Can you take hormone replacement therapy (HRT) with progesterone and have a progesterone-releasing intrauterine device (IUD)?

Hormone Replacement Therapy with Progesterone and Progesterone-Containing IUD

Yes, you can use hormone replacement therapy (HRT) with progesterone and simultaneously have a progesterone-releasing intrauterine device (IUD), but this combination should be carefully considered as it may provide excessive progesterone exposure without additional clinical benefit.

Understanding the Combination of HRT and Progesterone IUD

Safety and Efficacy

• Both systemic HRT with progesterone and progesterone-releasing IUDs are independently effective for their respective indications 1
• When used together, there is no evidence of harmful interactions, but there are considerations regarding redundant progesterone exposure

Clinical Considerations

• Progesterone-releasing IUDs primarily work locally in the uterus with minimal systemic effects
• Systemic HRT progesterone provides endometrial protection while managing menopausal symptoms

Specific Recommendations for Different Scenarios

For Women with an Intact Uterus

• Women with an intact uterus who take estrogen require progesterone to prevent endometrial hyperplasia
• Options include:
  1. Systemic HRT with progesterone + copper IUD (preferred if contraception is needed)
  2. Progesterone-releasing IUD alone + systemic estrogen (can eliminate need for oral/transdermal progesterone)
  3. Both systemic progesterone and progesterone IUD (generally unnecessary duplication)

For Women with Special Considerations

• For women with rheumatic and musculoskeletal diseases (RMDs):

  • IUDs (both copper and progestin) are strongly recommended for women receiving immunosuppressive therapy 2
  • Women with positive antiphospholipid antibodies (aPL) should avoid combined estrogen-progestin contraceptives but can use IUDs 2

• For women with acute hepatic porphyrias:

  • Contraceptive methods involving only progesterone, including progesterone-releasing IUDs, should be avoided 2
  • Barrier methods and copper IUDs that do not contain progesterone are safe alternatives 2

• For women with progesterone hypersensitivity:

  • Progesterone-containing IUDs should be avoided 3
  • Copper IUDs are a safe alternative 3

Evidence on Progesterone Delivery Methods for HRT

Levonorgestrel IUD with Estrogen

• Levonorgestrel IUD prevents endometrial proliferation at least as effectively as oral or vaginal forms of progesterone when combined with estrogen therapy 1
• The LNG-IUD has been shown to have fewer systemic side effects compared to oral progesterone 1
• In perimenopausal women, continuous intrauterine levonorgestrel administration combined with estrogen therapy provides adequate endometrial protection 4

Oral and Other Progesterone Forms

• Dydrogesterone combined with estradiol shows no increased risk of breast cancer, stroke, or venous thromboembolism in large case-control studies 5
• Natural progesterone and some derivatives like 19-norprogesterones have fewer androgenic side effects 6

Practical Approach to Decision-Making

1. Assess the primary need:

   • If using HRT for menopausal symptoms and already have a progesterone IUD for contraception: Consider using estrogen-only HRT systemically
   • If using HRT without an IUD: Consider either systemic estrogen+progesterone or estrogen with a progesterone IUD

2. Consider potential redundancy:

   • Using both systemic progesterone and a progesterone IUD provides redundant endometrial protection
   • This may increase progesterone exposure without additional clinical benefit

3. Monitor for side effects:

   • Watch for progesterone-related side effects (mood changes, bloating, breast tenderness)
   • If side effects occur, consider simplifying to one progesterone delivery method

Common Pitfalls to Avoid

• Assuming that more progesterone is better for endometrial protection
• Overlooking the potential for cumulative side effects from multiple progesterone sources
• Failing to consider individual risk factors (history of thrombosis, breast cancer, etc.)
• Not accounting for specific conditions like progesterone hypersensitivity where progesterone-containing IUDs should be avoided 3

In conclusion, while it is technically safe to use both HRT with progesterone and a progesterone-releasing IUD simultaneously, it may represent unnecessary duplication of therapy. A more streamlined approach would be to use either systemic estrogen with a progesterone IUD or systemic estrogen-progesterone therapy with a non-hormonal IUD if contraception is needed.