What are the brand names of continuous combination hormone replacement therapy (HRT) options for a perimenopausal woman seeking relief from symptoms such as hot flashes, night sweats, and vaginal dryness?

Brand Names of Continuous Combination Hormone Replacement Therapy for Perimenopause

For perimenopausal women with an intact uterus experiencing vasomotor symptoms, continuous combination HRT requires estrogen plus progestin, with common brand names including Prempro (conjugated equine estrogens/medroxyprogesterone acetate), Activella (estradiol/norethindrone), Climara Pro (transdermal estradiol/levonorgestrel patch), and Femhrt (ethinyl estradiol/norethindrone). 1, 2

Understanding Continuous Combination HRT

Continuous combination therapy means taking both estrogen and progestin every day without breaks, which typically results in amenorrhea (no bleeding) after the first few months. 3 This differs from cyclic regimens where progestin is taken only part of the month. 1

Why Combination Therapy is Mandatory

Women with an intact uterus must receive combined estrogen-progestin therapy—never estrogen alone—because unopposed estrogen increases endometrial cancer risk 10- to 30-fold after 5+ years of use. 1 Adding progestin reduces this endometrial cancer risk by approximately 90%. 1

Specific Brand Name Options

Oral Continuous Combination Products

• Prempro: Contains conjugated equine estrogens (CEE) 0.625 mg plus medroxyprogesterone acetate (MPA) 2.5 mg daily, the most extensively studied regimen from the Women's Health Initiative trials. 1

• Activella: Contains 17β-estradiol 1 mg plus norethindrone acetate 0.5 mg daily, using bioidentical estradiol rather than conjugated estrogens. 2

• Femhrt: Contains ethinyl estradiol plus norethindrone acetate in various dose combinations. 2

Transdermal Continuous Combination Products

Transdermal estradiol patches should be the first-line choice for HRT, as they bypass hepatic first-pass metabolism and demonstrate a more favorable cardiovascular and thrombotic risk profile compared to oral formulations. 1

• Climara Pro: Transdermal patch releasing estradiol 0.045 mg plus levonorgestrel 0.015 mg daily, changed weekly. 1

• CombiPatch: Transdermal patch with estradiol plus norethindrone acetate, changed twice weekly. 1

Alternative Approach: Separate Components

Many clinicians prefer prescribing estrogen and progestin as separate products for greater dosing flexibility:

• Estrogen component: Transdermal estradiol patches (Vivelle-Dot, Climara, Estraderm) releasing 50 μg daily, applied twice weekly. 1

• Progestin component: Micronized progesterone (Prometrium) 200 mg orally at bedtime is preferred over synthetic progestins due to superior breast safety profile while maintaining adequate endometrial protection. 1

Critical Timing Considerations for Perimenopause

HRT can be initiated during perimenopause when vasomotor symptoms begin—you do not need to wait until postmenopause. 1 The most favorable benefit-risk profile exists for women under 60 years of age or within 10 years of menopause onset. 1

For perimenopausal women still having irregular periods, continuous combination therapy may cause unpredictable bleeding initially, but amenorrhea rates approach 80-90% by one year. 3

Risk-Benefit Profile You Must Discuss

For every 10,000 women taking combined estrogen-progestin for 1 year, expect: 1

• Harms: 7 additional coronary events, 8 more strokes, 8 more pulmonary emboli, 8 more invasive breast cancers
• Benefits: 6 fewer colorectal cancers, 5 fewer hip fractures, 75% reduction in vasomotor symptom frequency

The breast cancer risk does not appear until after 4-5 years of combined therapy use, but cardiovascular and thrombotic risks emerge within the first 1-2 years. 1

Absolute Contraindications to All HRT

Never prescribe HRT if the patient has: 1

• History of breast cancer or other hormone-sensitive cancers
• Active or history of venous thromboembolism or pulmonary embolism
• History of stroke or coronary heart disease
• Active liver disease
• Antiphospholipid syndrome or positive antiphospholipid antibodies
• Unexplained vaginal bleeding

Common Pitfalls to Avoid

Do not prescribe estrogen-alone therapy to women with an intact uterus—this dramatically increases endometrial cancer risk. 1 Even if the patient is perimenopausal and still having periods, she still needs progestin protection if receiving systemic estrogen. 1

Do not initiate HRT solely for chronic disease prevention (osteoporosis, cardiovascular disease) in asymptomatic women—this carries a Grade D recommendation (recommends against) from the US Preventive Services Task Force. 1, 4

Avoid custom compounded "bioidentical" hormones, as there is no data supporting claims of greater safety or efficacy compared to FDA-approved products. 5, 4

Prescribing Algorithm

1. Confirm indication: Moderate to severe vasomotor symptoms (hot flashes, night sweats) disrupting quality of life. 1

2. Screen for contraindications: Particularly history of breast cancer, cardiovascular disease, stroke, or thromboembolism. 1

3. Choose formulation based on patient factors: 1

   • Prefer transdermal over oral for lower cardiovascular/thrombotic risk
   • Prefer micronized progesterone over synthetic progestins for lower breast cancer risk
   • Use lowest effective dose

4. Start with standard regimen: 1

   • Transdermal estradiol 50 μg patch twice weekly PLUS micronized progesterone 200 mg orally at bedtime
   • OR Climara Pro patch (estradiol/levonorgestrel) changed weekly
   • OR Prempro 0.625/2.5 mg daily if oral route preferred

5. Reassess at 3 months: Adjust dose based on symptom control, not laboratory values. 1

6. Annual review: Attempt dose reduction or discontinuation once symptoms controlled. 1