Practical issues in hormone therapy management

There are primarily 2 different regimens for HT, with several variations. Regardless of regimen, estrogen should always be dosed in a continuous (daily) manner. There is no physiological need to cycle estrogen therapy for 21 days with 7 days off, which could result in the return of menopausal symptoms in the pillfree period. Continuous-cyclic HT regimens provide estrogen daily and a progestin for at least 12 to 14 days each month, which often results in a regular monthly menstrual-like withdrawal period. The bleeding is predictable, usually after the 10th day of progestin therapy. If bleeding occurs prior to the 10th day of progestin therapy, a woman should be advised to consult her physician to undergo endometrial surveillance.4 Some women may not bleed, depending on the dose of estrogen or the type of progestin administered. Long-cycle regimens in which progestin is given less often than monthly (e.g., once every 3 months) are not routinely recommended, as endometrial safety has not been established. If long-cycle regimens are used, patients should have regular endometrial surveillance and any intra-cycle spotting or bleeding should be reported to a physician. The lowest possible dose of estrogen (e.g., 0.3 mg CEE or 0.5 mg 17β-estradiol) to alleviate menopausal symptoms should be used, but there is no conclusive data that lower doses have better safety profiles than standard doses. Oral estrogens may be administered every other day and estrogen-only transdermal matrix patches may be cut as long as they remain effective. Progestins are dosed differently, depending on the regimen with cyclic regimes requiring larger doses than continuous doses. The amount of progestin also depends on the amount of estrogen. Larger estrogen doses (standard dose is 0.625 mg CEE or equivalent) may stimulate the endometrial lining to a greater extent and therefore require higher doses of progestin for protection. Progestin doses are usually doubled if larger than standard doses of estrogen are used. Initial HT therapy should be selected using an individual woman's risk benefit profile and her personal preferences. Oral or transdermal therapy may be used to treat systemic symptoms, whereas vaginal therapy may be considered if urogenital symptoms are the primary concern. Choosing the estrogen dose may appear challenging. Most individuals want to start with the lowest dose possible and then increase the medication slowly. The opposite approach may be more successful. Start with