Funding of safer progesterone pill ‘great news’ for HRT equity

“The studies have failed to show any significant increase in breast cancer risk with this body-identical form of progesterone”

A safer progesterone pill is now fully funded, aiming at equity of access for patients requiring hormone replacement therapy.

Utrogeston (micronised progesterone) has been available to purchase for over a decade, but as of 1 December it has been funded by Pharmac without restriction, for any relevant use.

Utrogeston is a safer and more effective form of progesterone than other previously funded synthetic options, because it is identical to the body’s natural form of the hormone and much less likely to produce side effects, Christchurch endocrinologist Anna Fenton says.

Initially recognised to treat menopausal symptoms in women who have a uterus, Utrogestan also has potential benefits in gender-affirming care for transgender women on HRT.

Many transgender women and other trans-feminine people who were assigned male at birth (AMAB) choose to medically transition with HRT, and are initially prescribed estrogen. Some are additionally prescribed progesterone.

However, the synthetic options have possible masculinising side effects that would directly oppose the intended use, Dr Fenton says.

“[Utrogeston] is kind of nicer in terms of what it’s doing – no ‘splatter’ effect on other parts of the body.”

For some trans people who found synthetic progesterone didn’t work for them, “this will be a much better option”, Dr Fenton says.

While lack of research in gender-diverse healthcare means experts are unsure of progesterone’s true effect in trans people, Utrogestan is the safest form of progesterone and could offer people medically transitioning an extra option.

As the use of progesterone for cis gender women (people assigned female at birth, who’s gender identity aligns with their sex) during menopause is primarily to stop or control bleeding caused by estrogen, its use in trans patients is commonly overlooked, Dr Fenton says.

“It was initially thought that if [cis gender] women have had a hysterectomy and there’s no clear benefit of using progesterone, then trans people probably wouldn’t see benefit either.

“But that is slowly beginning to change a little,” she says. Research is suggesting progesterone offers feminising benefits such as breast or chest growth not occurring with estrogen.

“And now the cost is gone, which is great for equity of access as it opens it up to those who could not afford it.”

The funding news is also great for those with concern about the slight heighted risk of breast cancer from progesterone, Dr Fenton says.

“Women are often very anxious about starting hormone therapy because of perceived cancer risk – but with Utrogeston, you don’t see that risk.”

She says misinformation and sensationalist media headlines have damaged the reputation of estrogen and progesterone, even though research has shown that initial concern is not real.

The US’ Women’s Health Initiative study in the 2000s altered the way doctors prescribed hormone therapy, and “it has never really recovered from that”.

People often don’t know estrogen taken by itself from the beginning of menopause significantly decreases the risk of breast cancer, she says.

When synthetic progesterone is added to estrogen and taken for more than eight years, this may increase the risk of breast cancer for one in every 1000 people – a very slight increase that is often overblown, Dr Fenton says.

And this slight risk is not replicated in Utrogeston.

“The studies have failed to show any significant increase in breast cancer risk with this body-identical form of progesterone.”

This safety factor was a big factor in getting funding for Utrogeston across the line, Dr Fenton says.

The Utrogeston funding announcement is great news for equity of access, says Dr Fenton, who has been campaigning for this for over a decade.

People taking Utrogeston and estrogen “are really on the gold standard form of hormone therapy, you really can’t do any better,” she says.