From the Guidelines
During perimenopause, hormone therapy with estrogen and progesterone may be beneficial for women experiencing troublesome symptoms, but the decision to use hormone therapy should be individualized based on symptom severity and medical history, with the lowest effective dose used for the shortest duration necessary, as recommended by the USPSTF 1.
Key Considerations
- The role of estrogen and progesterone during perimenopause is complex, with fluctuating hormone levels leading to characteristic symptoms such as hot flashes, night sweats, and mood changes.
- Hormone therapy may be beneficial for women experiencing troublesome perimenopausal symptoms, but the risks and benefits must be carefully weighed, with consideration of individual risk factors and medical history.
- The USPSTF recommends against the routine use of estrogen and progestin for the prevention of chronic conditions in postmenopausal women, citing the potential harms of hormone therapy, including increased risk for breast cancer, venous thromboembolism, and coronary heart disease 1.
Treatment Options
- A typical regimen for hormone therapy includes estradiol (17-beta estradiol) at 0.5-1mg daily orally, or 0.025-0.05mg/day via patch, combined with progesterone 100-200mg daily for those with an intact uterus to protect against endometrial hyperplasia.
- Cyclical regimens (estrogen daily with progesterone 12-14 days per month) or continuous combined therapy (both hormones daily) are common approaches.
- Treatment should be individualized based on symptom severity, with the lowest effective dose used for the shortest duration necessary, and regular follow-ups every 6-12 months to reassess therapy 1.
Important Considerations
- The USPSTF concludes that the chronic disease prevention benefits of combined estrogen and progestin do not outweigh the harms in most postmenopausal women, and that the benefits of estrogen alone are unlikely to outweigh the harms in most postmenopausal women who have had a hysterectomy 1.
- Women should be informed of the potential risks and benefits of hormone therapy, including the increased risk for breast cancer, venous thromboembolism, and coronary heart disease, as well as the potential benefits for symptom relief and prevention of osteoporosis 1.
From the Research
Role of Estrogen and Progesterone during Perimenopause
- Estrogen and progesterone play a crucial role in regulating the menstrual cycle and reproductive health during perimenopause 2.
- The decline in circulating estrogen levels around the time of menopause can induce unacceptable symptoms that affect the health and well-being of women 3, 4, 5.
- Hormone therapy, including estrogen and progesterone combinations, is an effective treatment for these symptoms, but it is associated with risks such as endometrial hyperplasia and carcinoma 3, 4, 5.
- The addition of progestogen to estrogen therapy reduces the risk of endometrial hyperplasia, but may cause unacceptable symptoms, bleeding, and spotting 3, 4, 5.
Effects of Estrogen and Progesterone on Perimenopausal Symptoms
- Unopposed estrogen therapy is associated with an increased risk of endometrial hyperplasia, irregular bleeding, and non-adherence to therapy 3, 4, 5.
- The combination of estrogen and progestogen therapy helps to reduce the risk of endometrial hyperplasia and improves adherence to therapy 3, 4, 5.
- Continuous combined estrogen-progestogen therapy is more effective than sequential therapy in reducing the risk of endometrial hyperplasia at longer durations of treatment 3, 4, 5.
- Progestin-free hormone therapy options, such as conjugated estrogens combined with bazedoxifene, are available for postmenopausal women with a uterus who are not suitable for progestin-containing therapy 6.
Clinical Approaches to Perimenopausal Symptoms
- Clinical approaches to perimenopausal symptoms often involve hormone therapy, which can be safely given to most perimenopausal women on a short-term basis 2.
- Non-hormonal and behavioral therapeutic strategies can also be deployed to manage perimenopausal symptoms 2.
- Menopausal symptoms, such as hot flashes, poor sleep, depressed mood, and vaginal dryness, can be managed with a combination of hormone therapy and non-hormonal treatments 2.