Our role should be helping the patient arrive at her own conclusions based on the scientific data that we provide, as well as the symptoms she experiences.
Recommendations for initiating therapy
As has been stated, the only indications for EPT in menopausal women are vasomotor symptoms and associated quality-of-life issues. When the therapy is given for these reasons, women should be advised to take the lowest effective dose of the more physiologic preparations for as short a time as possible.
Again, the duration of therapy must be individualized and regularly assessed. This may require periodic interruption of the therapy to evaluate symptom recurrence and the patient’s tolerance of and response to safer alternatives.
Estrogen. I favor estradiol—either orally or transdermally—starting at daily doses of 0.5 mg or 0.035 mg, respectively. If symptoms are not adequately controlled and serum estradiol levels remain below 50 pcg/mL, I increase the daily dose to 0.75 mg or 0.075 mg, respectively. If necessary, I will increase it again to a maximum of 1 mg or 0.100 mg, respectively.
Asymptomatic women do not need—nor will they benefit from—ET/EPT.
Progestin. For the progestin component, I recommend 200 mg of oral micronized progesterone, to be taken at bedtime for 2 weeks of each or every other month to confer endometrial protection. If patients cannot tolerate micronized progesterone, I recommend norethindrone acetate in combination with estradiol, to be administered orally (Activella) or transdermally (CombiPatch).
Dr. Luciano reports that he receives research/grant support from Proctor & Gamble, Chitogenics, ML Labs, and TAP; is a consultant to Eli Lilly and Pharmacia; and serves on the speaker’s bureau of Eli Lilly and Pharmacia.