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Navigating Menopause: Insights from Dr Philippa Girling, GP and Menopause Specialist

Progestogen Challenges in HRT: A Comprehensive Guide

"As a women’s health lead and menopause specialist, I’ve listened to and advised many patients seeking Hormone Replacement Therapy (HRT) over the years. While most women respond favourably to HRT, some face unique challenges. Among these complexities, progestogen intolerance stands out as a significant concern," says Dr Girling.

The Crucial Role of Progestogen

Before delving into solutions, let’s understand the critical roles of progestogen and oestradiol (the primary oestrogen used in HRT). Oestradiol is the workhorse, alleviating perimenopausal and post-menopausal symptoms across various HRT forms from tablets, patches, and gels to sprays. But what about progestogen?

  1. Endometrial Protection: Progestogen’s primary job is to counterbalance oestradiol’s effects on the endometrium—the lining of the womb. Without adequate progesterone, women may experience ongoing bleeding issues and, over time, face a heightened risk of endometrial cancer.
  2. Varied Progestogens: Unlike oestradiol, progestogen options are diverse. Micronised progesterone tablets, often taken at night due to their mild sedating effect, are popular. However, synthetic progestogens can be useful alternatives, and they are available in tablets, patches, or hormonal coils.
  3. Dose Adjustment: Ensure the progestogen dose aligns with the oestrogen dose. High-dose oestrogen regimens demand proportionate progestogen levels for optimal endometrial protection.
Identifying Progestogen Intolerance

Women who react adversely to progestogens often have a history worth exploring. Consider the following:

  1. Personal History: Some women experience PMS (pre-menstrual syndrome) or PMDD (premenstrual dysphoric disorder), which could hint at progestogen sensitivity.
  2. Contraception Experience: If a woman has reacted poorly to progestogens in contraceptives, it’s relevant information for predicting potential HRT issues.

Strategies for Progestogen Intolerance

Now, let’s address practical solutions:

Tailored Progestogen Selection: Individualised progestogen choice based on the patient’s profile and personal preference. Micronised progesterone tablets are well-tolerated by many, but synthetic options may be necessary for specific cases, including better bleeding control.

Vaginal Administration: For those experiencing side effects with oral intake, vaginal administration of progesterone can be worth trying.

The Mirena intrauterine system (IUS) provides very effective endometrial protection within HRT regimens and may be better tolerated than oral progesterone. It also has the advantage of offering contraception and good control of bleeding.

Exploring Alternatives: When faced with progestogen sensitivity, we can consider switching to a different type of progestogen or altering the method of administration. Another option may be tibolone, a distinct form of HRT that can be used in post-menopausal women. Tibolone offers an alternative approach, potentially alleviating progestogen-related issues whilst simultaneously addressing perimenopausal symptoms.

Remember, progestogen plays a pivotal role in HRT, and understanding its nuances empowers us to navigate challenges effectively.

At Sulis Hospital, we understand the unique challenges that menopause brings. Our dedicated Menopause Clinic offers personalised care tailored to your individual needs. During a comprehensive 45-minute consultation, Dr Girling will address your concerns, provide expert guidance, and ensure you receive the attention you deserve. Take the first step toward better menopausal health with us.

Join our women's health event in May 2024.