Continuous combined systemic MHT

Continuous combined menopausal hormone therapy (MHT) provides progestogen continuously throughout the cycle; this avoids a monthly withdrawal bleed. It uses a lower dose of progestogen than that used in cyclical regimens.

Indications for continuous combined MHT are listed in Types of systemic menopausal hormone therapy and the appropriate subgroups of menopausal patients. Before starting systemic MHT, individualised assessment of the expected benefits and harms of treatment is needed. For a suggested approach to starting menopausal therapy, including considerations in choosing between oral and transdermal estrogen, see Approach to starting therapy for menopause.

Combined MHT regimens can be achieved using a single formulation containing estrogen plus progestogen, or separate estrogen and progestogen preparations. For continuous combined formulations, see Continuous combined formulations for systemic menopausal hormone therapy. For formulations of estrogen alone, see c_srg2-c24-s7.html#srg2-c24-s7__tsrg2-c24-tbl3; for progestogen alone, see Continuous combined formulations for systemic menopausal hormone therapy. Use of separate formulations simplifies dose titration, but combined formulations are easier to use and improve adherence. Consider patient preference for formulation.

For continuous combined MHT, use:

combined MHT formulation containing low-dose estrogen and continuous progestogen, orally or transdermally (see Continuous combined formulations for systemic menopausal hormone therapy for dosage and formulations); increase dose if needed (depending on symptoms, age and comorbidities). menopause, continuous combined formulations
Table 1. Continuous combined formulations for systemic menopausal hormone therapy

[NB1] [NB2]

Printable Table

low-dose estrogen with progestogen

medium-dose estrogen with progestogen

Estrogen (continuous)

Progestogen (continuous)

Brand name examples

low-dose estrogen with progestogen

oral low-dose estrogen+progestogen

estradiol 1 mg

drospirenone 2 mg

Angeliq 1/2 [NB3]

estradiol 1 mg

dydrogesterone 5 mg

Femoston-Conti

estradiol 1 mg

norethisterone 0.5 mg

Kliovance [NB3]

estradiol 1 mg

micronised progesterone 100 mg [NB4]

Bijuva 1/100 [NB3]

transdermal low-dose estrogen gel and oral progestogen

estradiol 0.75 mg (1 pump of 0.06% gel)

micronised progesterone 100 mg [NB4] [NB5]

Estrogel Pro [NB3]

medium-dose estrogen with progestogen

oral medium-dose estrogen+progestogen

estradiol 2 mg

norethisterone 1 mg

Kliogest [NB3]

transdermal medium-dose estrogen+progestogen patch

estradiol 50 micrograms

norethisterone 140 micrograms/24 hours

Estalis Continuous 50/140

(apply twice weekly)

estradiol 50 micrograms

norethisterone 250 micrograms/24 hours

Estalis Continuous 50/250

(apply twice weekly)

transdermal medium-dose estrogen gel and oral progestogen

estradiol 1.5 mg (2 pumps of 0.06% gel)

micronised progesterone 100 mg [NB4] [NB5]

Estrogel Pro [NB3]

Note:

NB1: A progestogen is required to prevent endometrial hyperplasia in individuals with a uterus, including those who have had endometrial ablation or subtotal hysterectomy. Some individuals with significant endometriosis may require a progestogen to prevent stimulation of endometrial deposits and malignant transformation (even if they have had a total hysterectomy); seek specialist advice.

NB2: This list may not be complete.

NB3: Not available on the Pharmaceutical Benefits Scheme (PBS) at the time of writing. See the PBS website for current information.

NB4: Micronised progesterone should be taken at night because it can cause drowsiness; this can be beneficial in individuals with sleep disturbance. The Australian product information for micronised progesterone recommends taking 100 mg for 25 days out of a 28-day cycle; however, if adherence is an issue, it can be taken daily.

NB5: The Australian product information for Estrogel Pro recommends taking micronised progesterone 100 mg for 25 days out of a 28-day cycle; however, if adherence is an issue, it can be taken daily.

If a suitable combination product is not available, or if separate estrogen and progestogen formulations are preferred, use:

estrogen in a low dose, orally or transdermally (see c_srg2-c24-s7.html#srg2-c24-s7__tsrg2-c24-tbl3 for dosage and formulations); increase dose if needed (depending on symptoms, age and comorbidities) menopause, combination therapy (continuous)

PLUS

progestogen at a dose determined by the estrogen dose. Oral or intrauterine formulations can be used; see #srg2-c24-s9__tsrg2-c24-tbl7 for dosage and formulations. menopause, combination therapy (continuous)

See Monitoring systemic MHT and Managing adverse effects of systemic MHT for guidance on adjusting continuous combined MHT.