POST MENOPAUSAL -
Continuous combined therapies.
"Period
free" or continuous combined therapy can be used by women who are
54 + yrs, or more than 1 yr post menopausal at any age. The criteria should
be fulfilled in order to offer such treatment to women who no longer have
a continuing ovarian cycle, so that steady levels of both estrogen and progestogen
can be achieved. When there are steady levels of estrogen and progestogen from
daily administration of both, the womb lining stays thin. Although some bleeding
in the first 6 months of therapy is common, there should not be bleeding after
that and the lining does not go through the stages of stimulation and then
shedding as it does during a normal cycle and with sequential therapy. Start with low dose
preparations and increase as necessary for symptom control. The products marked
* are licensed for osteoporosis treatment/prevention.
See WHY AND WHEN TO OFFER CONTINUOUS COMBINED THERAPY.
| ANGELIQ* | 1 mg estradiol & 2mg drospirenone | £8.60 |
| FEMOSTON CONTI* | 1 mg estradiol & 5mg dydrogesterone daily |
£6.79 |
| INDIVINA 1+2.5* | 1mg estradiol valerate & 2.5mg MPA daily |
£7.16 |
| INDIVINA 1+5* | 1mg estradiol valerate & 5mg MPA daily |
£7.16 |
| KLIOVANCE* | 1mg estradiol & 0.5 mgs norethisterone daily. |
£4.89 |
| PREMIQUE LOW DOSE | 0.3mg conjugated estrogen & 1.5mg MPA daily | £9.95 |
b. Medium dose:
| CLIMESSE* | 2 mgs estradiol valerate & 0.7mgs norethisterone daily. |
£10.34 |
| INDIVINA 2+5* | 2mgs estradiol valerate & 5 mg MPA daily. |
£7.16 |
| PREMIQUE* | 0.625mg conjugated equine estrogens & 5mgs MPA daily | £9.05 |
c. Higher dose:
| ELLESTE DUET CONTI* | 2 mgs estradiol & 1 mg norethisterone daily | £5.99 |
| KLIOFEM* | 2 mgs estradiol & 1 mg norethisterone daily |
£3.81 |
| NUVELLE CONTINUOUS* | 2 mgs estradiol &1mg norethisterone daily |
£5.62 |
| LIVIAL* (TIBOLONE) | gonadomimetic synthetic preparation with weak estrogenic, progestogenic & androgenic properties |
£10.77 |
Because of its androgenic component, Livial can be particularly helpful for postmenopausal patients with reduced libido. Current evidence suggests that Livial does not increase mammographic breast density, as occurs with other types of HRT and long term use of Livial is thought to be associated with a similar increased risk of breast cancer to that of estrogen alone, which is less than that of estrogen plus progestogen.
TRANSDERMAL - PATCH
| EVOREL CONTI* | 2 x Weekly | M | Transdermal estradiol 50mcg & transdermal norethisterone 170 mcg for 28 days |
£12.00 |
| FEMSEVEN CONTI | Weekly | M | 50mcg estradiol and 7mcg levonorgestrel per 24 hours |
£15.48 |
Tailored continuous combined effect allows flexibility but is less convenient to take. Use any continuous tablet or non-tablet estrogen with one of the following:-
| PROVERA | Medroxyprogesterone | 2.5 or 5 mgs daily |
| UTROGESTAN | Micronised progesterone | 100mg at bedtime from day 1 to 25 of each 28 day cycle |
Usually start with the lowest dose of progestogen and increase if persistent bleeding. Patients should be advised to expect some bleeding in the first few months of treatment, but should have settled by six months. Any bleeding persisting beyond 6 months of continuous combined therapy, or bleeding occurring at a later date, should be investigated.
WHY & WHEN TO CONSIDER CONTINUOUS COMBINED THERAPY
Why?
- No physiological reason for menstrual bleeds if can be avoided.
- Most women prefer a no-period option.
- Cheaper for patient - one prescription charge instead of the two for sequential combined therapy.
- Thought to be less risk of endometrial hyperplasia (thickening of the womb lining) in long term with continuous combined compared to sequential therapy.
When?
- Patient known to be post-menopausal at whatever age, ideally by having at least one year of amenorrhoea (no periods).
- If sequential therapy started while still having periods, wait till age 54 years. At 54 years 80% of women will have cessation of ovarian function and are likely to settle on continuous combined (period-free) therapy.
- Change from sequential to continuous combined by finishing current sequential pack and start new therapy at the end of the expected bleed.
Page last updated: 11 March 2008
