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Progesterone Vaginal Route or Oral Route?

Progesterone and vaginal use... ladies we need to discuss this. I see a lot of women start taking HRT, and after a bumpy first few weeks, or in some cases just days? Read something on the internet and decide by themselves they should take progesterone vaginally instead. They then switch without even consulting their prescribing practitioner.

But maybe before you do so, have a read of this article!

(*Note that taking your progesterone vaginally is only possible if you are on body-identical progesterone, the gummy capsules. Non body-identical progestins such as dydrogesterone, which come in tablet form, are only for oral use.)

Progesterone side effects - is it making me sick?

First of all, yes, progesterone might be making you feel off... for now. While the oestrogen part of body identical HRT tends to be easily tolerated by most women, progesterone can take time to get used to. Possibly even a few weeks.

At first, progesterone can lead to things like:

  • drowsiness and dizziness

  • nausea

  • bloating

  • headaches

  • breast tenderness

  • mood swings

  • changes in vaginal discharge.

But these symptoms are usually mild and temporary for most women. They pass after a few days or weeks. And please note HRT is almost always is a bit uncomfortable at first, and takes time to settle! Ladies we are not taking candy here but hormones, which affect almost all systems in our body.

So my point being, don't jump to conclusions immediately.

Progesterone intolerance is not a few side effects

If you actually have progesterone intolerance, which is a small percentage of women, myself unfortunately included, you'll know. It's not just a few days or weeks of feeling off-kilter and nauseous, or with headaches that nevertheless you can continue your day with.

For starters, I had heart palpitations that meant when I took progesterone before bed I felt like I had drank a cup of coffee. (This is because intolerance can cause metabolic changes, such as, in my case, changes to blood pressure). So while everyone else I knew slept like a baby on progesterone, my heart would pound so fast, it got to the point that about a week in I had a night with one, yes one, hour of sleep. I told myself it must be anxiety, as at that point I'd never heard of progesterone intolerance.

I then tried taking progesterone in the morning instead. Which saw me with sharp pains in my head that were blinding, and nausea so severe I was on the sofa unable to move until about one in the afternoon. I also experienced a dizzy spell so severe I had to crawl on my hands and knees to bed. I am not someone who usually is knocked out by illness, I am one of those 'get on with it' types, and yet this had me useless.

I decided to quit HRT, thinking it was just not for me, when I stumbled across information about progesterone intolerance, and the idea of taking progesterone vaginally. And booked to talk to my gynaecologist about it.

Progesterone vaginal use in menopause is NOT licensed

Why shouldn't you just switch to the vaginal route with progesterone? First of all, it's not even licensed for use this way. What does that even mean?

It means there is not currently enough valid research outlining the efficiency, safety, and best dosing of vaginal progesterone capsules during menopause. And that therefore it is not an 'officially recommended' way to use progesterone with HRT for menopause.

This is why you doctor does not tell you to take it vaginally when first prescribing progesterone, but will tell you to take it orally. For the most part they will only discuss vaginal progesterone with you if, as in my case, there is an issue. The gynaecologist conceded that I had a progesterone intolerance and could insert the progesterone vaginally instead.

But it says "oral or vaginal use' on the box!" you protest. Sure. But this medication is not prescribed just to women in menopause, but also to women going through fertility treatments, were vaginal use is licensed.

Progesterone vaginal suppositories and side effects

Second of all, using progesterone the vaginal way has many drawbacks.  

  • it can really burn and cause itching and irritation

  • you can end up with cycles of infections from using it

  • it disrupts use of vaginal oestrogen for atrophy (Gydrelle, Trophigil, etc)

  • your sex life can be effected (condoms are required, unless your partner also wants to be taking progesterone).

Also note that you can expect goopy melting progesterone capsule residue to come out in your pee in the morning, or onto your underwear the next day. Such fun.

Quite honestly if I could tolerate it I would much prefer to take progesterone orally. It is far easier. So ladies, think it through before switching.

Vaginal progesterone dosing is not necessarily the same as oral use

Randomly deciding to switch to vaginal use of progesterone without consulting a doctor is particularly not advisable when you might not even need the same dose. There is controversy around dosing, and I get into this further in my book.

But in summary, when taking progesterone vaginally, the progesterone is getting right to the area it needs to effect, the uterus. Remember, one of the main ways the progesterone part of HRT in menopause works is to keep your endometrium from thickening to the point is leaves you at risk for certain cancers.

So given the progesterone is getting right to it, so to speak, with what is called 'the vaginal first-pass effect', this can change the amount of progesterone you need. This of course depends on things like how much oestrogen you are taking.

You can develop progesterone tolerance over time

Another thing to note is that some women go from progesterone intolerant to tolerant over time, apparently. I was very excited to read this and gave oral progesterone another whirl after two years of vaginal use. I tried all different ways of taking it, and while I found a way that side effects weren't quite so brutal, I still struggled with oral use.

Although I did discover that the brand you take matters. There was one brand I managed to sort-of tolerate if I took it at certain odd hours. In the end I went back to vaginal use, but requested the brand that I tolerated better orally from the pharmacist. And turns out it caused me less burning and irritation vaginally. I get into that into more detail about brand considerations in my book.

Progesterone is destroying my sleep, should I switch to vaginal progesterone capsules?

For some women Progesterone can lead to restless sleep full of strange dreams. Meaning you wake up and you feel like you haven't slept at all. Or have huge dark circles under your eyes even though you weren't waking up in the night.

In this case you can always try taking your progesterone in the morning, or splitting your dose to half at night, half in the morning (depending on what dose you are on). If that doesn't work, then perhaps, yes, vaginal use of progesterone is required.

Andrea-Marie is a health writer and the author of 'HRT in France', a guide to navigating the French health system and getting a gold-standard HRT regime.

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