Progestogen safety and tolerance in hormonal replacement therapy

ABSTRACT

Introduction: Today, it is a mandatory practice to prescribe a combination of estrogens and progestogens for menopausal women requiring hormone therapy and with a uterus. The WHI study and its reanalysis demonstrate a big difference in results between the conjugated equin estrogen (CEE) only vs.CEE plus medroxyprogesterone acetate (MPA) arms in relation with breast cancer and cardiovascular risk. The conclusion is that risk is clearly higher in the arm with MPA than in the CEE only arm. Although the only progestogen used in the WHI study was medroxyprogesterone acetate, side effects and intolerance have been extrapolated as a class effect to all progestogens.

Areas covered: Progestogen tolerance and side effects in hormone therapy were reviewed. For that purpose, a limited literature search was conducted on key resources including Pubmed, the Cochrane Library, ECRI, and major international health technology agencies.

Expert opinion: Many of the tolerance effects are based on limited data. There are no double-blind randomized trials comparing long-term safety for breast cancer and cardiovascular risk among different progestogens. Short-term clinical studies, observational, and in animal and in vitro studies indicate that both micronized progesterone and dydrogesterone are the safer progestogens with an acceptable metabolic profile.

KEYWORDS:

• Progestogens
• safety
• tolerance
• hormone therapy

Article highlights

• The type of progestogen is important regarding tolerance and cardiovascular and breast cancer risk.

• There are large differences among progestogens in chemical structure and their behavior at the level of their binding with the different steroid receptors.

• There are no double-blind randomized trials comparing long-term safety for breast cancer and cardiovascular risk among different progestogens.

• Short-term clinical studies, observational, and in animal and in vitro studies suggest that both micronized progesterone and dydrogesterone are the safer progestogens with a an acceptable metabolic profile.

• There is a new alternative – the combination of conjugated estrogens with a SERM (bazedoxifene), which is therefore free of progestogens.

This box summarizes key points contained in the article.

Declaration of interest

S Palacios has received grants/or consulting fees from Pfizer, Servier, Amgen, MSD, Preglem, Leon Farma, Gynea, Sandoz, Procare Health and Bayer. S Palacios has also been a symposium speaker or advisory board member for Servier, Pfizer, GlaxoSmithKline. Abbott, Ferrer, Bioberis, Shiongi, Amgen, Novo Nordisk, Teva Womens Health, Bayer Healthcare and Gedeon Richter. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Additional information

Funding

This paper was not funded.