334 Obstetrics and Gynecology Board Review •••
❍ Is there an intravaginal estrogen therapy that is not systemically absorbed?
Yes. Vagifem (vaginal estradiol) as well as vaginal estrogen ring.
❍ What herbs contain estrogen-like compounds?
Ginseng, black cohosh, and red clover.
❍ What is the sequential method of hormone replacement administration?
Estrogen on days 1 to 25 or 1 to 30 and medroxyprogesterone acetate 5 mg or norethindrone 0.5 mg for 13 days
of estrogen administration per month.
❍ What is the recommended dose of micronized progesterone for sequential therapy?
200 mg for 14 days every month.
❍ What is the continuous combined method of HRT?
Daily estrogen and daily progestins, either medroxyprogesterone 2.5 mg, norethindrone 0.35 mg, or 100 to
200 mg micronized progesterone.
❍ What concentration differences of estrogen exist in the portal system versus the periphery after oral estrogen
administration?
The estrogen concentration is four to five times higher in the portal system.
❍ Does the first pass effect occur for transdermal estrogen administration?
No.
❍ What are some of the adverse symptoms associated with the dose of progesterone in sequential HRT?
Withdrawal bleeding, breast tenderness, bloating, fluid retention, and depression.
❍ What percentage of women on sequential hormone replacement will have progestin withdrawal bleeding?
80% to 90%.
❍ What percentage of women will experience breakthrough bleeding on continuous HRT?
40% to 60% in the first 6 months and 20% after 1 year.
❍ What is the origin of breakthrough bleeding in continuous HRT?
Progestational dominance resulting in an atrophic endometrium.
❍ What evaluation should be performed for breakthrough bleeding in patients on continuous therapy?
Observation for the first 6 months, then consider endometrial biopsy, or hysteroscopy and D&C to rule out
fibroids and polyps.
❍ What are some conservative treatment alternatives to overcome breakthrough bleeding on continuous HRT?
Observation, sequential therapy, or a progestin intrauterine device (IUD). A progestin IUD will suppress the
endometrium.