Hormone Replacement Therapy for Menopausal Women
Hormone Replacement Therapy (HRT) should be used at the lowest effective dose for the shortest time needed to manage menopausal symptoms, with treatment primarily indicated for vasomotor symptoms and genitourinary syndrome of menopause. 1, 2
Indications and Approach
HRT is most appropriate for:
- Treatment of moderate to severe vasomotor symptoms (hot flashes, night sweats)
- Treatment of vulval and vaginal atrophy
- Prevention of osteoporosis (though rarely used solely for this purpose)
Key Principles
- Use lowest effective dose for shortest duration necessary
- Reevaluate every 3-6 months to determine if treatment is still necessary
- For women with a uterus, combined estrogen-progestin therapy is required to reduce endometrial cancer risk
- For women without a uterus, estrogen-alone therapy is appropriate 2
Benefits vs. Risks Assessment
Benefits
- Effective relief of vasomotor symptoms
- Improvement in vaginal atrophy
- Prevention of osteoporosis
- Improved quality of life during menopausal transition 3
Risks
- Increased risk of breast cancer with extended use
- Increased risk of venous thromboembolism
- Increased risk of stroke
- Increased risk of coronary heart disease (particularly in women starting HRT >10 years post-menopause)
- Increased risk of gallbladder disease
- Possible increased risk of dementia in women over 65 2
Recommended Regimens
For Vasomotor Symptoms
- Initial dosage: 1-2 mg daily of estradiol, adjusted as necessary
- Administration should be cyclic (e.g., 3 weeks on, 1 week off)
- For women with a uterus: Add progestin (e.g., medroxyprogesterone acetate 2.5 mg/day or micronized progesterone 200 mg orally for 12-14 days per month) 1, 2
For Vaginal Symptoms Only
- Low-dose local estrogen therapy is preferred over systemic therapy 3
Contraindications
HRT should not be used in women with:
- Breast or endometrial cancer
- Cardiovascular disease
- Thromboembolic disorders
- Active liver disease 3
Duration and Discontinuation
- Most women should be able to discontinue HRT within a few years of starting treatment
- Approximately 75% of women who try to stop are able to do so without major difficulty
- For women who have difficulty stopping, tapering the dose slowly may be helpful 4
Special Considerations
Timing of Initiation
- Benefits generally outweigh risks for healthy women who start HRT at the time of menopause
- Starting HRT close to menopause (under age 60 or within 10 years of menopause onset) provides better benefit-risk ratio 5, 6
Route of Administration
- Transdermal estrogen may be preferred for women with hypertriglyceridemia
- Transdermal administration may have lower risk of venous thromboembolism compared to oral formulations 7, 6
Monitoring
- Regular breast examinations and mammography
- Endometrial sampling for undiagnosed persistent or recurring abnormal vaginal bleeding
- Blood pressure monitoring
- Lipid profile assessment 2
HRT remains an effective option for managing menopausal symptoms when used appropriately, with careful consideration of individual risk factors and regular reassessment of the need for continued therapy.