Yes or no on estrogen replacement therapy? A formulation for clinicians

Certain decisions must be made regarding therapy in the female climacteric: In the early menopause, in obese women over the age of 50 who have amenorrhea but display significant cervical mucus or vaginal cornification, progestin alone should be administered. If progestin induced withdrawal bleeding does not occur, then the decline of endogenous estrogen can be determined by simple observation of symptomatology, vaginal cornification, and cervical mucus. In nonobese individuals in the early menopause with little or no biologic evidence of estrogen, estrogen therapy can be utilized: conjugated equine urinary estrogens 0.3-0.6 mg per day for 3 weeks, or ethinyl estradiol 0.01-0.02 mg per day for 3 weeks with a 1 week rest period. Because of the increased concern over endometrial hyperplasia as a result of this therapy, it is advisable to add a progestin daily during the last week of estrogen administration as an antimitogenic agent and to determine if withdrawal bleeding occurs. If endometrial bleeding should occur under these circumstances, then office aspiration or equivalent biopsy must be performed and the estrogen dose returned immediately. In the late menopause, when atrophy is clearly evident, then 0.625 mg estrogen, but not more than 1.25 mg, can be administered cyclically. Again inclusion of progestin is advised. I cannot conceive of a circumstance in which it would be necessary to administer these estrogens parenterally; however, when there are medical complications or restrictions, intermittent vaginal placement of estrogen may be useful. The usefulness of androgen is often considered. In some patients the addition of methyltestosterone 5-10 mg provides a sense of well being that some physicians have found effective in patient management. There must be full physician patient dialogue to achieve understanding of the therapeutic limits of estrogen replacement therapy and its advantages and disadvantages.