Variations on HRT.

Vasomotor Symptoms

These classical and the most common symptoms of the climacteric are the vasomotor symptoms of hot flushes, palpitations, night sweats with insomnia and headaches which all respond well to oestrogen therapy. Patients with these symptoms require low dose oestradiol preparations either by an oral route, by gel or patch for 3 months or longer for the duration of symptoms. The commencing dose should be low but can be increased to a dose which alleviates the symptoms. Because of the anxiety about breast cancer many other treatments particularly herbal remedies, SSRIs or clonidine have been used but none are as effective as estrogen in women who have these troublesome symptoms. The increasingly popular natural herbal remedies are usually no better than placebo, but even if pharmacologically active, they are uncontrolled, poorly investigated, of unknown estrogenic potency and not without serious side effects.

These patients receiving estrogens will, of course, need cyclical or continuous progestogens if they have an intact uterus in order to protect the endometrium from hyperplasia or malignancy (23).  There is now much debate about the progestogen component, because this hormone, more than estrogen, seems to be implicated in the possible excess of breast cancer in the combined HRT preparations.  There is also a problem in that progestogen reproduces PMS type symptoms (24) particularly in women who have progestogen intolerance. (25) This is a major reason why women discontinue therapy. These women should try a different gestogen, at a lower dose, or should consider the long cycle of progestogen every 3 months. A Mirena IUS delivering local progestogen within the uterine cavity should be considered (26)
Another possibility is to have a shorter duration of progestogen every month.  One  regimen is for a progestogen such as norethisterone 5mg or MPA 5mg to be taken for the first 7 days of each calendar month which will bring about a withdrawal bleed on about day 10th day of each calendar month This will bring about 12 periods a year instead of 13 with fewer progestogenic symptoms of irritability depression tiredness and bloating This option is an important concept because following the demonstration of possible disadvantages of continuous progestogen there is currently a risk of accepting the other extreme of unopposed oestrogens, (27) without considering the compromise of  a shorter 7 day monthly course of progestogen which has already been shown to be effective in preventing endometrial pathology in  early work on this subject. (28).