A focus on progestogens in hormone replacement therapy

Abstract

Key content Women receiving estrogen replacement require concomitant progestogen to prevent endometrial hyperplasia and carcinoma. A variety of progestogens are used in hormone replacement therapy (HRT), with different advantages and disadvantages and routes of administration. Progestogenic side effects may be mild but can be debilitating and lead to the discontinuation of HRT, so progestogens should be tailored to the individual woman. Combined HRT containing estrogen and progestogens may be associated with a small increase in the absolute risk of breast cancer, which is not seen in women taking estrogen alone. However, this risk is small, particularly when compared with other modifiable lifestyle risk factors. The addition of certain progestogens to estrogen in the long term may be associated with an increased risk of heart disease, breast cancer and dementia. Learning objectives To understand relative advantages and disadvantages of the different progestogens, regimens and routes of administration. To be aware of current evidence for types, dose and routes of administration of different progestogens. To be able to prescribe progestogens safely in terms of side effect and risk profiles that are individualised to the patient. Ethical issues Well‐informed counselling including absolute, individualised risks for women considering HRT with a progestogenic component is essential to allow patients to make well‐informed choices.