Anxiety that seems to come from nowhere. Waking at 2 or 3am with your mind racing. Heavier periods, spotting before your period, worsening PMS, heart palpitations or suddenly feeling far more sensitive to stress. These can all be signs of low progesterone, and they can happen at any age, not just during perimenopause.
I’ve worked with women and their hormones for 20 years and I’ve seen low progesterone in women of all ages. In younger women it might be spotting, a short luteal phase, PMS, difficulty conceiving or recurrent miscarriage. By perimenopause, periods may become heavier or closer together, sleep can suddenly become a problem and women who have never considered themselves anxious can start waking in the night with their heart racing.
Progesterone is still thought of mainly as a reproductive hormone, or the hormone you take alongside oestrogen HRT to protect the womb lining. It does far more than that.
And a normal progesterone blood result doesn’t always tell us what we need to know.
15 signs of low progesterone
These are some of the signs I see in clinic:
- Waking between 2 and 4am
- Anxiety or feeling on edge
- Feeling wired but exhausted
- Heart palpitations or adrenaline surges
- PMS or PMDD
- Spotting before your period
- A short luteal phase or shorter cycles
- Heavy periods
- Breast tenderness
- Bloating and fluid retention
- Hormonal headaches or migraines
- Difficulty falling asleep or staying asleep
- Difficulty conceiving
- Recurrent early miscarriage
- Night sweats or worsening perimenopause symptoms
You don’t need to have all of these symptoms and they can have other causes. In clinic we use symptoms as a guide but rarely diagnose low progesterone from symptoms alone. We need to know what your hormones are doing and what your body is doing with the progesterone you produce.
Progesterone, anxiety and waking at 3am
Progesterone has a major effect on the brain and nervous system.
One of the ways your body metabolises progesterone produces allopregnanolone, a neurosteroid that acts on GABA-A receptors in the brain. GABA is one of our main calming neurotransmitter systems.
When progesterone falls, some women become much more sensitive to stress. They wake at 2 or 3am completely alert, experience adrenaline surges or palpitations, suddenly can’t tolerate caffeine or feel anxious when there is no obvious reason for it.
I hear this all the time in clinic, particularly during perimenopause.
Progesterone can be falling because ovulation is becoming less reliable while oestrogen is still fluctuating dramatically. At certain points oestrogen can still be very high.
You can therefore have plenty of oestrogen activity without the progesterone you previously produced after regular ovulation.
If anxiety, poor sleep and that wired-but-exhausted feeling are familiar, magnesium is also something I consider. Magnesium is involved in normal nervous-system function and GABA activity, and requirements can be difficult to meet through food alone. My Magnesium Complex combines magnesium bisglycinate, citrate and malate with taurine and zinc and is one I use regularly when sleep, tension and an overactive nervous system are part of the hormone picture.
Low progesterone can happen at any age
Progesterone is produced predominantly by the corpus luteum after ovulation. After an egg is released, the follicle it came from becomes the corpus luteum, which produces progesterone during the second half of your cycle. If you don’t ovulate, you don’t get the normal rise in progesterone afterwards. I don’t see low progesterone as purely a perimenopause problem.
I’ve worked with much younger women who are spotting before their period, struggling with severe PMS or irregular ovulation, or finding it difficult to conceive. I’ve also seen recurrent early miscarriage, where low progesterone may be part of what’s going on.
Stress, under-eating, excessive exercise and low thyroid function can all interfere with normal ovulation. Perimenopause makes anovulatory cycles more common, which is why progesterone can start declining years before periods finally stop.
Low progesterone, spotting and heavy periods
Progesterone helps regulate the endometrium, the lining of the womb.
As ovulation becomes less consistent and progesterone starts to fall, oestrogen can become more dominant. You might notice your periods becoming heavier or longer, coming closer together or becoming more irregular.
Spotting before a period is something I always pay attention to, particularly when it happens month after month. I want to know when you’re ovulating and whether progesterone is rising properly afterwards.
PMS can worsen too. Anxiety, irritability, breast tenderness, headaches, bloating and disturbed sleep can all become much more noticeable in the second half of the cycle.
For women in perimenopause, I also use Peri-Balance as broader nutritional and botanical support through the hormonal fluctuations that happen at this stage.
Progesterone and fertility
Progesterone prepares the endometrium for implantation and supports early pregnancy.
If I’m working with a woman who is struggling to conceive, has a consistently short luteal phase, several days of spotting before her period or a history of recurrent early miscarriage, progesterone needs investigating.
But I don’t want one progesterone blood test taken without looking at where you are in your cycle.
Why I don’t rely on a progesterone blood test alone
Women come into clinic having been told their progesterone is normal, but when I ask when it was tested, quite often the result doesn’t tell me very much.
Progesterone isn’t released at one steady level throughout the day. It is secreted in pulses and changes enormously depending on where you are in your cycle.
For a cycling woman, I want the test timed in relation to her ovulation, not automatically “day 21”. Day 21 only makes sense when ovulation has happened at the expected point in that particular cycle.
If you’re taking progesterone, timing in relation to the dose also needs to be considered. A morning serum result tells us what is circulating at that point. It doesn’t tell me the whole story of how you have metabolised that progesterone. I want more information than that.
What DUTCH testing tells me about progesterone
DUTCH Complete lets me look at progesterone metabolites rather than relying on serum progesterone alone.
I can see the relative activity of the 5-alpha and 5-beta progesterone pathways. At the same time, I can look at oestrogen metabolites, DHEA and cortisol and cortisone patterns across the day.
If a woman is still cycling and I need to understand what is happening across the month, I may use DUTCH Cycle Mapping. We can follow oestrogen and progesterone metabolites across the cycle rather than looking at one isolated day.
I can see whether she is ovulating, what happens to progesterone afterwards and how that relates to the symptoms she experiences at different points in the month.
5-alpha and 5-beta progesterone metabolism – What is your are sensitive to Progesterone?
There’s another part of progesterone that’s worth understanding. Your body doesn’t just produce it. It also has to convert and metabolise it.
So when progesterone appears low, I don’t only want to know whether you’re producing enough. I also want to understand what your body is doing with the progesterone you make. How progesterone is metabolised and cleared can affect the levels we see, which is one of the reasons I find hormone metabolite testing so useful.
DUTCH testing allows us to see the relative balance between the 5-alpha and 5-beta progesterone metabolite pathways. I’m interested in this because progesterone metabolites have different neuroactive properties. It can help us understand why two women can take the same progesterone and have completely different experiences. One sleeps better and feels calmer. Another feels groggy. Another becomes more anxious. Another tells me it has done absolutely nothing.
Some women find that progesterone makes them feel more anxious, agitated or low rather than calmer. This may be due to what’s known as the paradoxical GABA effect. Allopregnanolone, a metabolite of progesterone, normally has a calming effect on GABA receptors in the brain, but in some women it can have the opposite effect. Interestingly, research suggests this response may be dose dependent, with lower to moderate levels causing symptoms while higher levels can be calming. This may explain why in clinic we sometimes find that increasing progesterone can get a woman through that sensitivity rather than reducing it. We also look at how well she is detoxing progesterone, particularly if she seems sensitive to different forms, including topical progesterone.
Reference: Andréen L, Nyberg S, Turkmen S, et al. Sex steroid induced negative mood may be explained by the paradoxical effect mediated by GABA-A modulators. Psychoneuroendocrinology. 2009;34(8):1121–1132. doi:10.1016/j.psyneuen.2009.02.003.
Giving every one of those women the same dose in the same form doesn’t make sense to me.
If you are already taking progesterone and still don’t feel right, a Discovery Consultation gives us the opportunity to look at the whole picture and decide whether hormone metabolite testing would give us useful information.
Why can progesterone make some women feel worse?
Progesterone is often described as a calming hormone, and for many women it is. But not everyone responds to it in the same way.
I pay particular attention if you have a history of severe PMS or PMDD, as you may be more sensitive to changes in progesterone and allopregnanolone, one of the compounds your body makes from progesterone.
If you tell me progesterone is making you feel anxious, agitated, low or very groggy, I want to understand why. I’ll look at what you’re taking, the dose, when and how you’re taking it, whether you’re still cycling and what else is happening with your hormones.
The dose may need adjusting, or we may need to look at how you’re taking it.
And remember, your body also needs to process and clear hormones once they’ve done their job, including the progesterone you produce naturally and synthetic progestins. This is why in clinic we also look at supporting healthy hormone clearance, and why I often recommend my Detox supplement as part of that support.
Oral progesterone, vaginal progesterone, cream and compounded progesterone
How you take progesterone can make a difference to how you respond to it.
Oral micronised progesterone is processed through the liver, where it produces metabolites including allopregnanolone. For some women, this can be very helpful for sleep, while others can feel very sedated or groggy.
Vaginal progesterone is absorbed differently, and progesterone creams and compounded buccal or sublingual preparations work differently too.
This is why I don’t treat them all in the same way. If progesterone isn’t suiting you, I wouldn’t necessarily keep increasing the dose. I’d also look at how you’re taking it and whether another route may be more appropriate.
On days when I want something more immediate than an oral dose, I use the Platt progesterone cream, which I have added to my Pippa Loves page.
Is 100mg or 200mg of progesterone enough?
There isn’t one dose that suits every woman.
In standard HRT prescribing, micronised progesterone is commonly given as 100mg continuously or 200mg cyclically, depending on the HRT regimen. Those numbers have become so familiar that women can assume anything higher must be an unusually high dose.
There is clinical research using 300mg oral micronised progesterone (Dr Prior), including studies looking at sleep, hot flushes and night sweats. Dr Katharina Dalton’s historical work with natural progesterone for PMS and postnatal depression also used considerably higher doses.
That does not mean every woman needs more progesterone.
Dose needs to be considered alongside symptoms, oestrogen exposure, bleeding pattern, route and the reason progesterone has been prescribed.
If you’re taking progesterone as part of your HRT, particularly alongside systemic oestrogen, always speak to your prescribing clinician before making any changes to your dose.
Progesterone and oestrogen
Perimenopause isn’t a neat, gradual decline in all your hormones at the same time.
Progesterone can be falling while oestrogen is still fluctuating wildly. You can have periods of very high oestrogen and much less progesterone because you are no longer ovulating consistently.
I see women increasing their oestrogen because they are still symptomatic, but nobody has gone back and looked at progesterone alongside it.
If you have a uterus and are using systemic oestrogen HRT, adequate progestogen is essential for protecting the endometrium.
I also want to know how you feel. What has happened to your sleep? Have you developed breast tenderness? Has your bleeding changed? Are you more anxious? Are you getting headaches? What was happening before you started HRT?
Natural progesterone and synthetic progestogens (Mirena coil, OCPs) are not the same
Micronised progesterone is structurally identical to the progesterone our own bodies produce. Synthetic progestogens are not.
Levonorgestrel, for example, is the synthetic progestogen used in the Mirena coil and some contraceptive pills. It can have androgenic effects and, for some women, can contribute to acne and weight gain.
In clinic we see so many women who have been given the Mirena as part of their HRT and have been told they are replacing their progesterone. They’re not. The levonorgestrel is there to protect the lining of the womb, but it does not replace progesterone or do everything our own progesterone does in the body. We also see very low levels of a woman’s own progesterone on DUTCH testing when ovulation is being suppressed.
We see this a lot with endometriosis and adenomyosis too, where women are often offered the Mirena. These are oestrogen dominance conditions, so for us it’s not just about controlling the bleeding. In clinic we look at how a woman is metabolising and clearing oestrogen, as well as supporting progesterone. We often find progesterone cream works very well because it’s absorbed systemically, and in some cases we also use it over the lower abdomen. It’s about looking at what is driving the condition, rather than just putting a sticking plaster over the symptoms.
Progesterone has hundreds of roles in the body. It affects the brain and nervous system, sleep, mood, body temperature, bones and breasts. So while the Mirena may be protecting the lining of the womb, that does not mean a woman has replaced her progesterone. She can still be struggling with anxiety, poor sleep and night sweats.
And this is where I think women are being given the wrong message. I hear women, including women in the public eye, saying they are “replacing their progesterone” with the Mirena coil. They are not. Levonorgestrel is a synthetic progestogen. Micronised progesterone is progesterone. They are not interchangeable.
Join me LIVE to talk about progesterone
I’ve had so many questions about progesterone recently, particularly around the Mirena coil, HRT and low progesterone.
So next month (October) I’m doing a LIVE progesterone Q&A in my Facebook Group, where I’ll be talking about progesterone in more detail and answering your questions. Join my Facebook Group here.
Progesterone, thyroid and stress
I also want to know what’s happening with your thyroid and stress hormones.
Low thyroid function can affect ovulation and reproductive hormones, and long-term stress can interfere with the hormones involved in ovulation.
Progesterone and cortisol are both made from the precursor hormone pregnenolone. You may have heard this described as the “progesterone steal”, where the body supposedly steals progesterone to make cortisol when you’re under stress.
It isn’t quite as simple as progesterone literally being stolen to make cortisol. What we do know is that ongoing stress can disrupt the hormonal signalling needed for normal ovulation. And if you’re not ovulating regularly, you won’t be producing the same amount of progesterone.
When I’m looking at DUTCH results, I don’t just look at progesterone. I also look at cortisol, cortisone and DHEA to understand what else may be affecting your hormones.
Blood sugar and progesterone
A woman can be taking progesterone and still feel anxious, shaky and wired if her blood sugar is fluctuating throughout the day.
Long periods of fasting don’t suit every woman, particularly during perimenopause.
I want protein at breakfast, regular meals where needed and no coffee on an empty stomach.
For the anxious, racing-mind feeling, I also use Chill alongside the wider hormone work. And magnesium comes back in here too. Magnesium Complex is one of the supplements I use when poor sleep, anxiety, muscle tension and an overactive nervous system are part of the picture.
Supplements are support. They don’t tell me whether a woman needs progesterone, how much she needs or which route will suit her.
How I investigate low progesterone in clinic
After 20 years of working with women and hormones, I know two women can arrive with almost identical symptoms and have very different hormone results.
Two women can both be waking at 3am.
One may have declining progesterone alongside fluctuating oestrogen. One may have a disrupted cortisol pattern. One may already be taking progesterone but not responding well to the dose or route. Another may have thyroid and blood sugar problems contributing to the same symptoms.
The Pippa Campbell Method is test-led. I want to know which woman I’m dealing with before deciding what she needs.
Depending on her age, symptoms and whether she is still cycling, we may use DUTCH Complete or DUTCH Cycle Mapping.
I want to know whether she is ovulating. Whether progesterone is rising after ovulation. What oestrogen is doing alongside it. How she is metabolising progesterone. What her cortisol and DHEA are doing. Whether thyroid function is part of the picture.
If she is already taking progesterone, I want to know whether the dose and route make sense for her.
A single serum progesterone result cannot give me all of that information.
If you recognise yourself in these symptoms, you’ve been told your progesterone is “normal” but still don’t feel right, or you’re taking progesterone and it isn’t giving you the improvement you expected, book a Discovery Consultation.
We can then decide whether DUTCH testing is right for you and which test will give us the information we need.
