Does HRT mean periods again?

Initially when it was realised that unopposed oestrogen in hormone replacement therapy (HRT) could cause problems with the endometrium, progestogens were always administered sequentially even after the menopause. The sequential regimen produced withdrawal bleeds for the majority although a few would have no bleeds. This was, no doubt, a reason for many women deciding against HRT as understandably the idea of monthly withdrawal bleeds was unacceptable for them.

With the arrival of tibolone (Livial; Table 28.7) it became possible to give an HRT preparation to postmenopausal women who still have their womb without causing withdrawal bleeds. Even today, many postmenopausal women are surprised to learn that they can have HRT without enduring withdrawal bleeds.

We now know that it is safe to prescribe any oral (tablets taken by mouth) HRT in combination with a low dose progestogen daily and avoid periods (Figure 28.1). There are eight tablet preparations and one transdermal patch available for continuous combined HRT (Table 28.7)A continuous combined vaginal ring is currently being evaluated.

Figure 28.1

Table 28. 7Continuous Combined HRT preparations.

PREPARATION OESTROGEN/

PROGESTOGEN

 mg Company

TABLETS

Climesse

Oestradiol valerate / Norethisterone

2 / 0.7

Novartis

Elleste Duet Conti

Oestradiol / Norethisterone

2 / 1

Searle

Femoston-Conti

Oestradiol / Dydrogesterone

1 / 5

Solvay

Kliofem

Oestradiol /Norethisterone Acetate

2 / 1

Novo Nordisk

Kliovance

Oestradiol / Norethisterone

1 / 0.5

Novo Nordisk

Livial

Tibolone

2.5

Organon

Nuvelle Continuous

Oestradiol / Norethisterone

2 / 1

Schering

Premique

Conjugated oestrogens / Medroxyprogesterone Acetate

0.625 /  5

Wyeth

PATCH

Evorel Conti

Oestradiol  / Norethisterone

50/170mcg

Janssen-Cilag

FemSeven Conti

Oestradiol / Levonorgestrel

50/7

Merck

Beforethe menopause, if a LNG-IUS (Mirena -Mirena) is introduced, to provide endometrial protection for oestrogen replacement therapy, periods tend to be lighter or sometimes they stop. If you have gone through the menopause and wish to take HRT without having withdrawal bleeds and you cannot tolerate progestogens taken orally or in the patch, the LNG-IUS will provide endometrial protection and may not produce the same side effects.

Some slight spotting of blood is common for the first few weeks and occasionally up to six months with continuous combined HRT. If this should persist or if it occurs later on, the bleeding should be reported to the doctor as investigation is required (hysteroscopy D and C).


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