Transdermal HRT Options for Postmenopausal Women Requiring Estrogen and Progesterone
For postmenopausal women requiring both estrogen and progesterone, the recommended transdermal HRT option is a combination of transdermal estradiol patches with oral micronized progesterone. 1, 2
Estrogen Component Options
Transdermal Estradiol Patches
- First-line recommendation: 17β-estradiol transdermal patches 1
- Starting dose: 25-50 μg/day (lowest effective dose) 3
- Titrate based on symptom control
- Apply to clean, dry, non-irritated skin on lower abdomen or buttocks
- Change patch according to product instructions (typically every 3-7 days)
Benefits of Transdermal Route
- Avoids first-pass liver metabolism 4, 2
- Lower risk of venous thromboembolism compared to oral estrogen 1, 2
- Preferred in women with hypertension 1
- More favorable effects on lipid profile 1
- More stable serum estradiol levels 5
- Lower risk of gallbladder disease compared to oral formulations 1
- May have less impact on stroke risk compared to oral formulations 2, 6
Progesterone Component Options
Oral Micronized Progesterone
- First-line recommendation: Micronized progesterone 100-200 mg daily 1, 2
- Should be taken at bedtime to minimize side effects
- Provides adequate endometrial protection when used continuously
Alternative Progestogens
- Dydrogesterone 5-10 mg daily 1
- Medroxyprogesterone acetate (less preferred due to potential cardiovascular effects) 2
Administration Regimens
Continuous Combined Regimen
- Estradiol patch continuously
- Progesterone daily without breaks
- Provides best endometrial protection 2
- Suitable for women >1 year post-menopause
- Aims for amenorrhea (no bleeding)
Cyclical/Sequential Regimen
- Estradiol patch continuously
- Progesterone for 12-14 days per month 1
- May be preferred in early menopause or perimenopausal women
- Results in predictable withdrawal bleeding
Monitoring and Follow-up
- Annual clinical review with focus on compliance 1
- No routine monitoring tests required unless specific concerns arise 1
- Assess for side effects: breast tenderness, breakthrough bleeding, skin irritation
- Use lowest effective dose for shortest duration needed 7, 3
Important Considerations and Cautions
Transdermal estradiol is contraindicated in women with:
- History of breast cancer 1
- Active venous thromboembolism
- Uncontrolled hypertension
- Active liver disease
Women with intact uterus must always receive progesterone component to prevent endometrial hyperplasia 3
Local skin reactions occur in approximately 3% of women using patches 8
Transdermal estradiol with micronized progesterone appears to have a more favorable risk profile than oral combined HRT, particularly regarding VTE risk and potentially breast cancer risk 2
The choice between continuous combined or sequential regimens should be based on time since menopause and whether the woman desires to avoid monthly bleeding. For most postmenopausal women (>1 year from last period), the continuous combined regimen is preferred for better endometrial protection and to avoid withdrawal bleeding.