Select relevant parameters below for evidence-based, person-centred HRT advice

Treat as per Premature Ovarian Insufficiency (POI) Guideline.
Consider referral if appropriate.

DIAGNOSTICS

Consider blood tests to exclude other causes

  • FSH levels two occasions >4 weeks apart (> 25 IU/l on two occasions).
    Normal levels do not exclude POI and should not delay treatment.

  • FBC, TFT, coeliac screen, B12, folate, ferritin, HbA1c. Consider 21OHAb (adrenocorticol antibodies)

  • Estradiol levels

  • Total testosterone and SHBG to calculate FAI

  • Prolactin

Most of the available clinical evidence for HRT comes from studies of women starting HRT around the age of natural menopause, but women who undergo early menopause or who have been diagnosed with premature ovarian insufficiency benefit greatly from HRT as well.

TREATMENT

In the absence of endometrial protection (no Mirena coil or hysterectomy), combined estrogen/progesterone HRT is recommended.

Alternatively, if tolerated, a Mirena coil containing levonorgestrel (a progestogen), can be inserted. Progesterone protects the endometrial lining and reduces the risk of endometrial cancer.

Because LMP was more than 12 months ago, continuous HRT is recommended to minimise intermittent bleeding.

ESTROGEN
Estrogen can be delivered using patches, gels and sprays. It is recommended to start at the lowest dose.

Patches
Patches are usually applied twice a week and are water-resistant. The amount of estrogen they provide is constant, reducing the occurrence of migraines.

Evorel 25mcg 50mcg 75mcg

100mcg

Estradot 25mcg 50mcg 75mcg

100mcg

Gel
Gel is usually absorbed easily and can be used with patches to top up. The dose can be altered as needed, for example, on the days when symptoms are worse.
Oestrogel 2­-4 pumps a day
Sandrena 0.5-1mg sachets, once daily

Spray
Readily absorbed, easy to alter dose and can be used with patches to top up.
Lenzetto 1-­3 sprays a day

PROGESTERONE
Progesterone is needed to protect the endometrium. Body identical progesterone such as Utrogestan has been shown to have fewer side effects than other types of progestogens.
Utrogestan 100mg in the evening
Evorel Conti Twice weekly, transdermal patch containing estradiol with norethisterone

The Mirena coil, a synthetic progestogen that acts locally within the uterus, is a suitable alternative.

TREATMENT

In the absence of endometrial protection (no Mirena coil or hysterectomy), combined estrogen/progesterone HRT is recommended.

Alternatively, if tolerated, a Mirena coil containing levonorgestrel (a progestogen), can be inserted. Progesterone protects the endometrial lining and reduces the risk of endometrial cancer.

Because LMP was less than 12 months ago, or there is still intermittent bleeding, sequential (also known as cyclical: 2 weeks on, 2 weeks off) HRT is recommended.

ESTROGEN
Estrogen can be delivered using patches, gels and sprays. It is recommended to start at the lowest dose.

Patches
Patches are usually applied twice a week and are water-resistant. The amount of estrogen they provide is constant, reducing the occurrence of migraines.

Evorel 25mcg 50mcg 75mcg

100mcg

Estradot 25mcg 50mcg 75mcg

100mcg

Gel
Gel is usually absorbed easily and can be used with patches to top up. The dose can be altered as needed, for example, on the days when symptoms are worse.
Oestrogel 2­-4 pumps a day
Sandrena 0.5-1mg sachets, once daily

Spray
Readily absorbed, easy to alter dose and can be used with patches to top up.
Lenzetto 1-­3 sprays a day

PROGESTERONE
Progesterone is needed to protect the endometrium. Body identical progesterone such as Utrogestan has been shown to have fewer side effects than other types of progestogens.
Utrogestan 200mg in the evening over 12-14 days
Evorel Sequi Twice weekly, transdermal patch containing estradiol with norethisterone

The Mirena coil, a synthetic progestogen that acts locally within the uterus, is a suitable alternative.

TREATMENT

A woman with a hysterectomy will not be at risk of developing endometrial cancer, therefore progesterone is not needed for endometrium protection.

A Mirena coil will also provide protection against endometrial cancer. Estrogen-only HRT in the form of transdermal estrogen is therefore recommended.

There are many ways to deliver estrogen: patches, gels or sprays. It is recommended to start at the lowest dose.

Patches
Patches are usually applied twice a week and are water-resistant. The amount of estrogen they provide is constant, reducing the occurrence of migraines.

Evorel 25mcg 50mcg 75mcg

100mcg

Estradot 25mcg 50mcg 75mcg

100mcg

Gel
Gel is usually absorbed easily and can be used with patches to top up. The dose can be altered as needed, for example, on the days when symptoms are worse.
Oestrogel 2­-4 pumps a day
Sandrena 0.5-1mg sachets, once daily

Spray
Readily absorbed, easy to alter dose and can be used with patches to top up.
Lenzetto 1-­3 sprays a day

A small subset of women who have had a hysterectomy still need combined HRT rather than estrogen only. This includes women with widespread endometriosis or women who have undergone a subtotal hysterectomy.

Do not commence hormonal treatment and consider referral to specialist services.

More information

Information is sourced from NICE, RCOG, MHRA, and other published literature. No warrant is given that the module is free of errors, complete or up-to-date, and no information herein should be considered a substitution for medical expertise, experience and judgement. For feedback, please use the link above.