What are the recommended hormonal treatments for menopause?

Recommended Hormonal Treatments for Menopause

For menopausal symptom management, hormone therapy should be used at the lowest effective dose for the shortest duration possible, with transdermal estrogen formulations preferred over oral preparations due to their more favorable risk profile. 1

Appropriate Use of Hormone Therapy

Hormone therapy (HT) is primarily indicated for treating menopausal symptoms, not for preventing chronic conditions. The U.S. Preventive Services Task Force explicitly recommends against using HT for chronic disease prevention (Grade D recommendation) 2.

Indications for Hormone Therapy:

• Moderate to severe vasomotor symptoms (hot flashes, night sweats)
• Vulvovaginal atrophy and associated symptoms
• Sleep disturbances related to vasomotor symptoms
• Prevention of bone loss in select high-risk women

Recommended Hormone Therapy Regimens

For Women with an Intact Uterus:

• Estrogen + Progestin combination:
  • Conjugated equine estrogen 0.625 mg/day + medroxyprogesterone acetate 2.5 mg/day OR
  • Transdermal estradiol patch 0.025-0.0375 mg/day + progestin 1
  • Micronized progesterone is preferred over synthetic progestins due to potentially better safety profile 3

For Women Without a Uterus (Post-Hysterectomy):

• Estrogen-only therapy:
  • Estradiol 1-2 mg daily, adjusted as needed 4
  • Transdermal estradiol 0.025-0.0375 mg/day patch 1

Risk Assessment Before Initiating Therapy

Absolute Contraindications:

• History of hormone-dependent cancers
• History of venous thromboembolism
• Active liver disease
• Unexplained vaginal bleeding
• History of stroke or coronary heart disease 1
• Positive antiphospholipid antibodies or antiphospholipid syndrome 1

Risk Considerations:

• Breast Cancer: 8 additional cases per 10,000 women-years with estrogen-progestin therapy 1
• Cardiovascular Events: 8 additional strokes and 7 additional CHD events per 10,000 women-years 1
• Venous Thromboembolism: Increased risk (RR 2.14), highest in first year of use 1
• Gallbladder Disease: Increased risk (RR 1.8-2.5), higher with long-term use 1

Optimizing Hormone Therapy

Route of Administration:

• Transdermal estrogen is preferred over oral estrogen for:
  • Women with gallbladder disease history (bypasses first-pass liver metabolism) 1
  • Women at higher risk for venous thromboembolism 1, 5
  • Women with hypertension or cardiovascular risk factors 5

Dosing Principles:

• Start with lowest effective dose (e.g., 0.025 mg/day transdermal estradiol) 1, 4
• Titrate as needed for symptom control 4
• Regular monitoring at 4-6 weeks after starting therapy or changing doses 1
• Annual comprehensive reassessment of risks and benefits 1

Special Populations:

• Women with premature ovarian insufficiency: Continue HT until average age of natural menopause 1
• Breast cancer survivors: Consider non-hormonal options like SSRIs/SNRIs 1
• Women with diabetes, obesity, or metabolic syndrome: Transdermal estrogen may be preferable 5

Non-Hormonal Alternatives

For women with contraindications to hormone therapy:

• Low-dose paroxetine (7.5 mg daily) for vasomotor symptoms 1
• Venlafaxine for vasomotor symptoms 1
• Vaginal estrogen for isolated genitourinary symptoms 1

Monitoring and Follow-up

• Follow-up appointments 4-6 weeks after starting therapy or changing doses 1
• Annual comprehensive reassessment of risks and benefits 1
• For low-risk patients, return visits every 2-6 weeks are sufficient; higher-risk patients should return within 14 days 1
• Assess for side effects including breast tenderness, breakthrough bleeding, and mood changes

Important Caveats

• The timing of HT initiation is crucial: benefits outweigh risks when started before age 60 or within 10 years of menopause onset 6
• The risk-benefit ratio worsens with advancing age and time since menopause 6
• Despite its effectiveness for symptom relief, menopausal symptoms remain substantially undertreated 7
• Hormone therapy should be discontinued as soon as it is no longer needed for symptom control 4