What is the provera or progesterone challenge test?

If a woman does not have a menstrual period or bleeding she has "amenorrhea". The first step is to exclude pregnancy, usually with a pregnancy test. In the absence of a pregnancy, many doctors then perform the 'progestational challenge test' (progesterone withdrawal test or progestin challenge test) to find out the possible reason for the amenorrhea. This test is usually done by giving oral by mouth medroxyprogesterone acetate (Provera) 10 mg daily for 7-10 days. After the progesterone challenge test, a woman will either have vaginal bleeding within about 1 week after the last pill ('withdrawal bleeding') or she will not bleed. After the test there will either be vaginal bleeding or no vaginal bleeding.

There is bleeding after the progesterone challenge test: Usually anovulation

If there is withdrawal bleeding after the progestin challenge, that's an indication that there is enough estrogen present (usually over 40 pg/ml) and that the amenorrhea was due to not ovulating (anovulation). The next step is to do tests and find out why there is no ovulation (anovulation) 

There is no bleeding after the progesterone challenge test

If there is no withdrawal bleeding after the progestin challenge, most doctors will do a blood FSH level.

A high FSH level indicates that there is so called "diminished ovarian reserve", and additional tests are done

A normal FSH means usually that the doctor will add estrogen to see if there is vaginal bleeding after the estrogen.

No vaginal bleeding after progesterone+estrogen

Without bleeding after the progestin challenge test, then the patient's amenorrhea is likely to be due to either

  • low serum estradiol,
  • hypothalamic-pituitary axis dysfunction,
  • a nonreactive endometrium or
  • a problem with the uterine outflow tract, such as cervical stenosis or uterine synechiae (Asherman's syndrome).

In order to distinguish between hypoestrogenism or a uterine outflow tract problem/nonreactive endometrium, estrogen may be administered followed by a course of progestin in order to induce withdrawal bleeding.

Vaginal bleeding after progesterone+estrogen

If there is  bleeding with the combined estrogen/progestin therapy, then the amenorrhea is likely due to low estrogen.

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