What is the recommended treatment for perimenopausal symptoms using Divigel (estradiol) and Androgel (testosterone)?

Treatment of Perimenopausal Symptoms with Divigel and Androgel

For perimenopausal symptoms, Divigel (estradiol) may be used at the lowest effective dose for the shortest duration needed, but Androgel (testosterone) is not recommended as it is contraindicated for women with perimenopausal symptoms. 1

Hormone Replacement Therapy Options

Estrogen Therapy (Divigel)

• Divigel is an estradiol gel that has shown efficacy for treating vasomotor symptoms in perimenopausal women 2, 3
• Recommended dosing options include:
  • 0.25 mg/day (delivering approximately 0.003 mg estradiol)
  • 0.5 mg/day (delivering approximately 0.009 mg estradiol)
  • 1.0 mg/day (delivering approximately 0.027 mg estradiol) 3
• The 0.25 mg dose is the lowest effective dose for vasomotor symptoms and should be tried first 1, 3
• Divigel 1.0 mg showed the greatest efficacy for hot flush reduction but also had higher adverse event rates 2

Important Safety Considerations

• For women with an intact uterus, estrogen must always be combined with progestogen to prevent endometrial cancer 1
• Progestogen 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
  • Continuous regimen: minimum 2.5 mg oral medroxyprogesterone acetate daily 1

Testosterone Therapy (Androgel)

• Androgel (testosterone) is NOT recommended for perimenopausal women 1
• Testosterone therapy is specifically contraindicated in patients with hormone-dependent cancers 1
• There is no evidence supporting Androgel use for perimenopausal symptoms in women

Risks and Contraindications

Absolute Contraindications for HRT

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

Risks of Estrogen Therapy

• Increased risk of:
  • Breast cancer (hazard ratio 1.26)
  • Venous thromboembolism (relative risk 2.14)
  • Stroke (relative risk 1.12)
  • Gallbladder disease (relative risk 1.8-2.5) 1

Application and Adherence Considerations

• Patient education is critical as studies show 70% of patients fail to use estradiol gel as prescribed 4
• Common errors include:
  • Incorrect application sites
  • Uncertainty about missed dose procedures 4
• Proper application technique:
  • Apply to clean, dry skin
  • Avoid breast tissue and genital areas
  • Rotate application sites
  • Allow to dry completely before dressing

Monitoring and Follow-up

• Initial follow-up: 8-10 weeks after treatment initiation
• Regular reassessment: Every 3-6 months to determine if treatment is still necessary
• Annual comprehensive assessment of risks and benefits 1

Non-Hormonal Alternatives

For women with mild symptoms or contraindications to HRT, consider:

• SSRIs/SNRIs (paroxetine, venlafaxine)
• Gabapentin
• Clonidine
• Lifestyle modifications (regular exercise, weight loss, calcium and vitamin D supplementation) 1

Common Pitfalls to Avoid

1. Using estrogen alone in women with intact uterus
2. Continuing HRT beyond the necessary duration for symptom control
3. Prescribing testosterone (Androgel) for perimenopausal women
4. Failing to provide adequate patient education on proper gel application
5. Not regularly reassessing the risk-benefit profile of continued therapy