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The defining difference between HRT programs for women with and without a uterus
is the need to give progesterone (progestin) when the uterus is present. For this reason HRT programs for women
who have had a hysterectomy are less complex and avoid the symptoms of progesterone intolerance experienced by
many women.
A WORD ABOUT PROGESTERONE INTOLERANCE:
Approximately 30-40% of women who take progesterone experience unpleasant PMS-like symptoms which can range from
mild to severe such as moodiness, irritably, breast tenderness and muscle aches. Individuals who had significant
premenstrual symptoms while they were premenopausal are more likely to be affected. Progestins produce moodiness
and irritability by effecting specific sites in the brain. Changing the type of progesterone, the dose, the route
of administration and the length of treatment can lessen this effect. Forms of natural progesterone given by either
the oral or vaginal route may be less of a problem than synthetic progestins. But some patients are so sensitive
to the effects of progesterone they continue to have significant problems and just feel miserable. It is one of
the most challenging aspects of caring for the postmenopausal woman. A few physicians are vigorous in their suggestion
that natural progesterone cream as sole therapy is a miracle treatment for the postmenopausal woman, however a
careful and responsible analysis of accepted medical literature and investigations does not support this view.
WOMEN WITH A UTERUS:
HRT programs for women who have not had a hysterectomy fall into two categories, Cyclic, where progesterone is
given for part of the month and continuous combined therapy(CCT), where it is given daily.
Cyclic Therapy:
Cyclic therapy usually consists of the daily administration of estrogen usually in the form of an oral estrogen
tablet or a transdermal estrogen patch replaced once or twice weekly but worn continually plus progesterone in
tablet form taken 10-12 days a month. Estrogen stimulates and thickens the endometrium, (the lining of the uterus)
and then progesterone, which has antiestrogenic effects blocks the estrogen stimulation. Progesterone both shrinks
the uterine lining and prevents the development of abnormal changes.
Alternatively, the route of administration of the estrogen can be sublingual, transdermal gel or subcutaneous implantation.
The route of administration of the progesterone can include sublingual tablets and vaginal suppositories. If this
works the way it's supposed to, 2-5 days after finishing the progesterone the patient experiences "scheduled
withdrawal bleeding" which usually lasts from 3-5 days. And this "cycle" is repeated monthly. If
the bleeding occurs at any other time during the month it is called "unscheduled bleeding" and signals
the need to determine if any overgrowth or abnormal change of the uterine lining is present.
Continuous Combined Therapy:
Continuous combined therapy usually consists of a daily estrogen tablet or a transdermal estrogen patch worn as
above plus a smaller dose of progesterone taken daily. The purported benefit of this regimen is that in the majority
of cases daily progesterone even in small doses keeps the uterine lining thin and no bleeding occurs. Menstrual
bleeding is a very unattractive prospect for many postmenopausal women.
Some common oral estrogen and progesterone combinations. For years the most frequently prescribed combination consisted
of conjugated equine estrogen tablets (brand name Premarin) and medroxyprogesterone acetate (MPA) tablets (brand
name Provera). The congugated equine estrogen (CEE) or Premarin in earlier years was usually given in dose of 1.25
mg daily the 1-25th days of the month and the Provera was given the 16-25th days of the month. Nothing was given
from the 17th to the end of the month at which time the cycle was repeated. Many women experienced symptoms such
as hot flashes or sweats during the time they were off the estrogen and in more recent years the (CEE) is most
commonly every day instead of the 1-25th. The dose of CEE in most HRT regimens is usually lower and is most frequently
.625 mg. I have found that most of the time if a patients symptoms are not alleviated by this dose that higher
doses are no more effective and another product or route of administration might be more effective. The MPA is
usually given in a dosage of 10mg for 10-12 days a month. Some physicians give the MPA in a lower dose such as
5mg or every 2nd or third month to decrease the incidence of PMS like effects but this is a trade off you must
be aware of as the protection of the uterine is lessened.
In more recent years additional formulations of estrogen and progesterone were developed and are often substituted
in this regimen. Micronized estradiol brand name Estrace is from a plant source and has the hypothetical advantage
of actually being estradiol the bioactive form of estrogen although it is altered during intestinal absorption
as any other oral preparation would be. Some other brands of oral estrogen preparations include Ogen and Estratab.
Norethindrone acetate, brand name Aygestin and oral micronized progesterone brand name Prometrium are both commonly
used forms of oral progesterone replacement. Aygestin is more potent in its ability to shrink the lining of the
uterus and is useful as an alternative to MPA when heavy or "unscheduled bleeding" is a problem. It is
available as a 5 mg tablet and can be given in doses ranging from 1/4 of a tablet to 2 tablets 10-12 days a month
according to each individual's needs. Prometrium seems to cause less PMS-like effects in women who are sensitive
to progestins. It is distributed in 100 mg tablets and is usually given in a dose of 2 tablets at bedtime for 10-12
days a month.
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Dr Nosanchuk is currently in practice in Southeastern Michigan
and is accepting new patients. His office is located in Bingham Farms, a suburb of the Detroit Metropolitan Area.
Dr N specializes in the care and treatment of menopausal women and has a special interest providing treatment to
women whose lives have been altered by their menopause, hysterectomy, or both. This includes strategies to restore
quality of life, by resolving problems, such as persistent symptoms, loss of libido and disturbances of sexual
function.
Appointments with Dr Nosanchuk can be scheduled by calling (248) 644-7200
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