Progesterone and HRT

When discussing hormone replacement therapy (HRT), much of the focus is placed on oestrogen because it is responsible for many menopausal symptoms such as hot flushes, night sweats, mood changes, brain fog, and joint aches. However, for women with a uterus, progesterone is equally important and is often the factor that determines how well HRT is tolerated. 

Over the past 18 months, progesterone prescribing in the UK has evolved significantly, with new standalone progesterone options now available. These developments allow HRT and contraception to be tailored more effectively to individual women, particularly during the perimenopause. 

Why progesterone is important in HRT 

Women with a uterus who take oestrogen must also take progesterone to protect the womb lining. Oestrogen stimulates the endometrial lining of the womb, and without progesterone to oppose this effect, there is an increased risk of endometrial hyperplasia and endometrial cancer. 

In addition to endometrial protection, progesterone can affect: 

• Mood  
• Sleep  
• Bloating  
• Bleeding patterns  
• Skin  
• Overall treatment tolerability  

Progesterone intolerance is common and can significantly impact the success of HRT. 

HRT is not contraception 

A key point during the perimenopause is that HRT does not provide contraception. Even with irregular or infrequent periods, ovulation can still occur. 

Menopause is only confirmed after 12 months without menstruation. Contraception is still required: 

• For two years after the last period if under age 50  
• For one year after the last period if over age 50  
• Or at the age of 55 if neither of the above apply 

This is why progesterone-only contraceptive options remain highly relevant during the perimenopause. 

Drospirenone 4 mg (Slynd®) 

Slynd is a newer progesterone-only pill (POP) introduced in the UK in 2024. It is increasingly being used not only for contraception but also (off licence) as part of menopause management. For women using it as part of their menopause package it should be taken continuously (skipping the green pills). For women using it only for contraception the green placebo pills should be taken and this is typically when a women would have their period. Some spotting with this pill can happen, more so in the first 6 months. 

Progesterone tolerance 

Many women experience side effects from progesterone, including low mood, irritability, bloating, anxiety, or fatigue. 

In clinical practice, Slynd® may offer advantages because it: 

• Is generally more skin-friendly  
• Is less likely to worsen acne than desogestrel  
• May be better tolerated in women who are progesterone-sensitive  

Some women who struggle with micronised progesterone preparations such as Utrogestan or Gepretix® might tolerate drospirenone well. 

Benefits include: 

• Improved flexibility of prescribing  
• Better bleeding control in some women  
• Potentially lower breast cancer risk compared with some synthetic progestogens  

Importantly, it allows progesterone changes without altering an oestrogen regimen that is otherwise working well. 

So, if your current menopause treatment is not working well for you then come and speak to one of our women’s health specialists. We have the time and knowledge to really think through your symptoms. Menopause care is not a one size fits all option.