1. Data from the WHI and the HERS trials has determined that continuous estrogen-progestin therapy increases the risk of breast cancer, coronary heart disease, stroke, and venous thromboembolism over an average follow-up of 5.2 years. As a result, the primary indication for estrogen therapy is for control of menopausal symptoms, such as hot flashes.
2. Estrogen therapy remains the gold standard for relief of menopausal symptoms, and is a reasonable option for most postmenopausal women, with the exception of those with a history of breast cancer, CHD, a previous venous thromboembolic event or stroke, or those at high risk for these complications. Estrogen therapy should be used for shortest duration possible (eg, 6 months to 5 years).
3. Dose. A low-dose estrogen is recommended when possible (eg, 0.3 mg conjugated estrogens or 0.5 mg estradiol).
4. Adding a progestin. Endometrial hyperplasia and cancer can occur with unopposed estrogen therapy; therefore, a progestin should be added in women who have not had a hysterectomy. Medroxyprogesterone (Provera), 1.5 mg, is usually given every day of the month. Prempro 0.3/1.5 (0.3 mg of conjugated estrogens and 1.5 mg of medroxyprogesterone) or Prempro 0.45/1.5 (0.45 mg of conjugated estrogens and 1.5 mg of medroxyprogesterone), taken daily.
5. Low-dose oral contraceptives. A low-estrogen oral contraceptive (20 ^g of ethinyl estradiol) remains an appropriate treatment for perimenopausal women who seek relief of menopausal symptoms. Most of these women are between the ages of 40 and 50 years and are still candidates for oral contraception. For them, an oral contraceptive pill containing 20 ^g of ethinyl estradiol provides symptomatic relief while providing better bleeding control than conventional estrogen-progestin therapy because the oral contraceptive contains higher doses of both estrogen and progestin.
6. Treatment of vasomotor instability in women not taking estrogen: Venlafaxine (Effexor), at doses of 75 mg daily, reduces hot flashes by 61 percent. Mouth dryness, anorexia, nausea, and constipation are common.
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