What are examples of hormone replacement therapy (HRT) medications in Canada, including taper plans and follow-up visit discussions?

Hormone Replacement Therapy (HRT) Medications in Canada

The optimal approach to hormone replacement therapy in Canada involves using transdermal estradiol patches (0.025-0.0375 mg/day) combined with oral micronized progesterone (200 mg daily for 12-14 days per month) for women with an intact uterus, with the lowest effective dose for the shortest duration necessary to control symptoms. 1

Available HRT Medications in Canada

Estrogen Formulations

• Oral estrogens:
  • Conjugated equine estrogens (0.625 mg/day)
  • Estradiol tablets (1-2 mg daily)
• Transdermal formulations:
  • Estradiol patches (0.025-0.0375 mg/day, applied twice weekly)
  • Estradiol gels and sprays

Progestogens (for women with intact uterus)

• Micronized progesterone: 200 mg orally for 12-14 days per month
• Medroxyprogesterone acetate: 2.5 mg/day
• Combined estrogen-progestogen preparations

Other HRT Options

• Vaginal estrogens (for genitourinary symptoms only):
  • Estradiol vaginal tablets
  • Conjugated estrogen creams
  • Estradiol rings

Recommended HRT Regimens

For Women with Intact Uterus

• Combined HRT: Estrogen plus progestogen
  • Cyclic regimen: Estrogen daily with progestogen for 12-14 days per month
  • Continuous regimen: Both hormones taken daily

For Women Without a Uterus

• Estrogen-only therapy: No progestogen required 2

Tapering Plan for HRT Discontinuation

1. Initial Assessment: Evaluate symptom control and duration of therapy
2. Gradual Reduction:
   • Reduce dose by 25-50% every 4-8 weeks
   • Monitor for return of vasomotor symptoms
3. Alternative Approach:
   • Increase interval between doses (e.g., patch every 3-4 days instead of twice weekly)
   • Eventually discontinue completely
4. For Long-term Users:
   • More gradual tapering over 3-6 months
   • Consider temporary symptom management with non-hormonal options if needed

Follow-up Visit Discussions

Initial Follow-up (3 months)

• Assess symptom control and side effects
• Evaluate blood pressure and weight
• Discuss any vaginal bleeding patterns (if uterus intact)
• Adjust dosage if needed based on symptom control 1

Annual Follow-up

• Monitor:
  • Blood pressure
  • Weight
  • Lipid profile
  • Emerging symptoms
  • Bleeding patterns (if uterus intact)
• Discuss:
  • Benefits vs. risks of continued therapy
  • Consideration of lowest effective dose
  • Duration of therapy and potential discontinuation 1

Special Considerations

• Breast health: Annual mammography
• Bone health: Consider bone density testing
• Cardiovascular risk: Evaluate risk factors annually
• Thrombotic risk: Assess for symptoms of venous thromboembolism

Important Counseling Points

• HRT should be used at the lowest effective dose for the shortest duration necessary 1, 2
• Transdermal estradiol has lower thrombotic risk than oral formulations 1
• Oral micronized progesterone has a better cardiovascular safety profile than synthetic progestins 1
• HRT is not recommended solely for chronic disease prevention 3
• Regular follow-up is essential to monitor benefits and risks

Potential Risks and Contraindications

Absolute Contraindications

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

High-Risk Factors

• Smoking history
• Multiple stroke risk factors
• Strong family history of breast cancer
• History of endometrial cancer 1

By following these guidelines for HRT medication selection, tapering, and follow-up discussions, healthcare providers can optimize the benefit-risk ratio for postmenopausal women requiring hormone replacement therapy in Canada.