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Evidence summary

Prescribing MHT: Routes, Regimens and Progestogen Choice

Meridian · Women's Health After 50Generated: 4 August 2026

04Prescribing MHT: Routes, Regimens and Progestogen Choice

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

Key takeaways

  • —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.

Graded claims

B

Transdermal estradiol does not increase VTE risk

Supported in defined populationsConsistent 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-gradeEstablished; unopposed oestrogen is never acceptable with an intact uterus.

A

The LNG-IUS provides adequate endometrial protection with systemic oestrogen

Established — RCT / guideline-gradeLicensed 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 preliminaryObservational (E3N) signal; no RCT with breast cancer endpoints.

F

Compounded bioidentical hormones are safer than regulated preparations

Refuted or actively misleadingNo supporting evidence; documented harms and regulatory warnings.

B

Testosterone supplementation improves hypoactive sexual desire disorder in postmenopausal women

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

Supporting references

  1. Menopause: diagnosis and management (NG23) — prescribing — NICE https://www.nice.org.uk/guidance/ng23
  2. Hormone therapy and venous thromboembolism among postmenopausal women (ESTHER) — Canonico et al., Circulation 2007 https://pubmed.ncbi.nlm.nih.gov/17309934/
  3. Global Consensus Position Statement on the Use of Testosterone Therapy for Women — Davis et al., 2019 https://pubmed.ncbi.nlm.nih.gov/31498871/
Educational summary for registered health professionals. Grades reflect strength of evidence at the time of writing and do not replace current national guidance, product licences or clinical judgement.