What is the recommended hormone replacement therapy (HRT) regimen for women?

Recommended Hormone Replacement Therapy Regimen for Women

For women with an intact uterus, the recommended HRT regimen is transdermal estradiol (0.025-0.05 mg/day) combined with oral progestin, while women without a uterus should receive estrogen-only therapy. 1, 2, 3

General Principles of HRT

• HRT should be prescribed at the lowest effective dose for the shortest duration consistent with treatment goals and individual risk assessment
• Regular reassessment every 3-6 months is necessary to determine if continued treatment is needed 1
• Women with an intact uterus must receive progestin alongside estrogen to prevent endometrial cancer 2, 3
• Women without a uterus should receive estrogen-only therapy 2, 3

Recommended Regimens

Estrogen Component:

• First choice: Transdermal estradiol 0.025-0.05 mg/day patch 4, 1

  • Advantages: Mimics physiological estradiol concentrations, avoids hepatic first-pass effect, minimizes impact on hemostatic factors, more beneficial for lipid profiles and blood pressure 4
  • More effective for bone mineral density compared to oral formulations 4

• Alternative: Oral estradiol 1-2 mg daily or conjugated equine estrogens 0.625 mg daily 4, 1

Progestin Component (for women with intact uterus):

• Medroxyprogesterone acetate 2.5 mg/day (continuous regimen) 1
• Natural micronized progesterone is an alternative with potentially better cardiovascular and thrombotic risk profile 4

Administration Schedule Options

1. Continuous Combined Therapy: Daily estrogen plus daily progestin

   • Advantage: Eliminates monthly bleeding after initial adjustment period
   • Best for women who are at least 1 year post-menopausal

2. Cyclic/Sequential Therapy: Daily estrogen with progestin added for 10-14 days per month

   • Results in predictable monthly withdrawal bleeding
   • May be better tolerated by women in early menopause

Monitoring and Follow-up

• Initial follow-up at 2-4 weeks to assess symptom control and side effects
• Regular reassessment every 3-6 months 1
• Monitor estradiol, FSH, LH levels 8-10 weeks after dose adjustments 1
• Attempt to taper or discontinue medication at 3-6 month intervals 2, 3

Risks and Contraindications

Contraindications:

• History of breast cancer
• History of venous thromboembolism
• Undiagnosed vaginal bleeding
• Active liver disease
• Uncontrolled hypertension 1

Risks:

• Combined estrogen-progestin therapy increases risk of breast cancer, stroke, deep venous thrombosis, pulmonary embolism, and gallbladder disease 1
• Estrogen alone increases risk of stroke, deep venous thrombosis, and gallbladder disease 1

Special Considerations

• Patients with renal impairment may require 50-70% lower doses of estradiol 1
• HRT is not a contraceptive; women who are still having periods may need additional contraception 1
• For women with premature ovarian insufficiency due to chemotherapy or radiation, transdermal estradiol is preferred 4

Alternative Options for Women Who Cannot Use HRT

• SSRIs/SNRIs (venlafaxine, paroxetine) for vasomotor symptoms
• Gabapentin for hot flashes
• Non-hormonal vaginal moisturizers for vaginal dryness
• Lifestyle modifications including regular exercise and stress reduction techniques 1