It is common for medical professionals and naturopaths to prescribe progesterone to women with missing periods. This can be because progesterone is tested and found to be “low”, so supplementation is suggested (typically with the suggestion that this will help menstrual cycles resume), or to provide a “jumpstart” and get natural cycles going again.
Unfortunately, these recommendations don’t take into account the hormonal cascade of the menstrual cycle.
Progesterone is typically low during the follicular phase of the menstrual cycle (the time between when a woman starts her period and when she ovulates). For someone with hypothalamic amenorrhea (HA) / no period this is all the time, because we are not ovulating. So it’s not low progesterone that’s really the problem, it’s lack of ovulation.
The picture below illustrates some of the hormones involved in a typical menstrual cycle (with time of bleeding indicated by the red shaded areas) – someone with HA is essentially constantly at “cycle day 3 (CD3)” or thereabouts, with normal-ish FSH (around 6-7, sometimes lower than that if HA is more severe), low-ish LH (often less than 2, in about 30% of women, around the same as FSH), low-ish estradiol (<30 pg/mL – note this graph is in International System units, not US units, the conversion factor is 3.67) and of course, and “low” progesterone (typically < 1 ng/mL, conversion factor 3.18) because ovulation has not occurred.
Does progesterone supplementation fix your menstrual cycle?
Supplementing with progesterone is not going to do a thing to solve this issue. You can take all the progesterone you like and it’s not going to cause ovulation, because it’s a hormone that normally rises AFTER ovulation. In fact, there is the potential for progesterone to *prevent* ovulation because it can suppress the hormones needed to get a follicle growing (this one way some of the hormonal birth control options work, like Depo-Provera).
Nor does taking progesterone “jumpstart” your cycle. It can cause a bleed, because your body senses the drop in progesterone if/when you stop taking it (more info in Part 1 of this series), but doesn’t make any alterations in the natural hormone levels that would cause a menstrual cycle to start.
Along the same lines, taking estrogen and progesterone do not cause ovulation or “jumpstart” ovulation after you take them.
Providing the hormones artificially (i.e., your body is not producing them, you are taking them from outside your body) does not cause ovulation because these hormones are a *result* of a follicle growing / egg maturing / ovulating and not the cause of that maturation or ovulation. I fail to see how providing hormones that are downstream in the hormonal cascade is going to get the waterfall started.
Our reproductive hormonal system as a reservoir
Oooh, I like that analogy! Try this. Think of your body as a reservoir. When you have HA, you’ve drained the reservoir, and your hormones are low (and you can have all the associated side effects).
(Based on “Dry ground in the Sonoran Desert, Sonora, Mexico” by Thomas Castelazo licensed under CC BY 3.0)
As you work toward recovery as described in No Period. Now What? – eating more, exercising less, reducing stress, probably gaining some weight, the reservoir starts to fill up again. Once it reaches the overflow point and your baseline hormones are all back to normal, the water starts flowing into the stream leaving the reservoir. This “overflow” point is the signal that your brain gets to start producing Follicle Stimulating Hormone (FSH), which stimulates your follicle to grow and the egg inside to mature. THIS is what needs to happen to get your cycles started again.
The maturing egg secretes estradiol (active form of estrogen) – the stream is rocking and rolling now, tumbling down and revitalizing the parched land. When the follicle gets big enough / egg is mature, estrogen is nice and high and triggers the luteinizing hormone (LH) surge. THIS causes ovulation!
The follicle bursts, the egg is released, and starts traveling down your fallopian tubes to the now lush landscape below, your uterus, “watered” by the estrogen that’s been produced by the growing egg. Next, the cells in the follicle become luteal cells that produce progesterone, which further prepares your uterine lining to receive the embryo… like adding fertilizer. That’s about where the analogy stops making sense because if you don’t get pregnant your lining sheds… I guess kinda like a flood LOL and then the whole process starts over again.
(Based on “Jungle” by Luke Jones licensed under CC BY 2.0)
But…giving someone outside estrogen and progesterone is like sprinkling water from a watering can and throwing a little fertilizer onto completely barren earth (aka your body when it’s undernourished), outside of the reservoir and doesn’t do a thing to get that reservoir full and the waterfall flowing. Even if your reservoir is full, sprinkling some water and fertilizer isn’t doing anything to start the waterfall.
I know that there is a small number of women who start cycles after taking estrogen + progesterone, or progesterone alone. In the surveys I did for No Period. Now What? 74 women were prescribed E+P for this reason.
Only four had natural cycles that happened soon enough after the E+P that one *might* say that the two were related (next period happened 30 days, 35 days, 6 weeks, and 6 weeks after the E+P), and as these women were working toward recovery at the same time, it’s impossible to tell if the resumption of cycles was “jumpstarted” or would have happened regardless. In any case, this is only 5% of those who were prescribed the E+P.
There are times when it can make sense to use estrogen and progesterone. For example in someone with primary amenorrhea, or someone who has worked toward recovery, who has tried alternatives like Clomid, Femara, naltrexone, SSRIs, hypnosis, cognitive behavioral therapy (CBT) [these should be discussed with your physician – I can help you to understand the options and work with your doctor to select the most appropriate choice(s)] with no restart of menstrual cycles. Or someone who is absolutely not willing, yet, to work on recovery. Estrogen + progesterone, or oral contraceptive pills seem to help at least prevent further bone loss , although studies are equivocal on whether they help with bone density gains (and certainly, weight gain and period restoration is better!). Using estrogen and progesterone, or progesterone alone, is often used to create a bleed prior to start fertility treatments, that will be part 3 in this series.
But for the *vast* majority of women – over 95% of those who completed the NPNW surveys – cycles CAN be restored, the reservoir can be filled, waterfall can flow – by following the recovery plan and maybe adding on some additional interventions (see the “Still No Period” chapter in NPNW and/or work with me if this is needed). For example, Femara or Clomid can jumpstart your system, by giving your hypothalamus a push to get your natural hormones working. Think of Femara and Clomid as creating an opening in the reservoir that lets the water flow out (they do not work if your reservoir is still empty) – the drop in estrogen that they create is sensed by your brain which then produces follicle stimulating hormone to grow your follicle and mature the egg – and the rest of the process of ovulation and period (or not if you happen to get pregnant) follows.
Summary
To summarize, supplementing with progesterone, or estrogen and progesterone, does not cause natural menstrual cycles to resume. If following the recovery plan does not get things started on their own, Femara or Clomid are great options, either to help you ovulate to get pregnant, or to restore natural cycles.
<3
Nico
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Note: I always include references in my blog articles so that you can go and read for yourself the studies I base my conclusions on. However, in this case, I have not found a single study other than my own survey that examines the use of progesterone or estrogen + progesterone to jumpstart cycles. So this article is based on my observations and understanding of the female menstrual cycles gleaned over the last decade + of working with thousands of women with HA on cycle recovery and pregnancy.