The most effective method of delivery for hormone replacement therapy is the implantable estradiol and testosterone pellets. They consistently deliver physiologic levels of hormones without the fluctuations of other methods of delivery.
Because of dosing and concerns about cycling, progesterone is not delivered as a pellet. Progesterone is needed not only for its balancing effect on uterine tissue, but also its effect on the breast tissue, heart, brain, bones and its balancing effect on other hormones. Progesterone does NOT have the unwanted side effects of the synthetic progestins like Provera®.
Progesterone may be prescribed as:
• topical cream (applied to skin)
• vaginal cream (applied to the mucous membranes of the labia and vagina)
• oral capsule (compounded extended release, micronized in oil or prescription Prometrium®)
• sublingual capsule, lozenge, drops (used under the tongue for rapid onset of action)
Each person is an individual and may feel more comfortable with one method of delivery over another. Prometrium® is patented, oral micronized progesterone in peanut oil and may be covered by some insurance policies. However, even with a prescription card, Prometrium may be more expensive than compounded progesterone capsules depending on the co-pay.
In pre-menopausal females, progesterone is cycled to mimic nature. It may be used as a low dose (3%) topical or vaginal cream day 14-28 of the menstrual cycle (with day 1 being the first day of menses). The dose may vary depending on height, weight, metabolism and estrogen level. Oral or sublingual progesterone may also be used the last two weeks of the menstrual cycle. Some pre-menopausal females prefer to use progesterone the last three weeks of their menstrual cycle with a lesser dose day 7-14 (1/4-1/2 ml) and a slightly higher dose (1/2-1 ml) day 14-28. Progesterone is discontinued when the menses begin. A smaller volume (0.25 cc) of a higher strength cream (10%) may also be used either vaginally or topically on skin. Vaginal delivery allows a higher dose to the uterus and good systemic absorption without the accumulation which may be seen with continuous topical (skin) application. Patients may choose to alternate topical (skin) application with vaginal application.
Post menopausal females may use oral or sublingual progesterone 25-30 days per month with higher (200 mg) doses being needed when higher doses of estradiol are given (in women without a hysterectomy). If a post-menopausal woman chooses to use progesterone cream topically, it is recommended that she use the cream day 1-25 and take 5 or 6 days off per month. A patient may wish to alternate between topical (skin) and vaginal application. The 10% Progesterone cream is the most cost effective method of delivery. However, oral progesterone (and its metabolites) may work better for sleep. Progesterone given sublingually, under the tongue, avoids the first pass through the liver. It has a rapid onset of action and may be useful for headaches and anxiety (natural calming effect). Patients may want to combine several methods of delivery to see which works best for them.
In post-menopausal patients, hormone replacement therapy may cause uterine bleeding. If a uterine anomaly or an endometrial lesion is present, the estradiol may uncover it. However, the most common cause of uterine bleeding is, not taking progesterone properly or too low of a dosage. If a dose was missed and spotting occurs, double the dose of progesterone for 7 days and then return to the original dose. If bleeding occurs within the first two months, the dose of estradiol may be too high or the dose of progesterone too low. Stop the progesterone for 5-7 days to allow shedding of the uterine lining, then increase the dose of progesterone being used (200 mg of oral progesterone, or increase the volume of cream). You may want to use the stronger dose (10%) progesterone cream vaginally to get a higher dose to the uterus. If bleeding persists, you need to follow up with your gynecologist or family doctor. A transvaginal ultrasound and possible endometrial biopsy may be ordered to rule out any ‘uncovered’ pathologic causes of uterine bleeding.
You may want to request a lower dose of estradiol the next time pellets are implanted.
Progesterone 10% cream: 0.25 cc applied to the mucous membranes of the labia and vagina or topically (skin) day 1-25. For premenopausal females use 0.25 cc the last 2 weeks of the menstrual cycle (day 14-28). Some women prefer to take oral or sublingual progesterone continuously (30 days) to decrease the risk of bleeding.