If you have a uterus, estrogen therapy needs a progestogen, and which one you take affects early side effects and some long-term risk. The main choice is between micronized progesterone, which is the same molecule your body made, and synthetic progestins, a family of molecules built to protect the womb lining but which behave differently elsewhere. A hormonal IUD is another route.
Pick what fits to see the usual starting choice.
Past menopause
Micronized progesteroneEvery night
For most women with a uterus, micronized progesterone at bedtime is the starting choice. Use it continuously if you're past menopause and cyclically if you're still in the transition.
Cyclic or continuousStill having periods
Micronized progesterone12 to 14 days a month
For most women with a uterus, micronized progesterone at bedtime is the starting choice. Use it continuously if you're past menopause and cyclically if you're still in the transition.
Cyclic or continuousHeavy or erratic bleeding
Levonorgestrel IUDPerimenopause
A levonorgestrel IUD may fit if you're perimenopausal and need bleeding control or contraception, or if oral progestogens don't agree with you.
Compare all threeI need contraception
Levonorgestrel IUDPerimenopause
A levonorgestrel IUD may fit if you're perimenopausal and need bleeding control or contraception, or if oral progestogens don't agree with you.
Compare all threeProgesterone disagrees with me
Change the route or regimen
These symptoms often come from the progestogen rather than the estrogen, and they do not always mean you need to stop hormone therapy.
Four things to tryI'd like a combined patch
A synthetic progestinNorethindrone
A synthetic progestin may fit when a combined product is practical, such as a patch that pairs estradiol with norethindrone, or when bleeding control matters and an IUD isn't wanted.
Compare all threeI've had a hysterectomy
Estrogen alone
Use estrogen alone if you've had a hysterectomy, unless your clinician says otherwise.
The exceptionsEstrogen stimulates the lining of the uterus. Unopposed, over years, that raises the risk of endometrial hyperplasia and cancer several-fold. A progestogen keeps the lining thin or sheds it on a schedule, and with one in place the endometrial risk returns to baseline. That is its job in hormone therapy; everything else it does is a side effect, good or bad.
Women who have had a hysterectomy don't need one and usually take estrogen alone, which has the most favourable breast-risk profile of any regimen. The exceptions are a history of endometriosis, where residual tissue can respond to estrogen, and some cases after surgery for endometrial cancer; a clinician decides those.
Progesterone is the hormone your ovaries produced after ovulation. Micronized progesterone is that molecule, milled fine enough to absorb when swallowed, usually in a capsule with peanut oil (there are peanut-free preparations). It's bioidentical in the real sense, and it's FDA-approved.
Progestins are synthetic molecules engineered to act on the progesterone receptor in the womb lining. The common ones in US hormone therapy are medroxyprogesterone acetate (the progestin in the 2002 Women's Health Initiative trial), norethindrone acetate (in some combined patches and pills), levonorgestrel (in hormonal IUDs) and drospirenone. Because they were built for potency on the lining, they're reliable there; because they're not progesterone, they interact differently with breast tissue, mood, lipids and androgen receptors.
Tap one or more to narrow the cards. Tap again to clear.
Cyclic12 to 14 days a month
Progesterone for 12 to 14 days a month (usually 200 mg micronized), producing a planned bleed at the end of each course. Used in perimenopause and the first year or so after menopause, when a continuous regimen would cause irregular spotting. Some women prefer it long-term because the progestogen-free days feel better.
ContinuousEvery night
A lower daily dose (100 mg micronized) every night with the estrogen, aiming for no bleeding. The usual choice after about a year post-menopause. Irregular spotting is common for the first three to six months and then settles; see HRT side effects in the first weeks.
IUDFitted in person, lasts years
Continuous local protection for several years, no pills; see perimenopause: HRT or the pill for why it suits women still cycling.
No progestogenLining unprotected
Estrogen stimulates the lining of the uterus. Unopposed, over years, that raises the risk of endometrial hyperplasia and cancer several-fold. Women who have had a hysterectomy don't need one and usually take estrogen alone.
A minority of women feel worse on the progestogen than before treatment: low mood, anxiety, bloating, breast pain or headaches that track the days it's taken. These symptoms often come from the progestogen rather than the estrogen, and they do not always mean you need to stop hormone therapy:
If you're on a synthetic progestin, this often helps.
This can make drowsiness easier to manage and may reduce the flat daytime feeling.
Off-label, but widely used: the same capsule inserted at night protects the lining with much less reaching the brain and breast. For some women this is the difference between tolerating hormone therapy and not.
A cyclic regimen gives you progestogen-free days. A levonorgestrel IUD is another option and keeps most progestogen out of the bloodstream.
Do not skip the progestogen while keeping systemic estrogen. Over-the-counter "natural progesterone cream" does not deliver enough to protect the lining.
For most women with a uterus, micronized progesterone at bedtime is the starting choice. Use it continuously if you're past menopause and cyclically if you're still in the transition.
A levonorgestrel IUD may fit if you're perimenopausal and need bleeding control or contraception, or if oral progestogens don't agree with you.
A synthetic progestin may fit when a combined product is practical, such as a patch that pairs estradiol with norethindrone, or when bleeding control matters and an IUD isn't wanted.
Use estrogen alone if you've had a hysterectomy, unless your clinician says otherwise.
At Golden Leaf Health, micronized progesterone is the usual starting choice, taken at night, with the regimen matched to where you are in the transition. The IUD route is arranged with an in-person clinician when it's the better tool.
Talk.
A one-on-one video visit about your symptoms, your history and what you want to feel like again. Your first visit is $99, refunded if you cancel at least 24 hours ahead.
Test.
If your provider thinks it will help, a hormone blood panel adds lab results to what you’ve told them. Not everyone needs this step.
Treat.
If treatment is right for you, your plan can include hormone prescriptions, non-hormonal options, lifestyle changes and optional supplements. Then two to three follow-up visits with a doctor and text check-ins through HIPAA-compliant messaging, included in membership at $49 a month, which begins one month after your first visit. Prescriptions and labs are priced separately.
If you have a uterus, yes. Estrogen on its own thickens the womb lining and over time raises the risk of endometrial cancer; a progestogen prevents that. After a hysterectomy you usually take estrogen alone, with a few exceptions such as a history of endometriosis.
Progesterone is the hormone your body makes; micronized progesterone is the same molecule in a capsule, so it's bioidentical. Progestins are synthetic molecules designed to act like progesterone on the womb lining but differing elsewhere in the body, which is why their side effects and risks differ.
On current evidence, yes for breast risk: large observational studies found less increase in breast cancer with micronized progesterone than with synthetic progestins such as medroxyprogesterone acetate, the progestin used in the 2002 WHI trial. It's also neutral on blood pressure and lipids and helps sleep. The trade-off is that it's slightly less potent on the lining, so dose and regimen matter.
Drowsiness or vivid dreams, which is why it's taken at bedtime; sometimes bloating, breast tenderness or a flat, low mood, especially in the first weeks or on the days it's taken in a cyclic regimen. These often settle.
Yes. A levonorgestrel IUD protects the womb lining where it's needed with very little hormone reaching the rest of the body, provides contraception in perimenopause and often stops bleeding.
A video visit with a clinician who treats perimenopause and menopause, in 33 states.
