Starting Doses for Estrogen and Progesterone in Postmenopausal Women
For postmenopausal women requiring hormone therapy, the recommended starting doses are oral conjugated equine estrogen 0.625 mg/day with medroxyprogesterone acetate 2.5 mg/day for women with an intact uterus, or estrogen alone for women who have had a hysterectomy. 1
Estrogen Dosing Options
Oral Estrogen
Transdermal Estrogen
- Transdermal estradiol patch: 0.025-0.0375 mg/day 2
- Preferred for women with hypertension, liver disease, or elevated thrombosis risk due to lower thromboembolism risk compared to oral formulations
Progesterone Dosing Options
For Women with Intact Uterus
Progesterone must always be added to estrogen therapy in women with an intact uterus to prevent endometrial hyperplasia and cancer.
Continuous Combined Regimen
- Medroxyprogesterone acetate: 2.5 mg/day (daily) 1, 2
- This dose has been shown to effectively prevent endometrial hyperplasia 3
Cyclic Regimen
- Medroxyprogesterone acetate: 5-10 mg/day for 12-14 days per 28-day cycle 2
- Micronized progesterone: 200 mg/day for 12-14 days per 28-day cycle 2, 4
Important Clinical Considerations
Risk Assessment
Before initiating hormone therapy, it's crucial to assess:
- Risk factors for cardiovascular disease, stroke, and venous thromboembolism
- Personal or family history of breast cancer
- Liver function
- History of endometrial cancer or hyperplasia
Contraindications
Hormone therapy is contraindicated in women with:
- Active liver disease
- History of breast cancer
- History of coronary heart disease
- Previous venous thromboembolism or stroke 2
Risk-Benefit Profile
The USPSTF found that hormone therapy is associated with:
- Benefits: Reduced risk of fractures
- Risks: Increased risk of stroke, dementia, gallbladder disease, urinary incontinence, breast cancer, and venous thromboembolism 1
Monitoring
- Regular follow-up at 3-6 month intervals initially
- Annual assessment including blood pressure, weight, lipid profile, and cancer screening 2
- Evaluate for symptoms of estrogen excess (breast tenderness, fluid retention, headaches, nausea, mood changes)
Special Considerations
Women with Hysterectomy
- Estrogen alone (without progesterone) is appropriate 1
- Oral conjugated equine estrogen: 0.625 mg/day
Premature Ovarian Insufficiency
- Higher doses may be required
- Continue therapy until at least the average age of natural menopause (51 years) 2
Vasomotor Symptoms
- If hormone therapy is primarily for vasomotor symptoms (hot flashes), use the lowest effective dose for the shortest duration possible
- Non-hormonal alternatives include low-dose paroxetine, venlafaxine, and gabapentin 2
Remember that these recommendations are for starting doses, and adjustments may be needed based on symptom control and side effects. The USPSTF does not recommend hormone therapy for the primary prevention of chronic conditions, but rather for symptom management in appropriate candidates 1.