II. Indications
- Combination Estrogen Replacement in Late post-Menopause with intact Uterus
- Preferred over Sequential Estrogen Replacement in intact Uterus (lower risk of Endometrial Hyperplasia)
- Jaakkola (2009) Obstet Gynecol 114(6): 1197-1204 [PubMed]
III. Preparations: Estrogen with Progesterone Combination
- Estrogen must be taken with Progesterone if Uterus is intact (Endometrial Hyperplasia risk)
- Two pill regimen
- Combination Pill - Standard
- Activella (Estradiol + Norethindrone) 0.5/0.1 or 1.0/0.5 daily
- Angeliq (Estradiol + Drospirenone) 0.5/0.25 or 1.0/0.5 daily
- Duavee (Conj. equine Estrogen + Bazedoxifene) 0.45/20 mg daily
- FemHRT (Ethinyl Estradiol + Norethindrone) 2.5 mcg/0.5 daily
- Prempro (Conjugated Estrogen + Medroxyprogesterone) 0.625/2.5 (or 0.3/1.5, 0.45/1.5, 0.625/5.0) daily
- Combination Pills - Bioidenticals (no proven benefit over standard combination hormonal therapy)
- Bijuva (Estradiol 1 mg + Progesterone 100 mg)
- Cost for combined pill in 2019 is $215 compared with separate pills at $40 total
- (2019) Presc Lett 26(6)
- Bijuva (Estradiol 1 mg + Progesterone 100 mg)
-
Patch
- Climara Pro (Estradiol + Levonorgestrel) 0.45/0.015 applied once weekly
- Combipatch (Estradiol + Norethindrone) 0.05/0.14 or 0.05/0.25 applied twice weekly
IV. Preparations: Estrogen with Selective Estrogen Receptor Modulator (SERM)
- Background
- First agent in this combination class released in 2014 as alternative to combination Estrogen with Progesterone
- Unclear role outside of cases of Estrogen Replacement with intact Uterus, in which Progesterone is contraindicated
- SERMs add potential for increased adverse effects with no added benefit when used in combination with Estrogen
- No additional bone protection in Osteoporosis
- Agents
- Duavee (Conjugated Estrogen 0.45 mg with bazedoxifene 20 mg)
- References
- (2014) Presc Lett 21(3)
V. Preparations: Estrogens Options
- Estrogen must be taken with Progesterone if Uterus is intact (Endometrial Hyperplasia risk)
- Conjugated Estrogen (Premarin, Enjuvia) 0.625 mg orally daily (or 0.3, 0.45, 0.9, 1.25 mg)
- Estropipate (Ogen) 0.625 mg orally daily
- Esterified Estrogen (Estratab, Menest) 0.625 mg orally daily (or 0.3, 1.25, 2.5 mg)
- Estradiol (Estrace) 0.5 mg orally daily (or 1.0 or 2.0 mg)
- Estradiol transdermal patch (Estraderm, Alora, Climara, Minivelle) 0.05 mg patch/wk (or 0.025, 0.075 or 0.1)
- Estradiol transdermal gel (Divigel, Elestrin, Estrogel) 0.25, 0.5, 0.75 or 1.0 daily (depending on manufacturer)
- Evamist transdermal spray (1.53 per spray) start with 1 spray daily and advance to max of 3 sprays daily based on response
VI. Preparations: Progestin Options (choose one to accompany an Estrogen if intact Uterus)
- Provera 2.5 mg daily
- Norethindrone 0.35 mg daily
- Micronized Progesterone 0.1 mg daily
VII. Advantages: Compared with Sequential Estrogen Replacement
- Decreased uterine bleeding
VIII. Adverse effects
- Decreased Libido: Consider Estratest instead of Premarin
- Estrogen 1.25
- Methyltestosterone 2.5
- Recurrent Vaginal Bleeding
- Rule-out Endometrial Cancer with Endometrial Biopsy
- Change Estrogen Replacement regimen
- Estradiol 1 mg qd and
- Norethindrone Acetate (NETA) 0.1 to 0.5 mg qd
- NETA 0.1 mg: No bleeding in 79% at 1 year
- NETA 0.25 mg: No bleeding in 84% at 1 year
- NETA 0.5 mg: No bleeding in 90% at 1 year
- References
