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Perimenopause and Hormone Replacement Therapy

Estrogen, Progestogen, and Oral Contraceptives


Updated May 15, 2014

Before you begin any type of treatment for the symptoms of perimenopause, you will need to have a full physical exam that includes a detailed discussion about your medical history. Most women should have had a mammogram within the last twelve months before beginning medical therapy for perimenopausal symptoms. Your doctor might order a bone densitometry if your medical history and physical examination suggest bone density testing is a good idea. Your doctor may also want to perform additional tests, if needed.

See: Must Have Medical Tests for Women Treatments for menopause have traditionally meant hormone replacement therapy or HRT, or estrogen replacement therapy or ERT. A few years ago the results of the Women’s Health Initiative or WHI, and the Heart and Estrogen / progestin Replacement Study or HERS, caused many women to rethink using estrogen for perimenopausal symptoms.

According to the North American Menopause Society, the vasomotor symptoms of perimenopause such as hot flashes or night sweats are the primary indication for prescribing estrogen or estrogen-progestogen therapy. In fact, the labeling for virtually all estrogen and estrogen-progestogen products includes the vasomotor symptoms of perimenopause as a reason for taking the drugs.

Another hormonal treatment for perimenopausal symptoms, often prescribed by physicians, are low-dose oral contraceptives. Oral contraceptives provide effective relief from the vasomotor symptoms of perimenopause. One benefit of low-dose oral contraceptives over hormone replacement therapy during perimenopause is that oral contraceptives treat not only the hot flashes of perimenopause, they also regulate the irregular bleeding that frequently occurs. Hormone replacement therapy, on the other hand, does not control irregular bleeding during perimenopause. This approach delays hormone replacement therapy, if needed, until menopause occurs. You may want to discuss the pros and cons of using low-dose oral contraceptives during perimenopause, instead of estrogen therapy, with your physician before making your perimenopause treatment decision.

Women who experience moderate to severe symptoms of vulvar and / or vaginal atrophy that include vaginal dryness, painful sexual intercourse, and atrophic vaginitis use estrogen therapy may also want to use estrogen therapy. However, if vaginal problems are the only symptom that requires treatment, estrogen cream applied vaginally is preferred over systemic estrogens.

Why Use Estrogen and Progestogen

The addition of progestogen to estrogen provides protection against endometrial cancer for women whose uteri are intact. Estrogen therapy without the addition of progestogen, in women who still have their uterus, significantly increases the risk of endometrial cancer. There are two ways to prescribe progestogen therapy: a continuous-combined estrogen-progestogen therapy, or a continuous-sequential estrogen-progestogen therapy. Women who no longer have their uterus usually do not need progestogen added to their estrogen therapy. Low-dose estrogen, prescribed solely for vaginal atrophy and applied locally, normally does not require the addition of progestogen.

Unfortunately, EPT sometimes causes unpleasant side effects from the progestogen. However, there is not enough scientific evidence on endometrial safety to recommend the off-label use of long-cycle progestogens instead of the standard estrogen-progestogen therapies described above. Examples of this type of progestogen therapy include using progestogen for 12 to 14 days every three to six months; vaginal administration of progestogen; the hormonal IUD that releases levonorgestrel (a type of progestogen); or low-dose estrogen without progestogen. Should you choose to try any of these types of estrogen-progestogen therapies, your doctor should follow you closely for endometrial changes until scientists determine otherwise.

Generally, if you decide estrogen is the right choice for you, your doctor should prescribe the lowest effective dose of estrogen for the shortest possible time to help you with your perimenopausal symptoms.


"Estrogen and progesterone use in peri- and postmenopausal women: March 2007 position statement of The North American Menopause Society;" The North American Menopause Society; accessed 09/12/07.

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