Hormone Replacement Therapy for Menopausal Symptoms
Hormone therapy (HT) should be used primarily for treatment of vasomotor symptoms and urogenital symptoms associated with menopause, using the lowest effective dose for the shortest time necessary (typically 1-2 mg daily of estradiol for vasomotor symptoms), with women with an intact uterus requiring concurrent progestin therapy. 1, 2
Recommended Approach to HRT
Patient Selection and Risk Assessment
HT is indicated for:
Contraindications to HT include:
- History of breast cancer
- Active or recent venous thromboembolism
- Active liver disease
- Uncontrolled hypertension
- Current smoking, especially if >35 years
- Unexplained vaginal bleeding
- Endometrial cancer
- History of stroke or cardiovascular disease 1
Recommended Regimens
For Women with Intact Uterus:
- Estrogen + progestin combination is required to prevent endometrial cancer 1, 2
- Standard regimens:
- Conjugated equine estrogen 0.625 mg/day + Medroxyprogesterone acetate 2.5 mg/day, OR
- Transdermal estradiol 0.025-0.0375 mg/day patch + Progesterone 100 mg daily 1
For Women without a Uterus:
- Estrogen-only therapy is appropriate 2
- Typical starting dose: 1-2 mg daily of estradiol, adjusted as necessary 2
Administration Guidelines
- Start with the lowest effective dose 1, 2
- Titrate based on symptom control 1
- Administration should be cyclic (e.g., 3 weeks on and 1 week off) 2
- Regular follow-up every 3-6 months to assess symptom control and monitor for side effects 1
- Annual gynecological assessment for women on HT 1
- Attempt to discontinue or taper medication at 3-6 month intervals 2
Benefits and Risks of HRT
Benefits:
- Effective treatment for vasomotor symptoms (80-90% reduction) 1, 3
- Treatment for vaginal dryness and dyspareunia 1
- Prevention of bone loss and osteoporosis 1, 2
Risks:
The Women's Health Initiative found that for 10,000 women taking estrogen and progestin for 1 year:
- 7 additional coronary heart disease events
- 8 more strokes
- 8 more pulmonary emboli
- 8 more invasive breast cancers
- 6 fewer cases of colorectal cancer
- 5 fewer hip fractures 1
Combined estrogen/progestogen therapy increases breast cancer risk when used for more than 3-5 years 3
Transdermal estradiol has lower risk of venous thromboembolism compared to oral administration 1
Non-Hormonal Alternatives
For women with contraindications to HRT or who prefer non-hormonal options:
SSRIs/SNRIs:
Other medications:
- Gabapentin shows moderate effectiveness for hot flash control at 4-8 weeks 1
For vaginal symptoms:
Special Considerations
- Perimenopausal women: HRT does not provide contraceptive protection; consider combined oral contraceptives if contraception is also needed 1
- Premature ovarian insufficiency: May still be fertile and require contraception 1
- BRCA1/2 mutations: HRT is an option after prophylactic bilateral salpingo-oophorectomy without personal history of breast cancer 1
- Endometriosis: Combined estrogen/progestogen therapy can treat vasomotor symptoms and may reduce disease reactivation risk 1
Discontinuation of HRT
- Approximately 75% of women who try to stop are able to discontinue HRT without major difficulty 4
- Some women experience recurrence of vasomotor symptoms when attempting to stop 4
- Consider slow tapering of HRT, though effectiveness of this approach has not been well evaluated 4
Monitoring
- Any woman on HRT who experiences vaginal bleeding should contact their physician immediately for evaluation to rule out endometrial cancer 1
- For women with a uterus, adequate diagnostic measures, such as endometrial sampling, should be undertaken to rule out malignancy in cases of undiagnosed persistent or recurring abnormal vaginal bleeding 2