Estradiol with levonorgestrel

How it works

Estradiol relieves oestrogen-deficiency symptoms while levonorgestrel opposes endometrial proliferation, allowing a bleed-free regimen in suitably postmenopausal women.

Prescribing in practice

• Levonorgestrel is present to protect the endometrium against unopposed oestrogen, so it is essential for women who retain a uterus and the product should not be substituted with oestrogen alone.
• Continuous combined regimens suit women who are clearly postmenopausal; breakthrough bleeding in the early months is common but persistent bleeding needs investigation.
• Weigh thrombotic, stroke and breast cancer risk and avoid in active thromboembolic disease or oestrogen-dependent malignancy.

Monitoring

Monitor symptom response, blood pressure and bleeding pattern, and investigate bleeding that persists or starts after an initial settled phase.

Counselling the patient

• Some irregular bleeding or spotting is common in the first few months but report bleeding that persists or recurs.
• Seek urgent advice for breast changes or symptoms of a clot.
• Attend routine breast and cervical screening.

Evidence & guidelines

NICE menopause guidance underpins the use of combined continuous oestrogen-progestogen hormone replacement therapy in postmenopausal women.