From the Guidelines
Hormone replacement therapy (HRT) for menopausal women typically involves estrogen alone for women who have had a hysterectomy, or a combination of estrogen and progestin for women with an intact uterus. The goal of HRT is to alleviate menopausal symptoms such as hot flashes, night sweats, and vaginal dryness, as well as to prevent bone loss. Common estrogen preparations include conjugated equine estrogens (Premarin), estradiol (Estrace, Vivelle, Climara), and estropipate (Ogen) 1. Progestins used include medroxyprogesterone acetate (Provera) and micronized progesterone (Prometrium). Some key points to consider when administering HRT include:
- Typical estrogen doses range from 0.3-1.25 mg for oral conjugated estrogens or 0.025-0.1 mg for transdermal patches
- Progestin doses are usually 2.5-10 mg daily for medroxyprogesterone or 100-200 mg for micronized progesterone
- HRT can be administered orally, transdermally (patches, gels), or vaginally (for local symptoms)
- Treatment should be individualized based on symptom severity, with the lowest effective dose used for the shortest duration necessary, as recommended by the U.S. Preventive Services Task Force 1. It's essential to weigh the benefits of HRT against the potential risks, including increased chances of blood clots, stroke, and breast cancer, particularly with long-term use, and to consider alternative approaches to prevention, such as weight-bearing exercise for treating women with low bone density 1.
From the FDA Drug Label
The WHI estrogen-alone substudy stratified by age showed in women 50 to 59 years of age, a non-significant trend toward reduced risk for CHD [hazard ratio (HR) 0.63 (95 percent CI, 0.36-1.09)] and overall mortality [HR 0.71 (95 percent CI, 0.46-1. 11)]. The WHI estrogen plus progestin substudy was stopped early. According to the predefined stopping rule, after an average follow-up of 5.6 years of treatment, the increased risk of invasive breast cancer and cardiovascular events exceeded the specified benefits included in the "global index."
The type of Hormone Replacement Therapy (HRT) administered to women experiencing menopause is estrogen-alone or estrogen plus progestin therapy, as seen in the Women's Health Initiative (WHI) studies 2, 2, and 3.
- Estrogen-alone therapy is used for women who have had a hysterectomy.
- Estrogen plus progestin therapy is used for women with an intact uterus to prevent endometrial hyperplasia. Key points to consider when prescribing HRT include the timing of initiation relative to menopause, age of the patient, and individual risk factors.
From the Research
Types of Hormone Replacement Therapy (HRT)
The type of HRT administered to women experiencing menopause includes:
- Transdermal estradiol, which is considered to be a safer option compared to oral HRT, as it does not increase the risk of venous thromboembolism (VTE) and stroke 4, 5
- Micronized progesterone, which is a natural, 'body-identical' progesterone that has been shown to have a neutral effect on the vasculature and does not increase the risk of VTE 4, 5
- Continuous combined estrogen + progestogen, which provides full protection against endometrial hyperplasia and cancer 4
Administration Routes
The administration routes for HRT include:
- Transdermal route, which is considered to be a safer option compared to oral HRT, as it does not increase the risk of VTE and stroke 4, 5
- Oral route, which is associated with an increased risk of VTE, gallbladder disease, and possibly stroke 4
Considerations for HRT Use
Considerations for HRT use include:
- Age at initiation of HRT, with benefits typically outweighing risks when initiated within 10 years of menopause 6, 7
- Presence of chronic medical conditions, such as obesity, hypertension, dyslipidemia, diabetes, venous thromboembolism, and autoimmune diseases, which may alter the risk-benefit balance of HRT use 8
- Type of progestogen used, with micronized progesterone being considered a safer option compared to synthetic progestogens 4, 5