Sample Prescription for Transdermal Estrogen and Micronized Progesterone for Cyclical Hormone Therapy
For optimal management of menopausal symptoms, prescribe transdermal estradiol patches (Climara or Estraderm) 0.05 mg/day applied twice weekly, combined with oral micronized progesterone (Prometrium) 200 mg daily for 12-14 days per month. 1
Transdermal Estrogen Component
- Medication: Estradiol transdermal patch (Climara or Estraderm)
- Strength: 0.05 mg/24 hours
- Directions: Apply one patch to clean, dry, hairless area of lower abdomen or buttocks twice weekly (every 3-4 days). Rotate application sites.
- Quantity: Dispense 8-9 patches (1-month supply)
- Refills: 3
Micronized Progesterone Component
- Medication: Micronized progesterone (Prometrium) 200 mg capsules
- Directions: Take one capsule (200 mg) by mouth at bedtime daily for days 15-28 of each 28-day cycle
- Quantity: Dispense 14 capsules (1-month supply)
- Refills: 3
Rationale for This Regimen
Transdermal estradiol is preferred over oral formulations because:
- It bypasses first-pass hepatic metabolism 2
- Has a more favorable cardiovascular risk profile 1
- Provides stable serum estrogen levels 3
- Reduces the risk of venous thromboembolism compared to oral estrogen 1
Micronized progesterone is the recommended progestogen because:
- It provides effective endometrial protection (prevents hyperplasia) 4
- Has a lower risk of cardiovascular disease and venous thromboembolism compared to synthetic progestins 5
- Shows better breast safety profile than synthetic progestins 1
Cyclical vs. Continuous Regimen
The cyclical regimen (estrogen continuously with progesterone for 12-14 days per month) is appropriate for:
- Women in early menopause transition
- Patients who prefer having predictable withdrawal bleeding
- Those who experience side effects with continuous progesterone 6
Monitoring Recommendations
- Initial follow-up at 3 months to assess symptom control and side effects
- Adjust dosage based on symptom control (may increase to 0.075 mg/day patch if needed)
- Annual follow-up thereafter to monitor:
- Blood pressure
- Weight
- Lipid profile
- Symptom control
- Bleeding patterns
Important Considerations
- If breakthrough bleeding occurs or symptoms persist, consider increasing estradiol dose to 0.075 mg/day 5
- If progesterone side effects (drowsiness, dizziness) occur, advise taking at bedtime 4
- For women with intact uterus, progesterone is mandatory to prevent endometrial hyperplasia 4
- If migraine worsens during therapy, consider changing dose or regimen 5
Alternative Options
If the patient cannot tolerate or has contraindications to this regimen:
- Lower dose options: Estradiol patch 0.025 mg/day with micronized progesterone 100 mg for 12-14 days
- Combined patch options: Estradiol/levonorgestrel transdermal system (Climara Pro) releasing 0.045 mg estradiol and 0.015 mg levonorgestrel daily 7
This prescription provides optimal symptom relief while minimizing risks, with the goal of improving quality of life and reducing long-term health consequences of estrogen deficiency.