What are the available estrogen patches, such as Estraderm (estradiol), Climara (estradiol), and Vivelle-Dot (estradiol), and their normal dosages for hormone replacement therapy (HRT)?

Available Estrogen Patches and Normal Dosages

Transdermal estradiol patches are available in multiple formulations delivering 25-100 μg of 17β-estradiol per 24 hours, with standard dosing typically starting at 50 μg daily for hormone replacement therapy. 1

Common Estrogen Patch Formulations

Twice-Weekly Application Patches

• Estraderm (estradiol matrix patch): Delivers 50 μg estradiol per day, applied twice weekly 2
• Vivelle-Dot: Similar twice-weekly application system with doses ranging from 25-100 μg daily 3
• Available strengths typically include 25 μg, 37.5 μg, 50 μg, 75 μg, and 100 μg per 24 hours 3

Once-Weekly Application Patches

• Climara (7-day estradiol patch): Delivers 50-100 μg estradiol per day, changed weekly 4, 5
• The 7-day system maintains sustained blood levels for the full week of patch wear 5
• Buttock application provides 117.2% bioavailability compared to abdominal application 6

Standard Dosing Recommendations

Initial Dosing for Menopausal Symptoms

• Start with 50 μg daily patches for treatment of moderate to severe vasomotor symptoms and vulvovaginal atrophy 1
• Patches releasing 50-100 μg per 24 hours are the standard adult doses 1
• The FDA-approved oral equivalent starting dose is 1-2 mg daily estradiol, adjusted to control symptoms 3

Dose Titration

• Use the lowest effective dose that controls symptoms, determined by titration 3
• The 100 μg patch showed 74.6% reduction in hot flushes versus 64.5% for the 50 μg patch, supporting dose adjustment based on response 5
• Cyclic administration (3 weeks on, 1 week off) is recommended 3

Combined Estrogen-Progestin Patches

• Sequential combined patches: 50 μg estradiol daily for 2 weeks, followed by 50 μg estradiol + 10 μg levonorgestrel daily for 2 weeks 1
• Continuous combined patches: 50 μg estradiol + 7 μg levonorgestrel daily without interruption for women avoiding withdrawal bleeding 1

Required Progestin Supplementation

For Women with an Intact Uterus

• Progestin must be added when prescribing estrogen to reduce endometrial cancer risk 3
• Micronized progesterone 200 mg daily for 12-14 days every 28 days is the first-line choice due to lower cardiovascular and thrombotic risk 1, 7
• Alternative: Medroxyprogesterone acetate 10 mg daily for 12-14 days per month 1, 7
• Alternative: Dydrogesterone 10 mg daily for 12-14 days per month 1, 7

For Continuous Regimens

• Minimum doses: 1 mg oral norethisterone daily, 2.5 mg MPA daily, or 5 mg dydrogesterone daily 1, 7

Special Dosing Considerations

Duration and Monitoring

• Use the lowest effective dose for the shortest duration consistent with treatment goals 7, 3
• Reevaluate patients every 3-6 months to determine if treatment remains necessary 3
• Attempt to discontinue or taper medication at 3-6 month intervals 3

Application Site Optimization

• Buttock application is preferred over abdomen for more consistent absorption with once-weekly patches 6
• Skin irritation occurs in approximately 15% of users but rarely necessitates discontinuation 8
• The 7-day Climara patch demonstrates superior adhesion compared to twice-weekly systems 4, 5

Common Pitfalls to Avoid

• Never prescribe estrogen alone to women with an intact uterus without progestin coverage 3
• Avoid starting with high doses (>50 μg daily) as initial therapy, as evidence shows no additional benefit and increased harm 7
• Do not use progestins with anti-androgenic effects in women with low testosterone or sexual dysfunction 1