Systemic estrogen therapy
| Type | Route | Common products | Starting dose | Key considerations |
|---|
Estrogen only
(Hysterectomy patients) |
Transdermal patch |
Estradot, Climara, Evorel |
25-50 mcg/day |
Preferred route. No first-pass hepatic effect. Lower VTE risk vs oral. Change 1-2x/week. |
| Transdermal gel |
Oestrogel, Sandrena |
0.5-1.0 mg/day |
Flexible dosing. Apply to skin daily. Allow to dry before dressing. |
| Oral |
Estrofem, Progynova |
0.5-1.0 mg/day |
Higher VTE risk than transdermal. Consider transdermal for BMI >30, migraine, hypertension. |
| Type | Route | Common products | Starting dose | Key considerations |
|---|
Combined E+P
(Intact uterus) |
Patch + oral P |
Estradiol patch + micronized progesterone (Utrogestan) |
Patch 25-50 mcg + P 100-200 mg |
Micronized progesterone preferred. Better side-effect profile. Cyclical (12-14 days/month) or continuous. |
| Combined patch |
FemSeven Combi, Evorel Conti |
Per product |
Convenient single patch. Available as sequential or continuous. |
| Oral combined |
Femoston, Kliogest |
1/10 or 2/10 (sequential) |
Sequential for peri (still cycling). Continuous combined for 12+ months post last period. |
| IUD + Estrogen |
LNG-IUS + patch/gel |
Mirena + estradiol |
Standard |
Mirena provides endometrial protection + contraception. Licensed for HRT progestogen component. |
Local and adjunct therapies
| Type | Route | Common products | Starting dose | Key considerations |
|---|
| Vaginal estrogen |
Vaginal |
Vagifem, Ovestin cream, Estring |
10 mcg tab or 0.5 mg cream |
Safe for most women including breast cancer survivors (discuss with oncologist). Minimal systemic absorption. Can use alongside systemic HRT. |
| Testosterone |
Transdermal |
Androfeme 1%, compounded cream |
5 mg/day (1/10 of male dose) |
For hypoactive sexual desire. Off-label in most countries. Monitor levels at 3-6 months. Watch for androgenic side effects. |
| DHEA |
Vaginal |
Intrarosa (prasterone) |
6.5 mg/day |
For vulvovaginal atrophy. Converts locally to estrogen and testosterone. |
Absolute contraindications
- Undiagnosed vaginal bleeding
- Current or recent breast cancer
- Active VTE or PE
- Active liver disease
- Known thrombophilia (for oral route)
- Pregnancy
Use with caution / specialist referral
- History of breast cancer (individualize)
- History of VTE (transdermal preferred)
- CVD or stroke history
- Migraine with aura (transdermal preferred)
- Active gallbladder disease (transdermal preferred)
- Endometriosis
- Fibroids
Monitoring schedule
| Timepoint | Actions | Notes |
|---|
| Baseline |
BP, BMI, breast exam, cervical screening status, VTE/CVD risk assessment |
Mammography per national screening schedule. Lipid profile and glucose if risk factors present. |
| 3 months |
Review symptom response, side effects, bleeding pattern. BP check. |
Dose adjustment if needed. Most side effects settle by 3 months. If testosterone started, check levels. |
| 6-12 months |
Full review. Symptom check, BP, weight. Assess ongoing need. |
Transition from sequential to continuous combined if appropriate (12+ months post last period). |
| Annually |
Comprehensive review. BP, breast awareness, bleeding assessment. Discuss benefits vs risks. |
No arbitrary time limit on HRT (NICE NG23). Annual review of benefits and risks. Mammography per schedule. |
References: NICE NG23: Menopause: diagnosis and management (updated 2024). NAMS 2022 Position Statement on Hormone Therapy. BMS Consensus Statement on HRT (2024). IMS Recommendations on Menopausal Hormone Therapy (2023).
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