For millions of women navigating menopause with histories of venous thromboembolism, certain gynecologic cancers, or coronary artery disease, standard estrogen-containing hormone therapy has long been off the table — leaving a therapeutic gap that has persisted largely unaddressed. A narrative review in BJOG now consolidates the evidence that progestogen monotherapy can meaningfully fill that gap, challenging the clinical inertia that has kept this option historically underutilized.
The review, drawing on systematic reviews, randomized controlled trials, cohort studies, and clinical guidelines, mapped the indications, efficacy signals, and safety profiles of progestogens used as standalone menopausal hormone therapy (MHT). Vasomotor symptom relief was documented across multiple delivery formats — oral, intramuscular, and transdermal — suggesting flexibility in administration. Notably, micronized progesterone emerged as a distinct option within the class, demonstrating additional benefit for sleep quality beyond hot flash reduction. Synthetic progestins including medroxyprogesterone acetate, megestrol acetate, and norethindrone acetate showed variable efficacy profiles. The review identified relatively narrow contraindications: unexplained abnormal vaginal bleeding, personal history of breast cancer, and cautious use in patients with meningioma — a contrast to the broader contraindication list that limits estrogen therapy.
This synthesis matters because progestogen-only MHT sits at an intersection of oncology, cardiology, and menopause medicine that rarely gets integrated attention. The acknowledgment of select gynecologic malignancies — including low-grade endometrial stromal sarcoma and certain ovarian cancers — as potential indications rather than blanket contraindications reflects evolving oncologic thinking. That said, this is a narrative rather than systematic review, meaning selection bias in the included literature is possible and effect-size pooling was not performed. The heterogeneity of progestogen compounds is also clinically significant; micronized progesterone and synthetic progestins have meaningfully different receptor binding profiles and metabolic footprints that complicate class-level conclusions. For the broader research landscape, this review is best read as a consolidating, confirmatory contribution that should prompt prospective trials rather than immediate practice overhaul.