What is the recommended approach to initiate hormone therapy in women?

Hormone Therapy Initiation in Women

For women experiencing menopausal symptoms, hormone therapy should be initiated with the lowest effective dose for the shortest duration necessary, with treatment decisions based on menopausal status, symptom severity, and individual risk factors. 1, 2

Assessment Before Initiating Hormone Therapy

• Determine menopausal status, as this is critical for selecting appropriate hormone therapy regimen 3
• Evaluate for contraindications including:
  • History of breast cancer or other hormone-sensitive cancers 4
  • Active liver disease 4
  • History of venous thromboembolism or stroke 4
  • Antiphospholipid syndrome 4
  • Undiagnosed abnormal vaginal bleeding 4
• Consider cardiovascular risk factors, as hormone therapy increases risk in older women and those many years beyond menopause 5

Hormone Therapy for Premenopausal Women

For Women with Premature Ovarian Insufficiency (POI)

• For post-pubertal women with POI, a customized approach based on individual needs and preferences is recommended 3
• If no contraception is required, transdermal 17β-estradiol is the first-line treatment 3
• Treatment options should consider:
  • Route of administration preferences
  • Need for contraception
  • Desire for withdrawal bleeding 3
• For those requiring contraception, combined oral contraceptives are first choice, with transdermal 17β-estradiol as second choice 3

Hormone Therapy for Postmenopausal Women

For Vasomotor Symptoms

• Start with the lowest effective dose that controls symptoms 1
• For women with an intact uterus, always combine estrogen with a progestin to reduce endometrial cancer risk 4, 1
• For women without a uterus, estrogen-only therapy is appropriate 1
• Typical initial dosage range is 1-2 mg daily of estradiol, adjusted as necessary to control symptoms 1
• Administration should be cyclic (e.g., 3 weeks on and 1 week off) 1
• For progestin component, micronized progesterone (100-200 mg daily for 12-14 days every 28 days) is preferred due to its physiological and safe profile 3

Alternative Options for Vasomotor Symptoms

• If hormone therapy is contraindicated, consider:
  • Low-dose paroxetine (7.5 mg daily) for vasomotor symptoms 6
  • Venlafaxine, gabapentin, or clonidine as alternatives 3, 6
  • Cognitive behavioral therapy may provide additional benefit 3, 6
• Important caution: Paroxetine and fluoxetine should not be offered to women taking tamoxifen as they inhibit conversion to active metabolites 3, 6

Route of Administration Considerations

• Transdermal estrogen (patches or gel) may be preferred for:
  • Women with cardiovascular risk factors 7
  • Those at higher risk of venous thromboembolism 7
• Oral estrogen may have additional benefits for:
  • Relief of vasomotor symptoms
  • Prevention of osteoporosis 8
• Vaginal estrogen is preferred when only vaginal symptoms are present 5

Monitoring and Follow-up

• Reevaluate patients periodically (every 3-6 months) to determine if treatment is still necessary 1
• For women with a uterus, perform adequate diagnostic measures such as endometrial sampling when indicated for abnormal vaginal bleeding 1
• Attempt to discontinue or taper medication at 3-6 month intervals 1
• The minimal effective dose for maintenance therapy should be determined by titration 1

Common Pitfalls to Avoid

• Initiating hormone therapy solely for prevention of chronic conditions rather than symptom management 4
• Using estrogen therapy without progestin in women with an intact uterus 4
• Continuing hormone therapy without periodic reassessment of risks and benefits 2
• Starting hormone therapy in women more than 10 years past menopause or over age 60, as cardiovascular risks increase 5

Remember that the benefits of hormone therapy generally outweigh risks for healthy women with bothersome symptoms who start therapy around the time of menopause 5, but therapy should be individualized based on symptom severity and risk factors.