What are the guidelines for receiving estrogen (hormone replacement therapy) therapy for women with menopause (postmenopausal syndrome) or perimenopause (premenopausal syndrome)?

From the Guidelines

Estrogen therapy for menopausal or perimenopausal women should be considered for those experiencing severe symptoms, but should be used at the lowest effective dose for the shortest duration necessary, generally less than 5 years and before age 60, due to the associated risks of breast cancer, cardiovascular and thromboembolic morbidity 1. The decision to initiate estrogen therapy should be based on the individual woman's clinical situation, preferences, and values, taking into account the potential benefits and harms of treatment. Some key points to consider when prescribing estrogen therapy include:

• The use of combined estrogen and progestin is not recommended for the prevention of chronic conditions in postmenopausal women 1.
• Estrogen therapy may be associated with an increased incidence of stress, mixed, or any urinary incontinence in previously asymptomatic women 1.
• Women with an intact uterus must also take progesterone to prevent endometrial hyperplasia.
• Estrogen therapy is contraindicated for women with a history of breast cancer, coronary heart disease, previous venous thromboembolism, stroke, active liver disease, or unexplained vaginal bleeding. The benefits of estrogen therapy include improved quality of life through symptom relief and potential protection against osteoporosis, while the risks include slightly increased chances of blood clots, stroke, and breast cancer with long-term use. Regular follow-up appointments are essential to monitor for side effects and reassess the need for continued therapy. In terms of specific treatment options, common estrogen preparations include oral estradiol, transdermal patches, vaginal creams, rings, or tablets, and the choice of therapy should be individualized based on the woman's symptoms and medical history 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. A woman without a uterus does not need progestin 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 guidelines for receiving estrogen therapy for women with menopause or premenopause are:

• Lowest effective dose: Use the lowest effective dose of estrogen for the shortest duration consistent with treatment goals and risks.
• Combination with progestin: For women with a uterus, a progestin should be initiated to reduce the risk of endometrial cancer.
• Monitoring: Patients should be reevaluated periodically (e.g., 3-month to 6-month intervals) to determine if treatment is still necessary.
• Discontinuation: Medication should be discontinued as promptly as possible when symptoms are controlled.
• Dosage: The usual initial dosage range is 1 to 2 mg daily of estradiol, adjusted as necessary to control presenting symptoms 2.
• Administration: Administration should be cyclic (e.g., 3 weeks on and 1 week off) 2.

From the Research

Guidelines for Estrogen Therapy

The guidelines for receiving estrogen therapy for women with menopause or pre-menopause are as follows:

• Estrogen therapy is an effective treatment for menopausal symptoms, including vasomotor symptoms and genitourinary syndrome of menopause 3, 4.
• Recently menopausal women with moderate or severe symptoms are appropriate candidates for hormone therapy (HT) in the absence of contraindications or other major comorbidities 3.
• The timing of HT initiation is important, with more favorable effects on coronary heart disease and all-cause mortality in younger women (close proximity to menopause) than in women more than a decade past menopause 3, 5.
• The type and route of administration of HT should be considered, with options including oral conjugated estrogens and percutaneous estradiol 6.
• Patient-specific considerations, such as age, time since menopause, and comorbidity status, should be weighed when prescribing HT 3, 5.

Eligibility for Estrogen Therapy

Women who are eligible for estrogen therapy include:

• Those with bothersome menopausal symptoms, such as vasomotor symptoms and genitourinary syndrome of menopause 5, 4.
• Those with a history of osteoporosis or at risk of osteoporosis 3, 4.
• Those who have not had a contraindication to estrogen therapy, such as a history of breast cancer or stroke 3, 5.

Administration of Estrogen Therapy

Estrogen therapy can be administered through various routes, including:

• Oral conjugated estrogens 6.
• Percutaneous estradiol 6.
• Other routes of administration, such as transdermal patches or vaginal creams, may also be available 4.