Why might I need progestogen in addition to oestrogen replacement?
If your uterus is present, progestogen is essential to protect the lining of the womb from undue thickening (hyperplasia) by the oestrogen in HRT and the potential for malignant change (20). Progestogen almost completely prevents the risks of malignancy. It has been shown that if you take oestrogen replacement therapy together with progestogen, you are even less likely to develop cancer of the endometrium than a lady who has never been on HRT.
Many women who have not yet reached the menopause experience symptom relief with HRT. In general, progestogens are prescribed for ten or twelve days on a sequential basis. A withdrawal (period-like) bleed usually occurs about 2 to 4 days after the progestogen course has been completed. As with the combined pill, the withdrawal bleed with HRT should replace your period and would not be in addition to it.
The choice includes a combination of an oestrogen preparation (Figure 28.1 Group A) with a progestogen (Group B), or a combination pack with the oestrogen and sequential progestogen (Group C). Two progestogens have been marketed specifically for combination with an oestrogen. These are Micronor HRT (norethisterone 1mg – Janssen-Cilag) and Duphaston HRT (Dydrogesterone 10mg - Solvay). It must be emphasised that these are to be used in combination with an oestrogen – they are not in themselves forms of HRT. Progesterone gel (Crinone - Serono) can be introduced vaginally every other night from the 15th to the 25th day of the cycle. There are two strengths – 4% and 8%.
Figure 28.4
The amount of progestogen required varies between individuals. As with any medication one tries to prescribe the lowest amount required to achieve the objective. Some women have side effects from the progestogen such as premenstrual syndrome type problems. For some patients it may be necessary to increase the progestogen to prevent light bleeding at inappropriate times. If problems arise, a different progestogen may be considered.
There is one preparation, Tridestra (Orion) which has the progestogen for 14 days but on a three-monthly basis. This has the benefit of three-monthly rather than monthly withdrawal bleeds for women thought to be close to the menopause. Several companies provide packages of oral oestrogen with sequential progestogens (Figure 28.1C; Table 28.5).
Table 28. 5 sequential HRT preparations (cyclical progestogen tablets). PREPARATION OESTROGEN/PROGESTOGEN mg
COMPANY
TABLETS
Nuvelle Oestradiol / Levonorgestrel 2 / 75mcg Schering Climagest 1 mg Oestradiol / Norethisterone 1 / 1 Novartis Climagest 2 mg
2 / 1 Novartis
Cyclo-Progynova Oestradiol / Levonorgestrel 1 / 0.25 Asta
Cyclo-Progynova Oestradiol / Levonorgestrel 2 / 0.5 Asta Elleste Duet 1mg Oestradiol / Norethisterone 1/1 Searle Elleste Duet 2mg Oestradiol / Norethisterone 2/1 Searle
Femoston 1/10 Oestradiol / Dydrogesterone 1 / 10 Solvay Femoston 2/10 Oestradiol / Dydrogesterone 12/ 10 Solvay
Prempak-C 0.625 Conjugated oestrogens/Norgestrel 0.625 / 0.15 Wyeth Prempak-C 1.25 Conjugated oestrogens/Norgestrel 1.25 / 0.15 Wyeth
Premique Cycle Conjugated oestrogens/ Medroxyprogesterone acetate
0.625 / 10 Wyeth PREPARATION OESTROGEN/PROGESTOGEN mg COMPANY
TRANSDERMAL PATCH + TABLETS
Estrapak Oestradiol / Norethisterone 50 mcg/ 24hr / 1 Ciba
Evorel-Pak Oestradiol / Norethisterone 50 mcg/ 24hr / 1 Janssen-Cilag
Femapak 40 Oestradiol / Dydrogesterone 40 mcg/ 24hr / 10 Solvay
Femapak 80 Oestradiol / Dydrogesterone 80 mcg/ 24hr / 10 Solvay
Most have a continuous daily amount of oestrogen but Trise quens and Trise quens Forte (Novo Nordisk) have varying amounts of oestrogen designed to imitate the natural cycle.
For those who prefer to avoid tablets there are currently three transdermal patches with sequential progestogen applied during the second half of the cycle (Fig. 28.1 C; Table?28.6).
Table 28. 6 sequential HRT patches.
|
PREPARATION |
OESTROGEN/ PROGESTOGEN |
mg |
COMPANY |
|
Estracombi? |
Oestradiol / Norethisterone |
50 mcg + 250mcg/ 24h |
Ciba |
|
Evorel Se qui? |
Oestradiol / Norethisterone |
50 mcg + 170mcg/24 h |
Janssen-Cilag |
|
FemSeven Se qui |
Oestradiol / Levonorgestrel |
50 mcg 10mcg /24 h |
Merck |
|
Nuvelle TS? |
Oestradiol / Levonorgestrel |
80 / 50 + 20 mcg /24 h |
Schering |
