II. Indications
-
Estrogen only Preparations
- Status post Hysterectomy
- Combination Estrogen Replacement in Late post-Menopause with intact Uterus
- Continuous is preferred over Sequential Estrogen Replacement in intact Uterus
- Continuous Replacement is associated with a lower risk of Endometrial Hyperplasia
- Jaakkola (2009) Obstet Gynecol 114(6): 1197-1204 [PubMed]
III. Medications: Estrogen with Progesterone Combination
- Estrogen must be taken with Progesterone if Uterus is intact (Endometrial Hyperplasia risk)
- Two pill regimen
- Combination Pill - Standard Estrogen and Progesterone
- Activella (Estradiol + Norethindrone) 0.5 mg/0.1 mg or 1.0 mg/0.5 mg daily
- Prefest (Estradiol + Norethindrone) 1 mg/0.09 mg
- Taken in 4 day cycles (Estradiol alone for 1 day, Estradiol/Norethindrone for 3 days)
- Angeliq (Estradiol + Drospirenone) 0.5 mg/0.25 mg or 1.0 mg/0.5 mg daily
- Fyavolv or FemHRT (Ethinyl Estradiol + Norethindrone) 2.5 mcg/0.5 mg daily (lower cost in 2023)
- Jinetli (Ethinyl Estradiol + Norethindrone) 5 mcg/1 mg daily (lower cost in 2023)
- Prempro (Conjugated Estrogen + Medroxyprogesterone) 0.625 mg/2.5 mg (or 0.3/1.5, 0.45/1.5, 0.625/5.0) daily
- Combination Pills - Bioidentical Estrogen and Progesterone
- Bioidenticals have 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)
- Combination Pill - Estrogen and Selective Estrogen Receptor Modulator (SERM)
- Duavee (Conjugated equine Estrogen + Bazedoxifene) 0.45/20 mg daily
- Combination Transdermal 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. Medications: Estrogen-Only Hormone Replacement Therapy
- Estrogen must be taken with Progesterone if Uterus is intact (Endometrial Hyperplasia risk)
- Some protocols stop Estrogen for the last 5 to 7 days of the months
- Oral
- Estradiol (Estrace, bioidentical)
- Take 0.5 mg orally daily (up to 1.0 or 2.0 mg)
- Conjugated Estrogen (Premarin, Enjuvia)
- Take 0.625 mg orally daily (or 0.3, 0.45, 0.9, 1.25 mg)
- Estropipate (Ogen)
- Take 0.625 mg orally daily
- Esterified Estrogen (Estratab, Menest)
- Take 0.625 mg orally daily (or 0.3, 1.25, 2.5 mg)
- Estradiol (Estrace, bioidentical)
-
Transdermal Estrogen
-
Estradiol transdermal patch (Bioidentical; Estraderm, Alora, Climara, Minivelle)
- Apply 0.05 mg patch/week (or 0.025, 0.075 or 0.1)
-
Estradiol transdermal gel (Divigel, Elestrin, Estrogel)
- Apply 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
-
Estradiol transdermal patch (Bioidentical; Estraderm, Alora, Climara, Minivelle)
V. Preparations: Progestin Options (choose one to accompany an Estrogen if intact Uterus)
- Provera 2.5 mg daily
- Norethindrone 0.35 mg daily
- Micronized Progesterone (Prometrium) 0.1 mg daily
VI. Advantages: Compared with Sequential Estrogen Replacement
- Decreased uterine bleeding
VII. 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 daily 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
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Related Studies
| fyavolv (on 12/21/2022 at Medicaid.Gov Survey of pharmacy drug pricing) | ||
| FYAVOLV 0.5 MG-2.5 MCG TABLET | Generic | $1.06 each |
| FYAVOLV 1 MG-5 MCG TABLET | Generic | $0.75 each |
| bijuva (on 1/1/2023 at Medicaid.Gov Survey of pharmacy drug pricing) | ||
| BIJUVA 1 MG-100 MG CAPSULE | $7.71 each | |