Ask an Expert: Q&A – December 2022

Question 1

I have a 60-year-old patient who was put on MHT just before her 60th birthday after putting up with symptoms for some time and being postmenopausal for around seven to eight years. When I saw her, she was on 50mcg estogen patches and continuous Prometrium 100mg but was still having some hot sweats, aches and pains and insomnia and wanted to try a higher dose. She trialled 75mcg patches and feels much better. My question relates to how to balance the higher dose of oestrogen in a woman of 60. She is currently taking Prometrium 200mg continuously as there doesn’t seem to be much information on the safe dose? She was open to a Mirena but is otherwise keen on body-identical progesterone.

Answer

From Jean Hailes gynaecologist and Medical Director Dr Elizabeth Farrell AM

If your patient aged 60 is symptomatic and between 50-60 years or within 10 years of menopause, it is safe for her to use MHT. Your prescribed doses are appropriate. Some women require higher oestrogen doses for symptom relief.

With the 75mcg patch, add Prometrium 100mg 2 tablets nightly or “off label” use Prometrium 100mg vaginally at night. Both the patch and Prometrium are bioidentical hormones. Compounded hormones are not recommended.

Question 2

Do you need to use progesterone or do ultrasounds if using long-term vaginal oestrogen?

Answer

From Jean Hailes gynaecologist and Medical Director Dr Elizabeth Farrell AM

No, an ultrasound or a progesterone challenge are unnecessary if the vaginal product is used according to the recommended dose regimen, as the amount of oestrogen absorbed into the general circulation is very small. We recommend placing the oestrogen preparation into the lower third of the vagina as the blood supply is different from the upper two-thirds, and supplies the lower vagina, base of bladder, the urethra and vulva.

Question 3

I had a colleague with a patient presenting for a script repeat of her MHT from a specialist using topical oestrogen but oral Prometrium 100mg used PV not orally. Is this a treatment regimen? Can you use progesterone meant orally for PV treatment?

Answer

From Jean Hailes gynaecologist and Medical Director Dr Elizabeth Farrell AM

Prometrium vaginally in MHT is “off label” use and is not recommended or registered by the pharmaceutical company nor the Australasian Menopause Society as there is no supporting literature in MHT.

It is available in a vaginal tablet for IVF with satisfactory absorption and endometrial protection. It is thought 100mg vaginally is equivalent to 200mg orally.