What is the initial dosing for bioidentical hormone replacement therapy (BHRT) in postmenopausal women?

From the Guidelines

Bioidentical hormone therapy in postmenopausal women should be initiated with low doses of estrogen, such as estradiol 0.5-1 mg orally daily, and progesterone if the woman has an intact uterus, with the goal of achieving symptom control while minimizing risks. When considering the use of bioidentical hormone therapy, it is essential to weigh the benefits and harms, as there is limited evidence on the safety and effectiveness of these products, particularly for the prevention of chronic diseases in postmenopausal women 1. The US Preventive Services Task Force recommends against the use of menopausal hormone therapy for the primary or secondary prevention of cardiovascular disease, and other organizations, such as the American Heart Association and the American Congress of Obstetricians and Gynecologists, also advise against its use for this purpose 1.

Key considerations for initiating bioidentical hormone therapy include:

• Starting with the lowest effective dose and individualizing treatment based on symptom relief and tolerability
• Using estrogen alone for women who have undergone a hysterectomy, or combining estrogen with progesterone for women with an intact uterus to prevent endometrial hyperplasia
• Monitoring patients regularly, including follow-up at 1-3 months to assess symptom improvement and side effects, with annual evaluations thereafter
• Being aware of the potential risks and benefits of bioidentical hormone therapy, as the evidence on its safety and effectiveness is limited, particularly compared to conventional hormone therapy regimens 1.

In terms of specific dosing, options may include:

• Estradiol 0.5-1 mg orally daily
• Estradiol 0.025-0.0375 mg/day transdermal patch (changed twice weekly)
• Estradiol gel 0.25-0.5 mg daily
• Micronized progesterone 100 mg daily for continuous regimens or 200 mg daily for 12-14 days per month in cyclic regimens, for women with an intact uterus.

From the FDA Drug Label

When estrogen is prescribed for a postmenopausal woman with a uterus, a progestin should also be initiated to reduce the risk of endometrial cancer. Patients should be started at the lowest dose for the indication The usual initial dosage range is 1 to 2 mg daily of estradiol adjusted as necessary to control presenting symptoms.

The initial dosing for bioidentical hormone therapy with estradiol for postmenopausal women is 1 to 2 mg daily, and should be adjusted as necessary to control presenting symptoms. The lowest effective dose should be used, and medication should be discontinued as promptly as possible. Administration should be cyclic (e.g., 3 weeks on and 1 week off) 2.

• The dose may need to be titrated to determine the minimal effective dose for maintenance therapy.
• Patients should be reevaluated periodically (e.g., 3-month to 6-month intervals) to determine if treatment is still necessary.

From the Research

Initial Dosing of Bioidentical Hormone Therapy

• The initial dosing of bioidentical hormone therapy for postmenopausal women is not explicitly stated in the provided studies, but it is mentioned that low doses should be used and increased gradually until effective control of symptoms is achieved 3.
• A study on compounded bioidentical transdermal hormone therapy used a daily dose of BiEst (80% Estriol/20% Estradiol) and/or Progesterone to meet established physiologic reference ranges for the luteal phase in premenopausal women 4.
• Another study found that bioidentical hormone replacement therapy relieved symptoms of menopause and was well tolerated, with the most commonly reported side effects being weight gain, breast tenderness, and bloating 5.

Factors Affecting Initial Dosing

• The decision to use bioidentical hormone replacement therapy is influenced by factors such as symptoms unalleviated by synthetic hormone replacement therapy, side effects from synthetic hormone replacement therapy, and personal preference 6.
• Women obtain information and support from various sources, including family and friends, publications, and specialists in menopausal health 6.

Safety and Efficacy

• Bioidentical hormones that are approved by the FDA may be preferred over standard hormone replacement therapy due to their physiologic benefits and safety profile 7.
• A study found that compounded bioidentical transdermal hormone therapy significantly relieved menopausal symptoms and favorably impacted cardiovascular biomarkers, inflammatory factors, and health outcomes 4.
• However, it is essential to note that the safety and efficacy of bioidentical hormone replacement therapy can vary depending on the specific formulation and dosage used, as well as individual patient factors 3, 4, 7, 6, 5.