Progestogen Therapy In Surgical Menopause
This page is for those people in surgical menopause who have kept their uterus (so they have had both ovaries removed but not had a hysterectomy) and are using estrogen therapy. In these cases, a form of progestogen is needed to protect the uterus from a build up of cells which can lead to hyperplasia.
How does surgical menopause influence progesterone levels?
What are the different progestogens and methods for dosing? Are some better than others?
When should I start progestogen therapy? When should I stop taking it?
How much progestogen do I need?
For benefits and risks of progestogen therapy visit:
What are progestogens?
Progestogens are a broad category of molecules that act at the progesterone receptor in the body. Progesterone is the natural form that your body makes. It is secreted primarily by the corpus luteum, a temporary endocrine gland that the female body produces after ovulation during the second half of the menstrual cycle.
Generally speaking, those in surgical menopause need to take estrogen therapy in order to prevent bothersome menopausal symptoms as well as long-term health risks due to low estrogen. However, when a person in surgical menopause keeps their uterus (no hysterectomy), a progestogen medication must be added to the estrogen therapy. This is because estrogen alone stimulates the thickening of the uterine lining, and this thickening can lead to cancer if it is not counteracted by a progestogen.
For this reason, those who are sensitive to progestogen based treatments will usually have their uterus removed (hysterectomy), along with cervix, as part of their procedure when having their ovaries removed - removing the need to add back progestogens into their system.
How does surgical menopause influence progesterone levels?
When you have both ovaries removed (bilateral oophorectomy or surgical menopause), you remove your body’s main source of progesterone, and levels plummet lower than in natural menopause.
What are the different progestogens and methods for dosing? Are some better than others?
Several expert guidelines for hormone therapy in premature menopause (ACOG-POI; ACOG-young POI, BMS-POI) recommend starting with the use of oral micronized progesterone in order to mimic the natural pre-menopausal state as closely as possible and avoid some of the health risks of synthetic progestins. However, a variety of other progestogens are available; please see here for an exhaustive list describing different methods of taking progestogens, their pros and cons, and their availability. Existing studies indicate that all progestogens are effective for protecting against uterine overgrowth when taking an estrogen.
The most common (and recommended) form of progestogen therapy is oral micronized progesterone. For those who require a more potent progestin to prevent endometrial overgrowth, an oral synthetic progestin is often used. Additional options include the hormonal IUD and, for those who are unable to tolerate any progestogen, a selective estrogen receptor modulator. Each of the most common options are detailed below.
Oral micronized progesterone. Oral micronized progesterone is a “bioidentical” option that provides the same progesterone molecule that is made naturally by the body.
Combined estrogen and progestin patches. Combined patches that include transdermal estradiol and a synthetic progestin are available.
Oral progestin. Synthetic progestogens such as medroxyprogesterone acetate, norethindrone, norgestimate, and drospirenone are sometimes used. They are more potent activators of the progesterone receptor than oral micronized progesterone and are sometimes used when oral micronized progesterone is not effective for thinning the uterine lining.
Levonorgestrel-Containing Intrauterine System (LNG-IUS; “Mirena”). The hormonal IUS/IUD is placed by a doctor and releases progestins in the uterus to protect against endometrial overgrowth. Only a small amount of progestin goes into the bloodstream. However, this small amount may be sufficient to trigger symptoms in some people who are hormone-sensitive. This can be a good option for those in surgical menopause who have tolerated the IUD well in the past.
When should I start progestogen therapy? When should I stop taking it?
If you are in surgical menopause and you still have a uterus (i.e. you did not have a hysterectomy as well as ovary removal), then you should take progestogen therapy as long as you are taking estrogen therapy, since it is important for protecting you against endometrial cancer.
How long do progestogens take to work? How long should I try out a certain dose before making a change?
Progestogen therapy immediately begins to prevent estrogen-related overgrowth of the uterine lining.
However, temporary side effects after starting these medications can sometimes take several months to dissipate (although some can be persistent). We recommend tracking your symptoms and side effects daily (or at least weekly) in order to have a clear visual of how symptoms are responding, and whether side effects are decreasing over time. It is also a good idea to track any menstrual bleeding, as this may be useful to your doctor when deciding how to proceed.
Similarly, any changes made to your therapy route, dosage or frequency should be evaluated using daily ratings so that the pattern of change can be monitored objectively. We recommend waiting at least one full month on the new therapy before evaluating the new treatment or making any additional changes, since effectiveness and side effects may fluctuate prior to stabilizing again on the new treatment.
This is particularly important for those who have an emotional hormone sensitivity; studies suggest that any change in hormone levels can provoke symptoms among those patients, but that those symptoms go away again after one month of the new therapy. Therefore, patience and support are needed to evaluate the “true” effects of any treatment change.
How much progestogen do I need?
Expert guidelines for hormone therapy in premature menopause (ACOG recommendations; ) recommend the following roughly equivalent doses for those in premature menopause who are taking estrogens and still have a uterus:
Oral micronized progesterone (Recommended by all Expert Guidelines)
100 mg/daily (recommended) or 200mg for two weeks per month. If needed, higher doses can be given with no increased risks.
Orally at night
Levonorgestrel-containing Intrauterine system (IUS/IUD) (Recommended by all Expert Guidelines)
20 micrograms/day
Inserted at a doctor’s appointment; the procedure can be painful but rarely causes risks.
Medroxyprogesterone Acetate (MPA) (Not Recommended Per Expert Guidelines)
2.5 mg daily
Orally
Other progestins, including Norethindrone acetate, Norgestimate, and Drospirenone
[various]
Orally or via a combined estrogen-progestin patch
