Hormone Replacement Therapy for Menopausal Women

Estrogen Replacement Therapy

For women without a uterus, estrogen-alone therapy can be used 1
The American College of Obstetricians and Gynecologists recommends 17-β estradiol as the preferred estrogen for replacement therapy, due to its preference over ethinylestradiol or conjugated equine estrogens 2

Transdermal routes of administration are preferred as they have less impact on coagulation factors and may be safer for cardiovascular health 2, 1

Estrogen therapy increases bone density and reduces risk for fractures by approximately 30-50%, according to the American College of Physicians 3, 1
The North American Menopause Society suggests that HRT may have a role in primary prevention of cardiovascular disease when initiated early in women with POI (Premature Ovarian Insufficiency) 2

Women should be informed of potential risks including venous thromboembolism, stroke, and possibly breast cancer with long-term use, as stated by the American Academy of Family Physicians 4, 5
The American Heart Association notes that these risks appear to increase with longer-term HRT use, particularly beyond 5 years 4, 5
Once established on therapy, women should have a clinical review annually, paying particular attention to compliance, as recommended by the European Society of Human Reproduction and Embryology 2

The Endocrine Society states that androgen treatment for low testosterone is only supported by limited data, and long-term health effects are not well established 2
For women with hypogonadism, testosterone replacement may be considered, though this is not FDA-approved for women, according to the European Society of Endocrinology 6

Confirm menopausal status and low hormone levels (estradiol <15 pg/mL, testosterone 6 ng/dL), and assess for symptoms, as recommended by the American College of Obstetricians and Gynecologists 6, 1
Evaluate risk factors for osteoporosis, cardiovascular disease, as suggested by the National Osteoporosis Foundation and the American Heart Association 4, 7

Ensure adequate calcium (1500 mg/day) and vitamin D (400-800 IU/day) intake, and encourage weight-bearing exercise, as recommended by the National Institutes of Health 1
Smoking cessation is also recommended, as stated by the American Lung Association 2

Annual clinical review, as recommended by the European Society of Human Reproduction and Embryology 2
Assess symptom control and side effects, and consider bone density testing if osteoporosis is a concern, as suggested by the National Osteoporosis Foundation 1, 7

Avoid using HRT routinely for the specific purpose of preventing chronic disease without considering individual risk-benefit profile, as stated by the American Academy of Family Physicians and the US Preventive Services Task Force 4, 5
Remember that women with hypogonadism may benefit from continuing HRT until the average age of natural menopause, according to the European Society of Human Reproduction and Embryology 2