From the Guidelines
Hormone replacement therapy for post-menopausal women should be approached with caution, considering the potential risks and benefits, and estrogen-only therapy is unlikely to outweigh the harms in most postmenopausal women who have had a hysterectomy, as concluded by the USPSTF with moderate certainty 1. When considering hormone therapy for post-menopausal women, it's essential to weigh the benefits and risks. The USPSTF recommends against the use of combined estrogen and progestin for the primary prevention of chronic conditions in most postmenopausal women, due to the increased risk of serious adverse events such as stroke, invasive breast cancer, and dementia 1. For women with an intact uterus, a common protocol may include oral estradiol (1-2 mg daily) or transdermal estradiol patch (0.025-0.1 mg/day) combined with oral micronized progesterone (100-200 mg daily) or medroxyprogesterone acetate (2.5-5 mg daily). Some key points to consider when prescribing hormone therapy for post-menopausal women include:
- Starting treatment at the lowest effective dose and individualizing based on symptoms
- Initiating HRT within 10 years of menopause for optimal benefit-risk ratio
- Regular monitoring, including annual breast examinations, mammograms, and pelvic exams
- Avoiding HRT in women with a history of breast cancer, stroke, heart disease, or blood clots, or discussing alternative approaches with their healthcare provider Testosterone supplementation is not FDA-approved for women but may be prescribed off-label for sexual dysfunction at doses of 300-1200 mcg/day via transdermal preparations 1.
From the FDA Drug Label
When estrogen is prescribed for a postmenopausal woman with a uterus, a progestin should also be initiated to reduce the risk of endometrial cancer. Use of estrogen, alone or in combination with a progestin, should be with the lowest effective dose and for the shortest duration consistent with treatment goals and risks for the individual woman. For treatment of moderate to severe vasomotor symptoms, vulval and vaginal atrophy associated with the menopause, the lowest dose and regimen that will control symptoms should be chosen and medication should be discontinued as promptly as possible. The usual initial dosage range is 1 to 2 mg daily of estradiol adjusted as necessary to control presenting symptoms.
The FDA drug label does not provide information on testosterone protocols for post-menopausal women. For estrogen protocols, the label recommends:
- Using the lowest effective dose and for the shortest duration consistent with treatment goals and risks.
- Initiating a progestin when prescribing estrogen for a postmenopausal woman with a uterus to reduce the risk of endometrial cancer.
- Starting with a dose of 1 to 2 mg daily of estradiol, adjusted as necessary to control presenting symptoms, for treatment of moderate to severe vasomotor symptoms and vulval and vaginal atrophy associated with menopause 2.
From the Research
Estrogen and Testosterone Protocols for Post-Menopausal Women
- The current evidence does not provide a clear protocol for estrogen and testosterone treatment in post-menopausal women, but it does discuss the efficacy of progestin-only treatment and menopausal hormone therapy (MHT) with estradiol and progesterone 3, 4.
- Progestin-only treatment has been shown to improve vasomotor symptoms (VMS) in some studies, with oral progestin using 300 mg micronized progesterone reporting a 58.9% improvement in VMS 3.
- MHT with estradiol (E2) and progesterone (P4) may have a better safety profile compared to other estrogens and progestins, with potentially lower risks of venous thromboembolism, cardiovascular outcomes, and breast cancer 4.
- The optimal route and dosage of progestin monotherapy have not been established, with administration ranging from 5 to 60 mg of transdermal progesterone and 10 to 20 mg oral medroxyprogesterone acetate 3.
- Testosterone protocols are not discussed in the provided evidence, and therefore, no information can be given on this topic.
Menopausal Hormone Therapy
- MHT with E2 and P4 may be associated with a lower risk of endometrial hyperplasia/cancer, venous thromboembolism, and cardiovascular outcomes compared to other estrogens and progestins 4.
- E2 may potentially protect better against age-related cognitive decline and bone fractures compared to conjugated equine estrogens (CEE) 4.
- P4 may have a similar or possibly better profile for breast cancer and cardiovascular outcomes compared to progestins 4.