What is the recommended starting dose for Bioidentical Hormone Replacement Therapy (BHRT)?

Recommended Starting Doses for Bioidentical Hormone Replacement Therapy (BHRT)

For menopausal symptoms, BHRT should start with the lowest effective dose: 50-100 μg/24 hours for transdermal estradiol or 0.5-1 mg daily for oral estradiol, with 100-200 mg daily of micronized progesterone for women with an intact uterus. 1

Estrogen Component Dosing

Transdermal estradiol is the preferred delivery method due to:

• Avoidance of first-pass hepatic metabolism
• More physiological estradiol:estrone ratio
• Lower cardiovascular risk profile (reduced VTE and stroke risk) 1

Starting Doses by Formulation:

• Transdermal estradiol patch: 50 μg/24 hours (can range from 25-100 μg/24 hours)
• Oral estradiol: 0.5 mg daily (can range from 0.5-2 mg daily)

Dose Titration Protocol:

• Begin with the lowest effective dose
• Evaluate clinically at 3-6 months initially
• Adjust dose based on symptom control and side effects
• Maximum doses: 100-200 μg/24 hours for transdermal or 2-4 mg daily for oral estradiol 1

Progesterone Component Dosing

For women with an intact uterus, progesterone is essential to prevent endometrial hyperplasia:

• Micronized progesterone: 100-200 mg daily (preferred due to physiological profile and safety) 1
• Administer for 12-14 days per month in cyclic regimens or daily in continuous regimens

Special Population Considerations

Adolescents with Premature Ovarian Insufficiency

Gradual dose escalation protocol:

• Initial 0-6 months: 1/8 patch weekly or 1/4 patch for 3-4 days/week (transdermal); or 0.5 mg every other day (oral)
• 6-12 months: 1/4 patch weekly; or 0.5 mg every other day (oral)
• 12-18 months: 1/2 patch for 3-4 days, 1/4 patch remaining days; or 0.5 mg daily (oral)
• 18-24 months: 1/2 patch weekly; or 0.5 mg and 1 mg alternating days (oral)
• >24 months: Full patch weekly; or 1 mg daily (oral) 1

Transgender Women/Transfeminine Individuals

• May require higher doses: up to 100-200 μg/24 hours transdermal estradiol
• Often combined with anti-androgens to reduce testosterone to female range (<50 ng/dL) 1

Monitoring and Follow-up

• Clinical evaluation every 3-6 months initially, then annually
• Report any persistent or recurrent abnormal vaginal bleeding immediately
• Assess symptom control and compliance at each visit 1

Common Side Effects and Management

• Irregular bleeding (common during first 3-6 months)
• Breast tenderness
• Nausea
• Headache

These side effects are typically transient and decrease with continued use 1

Important Precautions

BHRT is contraindicated in patients with:

• History of hormonally mediated cancers
• Breast cancer
• Undiagnosed vaginal bleeding
• Active thromboembolic disorders
• Current or history of arterial thrombotic disease 1

Clinical Pearls

1. Always start with the lowest effective dose and titrate as needed
2. Transdermal formulations have better safety profiles than oral formulations
3. Individualize dosing based on symptom control rather than hormone levels
4. Unscheduled bleeding is common during the first 3-6 months
5. Progesterone is essential for women with an intact uterus to prevent endometrial hyperplasia

By following these dosing guidelines, clinicians can optimize symptom control while minimizing risks associated with BHRT.