Gynecology Book

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Sequential Estrogen Replacement

Aka: Sequential Estrogen Replacement, Cyclic Estrogen Replacement
  1. See Also
    1. Menopause
    2. Estrogen Replacement
    3. Continuous Estrogen Replacement
    4. Vaginal Estrogen
    5. Transdermal Estrogen
  2. Indications
    1. Combination Estrogen Replacement in Late post-Menopause with intact Uterus
      1. Continuous Estrogen Replacement is preferred instead (lower Endometrial Hyperplasia risk)
      2. Jaakkola (2009) Obstet Gynecol 114(6): 1197-1204 [PubMed]
  3. Protocol
    1. Estrogen taken daily
    2. Progestin taken for 2 weeks of each month (if intact Uterus)
      1. First 2 weeks of month may be better remembered
  4. Preparations: Estrogen and Progestin Sequential Combinations
    1. Premphase (Conjugated Estrogens 0.625 + Medroxyprogesterone 5.0)
      1. Days 1-14: Estrogen alone
      2. Days 15-28: Estrogen with Progesterone
    2. Prefest (Estradiol 1.0 and Norgestimate 0.09)
      1. Repeated 6 day cycles (Estrogen alone for 3 days, Estrogen/Progesterone for 3 days)
  5. Preparations: Estrogens Options (choose one to accompany a Progesterone)
    1. Estrogen must be taken with Progesterone if Uterus is intact (Endometrial Hyperplasia risk)
    2. Conjugated Estrogen (Premarin, Enjuvia) 0.625 mg orally daily (or 0.3, 0.45, 0.9, 1.25 mg)
    3. Estropipate (Ogen) 0.625 mg orally daily
    4. Esterified Estrogen (Estratab, Menest) 0.625 mg orally daily (or 0.3, 1.25, 2.5 mg)
    5. Estradiol (Estrace) 0.5 mg orally daily (or 1.0 or 2.0 mg)
    6. Transdermal Estrogen (must be an Estrogen only product if used sequentially)
      1. Estradiol transdermal (Estraderm, Alora, Climara, Minivelle) 0.05 mg patch/wk (or 0.025, 0.075 or 0.1)
  6. Preparations: Progestin Options (choose one to accompany an Estrogen if intact Uterus)
    1. First line:
      1. Provera 5 mg orally daily for 2 weeks of each month
    2. Second line (refractory to Provera)
      1. Norethindrone orally daily for 2 weeks of each month
      2. Micronized Progesterone 200 ug orally daily for 2 weeks of each month
  7. Adverse Effects
    1. Cyclic withdrawal bleed in 80-90% within 6 months
  8. References
    1. Hill (2016) Am Fam Physician 94(11): 884-9 [PubMed]

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