Continuous Bleeding & The Progesterone Challenge

by Jim Paoletti, BS Pharmacy, FAARM, FIACP – Director of Education | Power2Practice  

Continuous menstrual flow is a problem that you may encounter with some peri-menopausal patients. It results from too much proliferation from the action of estrogen on the uterus, compared to a lack of action by progesterone. Common causes are low progesterone production, high estrogen production, exposure to xenoestogens and other estrogen-like agents, and lack of adequate estrogen metabolism and elimination. All the causes need to be assess and addressed. More serious causes such as a possible endocrine tumor should first be ruled out.

The main issue is with patients who experience continuous bleeding, occurring for many days, or possibly even a month or two.

High-dose progesterone may be needed temporarily.

Adding progesterone at normal physiologic doses may adequately address the issue and control the bleeding. But when it does not, a high dose of progesterone may be warranted. 400mg oral Progesterone SR (compounded) daily, and sometimes higher, has been tried to stop bleeding. Occasionally it works well, and the main side effect is drowsiness. After bleeding is controlled, progesterone is dosed cyclically at normal physiologic doses.

Consider synthetic progesterone in this case.

Although I general do not suggest the use of synthetic progestins, uncontrolled bleeding is one situation where it may be warranted to use such agents. Progestins actually have a stronger effect on the uterus than natural progesterone. They can be used in a taper schedule which reduces the dose over 30 days, and then natural progesterone can be initiated once bleeding is controlled.

Here is the Aygestin taper that was suggested by one of my Ob-Gyn Functional Medicine Mentors, Dr Jack Monaco:

  • Aygestin 5 mg tablets, #50
  • Take 4 tablets daily for 4 days, followed by 3 tablets daily for 3 days, then 2 tablets daily for 2 days, and finally one tablet daily for 21 days.

This stops uterine bleeding within 1-2 day or two… She will then have a withdrawal bleed 2-5 days after taking the last tablet. Progesterone can be dosed at 200 mg SR oral capsules starting on day 12 of each subsequent cycle for 14 days. This most often regulates the patient. Continue this cyclic dosing until the patient has no withdrawal bleed for at least 2 months in a row.

Failure to experience withdrawal 2 months in a row indicates they are most likely menopausal (not enough estrogen to prime the endometrium) and progesterone can be dosed daily, along with estrogen as needed.

Peri-Menopause or Menopause? Try the Progesterone Challenge to Find Out.

One issue that is confusing at times is determining whether a new patient is still in peri-menopause or is menopausal. Estrogen levels fluctuate dramatically at the end of peri-menopause, and amenorrhea can occur on an irregular basis.

If the patient has had several cycles of amenorrhea, rather than check FSH/LH, which is regulated by inhibin more than estrogen, you might want to try a “progesterone challenge.”

  • Have the patient take progesterone 200 mg (Compounded SR or IR Prometrium will both work) daily for 10 days.
  • If there is no withdrawal, then they are most likely menopausal and your discussion of her hormone replacement therapy needs can be based on that.

Related Reading: How to Test for a Female’s Hormone Needs


About the Author

Jim Paoletti, BS Pharmacy, FAARFM, FIACP

Jim Paoletti is the Director of Education at Power2Practice and a Clinical Consultant with over 30 years of experience creating and using bio-identical hormone therapies in both retail pharmacy and clinical practice.

Jim is a Diplomat in Functional Medicine in addition to being a former faculty member for the Fellowship of Functional Medicine. Jim is also author of the book “A Practitioner’s Guide to Physiologic Bioidentical Hormone Balance.”

At Power2Practice, he applies his wealth of knowledge and experience by hosting live webinars and creating useful content, such as blogs, podcasts and clinical support tools.