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High Dose Oestrogen HRT Regimes Guideline Update

I am writing to you to share some information on recent changes to HRT guidelines. The British Menopause Society (BMS) have recently updated their recommendations for progesterone dosage in women using higher doses of oestrogen as part of their HRT. High dose oestrogen is defined as:

  • 100mcg patch
  • 4 pumps of oestrogel
  • 3mg Sandrena
  • 6 sprays Lenzetto
  • 4mg oral estradiol

As you may recall from when you started HRT, whenever we give oestrogen to women with a uterus (womb) it is very important that we give them progesterone alongside it. If we were to give oestrogen without progesterone the lining of the womb (endometrium) can thicken and over time this can lead to endometrial cancer. The progesterone protects the endometrium from this risk. Signs that would prompt us to consider investigations for endometrial cancer would be any bleeding that occurs over 12 months after your periods have stopped or a change in your bleeding pattern if you periods haven’t stopped (more frequent, heavier, or prolonged bleeding).

As you may also remember the reason that we tend to use Utrogestan (also known as microionised progesterone) for the progesterone component is that the data suggests this carries very little or no increased risk in breast cancer.

The new BMS guidelines state:

“There are insufficient data to advise on endometrial cancer risk when micronised progesterone, at a dose used for low or standard dose estrogen, is used in combination with moderate or high dose estrogen. Until evidence relating to safety with moderate and high dose estrogen is available, a pragmatic approach needs to be considered, as the risk to breast tissue from increasing the progesterone dose is also unknown; the use of 200 mg as a continuous preparation [this means if you are taking it daily] and 300 mg as a sequential preparation [this means if you are taking it for 2 weeks out of every 4] should be offered if using high dose estrogen”.

In view of these new guidelines you have four options going forward:

  1. Reduce your oestrogen dose
  2. Increase your progesterone dose as above – accepting that we don’t know if there is an increased risk of breast cancer associated with this regime
  3. Continue on your current regime – accepting that there may be an increased risk of endometrial cancer associated with this regime. If you choose this option it is very important that you report any vaginal bleeding (if your periods have stopped) or change to your bleeding pattern (if you are still having periods)
  4. Consider having a Mirena coil as the progesterone part of your HRT regime – this is a great option as it provides excellent protection against endometrial cancer on all doses of HRT and has little or no increased risk of breast cancer. Once the coil has been fitted it works for 5 years before needing to be changed. It also provides contraception if you need it. After the first couple of months most women will have no bleeding at all with a Mirena. I fit them here at the practice, though this is currently a waiting list of a couple of months. Here is a link to some more information:

Mirena™ information sheet | My Menopause Centre

We appreciate this is a lot of information to consider, and you may wish to discuss this with a clinician. If this is the case please select this option on the survey.

Dr Emma Lynch

Brookfield Surgery

November 2024

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