Should I take continuous progesterone (medroxyprogesterone acetate or norethindrone) without stopping, even during my period, for hyperplastic endometrium?

Treatment of Hyperplastic Endometrium with Continuous Progesterone

Yes, you should take continuous progesterone without stopping during your period for hyperplastic endometrium. The evidence strongly supports continuous (not cyclic) progestin therapy as the appropriate regimen for treating endometrial hyperplasia, and this continuous dosing does not require interruption during menstrual bleeding. 1

Rationale for Continuous Therapy

Continuous progestin-based therapy is the recommended approach for endometrial hyperplasia, whether you are using medroxyprogesterone acetate, megestrol acetate, or a levonorgestrel intrauterine device. 1 The guidelines explicitly state this should be "continuous" therapy, meaning you do not stop during periods. 1

Why Continuous Rather Than Cyclic

• Continuous combined regimens provide superior endometrial protection compared to cyclic regimens, with rates of hyperplasia similar to placebo (<1%) versus significantly higher rates with cyclic dosing. 2
• The continuous exposure to progestogen prevents the proliferative effects of estrogen on the endometrium throughout the entire cycle. 3, 2
• Cyclic regimens are designed for hormone replacement therapy in women without hyperplasia, not for treating existing endometrial pathology. 1

Specific Medication Options

Medroxyprogesterone Acetate (MPA)

• MPA is the only progestin with proven full effectiveness in inducing secretory endometrium when used regularly at appropriate doses. 1
• Typical dosing for hyperplasia treatment: oral medroxyprogesterone acetate continuously. 1
• MPA transforms proliferative endometrium into secretory endometrium, counteracting hyperplastic changes. 4

Norethindrone Acetate

• Continuous norethindrone acetate at doses as low as 0.1 mg combined with estrogen effectively prevents endometrial hyperplasia. 5
• This medication is also listed as an acceptable option for continuous progestin therapy in hyperplasia. 1

Alternative: Levonorgestrel IUD

• The levonorgestrel intrauterine device provides continuous local progestogen delivery and is an effective option for hyperplasia treatment. 1

Monitoring Requirements

You must have close surveillance with endometrial sampling every 3 to 6 months while on continuous progestin therapy. 1

• Endometrial biopsies or D&C should be performed at these intervals to assess treatment response. 1
• If hyperplasia persists after 6 to 12 months of continuous progestin therapy, hysterectomy with surgical staging should be recommended. 1
• If progression to more severe hyperplasia or cancer is documented on biopsy, surgical intervention is indicated. 1

Expected Outcomes

• Approximately 50% of patients achieve a durable complete response with continuous progestin therapy for hyperplasia. 1
• Higher success rates (65.8%) are seen with hyperplasia compared to early-stage cancer (48.2%). 1
• In studies where hyperplasia resolved with progestin therapy, 94% of cases reverted to normal endometrium. 6

Important Contraindications to Consider

Before starting continuous progestin therapy, ensure you do not have the following contraindications:

• History of breast cancer, stroke, or myocardial infarction. 1, 7
• Active or history of pulmonary embolism or deep vein thrombosis. 1, 7
• Current smoking (particularly with other risk factors). 1, 7

Common Pitfalls to Avoid

• Do not use cyclic progestin regimens for treating hyperplasia—these are designed for hormone replacement therapy in women without endometrial pathology, not for therapeutic treatment of hyperplasia. 2
• Do not skip monitoring biopsies—regular endometrial sampling is essential to detect treatment failure or progression. 1
• Do not continue therapy indefinitely without reassessment—if hyperplasia persists beyond 6-12 months, surgical management should be considered. 1
• Be aware that medroxyprogesterone acetate may have less favorable cardiovascular and metabolic effects compared to micronized progesterone, though MPA has the strongest evidence for endometrial protection. 1, 8