Below are two examples of an 'opposed' dosage regimen, one in which Premarin and norethisterone are taken cyclically and the other in which Estraderm skin patches and Duphaston are used cyclically:

Example 1:

Premarin tablets 625 micrograms are taken from day 1 to day 24 inclusive in each calendar month.

Norethisterone tablets 1 mg are added from day 13 to day 24 inclusive in each calendar month.

Women still having periods should start the Premarin on the first day of the period. The norethisterone is taken daily from day 13 to day 24 inclusive in the cycle.

Example 2:

Estraderm TTS 50 micrograms is applied twice weekly from day 1 with removal of the last patch on day 24 in each calendar month (6-8 applications).

Duphaston tablets 10 mg 1-2 daily orally from day 13 to day 24 in each calendar month. Note: it does not matter when in the calendar month progestogen is taken, provided it is for 12 days and always at the same time in the month.

Women still having periods should apply the first patch on the first day of the period. The Duphaston is taken once or twice daily from day 13 to 24 inclusive in the cycle.

If menstrual bleeding starts prior to the last day of progestogen treatment this may indicate inadequate endometrial protection and a slightly higher progestogen dosage may therefore be required.

Some doctors prefer to prescribe calendar packs for 'opposed' regimens, but these are highly inflexible: they do not allow the dosage levels to be changed, at an early point, to suit the individual. Such tailoring of HRT is desirable because sometimes women show abnormal blood lipid changes and experience PMS-type symptoms in reaction to certain oestrogen and progestogen combinations. The

PMS-type symptoms are experienced by 30-40 per cent of women on the opposed dosage regimen, at the point in the cycle when the progestogen is added to the oestrogen.

Within the last two years a more modern alternative approach to the above HRT regimens has been introduced. The oestrogen is taken on a continuous basis, producing a steadier blood level. The progestogen is taken for the usual 12 days.

Alternative regimen 1:

Instructions for Premarin and norethisterone are:

Premarin: a woman who is still having regular periods should start the Premarin on the first day of the period, and take it daily on a continuous basis. A woman who has not had a period for over two months may start the Premarin at any time. Norethisterone (progestogen): a woman who is still having regular periods should start taking the progestogen (1 tablet daily) on day 17 of the cycle and continue until day 28. A woman who has not had a period for over two months should start taking the progestogen on the first calendar day of each month and continue until day 12.

Alternative regimen 2:

Instructions for Estraderm and Duphaston are:

Estraderm: a woman who is still having regular periods should apply the patch on the first day of her period and change it twice weekly on a continuous basis. A woman who has not had a period for over two months may start the Estraderm at any time.

Duphaston (progestogen): same regimen as norethisterone above, but taking 1-2 Duphaston tablets (10 mg) orally.

Nuvelle (revised form of Cyclo-Progynova) uses oestradiol valerate combined with levonorgestrel as the progestogen. One tablet is taken each day on a 28-day cycle. Menstrual bleeding takes place, usually between day 26 of one cycle and day 6 of the next. Some 'spotting' between true bleeds has been reported.

For women who do not wish to put up with the continuation of a monthly bleed after the menopause, there is a further method by which continuous combined oestrogen and progestogen therapy can be used. This opposed regimen protects the endometrium from hyperplasia, there is no bleed, and cyclic PMS-type symptoms are also often reduced. For the first few months of therapy 'tailoring' has to take place while the ideal oestrogen/progestogen combination is found.

This continuous combined oestrogen and progestogen regimen is being further developed and is currently used only in menopausal clinics, where careful monitoring can take place.

Distressing menopausal symptoms such as hot flushes and night sweating can be controlled using Depo-Provera (long-acting progestogen) 150 mg injected deep into the buttock muscle. This lasts up to three months. It is unlikely to remedy vaginal dryness, and what positive effect Provera may have as regards osteoporosis is in doubt: a 1991 report from New Zealand indicates that Provera used over an extended period of time (five to ten years) may have an adverse effect on bone density and, therefore, encourage the development of osteoporosis.

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Women’s health