Progesterone and periods — part 1: Provera challenge
It is common to be prescribed progesterone or Provera (which is progestin, a synthetic form of progesterone), during the process of determining why you have no period, in order to see if you get a bleed. If you’re given some random pills and told to take them to help with diagnosis, this is almost certainly what the pills are. For the rest of this post I will use “Provera” to mean either Provera or bioidentical progesterone because for these purposes the two do the same thing.
Instead of coming up with a different way of saying it, I’m going to copy the text from my book No Period. Now What? that describes the Provera challenge:
In addition to the blood tests and physical exam, another common diagnostic tool is the “Provera challenge.” Your doctor will give you a prescription for Provera … a synthetic version of progesterone. In a normal menstrual cycle, progesterone rises after ovulation to prepare the uterus for a fertilized egg. If no pregnancy occurs, progesterone drops and a period ensues.
Provera mimics this cycle. You’ll take it for anywhere from 5 to 10 days to see if you bleed after you stop. The standard protocol is to wait two weeks to see if there is any spotting or bleeding, although among our survey respondents, all but one person who got a withdrawal bleed did so within eight days. About 18% (48/256) responded to Provera the first time they tried it (i.e., they got a bleed). This indicates a less severe degree of HA. No bleed suggests a more suppressed reproductive system without adequate estrogen to build a uterine lining—in other words, full blown HA [hypothalamic amenorrhea].
The degree of HA is based on response to Provera and Clomid: • HA degree 1 (least severe): You bleed after taking Provera and Clomid. • HA degree 2 (moderately severe): You bleed after taking Provera but do not respond to Clomid. • HA degree 3 (most severe): You don’t get a withdrawal bleed after taking Provera.
Here is some additional data I didn’t put in the book. 86 women responded with the amount of time it took them to bleed after their Provera challenge:
The median time to response was three days after the last pill (meaning half responded within three days, the other half three days or later)
95% bled by five days after the last pill
All but one responded by eight days after the last pill
Some women are told that if they respond to Provera they do not have HA, and must have PCOS instead. This is not valid. It is absolutely possible to have HA and respond to Provera, it simply means your system is less suppressed. (Please see this post for more resources on HA vs. PCOS).
As I stated, it is common to do the Provera challenge as you work toward a diagnosis. If you do not bleed and have ruled out physical issues preventing a bleed, then this can solidify the diagnosis of HA. If you do bleed, this isn’t particularly helpful for diagnosis, but likely means that if you do have HA, it’s on the milder side. Interestingly, when I analyzed my data on Provera response, it did not predict recovery of natural periods. 46% of those who bled in response to the challenge restored natural cycles (the remainder moved on to fertility treatments), compared with 47% of those who did not bleed.
Is repeating the Provera challenge useful?
Some women will try a second Provera challenge as they work toward recovery. There isn’t a particular benefit to doing so, but nor is it going to set you back. It’s really up to you and how the result might make you feel.
If you bleed, will it help you to feel more confident in what you’re doing as you work toward recovery? (bloodwork might serve the same purpose?)
If you do not bleed, will that set you back and make it harder to stay the course?
If you do choose to do a second Provera challenge, I’d suggest going into it with the expectation that you will not bleed; that way if you do it’s a bonus, if you do not, well, that’s kinda what you expected and you’ll stick with what you’re doing anyway (if you need encouragement please join my facebook support group and check out the “recovery story” tag, which we started using May 4, 2018 – already 37 posts!) In the data from my survey, 26% (31/119) responded to a subsequent Provera challenge after not having responded the first time.
Does Provera provide a jumpstart?
What the Provera challenge can not and does not do is “jumpstart” a natural cycle. This is because in a normal menstrual cycle progesterone is a “downstream” hormone – the *result* of ovulation. It’s not one of the hormones that *causes* ovulation. So even if you bleed from the outside progesterone, it does nothing to change your natural hormones that are low – it does not increase Follicle Stimulating hormone to actually get a follicle growing and egg maturing.
Many doctors will prescribe progesterone, or even birth control pills, telling patients this might jumpstart a natural cycle – this does not happen. More in my next post!
If you have any questions about the Provera or progesterone challenge, drop them in the comments!
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