Curriculum
Module 04 · 70 min

Prescribing MHT: Routes, Regimens and Progestogen Choice

From 'she needs HRT' to an actual prescription — with endometrial protection you can defend.

Endocrine & MHTPrimary care track
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Learning objectives

By the end of this module you will be able to

  • L01Write a complete MHT prescription including route, dose, progestogen, regimen type and review interval.
  • L02Select transdermal delivery for patients with raised VTE risk, migraine with aura, hypertriglyceridaemia, BMI >30 or malabsorption.
  • L03State the endometrial protection requirement for any woman with an intact uterus on systemic oestrogen.
  • L04Apply a structured approach to unscheduled bleeding after 6 months of continuous combined therapy.
  • L05Advise on contraception until 55 or 12 months of amenorrhoea over 50.
Scope

Topics covered

01Oral vs transdermal estradiol: first-pass effects, VTE, SHBG, triglycerides
02Sequential vs continuous combined regimens and when to switch
03Progestogen options: micronised progesterone, dydrogesterone, LNG-IUS, MPA, norethisterone
04Dose titration and equivalence tables
05Absolute vs relative contraindications
06Managing unscheduled bleeding on MHT
07Contraception during the transition
Module narrative

How this plays out in practice

Primary care view· your track

A defensible default for a symptomatic 52-year-old with a uterus: transdermal estradiol 50 micrograms/24h patch twice weekly (or 1–2 pumps of gel daily), plus micronised progesterone 100 mg nightly continuously if she is more than 12 months postmenopausal, or 200 mg nightly for 12 days per month if she is still bleeding. Review at 3 months for dose titration, then annually. Add vaginal oestrogen separately if genitourinary symptoms persist.

Specialist view

Non-response usually means under-dosing, poor absorption or the wrong diagnosis. Patch absorption falls with high BMI and with application to the wrong site; gel absorption varies with skin surface. Estradiol levels can guide titration in poor responders and in POI, where target physiological levels are higher. For progestogen intolerance, consider LNG-IUS, lower-dose continuous micronised progesterone, or vaginal progesterone off-label with informed consent.

Advanced note

Oral oestrogen raises SHBG, CRP and triglycerides and lowers free testosterone — clinically relevant in women with low libido or hypertriglyceridaemia. Progestogen receptor pharmacology differs meaningfully: MPA has glucocorticoid and partial androgenic activity, norethisterone is androgenic and partly metabolised to ethinylestradiol, while micronised progesterone is neutral to mildly anti-mineralocorticoid with GABA-A active allopregnanolone metabolites — the mechanism behind its sedative effect.

Expected takeaways

What you should walk away believing

  • →Transdermal estradiol avoids hepatic first pass: no increase in VTE risk, neutral triglycerides, safe with migraine with aura.
  • →MHT is not contraception. The LNG-IUS provides both endometrial protection and contraception in one device.
  • →Sequential regimens are for women still menstruating or within 12 months of their last period; continuous combined for those beyond it.
  • →Micronised progesterone is the progestogen with the most favourable observational breast and cardiovascular profile, and is sedating — dose at night.
  • →Unscheduled bleeding beyond 6 months on continuous combined therapy requires investigation, not a dose fiddle.
Myth-buster

What patients — and colleagues — get wrong

The claim

“Compounded 'bioidentical' hormone pellets are safer because they're customised to your levels.”

Reality

Compounded preparations are not subject to the same batch consistency, purity or labelling requirements, salivary monitoring has no analytic validity, and pellets deliver supraphysiological, non-reversible doses with documented endometrial hyperplasia cases. Regulator-approved body-identical estradiol and micronised progesterone deliver the same molecules with quality assurance.

Graded claims

Evidence grading for this module

B

Transdermal estradiol does not increase VTE risk

Supported in defined populations — Consistent observational and nested case-control data (ESTHER, UK CPRD).

A

Systemic oestrogen without a progestogen in a woman with a uterus causes endometrial hyperplasia and carcinoma

Established — RCT / guideline-grade — Established; unopposed oestrogen is never acceptable with an intact uterus.

A

The LNG-IUS provides adequate endometrial protection with systemic oestrogen

Established — RCT / guideline-grade — Licensed for this indication in many jurisdictions; typically 4–5 years of protection.

C

Micronised progesterone carries lower breast cancer risk than synthetic progestins

Promising but preliminary — Observational (E3N) signal; no RCT with breast cancer endpoints.

F

Compounded bioidentical hormones are safer than regulated preparations

Refuted or actively misleading — No supporting evidence; documented harms and regulatory warnings.

B

Testosterone supplementation improves hypoactive sexual desire disorder in postmenopausal women

Supported in defined populations — Global Consensus Position Statement 2019 — supported for HSDD only, at female physiological doses.

Evidence summary

Graded claims, key takeaways and sources for this module.

Open printable summary
Clinical vignettes

Apply it in clinic

Progestogen intolerance

A 50-year-old on sequential estradiol plus norethisterone reports 10 days of low mood, bloating and irritability each cycle. VMS are well controlled. She wants to stop everything.

Best next step?

Self-assessment

Check your recall

Q1

A 54-year-old with BMI 34 and a previous provoked DVT needs MHT for severe VMS. Best route?

Q2

A woman with an intact uterus, 3 years postmenopause, starting estradiol gel. Which is appropriate?

Q3

Persistent unscheduled bleeding at 9 months on continuous combined MHT. Next step?

Q4

A 51-year-old on sequential MHT asks about contraception. Correct advice?

Flashcards

Retrieval practice

Card 1 / 6
Reviewed 0 / 6
Glossary

Terms used in this module

Continuous combined
Daily oestrogen plus daily progestogen; produces amenorrhoea and is used beyond 12 months postmenopause.
Sequential (cyclical)
Daily oestrogen with progestogen for 12–14 days per month; produces a predictable withdrawal bleed.
LNG-IUS
Levonorgestrel intrauterine system — endometrial protection plus contraception with minimal systemic exposure.
Body-identical
Regulator-approved 17β-estradiol and micronised progesterone, structurally identical to endogenous hormones — distinct from compounded 'bioidentical' products.
Primary sources

Read the evidence yourself