What are the recommended dosages for hormone replacement therapy (HRT) in postmenopausal women?

Recommended Dosages for Hormone Replacement Therapy in Postmenopausal Women

For postmenopausal women requiring hormone replacement therapy, the standard dosage is 0.625 mg of conjugated equine estrogen daily with 2.5 mg of medroxyprogesterone acetate daily for women with an intact uterus, or estrogen alone for women who have had a hysterectomy. 1

Standard HRT Dosing Regimens

For Women with Intact Uterus:

• Combined Estrogen-Progestin Therapy:
  • Oral conjugated equine estrogen (CEE): 0.625 mg daily
  • Medroxyprogesterone acetate (MPA): 2.5 mg daily (continuous regimen) 1, 2
  • OR
  • CEE: 0.625 mg daily
  • MPA: 10 mg daily for 12-14 days each month (cyclic regimen) 1

For Women Post-Hysterectomy:

• Estrogen-Only Therapy:
  • Oral conjugated equine estrogen: 0.625 mg daily 1
  • OR
  • Transdermal estradiol: 50-100 μg/day 3

Low-Dose Options

Recent evidence supports starting with lower doses, which may provide benefits while minimizing risks:

• Low-Dose Oral Options:

  • CEE: 0.3 mg daily 4, 5
  • Oral estradiol: 0.5-1 mg daily 6

• Low-Dose Transdermal Options:

  • Estradiol patch: 25 μg/day 7, 5

Clinical Considerations and Risk Management

Route of Administration

• Transdermal administration is preferred for women with hypertriglyceridemia 6
• Transdermal estrogen has lower risk of venous thromboembolism compared to oral formulations 8

Duration of Therapy

• Use the lowest effective dose for the shortest duration to manage symptoms 8
• Regular reassessment of risks and benefits is essential 8

Risk Assessment

The Women's Health Initiative (WHI) found that combined estrogen-progestin therapy is associated with:

• 8 additional cases of breast cancer per 10,000 women-years
• 8 additional strokes per 10,000 women-years
• 16 additional cases of pulmonary embolism per 10,000 women-years 3

Special Populations

Women with Premature Ovarian Insufficiency (POI)

For adolescents with POI, a gradual dose escalation approach is recommended:

• Age 12-13 years: Start with low-dose estrogens (transdermal: 6.25 μg/day or oral: 5 μg/kg/day)
• Age 12.5-15 years: Gradually increase dose over 2-3 years
• Age 14-16 years: Begin cyclic progestogen after 2 years of estrogen or when breakthrough bleeding occurs 1

Important Cautions

• HRT is contraindicated in women with a history of breast cancer, venous thromboembolism, stroke, or heart disease 1, 8
• The USPSTF recommends against using HRT solely for prevention of chronic conditions 1
• Estrogen plus progestin therapy increases the risk of coronary heart disease, stroke, and breast cancer 1, 2

Monitoring

• Women taking estrogen should have annual clinical reviews 1
• Women taking cyclic progestins who develop bleeding outside of withdrawal periods should be evaluated 1
• No routine monitoring tests are required but may be prompted by specific symptoms or concerns 1