurrent urinary tract infections, according to the most recent guidelines from The Menopause Society. Clinically, hormone replacement therapy has also been shown to be highly effective in relieving symptoms of insomnia, mood changes, and brain fog.‍

Hormone replacement therapy comes in two main forms: 

• Combined estrogen and progesterone therapy: This is the most common form of HRT. To protect the uterus, clinicians add progesterone or progestin to estrogen, which reduces any risk of uterine cancer. Some patients who have had a hysterectomy (and don’t need protection from uterine cancer) may still be counseled to include progesterone as it’s been shown to help with sleep and insomnia. 
• Estrogen-only therapy: This option is typically reserved for women who have had their uterus removed (hysterectomy). Estrogen-only therapy can be taken on its own in women with a uterus if the HRT in question is vaginal estrogen.

Which route you take depends on many factors, including your medical history. A healthcare professional can help you determine the approach that’s best for you.

Understanding Progesterone’s Role in HRT

You might hear progesterone referred to as progestin; progestin is the synthetic (or man-made) form of progesterone. We will use progesterone when we’re talking about HRT therapy.

When it comes to HRT, progesterone serves two important purposes:

• Balances out the uterine lining: Estrogen is the MVP when it comes to relieving menopause symptoms, like hot flashes that aggravate your day, night sweats that disturb sleep, vaginal dryness that makes sex uncomfortable, or a lower libido that makes you want to swear off sex in the first place. That’s why estrogen needs to be on board in HRT. However, as effective as estrogen is for alleviating symptoms, taking the hormone may also thicken the uterine lining. In some cases, that lining can grow too thick, which is a risk factor for uterine cancer, a type of cancer affecting more than 860,000 women in the US. Adding progesterone to HRT is key because it reduces this thickening and sends the risk for developing uterine cancer back to baseline. 
• Helps you sleep better: This is actually considered to be a good side effect of progesterone. About half of women have sleep problems during menopause, be it trouble falling asleep, staying asleep, or getting up long before your alarm. “We know that progesterone can cause sedation and help with sleep,” says Midi’s Chief Clinical Officer, Mindy Goldman, MD, a practicing OB/GYN at the University of California, San Francisco (UCSF) for almost three decades who currently serves as the Director of the UCSF Gynecology Center for Cancer Survivors and At-Risk Women. 

Have More Questions about HRT and Progesterone? Watch our webinar with Dr. Goldman.

How to Know If You Need Progesterone

To know if progesterone is recommended for you, there are a few key things to keep in mind. Consider these questions when talking to your healthcare provider:

• Do I need contraception? During perimenopause, you can still get pregnant (yes, really!) even if ovulation is becoming irregular but hasn’t stopped. If you’re not looking to grow or start a family and you’re perimenopausal, your clinician will most likely recommend you take progesterone in the form of hormonal birth control. Once you’re no longer ovulating, your clinician will recommend taking it as part of HRT, depending on your symptoms.
• Am I a candidate for progesterone? If you’ve had a hysterectomy, then your clinician will suggest estrogen-only therapy. You don’t need progesterone since there’s no risk of developing uterine cancer but you still may benefit from some of its perks. If you still have a uterus, that’s when progesterone will most likely come into play. 
• Is there any reason I should avoid progesterone? In some instances, having a peanut allergy would mean you should avoid certain types of progesterone (progesterone capsules contain peanut oil). There are also many health-related reasons why you might not be a candidate for HRT in general, including having hormone receptor positive breast cancer. A thorough chat about your health history with your clinician is important.
• How often do I need progesterone? Progesterone can be taken every day or certain days of the month (cyclically). Your clinician will go over your options and recommend the route that helps you feel your best.

Understanding Your Progesterone Dosage Options

Progesterone is available in several forms:

• Pill: This is the most common form prescribed to start. 
• Hormone Intrauterine Device (IUD): If you’re experiencing side effects on an oral progesterone pill, your clinician may recommend an intrauterine device (IUD). An IUD is placed by your clinician, and it will provide a continuous low dose of progesterone that you don’t have to think about. (It’s truly set-it-and-forget-it.) 
• Vaginal progesterone: This is another alternative, though it’s less clear how well it balances and protects your uterus due to the lack of long-term data.
• Patch: If you have side effects from oral progesterone and don’t want an IUD, then a combination estrogen-progesterone patch might be a good option for you.

The firstline recommendation is oral progesterone, prescribed in one of three ways, and the dosages can vary. The lowest dose of progesterone for HRT may work for you, but it may not. Every woman’s experience is different which is why working with a clinician who truly understands the nuances of HRT can help you land on the most effective, safest treatment for you. 

Here, three common progesterone regimens for HRT:

• Daily with estrogen: In this case, progesterone is taken as a 100mg dose as a nightly oral capsule along with an estrogen patch. At Midi, this is what we often recommend. Why?Taking medication every day helps you stick to a schedule, making it less likely you’ll miss a dose. Progesterone may also help you sleep better, something you obviously want every night.There is less of a risk of having withdrawal bleeding, which is bleeding that happens when you stop taking the medication and your hormone levels drop. (This is what happens on oral birth control pills during your “period” week.)‍
• ‍Certain days of the month, with estrogen: An oral dose of progesterone at 100 or 200 milligrams (mg) taken for 12 days each month along with an estrogen patch may be more suitable for some women.
• ‍Daily, without estrogen: If you have hot flashes and night sweats that disrupt your sleep, but your clinician advises against taking estrogen, there’s an option to take progesterone alone. In that case, you’ll be prescribed 100mg nightly as an oral capsule. If that’s not enough to suppress hot flashes or night sweats, then that dosage may be increased to 200 or 300 mg.

Frequently Asked Questions About Progesterone for HRT

Midi’s Chief Clinical Officer, Mindy Goldman, MD, answers the most common questions she receives from patients about progesterone: 

Got Questions about progesterone?

Is Progesterone Safe? What About Side Effects?

Progesterone is a safe element of HRT—after all, it’s there to protect your body from uterine cancer. However, HRT in general may not be right for everyone. There’s good evidence that taking HRT within 10 years of the start of menopause if you’re younger than age 60 delivers more benefits than risks. However, for those older than age 60 or if it’s been more than 10 years since your last period, it’s best to discuss your options with a healthcare professional, like a Midi clinician, to find the most appropriate treatment option for you.

There are also side effects that can occur when starting progesterone. Oddly enough, in some instances, these are the very symptoms you may be trying to avoid in the first place. (But there is some good news on this front, below.) For progesterone in particular, you may notice some side effects, such as:

• Bloating
• Breast tenderness or swelling
• Fatigue
• Irregular bleeding
• Moodiness
• Stomach upset

Here’s the good news: Most of these symptoms go away on their own as your body adjusts to progesterone, but if you’re concerned about these initial side effects or have questions about the best way to manage them, schedule a visit with a Midi clinician or other healthcare professional. If you find that these side effects aren’t tolerable or you feel worse than you did before taking progesterone, you’ll want to stop taking this hormone and book a follow-up visit with your clinician.

In addition, certain severe side effects are rare but possible:

• Depression
• Fast heart rate 
• Migraine
• Severe dizziness or faintness
• Sharp chest pain
• Weakness or numbness in arms or legs

While this is not a comprehensive list, you’re encouraged to call your doctor or seek medical help immediately if you notice a severe side effect or have questions about any side effects you’re experiencing after starting the medications. 

Will Progesterone Affect My Weight?

Because weight gain is often linked to menopause, many women wonder what will happen to their weight when they go on HRT. Research is mixed. While going on HRT alone may not cause weight gain or weight loss, it may help regulate your weight. Some studies suggest that HRT that includes progesterone can help keep your weight stable and prevent excess weight gain. 

However, there’s a distinct perk to HRT because controlling the symptoms of menopause can improve your sleep and mood. Ultimately, relief in those areas can make it easier to stick to habits like exercise or eating a balanced diet, moving the needle on the scale and helping you build muscle. Medication affects everyone differently, of course, so if you have concerns about weight gain or loss after starting progesterone, that’s another time to connect with your clinician.

What Are Alternative Treatment Options to Progesterone and HRT?

For some women, hormone replacement therapy may not be the right choice. But that doesn’t mean you’re stuck with crummy symptoms and out of options. In fact, there are several options you can try, says Dr. Goldman:

Monitoring and Adjusting Progesterone Dosage: Schedule Regular Check-Ups

When you start progesterone, it’s a good idea to schedule a quick check-in within four to six weeks, as well as a follow-up visit after two months to talk about how the dosage is working. You may notice some cramping, bloating, and mild moodiness, but these are expected to go away as your body adjusts to your dosage. If you’re feeling worse—not better—after adding progesterone, reach out to your clinician.

Remember: Don’t think you just have to power through uncomfortable symptoms alone—your healthcare provider can help you find the best, most effective treatment plan for you. Sometimes lifestyle changes may help you feel even better and mitigate side effects from progesterone so you can still enjoy its benefits.

How Much Progesterone Is Too Much?

There aren’t many telltale signs that your progesterone dosage may be too high, but one clue is increased grogginess in the morning or feeling dizzy. While this isn’t typically seen with an 100mg dosage of progesterone, it has been reported at higher amounts.  

Testimonials: Women Share Their Experience with Progesterone for HRT

Many Midi patients have had positive experiences on HRT, including progesterone, and have seen a complete change in their symptoms. 

Women outside the Midi universe are also finding success on progesterone, like this video from @annamaegroves:

The Takeaway

The key to being on progesterone is working closely with your clinician. That’s because it’s important to approach HRT in an individualized way to determine the best dosage of progesterone for you. You’ll start on the lowest possible dosage of progesterone for your needs, with increases if needed. When treatment is tailored specifically to you, it’ll give you the best shot of controlling the symptoms of menopause while reducing the chance of side effects. 

One of the great things about HRT, including progesterone specifically, is that it’s available in several forms and dosages so that your clinician can find the best prescription for you. In other words: There is more than one way to stifle a hot flash and get better sleep. Along with adjusting the form of progesterone, your clinician can also tweak the dosage of progesterone up or down. Sometimes all you need is a small adjustment to get the right hormonal recipe for your body. And that’s chef’s kiss.