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Menopause - Management
How do I manage progestogen-related adverse effects (other than bleeding)?
- Progestogen-related adverse effects tend to occur in a cyclical pattern during the progestogen phase of cyclical hormone replacement therapy (HRT). They include fluid retention, breast tenderness, headaches or migraine, mood swings, depression, acne, lower abdominal pain, and backache.
- Encourage the woman to persist with therapy for about 3 months to await possible resolution of adverse effects.
- For persistent or troublesome symptoms, consider the following options. Many of these are the opposite of what may be needed to better control bleeding:
- Changing the progestogen type, for example from more androgenic ones, such as norethisterone and norgestrel, to less androgenic ones, such as medroxyprogesterone or dydrogesterone.
- Changing the route of progestogen, for example from oral to transdermal, vaginal, or intrauterine progestogen. This may be most beneficial when the woman is nauseous while receiving oral HRT. If the oestrogen is to be delivered by a different route to the progestogen, the woman can easily miss out the progestogen as desired if it is causing unpleasant adverse effects. However, the woman must fully understand that the progestogen is being given to provide endometrial protection.
- Reducing the duration of progestogen administration: progestogens can be taken for 12–14 days of each monthly sequential regimen, so swapping from a 14-day to a 12-day product may provide benefit.
- Changing to a product with a lower dose of progestogen (dosages are preparation dependent).
- Reducing the frequency of progestogen dosing. This can be achieved by switching to a long-cycle regimen administering progestogen for 14 days every 3 months (but this strategy is suitable only for women without natural regular periods).
- Changing to continuous combined therapy or tibolone often reduces progestogenic adverse effects with established use (as these products contain lower dosages of progestogen), but this is suitable only for postmenopausal women.
Basis for recommendation
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