Canterbury DHB
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Treatment is started with low dose estrogen and a progestogen. Low starting doses are recommended to minimise side effects, although higher than average doses may ultimately be required to fully settle symptoms of estrogen deficiency.
Start with oral estradiol 1 mg, or transdermal estradiol 25 mcg daily or Premarin® 0.3 mg. Transdermal estrogen is the preferred method of hormone delivery in young women. This minimises the impact on SHBG (sex hormone binding globulin). Oral estrogen increases SHBG and this reduces free androgen levels and leads to an impairment in libido and energy. The dose of estrogen can be increased at 2-3 weekly intervals until symptoms are controlled.
The progestogen is added for the first 10-14 days of each calendar month. This will produce regular periods in 75% of women. The timing of the bleed in relation to the course of progestogen is no longer important. The cyclical progestogen also allows early detection of pregnancy, which can occur, in 5-10% of women with premature ovarian failure. Side effects can be minimised by keeping the dose of progestogen as low as possible, e.g. norethisterone 1 mg, medroxyprogesterone acetate 5 mg, or micronised progesterone 200 mg daily. Micronised progesterone is unfunded but is the preferred progestogen due to its neutral effects on metabolic indices and breast cancer risk.
If a combination of estrogen and progestogen doses is achieved that fits a pre-packaged HRT formulation, a switch can be made to:
All these combination hormone preparations carry a part charge.
Trisequens will bring about regular withdrawal bleeds in most women. The other regimes will allow the woman to be bleed-free. Some no-bleed HRTs may cause initial breakthrough bleeding. However this usually settles within approximately 3 to 6 months.
Oral progestogen therapy is not required for patients who have had a hysterectomy or who have a Mirena IUS.
In young patients in particular consider evaluating bone density prior to starting HRT as a baseline.
It is recommended that patients receive HRT until at least age 45 years, if not until age 50 years. The Mayo Clinic database suggests higher risks of CAD, fracture, dementia, Parkinson’s disease and mental health disorders if inadequate estrogen replacement is given. Treatment beyond the normal age of menopause should be evaluated on an individual basis according to menopausal symptoms and risk factors for osteoporosis and cardiovascular disease.
Therapy should be tailed off gradually over a period of 2 to 3 months to prevent exacerbation of hot flushes and night sweats. Reduce to the lowest strength tablet for 3 to 4 weeks and then give this on alternate days for another 3 to 4 weeks and finally increase the duration between tablets to 4 to 5 days for a further 2 weeks prior to stopping. For patients using the transdermal therapy, gradually reduce the oestradiol to the lowest strength over 3 to 4 weeks. Then introduce treatment free days of 1 to 2 days per week for a couple of weeks, increasing this gradually until the patches are only worn 3 days out of every 7 to 10. Treatment can then be stopped. Advise the patient that hot flushes, night sweats and psychological problems may occur during the weaning off process and may require recommencement of therapy.
Non-hormonal options for managing menopausal symptoms include Remifemin, clonidine, SSRI or SNRI antidepressants, gabapentin, or stellate ganglion blockade. Recent evidence supports the use of hypnosis and acupuncture. CBT may be helpful for some women with vasomotor symptoms.
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Topic Code: 6589
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