What are the contraindications for progesterone therapy?

Contraindications for Progesterone Therapy

Progesterone therapy is contraindicated in patients with known hypersensitivity to its ingredients (particularly peanut oil), undiagnosed abnormal genital bleeding, known/suspected/history of breast cancer, active or history of thromboembolic disease, active arterial thromboembolic disease, known liver dysfunction or disease, and known or suspected pregnancy. 1

Absolute Contraindications

• Hypersensitivity reactions:

  • Patients with severe peanut allergies should avoid progesterone formulations containing peanut oil 2, 1
  • Alternative gel formulations that don't contain peanut oil may be used in these patients 3

• Hormone-sensitive cancers:

  • Known, suspected, or history of breast cancer 1
  • Hormone receptor-positive breast cancer 2

• Thromboembolic conditions:

  • Active deep vein thrombosis or pulmonary embolism 1
  • History of thromboembolic disorders 2
  • Active arterial thromboembolic disease (stroke, myocardial infarction) 1
  • History of arterial thromboembolic events 1

• Liver conditions:

  • Known liver dysfunction or disease 1
  • Hepatic adenomas or carcinomas 3
  • Cholestatic jaundice of pregnancy or jaundice with previous hormonal therapy 3

• Reproductive/Gynecologic conditions:

  • Undiagnosed abnormal genital bleeding 1
  • Known or suspected pregnancy 1

Relative Contraindications and Special Considerations

• Gynecologic malignancies:

  • Low-grade serous epithelial ovarian cancer 3
  • Granulosa cell tumors 3
  • Certain types of sarcoma (leiomyosarcoma and stromal sarcoma) 3
  • Advanced endometrioid uterine adenocarcinoma 3

• Hematologic disorders:

  • Hypercoagulopathies 3
  • Thrombogenic valvular or thrombogenic rhythm diseases 3

• Cardiovascular conditions:

  • Uncontrolled hypertension 3
  • Cerebrovascular disease 3
  • Coronary artery disease 3

• Other considerations:

  • Smoking if >35 years of age 3
  • Headaches with focal neurologic symptoms or migraine headaches with aura if >35 years of age 3
  • Renal dysfunction 3
  • Adrenal insufficiency 3

Specific Clinical Contexts

Gynecologic Cancer Survivors

The risk/benefit profile of hormone therapy is favorable for most non-epithelial and epithelial ovarian cancers (high grade, clear cell and mucinous) and for early-stage endometrial cancer patients. However, hormone treatment is contraindicated in patients with low-grade serous epithelial ovarian cancer, granulosa cell tumors, certain types of sarcoma, and advanced endometrioid uterine adenocarcinoma 3.

Myeloproliferative Neoplasms

For patients with myeloproliferative neoplasms, an individualized risk-benefit assessment should be undertaken when considering hormonal therapy. Progesterone-only preparations are acceptable, but combined oral contraceptives (containing both progesterone and estrogen) are not recommended due to thrombosis risk 3.

Pregnancy and Preterm Birth Prevention

For pregnant women with a singleton gestation and short cervix, vaginal progesterone may be prescribed to reduce the risk of preterm birth, with micronized progesterone capsules containing peanut oil being contraindicated in those with severe peanut allergies 3.

Practical Considerations

• When prescribing progesterone, always check for peanut allergies and consider alternative formulations (vaginal gels) that don't contain peanut oil 3, 2
• Monitor patients with risk factors for thromboembolic events closely when progesterone therapy is necessary
• Consider the specific indication for progesterone therapy when weighing risks and benefits
• For women with a history of miscarriage who present with bleeding in early pregnancy, vaginal micronized progesterone may provide benefit with a favorable safety profile 4

Remember that while progesterone has important therapeutic applications in reproductive health, careful patient selection and consideration of contraindications are essential to minimize risks and optimize outcomes.