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Menopausal symptoms are largely driven by a lack of oestrogen. HRT helps these symptoms by topping up your body’s depleted oestrogen levels. HRT will also contain progesterone, unless you’ve had a hysterectomy. Understanding the pros and cons of different types of progesterone in HRT is key to choosing the most suitable HRT for you.

This article was included in issue 83 (winter 2019/2020) of The Menopause Exchange newsletter.

Progesterone at the menopause
Progesterone is key for the regulation of your periods. Its role is to prepare your uterus (womb) for pregnancy. If you have regular periods, progesterone is produced by your ovary after ovulation. If no fertilisation occurs, your progesterone levels drop and your period starts.

The perimenopause is accompanied by unpredictable ovulation. If you don’t ovulate, your progesterone remains low, leading to periods that can be early, late, heavy or very light. Eventually your ovaries stop responding to hormones and your oestrogen and progesterone levels drop, leading to a thin uterine lining that doesn’t bleed.

Progesterone in HRT
Progesterone in HRT is essential to protect your uterine lining and regulate bleeding. Progestogen, also known as ‘progestin’, includes both synthesised and natural hormones. Women with a uterus need HRT containing oestrogen and a progestogen. Oestrogen alone leads to thickening of the uterine lining, which can be associated with endometrial cancer.

Types of HRT products
Intermittent progestogen: Monthly bleed HRT uses oestrogen every day and a progestogen for the second half of the cycle. Bleeding is expected towards or at the end of each HRT cycle. This is known as combined sequential or combined cyclical HRT. Taking HRT in this way provides a more predictable bleed. If you’ve had a period within the last 12 months, this is the correct type to use. But if your periods have almost stopped, this can be an unwelcome effect. Some regimes will trigger a bleed three times a year only. These are less common.
Continuous progestogen or ‘no bleed HRT’: This involves using oestrogen and progestogen every day and is known as continuous combined HRT. If you’ve had no periods for the past 12 months, this is the correct type of HRT for you. No bleeding is expected, although it can occur in the first three to six months as your body adjusts.

Progestogens used in HRT
The individual properties of hormones vary enormously in how they interact with your body.

For a simple regime:
Norethisterone is an ‘old favourite’. Women who got on well with Brevinor or Norimin as contraceptive pills may find it suits them. Patches and pills containing oestradiol and norethisterone are widely prescribed in primary care, but many have been subject to recent supply issues, e.g. Evorel Sequi, Evorel Conti patches, Elleste Duet and Elleste Duet Conti.

For good bleeding control:
Medroxyprogesterone acetate is found in oral HRT, both in combination and standalone tablets. It’s one of the most tried and tested progestogens and is excellent for bleed control. However, it can cause PMS-type symptoms. Examples include Tridestra, Indivina and Premique Low Dose.
Levenorgestrel is found in the Mirena IUS, a plastic device that a healthcare professional fits into your uterus. It provides progestogen directly to your uterine lining. Menstrual bleeding is lightened and will very commonly stop completely. Avoiding digestion reduces the risk of side effects. However, rarely, women who are very sensitive to progestogens may experience PMS-type side effects in the first six months or so. Levenorgestrel is also found in Femseven patches, which are due to be available once again in 2020.

For the reduction of PMS symptoms:
Dydrogesterone is found in oral HRT in the Femoston range. It’s an excellent choice for those who have felt irritable or experienced acne with other more ‘androgenic’ HRT’s. However, it’s not available in patch form.
Utrogestan is a progesterone tablet that needs to be combined with a separate oestrogen. It’s a ‘body identical’
progesterone derived from vegetable sources. It’s been micronised, which means ‘made into tiny pieces’. Its structure matches the body’s own progesterone very well, reducing unwanted side effects. It’s an excellent choice if you prefer a natural approach. It also has a calming effect, which can help with sleep if taken at night. However, it may offer less predictable bleed control than some of the more synthetic options. Utrogestan is a very popular choice and not subject to current supply issues.

For flexibility:
Using a ‘mix and match’ regime aids flexibility. Many women get on very well with oestrogen delivered as a patch, gel or pill with a progestogen tablet or ‘IUS’. Utrogestan and medroxyprogesterone acetate are good oral options.

If contraception is required:
Any combined oral contraceptive, providing there are no contraindications, can work well for bleed control and menopausal symptoms. Consider using one of the new ‘long cycle regimes’, if suitable. They are normally prescribed up to the age of 50.
Dienogest is found in Qlaira, a combined oral contraceptive tablet. It has a licence for heavy menstrual bleeding and contains the same kind of oestrogen as found in HRT. It can be excellent for women experiencing perimenopausal symptoms and heavy bleeding.

Understanding progesterone in HRT will help you work with your doctor to make an informed choice about your best possible treatment options.

About the author
Dr Jane Davis is a GP and Specialty doctor in sexual and reproductive healthcare in Cornwall.

Created Winter 2019/2020 

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