Menopause : Progestogen & EPT

Another hormone, progestogen, has sometimes been used alone during perimenopause to treat symptoms such as hot flashes, to manage abnormal uterine bleeding, or to counter “estrogen dominance” that can occur in some women as estrogen levels fluctuate to high levels during this transition. But the most common use for progestogen is to protect against uterine cancer associated with ET. Combined estrogen-progestogen therapy and progestogen-alone therapy are also used as birth control pills. However, the doses used for menopause are not high enough to provide birth control, so contraceptive methods are required until a woman has had 12 months without a natural period

Progestogen Types

There are various progestogen options and they allow tailoring to a woman’s unique needs (see Chart on this page). Not all are government approved for EPT, and some are legally prescribed “off-label”. These include progesterone (bioidentical to the hormone produced by the ovaries) and several different progestins (compounds synthesized to act like progesterone). As with estrogen, progestogens are available in custom-made formulations prepared by a compounding pharmacist following a healthcare provider’s prescription. Progesterone skin creams, whether custom-made from a prescription by a compounding harmacy or purchased without a prescription, should not be used in EPT. No studies have been done that demonstrate that these skin creams protect the uterus from estrogen stimulation

EPT & Uterine Bleeding

In most women, using a progestogen with estrogen causes the endometrium to be shed from the uterus as bleeding, similar to a menstrual period, although fertility is not restored. Some women find this progestogeninduced bleeding very bothersome, but the bleeding often decreases or stops over time.

Newer dosage schedules that combine estrogen and progestogen daily eventually result in no uterine bleeding while still protecting the lining of the uterus. However, many women, particularly those recently past menopause, do have uterine bleeding or spotting during the first 6 months or more of these regimens. A woman should report any persistent irregular bleeding to her clinician right away.

EPT Regimens

Various EPT dosing schedules (often called “regimens”) can be used. These regimens include taking estrogen and progestogen separately or through convenient combination EPT products (see Chart on page 52). Each woman should feel comfortable exploring different options with her clinician to determine which is best for her. The most common EPT regimens are the following:

• Cyclic EPT

provides estrogen for 25 days each month, adding progestogen on the last 10 to 14 days, followed by 3 to 6 days of no therapy. Thus, both hormones are “cycled.” The popularity of this regimen has waned because of uterine bleeding each month when the progestogen cycle ends (called “withdrawal bleeding”) and the possibility of hot flashes returning during the estrogen-free interval.

• Continuous-cyclic EPT

(sometimes called sequential EPT) provides estrogen every day, with progestogen added for 10 to 14 days each month. As with cyclic EPT, this regimen causes uterine bleeding in about 80% of women when the progestogen cycle ends each month. However, bleeding gradually declines and stops in many women after a year or more.

• Continuous-combined EPT

provides both estrogen and progestogen every day. With this EPT regimen, less uterine bleeding occurs (40% of women during the first 6 months), but the timing is less predictable. After a year of therapy, uterine bleeding stops in nearly 90% of women.

• Intermittent-combined EPT

(provided by the brand Prefest) provides estrogen every day, then adds progestogen intermittently in cycles of 3 days on, 3 days off. Bleeding and endometrial protection are similar to that with a continuous-combined regimen.

A few healthcare providers are now prescribing estrogen every day, adding progestogen at longer intervals to lower exposure to progestogen. This “long-cycle” regimen needs further testing to confirm that it adequately

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