A 49-year-old woman whose last menstrual period was 8 months ago requests hormone therapy for troublesome vasomotor symptoms. She has an intact uterus and no contraindications. Which regimen is most appropriate?

• A Continuous combined oestrogen-progestogen daily
• B Oestrogen daily with progestogen added for 3 days per month
• C Unopposed oestrogen daily
• D Sequential combined therapy: oestrogen daily with progestogen added for 12 to 14 days per cycle ✓

Explanation

With an intact uterus, progestogen must accompany oestrogen to prevent unopposed oestrogen driven endometrial hyperplasia and carcinoma. Within 12 months of the last period, unpredictable breakthrough bleeding makes continuous combined regimens unsuitable, so sequential therapy with 12 to 14 days of progestogen per cycle is preferred. Continuous combined therapy is appropriate only after 12 months of amenorrhoea, and 3 days of progestogen gives inadequate endometrial protection.

Reference: Williams Gynecology, 3rd ed.

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