Update on HRT Guidelines
HRT Guidelines update for women using High Dose Oestrogen HRT Regimes
There was a change to the HRT guidelines in 2024. The British Menopause Society (BMS) updated their recommendations for progesterone dosage in women using higher doses of oestrogen as part of their HRT.
You class as using a high dose oestrogen regime if you use:
- 100mcg patch
- 4 pumps of oestrogel daily
- 3mg Sandrena daily
- 6 sprays Lenzetto daily
- 4mg oral estradiol daily
When oestrogen is given to women with a uterus (womb) it is very important that we give them progesterone alongside it to prevent a possibility of the oestrogen causing endometrial cancer. 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 your periods haven’t stopped (more frequent, heavier, or prolonged bleeding). Or bleeding on HRT after 6 months of starting or having a dose change.
Micronised progestrogen (utrogestan or gepretix) is usually used as the progesterone component of HRT as 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 oestrogen, is used in combination with moderate or high dose oestrogen. Until evidence relating to safety with moderate and high dose oestrogen 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 oestrogen”.
In view of these new guidelines you have four options going forward if you use high dose oestrogen:
- Reduce your oestrogen dose
- 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
- 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)
- 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: