What is the recommended hormone replacement therapy (HRT) for a patient with menopause symptoms?

Hormone Replacement Therapy for Menopausal Symptoms

For patients with menopausal symptoms, the recommended hormone replacement therapy is the lowest effective dose of estrogen (such as oral estradiol 1-2 mg daily or transdermal estradiol 0.025-0.0375 mg/day patch), combined with progestogen for women with an intact uterus, used for the shortest duration needed to control symptoms. 1, 2

Patient Selection and Initial Assessment

• Determine if patient is appropriate for hormone therapy:

  • Most effective for vasomotor symptoms and vaginal atrophy 1
  • More favorable benefit-risk ratio when started in early menopause (within 10 years or before age 60) 1

• Absolute contraindications:

  • History of hormone-dependent cancers (breast, uterine) 1
  • Active liver disease 1
  • Recent or active venous thromboembolism 1
  • History of prostate cancer 1

Treatment Regimens

For Women with Intact Uterus:

Estrogen must always be combined with progestogen to prevent endometrial cancer 1, 2

1. Cyclic/Sequential Regimen:

   • Continuous estrogen with progesterone added for 12-14 days each month
   • Options include:
     • 200 mg oral/vaginal micronized progesterone for 12-14 days every 28 days
     • 10 mg medroxyprogesterone acetate for 12-14 days per month
   • Results in predictable withdrawal bleeding 1

2. Continuous Combined Regimen:

   • Daily estrogen and progesterone
   • Minimum 2.5 mg oral medroxyprogesterone acetate daily
   • Designed to minimize bleeding over time (may cause irregular bleeding initially) 1

For Women without Uterus:

• Estrogen-only therapy is appropriate 2
• No progestogen needed 2

Estrogen Formulations and Dosing:

• Oral estradiol: 1-2 mg daily 1, 2
• Transdermal estradiol: 0.025-0.0375 mg/day patch 1
• Conjugated equine estrogen: 0.625 mg/day 1

Monitoring and Follow-up

• Initial follow-up: 8-10 weeks after treatment initiation 1
• Regular reassessment: Every 3-6 months to determine if treatment is still necessary 1, 2
• Annual comprehensive assessment of risks and benefits 1
• For women with a uterus: Endometrial sampling when indicated for undiagnosed persistent or recurring abnormal vaginal bleeding 2

Important Considerations and Risks

• HRT carries risks including:

  • Increased breast cancer risk (hazard ratio 1.26) with combined therapy used >3-5 years 1, 3
  • Venous thromboembolism (RR 2.14) 1
  • Stroke (RR 1.12) 1
  • Gallbladder disease (RR 1.8-2.5) 1

• Micronized progesterone is associated with lower cardiovascular and thrombotic risk compared to synthetic progestins 1

• Transdermal estrogen may be preferred for women with hypertriglyceridemia as it has less effect on lipid metabolism 4

Discontinuation

• Approximately 75% of women can stop HRT without major difficulty 5
• Consider tapering therapy at 3-6 month intervals 2
• Some women may experience return of vasomotor symptoms when stopping 5

Alternative Options for Those Who Cannot Use HRT

For patients with contraindications to HRT or who prefer non-hormonal approaches:

• Non-hormonal pharmacologic treatments:

  • SSRIs/SNRIs (paroxetine, venlafaxine)
  • Gabapentin
  • Clonidine 1, 3

• Local vaginal estrogen for isolated vaginal symptoms 1

• Lifestyle modifications:

  • Regular aerobic and resistance exercise
  • Calcium and vitamin D supplementation
  • Weight-bearing exercise
  • Healthy calorie-restricted diet 1

HRT remains the gold standard for managing vasomotor and vaginal symptoms of menopause 6, but treatment decisions should be based on symptom severity, risk factors, and patient preferences, with the goal of using the lowest effective dose for the shortest necessary duration.