Do you prescribe progesterone (a progestin) to a patient without a uterus?

Progesterone Use in Patients Without a Uterus

Progesterone should not be prescribed to patients without a uterus as there is no clinical indication and it may increase unnecessary risks.

Rationale for Not Using Progesterone After Hysterectomy

• The primary purpose of adding progesterone to hormone therapy is to protect the endometrium from estrogen-induced hyperplasia and cancer in women with an intact uterus 1
• When the uterus is absent, estrogen treatment alone is sufficient for managing menopausal symptoms such as hot flashes and/or genital atrophic symptoms 1
• Adding a progestogen to estrogen therapy after hysterectomy provides no additional benefit for symptom relief but increases potential risks 1

Evidence Against Combined Therapy After Hysterectomy

• Multiple lines of evidence suggest that regimens containing both estrogen and progestogen versus estrogen alone are associated with a greater relative risk of breast cancer without additional improvement in relief of menopausal symptoms 1
• There is no evidence to support routine use of progesterone in patients without a uterus, as the primary indication for progesterone is endometrial protection 1
• Progesterone and progestins may have adverse effects including dizziness, drowsiness, and psychological side effects that can be avoided when not clinically necessary 2

Limited Indications for Progesterone After Hysterectomy

• Rare exceptions where progesterone might be considered after hysterectomy include:
  • Presence of residual endometriosis after hysterectomy 1
  • History of endometrial neoplasia with potential microscopic residual disease 1
  • These situations require individualized risk assessment and are not routine indications

Safety Considerations

• Micronized progesterone is contraindicated in patients with severe peanut allergies, as many formulations contain peanut oil in the excipients 3
• Progesterone is also contraindicated in patients with hormone receptor-positive cancers 3, 4
• The use of progesterone may increase breast cancer risk without providing additional benefits in women without a uterus 1

Clinical Decision Algorithm

1. Determine if patient has had a hysterectomy (complete removal of uterus)
2. If yes, progesterone is not indicated for routine hormone therapy
3. If menopausal symptoms are present, estrogen-only therapy is appropriate
4. Only consider progesterone if there is documented residual endometriosis or history of endometrial neoplasia
5. If progesterone is being considered, evaluate for contraindications including peanut allergy and hormone-sensitive cancers

In conclusion, the evidence clearly demonstrates that for patients without a uterus, estrogen-only therapy is the appropriate approach for managing menopausal symptoms, and adding progesterone provides no additional benefit while potentially increasing risks 1.