What is the starting regimen for hormone replacement therapy (HRT) for menopause symptoms?

Starting Regimen for Hormone Replacement Therapy for Menopausal Symptoms

For women with menopausal symptoms, the recommended starting regimen for hormone replacement therapy (HRT) is transdermal 17-β estradiol at 0.025-0.0375 mg/day patch, with the addition of micronized progesterone 200 mg orally for 12-14 days per month for women with an intact uterus. 1

Estrogen Component Options

• Transdermal estradiol (preferred): 0.025-0.0375 mg/day patch 1

  • Advantages: Lower risk of venous thromboembolism compared to oral formulations
  • Especially recommended for women with hypertension

• Oral estradiol: 1-2 mg daily 2

  • The usual initial dosage range is 1 to 2 mg daily adjusted as necessary to control symptoms

Progestogen Component (for women with intact uterus)

• Micronized progesterone (preferred): 200 mg orally for 12-14 days per month 1

  • Associated with lower breast cancer risk than synthetic progestins

• Medroxyprogesterone acetate: 2.5 mg daily 1

  • Alternative option if micronized progesterone is not tolerated

Administration Patterns

• Cyclic regimen: Estrogen for 3 weeks followed by 1 week off 2

  • May be preferred initially to minimize side effects

• Continuous regimen: Daily administration of both hormones

  • May be considered after initial therapy is well-tolerated

Dosing Principles

1. Start with lowest effective dose for symptom control 3, 2
2. Use for shortest duration consistent with treatment goals 3
3. Titrate dose based on symptom control and side effects 1
4. Reevaluate at 3-6 month intervals to determine if treatment is still necessary 2

Contraindications

HRT is contraindicated in women with:

• Active liver disease
• History of breast cancer
• History of coronary heart disease
• Previous venous thromboembolism or stroke
• Positive antiphospholipid antibodies 1

Risk-Benefit Considerations

• Benefits: Relief of vasomotor symptoms, prevention of osteoporosis and fractures 1
• Risks: Increased risk of stroke, venous thromboembolism, gallbladder disease 3
  • Combined estrogen/progestin therapy increases risk of breast cancer with long-term use
  • Estrogen-only therapy (for women without a uterus) is associated with small reduction in breast cancer risk 1

Follow-up and Monitoring

• Initial follow-up at 3-6 months 1, 2
• Annual assessments including blood pressure, weight, lipid profile, and cancer screening 1
• Attempt to discontinue or taper medication at 3-6 month intervals 2

Non-Hormonal Alternatives

For women with contraindications to HRT or who prefer non-hormonal options:

• Low-dose paroxetine, venlafaxine, or gabapentin for vasomotor symptoms 1, 4
• Vaginal moisturizers for genitourinary symptoms 4

Important Caveats

• Women with intact uterus must receive progestogen to prevent endometrial cancer 2, 5
• Transdermal estradiol may have better cardiovascular safety profile than oral estrogen 6
• The combination of transdermal estradiol with micronized progesterone appears to have the most favorable risk profile 6

Remember that HRT decisions should be based on the severity of menopausal symptoms and the woman's cardiovascular risk profile, with the goal of using the lowest effective dose for the shortest duration necessary to control symptoms 3.