A little gratitude for the hormone everyone forgets 💛

PLUS: The NIH just dedicated three days to menopause research—here's why it matters

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Welcome to the April 28th edition of Menopaussible—bringing you the news you can use and the ⚡ energy ⚡ you need to support your menopause journey.

I’m Maria Caracci Ciccolella—mindset coach and menopause advocate. (Connect with me on ​IG​ or ​LinkedIn​!)

Whenever talk turns to the topic of menopause hormone therapy (MHT), the spotlight immediately focuses on estrogen. Lost in its shadow is the other hormone also quietly making its exit at this time: progesterone. For all the attention estrogen gets, it’s progesterone that does the quiet work—significant, and long overdue for its moment.

In this newsletter, I have the pleasure of welcoming a special guest: women’s health—and menopause—specialist Katie Rowan, MD! She’s going to address some of the top questions she sees come up in her practice regarding progesterone and where it may fit into one’s menopause hormone therapy plan.
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Shall we get started?

Progesterone 101: The Forgotten Balancer

If estrogen and progesterone were superhero characters, progesterone would definitely be portrayed as the “sidekick.” Yet, as we all know, in many of these stories, it's the sidekick who helps balance out our hero—bringing important intelligence, observation or skills—that allow our hero to save the day.

Meet progesterone—the other half of the dynamic duo that, until recently, kept your body running like a well-coordinated team. Progesterone works as a natural counterbalance to estrogen, keeping the constant activity of cell turnover and function in check.

Broadly speaking, where estradiol (estrogen) acts a “growth promoter,” supporting healthy tissue production throughout the body, progesterone helps tissues mature, preventing overgrowth.
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But just as estrogen is a multi-functional player in the body, facilitating a number of cell activities, so, too, is progesterone. Some of its more specific benefits include:

• Providing neuroprotection—protecting neurons from dying off, protecting the blood-brain barrier (keeping harmful substances out of the brain), promoting neurogenesis (the creation of new neurons) and supporting the repair of nerve cells
• Calming the brain—having an anti-anxiety effect, by increasing the inhibitory effect of GABA, a neurotransmitter that promotes relaxation and reduces excitability
• Regulating immune response—tamping down inflammation and immune response
• Stabilizing connective tissue—increasing the tension on connective tissue in opposition to the flexibility created by estrogen
• Tempering pain response—modulating the emotional response to pain, and thereby the intensity felt
• Building bone—playing a role in bone formation, stimulating growth of new bone cells and decreasing the rate of bone resorption (loss), as well as calcium lost through urine

It’s such a big player that once you understand all the roles progesterone plays—one can start to see the impacts of its decline in the menopause transition:

• That sudden onset of anxiety? Progesterone loss
• That increase in thought cycling in the middle of the night? Progesterone loss
• ACL/MCL tears? Progesterone loss

Progesterone’s Role in Menopause Hormone Therapy

When it comes to menopause hormone therapy, progesterone is primarily prescribed to women who still have their uterus. In these instances, it serves as a check on prescribed estrogen—the goal: prevent overgrowth of the endometrial lining, thereby reducing cancer risk.

Women who no longer have a uterus, having undergone a hysterectomy, are primarily prescribed estrogen alone.

But given everything progesterone does, is there more to consider when pursuing menopause hormone therapy?

To understand that better, I turned to Dr. Katie Rowan, a Menopause Society-certified specialist in women’s hormone health and founder of Katie Rowan Wellness.

Q&A: Shining a Light on Progesterone—With Katie Rowan, MD

Q1. Before we dive in—can you clarify what we mean when we talk about "progesterone" in the context of hormone therapy? There seems to be some confusion in the general conversation about what's actually being prescribed.

Of course. The body makes progesterone, and the byproduct it produces when it breaks down is what acts on the nervous system.

Micronized progesterone is the medication we use to give back progesterone, and this is “bio-similar.” There are synthetic versions that do the same job of protecting the uterus, but they don’t have the same effects on the brain and nervous system.

Q2. What are some use cases in which you would prescribe progesterone (outside of protecting against cancer risk for women who have their uterus)?

I often prescribe micronized progesterone without estrogen to women in early perimenopause. These are women who are often still ovulating regularly, but they are starting to notice they are becoming more irritable or anxious, or they are having difficulty sleeping at night.

I also use it in women who are taking estrogen but don’t need it because they had a hysterectomy. Many of these women who notice irritability, anxiety, or difficulty sleeping can benefit from it as well.

Q3. In what form is progesterone typically prescribed (oral, vaginal, IUD, patch, etc.), and how is dosing structured—daily vs. cyclical?

Micronized progesterone is an oral pill that comes in 100 mg or 200 mg pills. I will often prescribe this daily to be taken at night. I like this approach because it’s easier to remember, and many women find it beneficial for mood or sleep.

Our bodies naturally make progesterone only during the second half of our cycle, so it’s also an option to mimic that and take progesterone for only 12–14 days of the month. If taking it this way, you need to take at least 200 mg each day that you take it.

Other formulations and delivery methods can balance estrogen and protect the uterus—but they don't replicate the mood and sleep benefits specific to oral micronized progesterone.

For someone who doesn’t tolerate oral progesterone due to side effects, you can take the capsule and insert it vaginally. This will provide adequate protection to the uterus without the side effects.

There are synthetic progestin options available as well. For perimenopausal women experiencing very heavy periods, a newer generation progesterone-only pill such as Slynd can help control bleeding—as can a progesterone IUD (such as Mirena or Kyleena). And for women who want both: it's perfectly fine to combine a progestin IUD with oral micronized progesterone, giving you the uterine protection and bleeding control of the IUD alongside the mood and sleep benefits of micronized progesterone.

There are patches that combine estrogen and progesterone for those who like to "set it and forget it." These contain a synthetic progestin because the progesterone molecule is too large to be absorbed through the skin, so micronized progesterone does not come in a patch.

Older synthetic progestins like Provera—used in the Women’s Health Initiative Study—have shown a small increased breast cancer risk: approximately 1 additional case per 1,000 women, or roughly the same increased risk associated with drinking a glass of wine daily. They still have appropriate use cases but are prescribed less frequently today.

Q4. What side effects exist, if any, should women be aware of—and how common are they?

Some women find that micronized progesterone makes them sleepy during the day. I have people take it at night, but some still feel sleepy the next day. Some women don’t tolerate progesterone. They may have bloating, upset stomach, swelling in the legs, greasy skin, or a change in body odor. About one quarter to one third of women may experience negative side effects.

Q5. What if someone experiences “progesterone intolerance”? Are there ways to adjust or switch formulations?

If someone has progesterone intolerance, I may have them try inserting the micronized progesterone capsule vaginally, or we may switch to a synthetic progesterone such as in the combipatch or those found in a progesterone-only birth control.

Q6. What about the progesterone creams and compounded products sold online or by specialty pharmacies—are they safe or effective?

While some women may report improvement in symptoms from progesterone creams, these do not provide the progesterone needed to protect the uterus. The progesterone molecule is too large, so it’s not actually being absorbed through the skin. This puts anyone who is taking estrogen at risk for developing uterine cancer.

Q7. For women who've had a hysterectomy and are on estrogen-only therapy, is there a case for considering progesterone for its non-uterine benefits?

Absolutely! While you don’t need to take progesterone if you don’t have a uterus, you certainly can if it helps with mood or sleep.

Note: The information shared in this newsletter and Q&A is for educational purposes only and does not constitute medical advice. Please consult your healthcare provider before making any changes to your hormone therapy.

A Note About Our Guest Expert 💛 Katie Rowan, MD is a Menopause Society-certified women's health and menopause specialist based in New York. If today's Q&A sparked questions you'd like to explore with a specialist who truly gets it, Katie is currently accepting patients in New York State. 🌐 katierowanwellness.com 📱 @katierowanmd on Instagram

All the Paussibilities

This issue has been about something that's been doing important work all along—quietly, without recognition, without fanfare. Sound familiar?

A lot of women in this transition find themselves in exactly that position. Carrying more than anyone sees. Managing more than anyone asks about. Doing the work—and wondering when it will finally be their turn to be seen, heard, or simply given the space to ask: what do I actually want now?

If that question is whispering—or starting to get louder— hit 📩 reply. I'd love to hear where you are.

Plus: Speaking of Hormones That Deserve More Attention…⚡

The NIH Just Dedicated Three Days to Menopause Research

This past month, the NIH Office of Disease Prevention hosted a three-day Pathways to Prevention workshop dedicated entirely to advancing research on the menopausal transition—bringing together federal agencies, researchers, clinicians, and community members to identify gaps in the current science and make recommendations for future research and practice. The NIH's Pathways to Prevention program is designed specifically for health topics with limited or underdeveloped research—which tells you something about where menopause has historically ranked as a federal priority. The fact that it got its own dedicated workshop is meaningful. Three days. From the NIH. On menopause. We'll take it.