Recommended Starting Dose of HRT for Perimenopausal Women
For perimenopausal women, hormone replacement therapy should be initiated at the lowest effective dose, specifically transdermal estradiol at 0.025-0.0375 mg/day via patch or oral 17β-estradiol at 1 mg daily, with appropriate progestogen for those with an intact uterus. 1
Estrogen Component Options
Transdermal Administration (First Choice)
- Starting dose: 0.025-0.0375 mg/day patch 1
- Can be increased to 0.05-0.1 mg/day if needed for symptom control 2
- Changed twice weekly or weekly depending on specific product instructions
- Benefits: Lower risk of venous thromboembolism compared to oral formulations
Oral Administration (Alternative)
- Starting dose: 1 mg daily of 17β-estradiol 2, 1
- Can be increased to 2 mg daily if needed for symptom control
- 17β-estradiol is preferred over conjugated equine estrogen (CEE) 1
Progestogen Component (for women with intact uterus)
First Choice
- Micronized progesterone: 200 mg orally for 12-14 days per month in sequential regimens 2, 1
- Associated with lower risk of cardiovascular disease and venous thromboembolism 2
Alternative Options
- Medroxyprogesterone acetate: 2.5 mg/day (continuous) or 10 mg for 12-14 days/month (sequential) 2, 1
- Dydrogesterone: 5 mg daily (continuous) or 10 mg for 12-14 days/month (sequential) 2
- Norethisterone: minimum 1 mg daily (continuous) 2
Regimen Selection
Sequential Combined Regimen
- Estrogen administered continuously
- Progestogen administered cyclically (12-14 days every 28 days)
- Results in withdrawal bleeding
- May be preferred for early perimenopausal women still experiencing irregular cycles
Continuous Combined Regimen
- Both estrogen and progestogen administered daily
- Avoids withdrawal bleeding
- Better suited for late perimenopausal or postmenopausal women
Dose Adjustment Considerations
- Start with the lowest effective dose to minimize side effects 3, 4
- Low-dose therapy (25 mcg/day transdermal or 0.3 mg/day oral) effectively controls vasomotor symptoms in most women 3
- Evaluate treatment effect after 3-6 months 1
- Increase dose only if initial dose is insufficient for symptom control 4
- Adjust according to each woman's tolerance and sense of wellbeing 2
Important Considerations
- Low-dose initiation reduces hyperestrogenic side effects and improves long-term compliance 3, 4
- Avoid progestins with anti-androgenic effects in women with diminished libido 2
- HRT is not indicated for primary or secondary prevention of cardiovascular disease or dementia 5
- Absolute contraindications include history of hormone-related cancers, active liver disease, abnormal vaginal bleeding, previous venous thromboembolism or stroke, and coronary heart disease 1
Monitoring
- Initial follow-up at 3 months, then annually 1
- Monitor blood pressure, weight, lipid profile, symptom control, and bleeding patterns 1
- No routine monitoring tests required unless prompted by specific symptoms 1
Starting with the lowest effective dose and titrating as needed provides the optimal balance between symptom relief and minimizing adverse effects, leading to better long-term compliance with HRT in perimenopausal women.