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HRT preparations: for Perimenopause


Please note: Patients should consult a health professional to decide on the appropriate treatment option to be prescribed.

PERI-MENOPAUSAL SEQUENTIAL COMBINED THERAPY

Used in women with an intact uterus (womb) who are not yet postmenopausal, i.e. have some periods due to continuing ovarian function. Products contain daily estrogen and cyclical progestogen.
Progestogens which can be used cyclically are of 3 main types:

  1. Testosterone derived - Norgestrel, Norethisterone acetate and Levonorgestrel.
  2. Less testosterone related - Medroxyprogesterone acetate(MPA).
  3. Least testosterone related - Dydrogesterone and Micronised progesterone (Utrogestan).

Side effects are often experienced during the progestogen phase of treatment and can be reduced by using a product containing a different type or route of progestogen.

TABLET

a. Low dose - recommended starting dose.

CLIMAGEST 1mg Estradiol valerate 1mg
Norethisterone 1mg for 12 days/28

£4.59

ELLESTE DUET 1mg Estradiol 1mg
Norethisterone 1mg for 12 days/28
£3.06
FEMOSTON 1/10* Estradiol 1mg
Dydrogesterone 10mg for 14 days/28

£4.49

NOVOFEM* Estradiol 1mg
Norethisterone 1mg for 12 days/28

£3.81

b. Medium dose -

CLIMAGEST 2mg Estradiol valerate 2mg
Norethisterone 1mg for 12 days/28

£4.59

CLINORETTE 2mg Estradiol 2mg
Norethisterone 1mg for 12 days/28
£3.08
CYCLO-PROGYNOVA 2mg* Estradiol valerate 2mg
Norgestrel 0.5mg for 10 days/21, followed by 7 tablet-free days.
£3.11
ELLESTE DUET 2mg* Estradiol 2mg
Norethisterone 1mg for 12 days/28.
£3.24
FEMOSTON 2/10* Estradiol 2mg
Dydrogesterone 10mg for 14 days/28

£4.49

PREMPAK-C 0.625* Conjugated estrogens 0.625mg  Norgestrel 150mcg for 12 days/28 £2.08
TRISEQUENS* Estradiol 2mg/1mg
Norethisterone 1mg for 10 days/28

£3.70

c. Higher Dose -

PREMPAK-C 1.25* Conjugated estrogens 1.25mg
Norgestrel 150mcg for 12 days/28
£2.47

All the above cause a monthly bleed in 85% of patients.

Long cycle treatment - useful in perimenopausal patients who are having infrequent periods, but may not be sufficiently post menopausal to offer continuous combined therapy to, and will confer a bleed every 3 months. Available is:

TRIDESTRA* Estradiol valerate 2mg
Medroxyprogesterone 20mgs for 14 days/3 month pack.

£6.83

TRANSDERMAL

Medium Dose

EVOREL SEQUI* M2 x Weekly Transdermal estradiol 50mcg/24hrs
Trandsermal norethisterone 170mcg/24hrs for 14 days/28

£11.09

FEMSEVEN SEQUI MWeekly Transdermal estradiol 50mcg/24hrs
Transdermal levonorgestrel 10mcg/24hrs for 14 days/28
£13.18

Tailor made sequential combined therapy is useful in patients who develop PMS type symptoms on a fixed HRT, particularly if the regime contains a progestogen of testosterone derivation (norethisterone, norgestrel and levonorgestrel). FEMOSTON, PREMIQUE CYCLE & TRIDESTRA are fixed preparations using the less androgenic medroxyprogesterone acetate or dydrogesterone.

PROGESTOGENS - Progestogens are given with estrogen to protect the womb lining from becoming thickened from stimulation by estrogen. Progestogens are generally not required after a hysterectomy (removal of the womb). (See Menopause and HRT after hysterectomy)

In the Perimenopause, progestogens are given for part of each 4 week cycle of estrogen, leading to a 4 weekly bleed in most users. This is known as “Sequential” HRT.

Please note: Patients should consult a health professional to decide on the appropriate treatment option to be prescribed.

As well as being given as part of a ready made combined therapy, the following progestogens can be given with estrogen only regimes:

PROVERA -
also available as Climanor (5mg tabs)

MPA 10 mgs daily for 14 days per 28 days £3.27 for 28 5mg tablets
UTROGESTAN micronised progesterone 200mg daily at bedtime for 12 days per 28 days (days 15-26 inclusive) £5.13 for 15 200mg capsules

Careful explanation is required as to the timing of administration of the separate progestogen, in order to synchronise it with the existing cycle.


MIRENA
Mirena is a levonorgestrel (type of progestogen) releasing system which sits inside the womb, gradually releasing the progestogen into the womb. It is licensed in the UK and Ireland as a contraceptive agent, for treatment of heavy periods and, from August 2004, also for the progestogen component of HRT. It can be used in both the perimenopause and postmenopause and it is particularly useful for:

  1. Persistent progestogenic side effects from systemic HRT despite changes in type and route of progestogen.
  2. When contraception is required along with HRT in the perimenopause.
  3. When withdrawal bleeds on sequential HRT are heavy, after investigation if indicated. (see WHEN TO BE REFERRED)
With Mirena in place, systemic estrogen alone can be taken as the Mirena provides adequate protection of the womb lining and the estrogen dose and route can be tailored to meet the individual's needs.
Progestogenic absorption throughout the body is minimal so reducing progestogenic side effects. The effect of Mirena on the womb lining can significantly reduce bleeding and when used as part of an HRT regimen, in time, 30 to 60% of women have no bleeding at all. Although Mirena used for contraception is licensed for 5 years, the license for use for the progestogen part of HRT is currently 4 years.
Price: £88.00

Page last updated: 5 December 2013

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