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ATC Code (read only) Comments/Instructions 1. Systemic therapy for menopausal flushing 2. Intact uterus, cyclical therapy 3. Oral therapy conjugated estrogens 0.625 mg, once daily on days 1-25 of each month $1.94/25 days or conjuated equine estrogens 0.625 mg, once daily on days 1-25 of each month $3.04/25 days or estropipate 0.625 mg, once daily on days 1-25 of each month $3.55/25 days or estradiol 17b(micronized) 1 mg, once daily on days 1-25 of each month $5.41/25 days AND, with any of the above, 1 of the following medroxyprogesterone 5-10 mg, once daily on days 12 or 14 to 25 of each month $2.27-4.58/2 weeks or norethindrone 0.35-0.70 mg, once daily on days 12 or 14 to 25 of each month $6.16-12.32/2 weeks or progesterone 200 mg, hs on days 12 or 14 to 25 of each month $12.88/2 weeks 4. Transdermal therapy estradiol 50 µg patch, twice weekly for first 2 weeks of each month then $20.65/4 weeks estradiol-norethindrone 50 µg/250 µg patch, twice weekly for next 2 weeks 5. Combined oral and transdermal therapy estradiol 50-100 µg patch, twice weekly on days 1 to 25 of each month $19.70-22.16/25 days AND, 1 of the following medroxyprogesterone 5-10 mg, once daily on days 12 or 14 to 25 of each month $2.27-4.58/2 weeks or norethindrone 0.35-0.70 mg, once daily on days 12 or 14 to 25 of each month $6.16-12.32/2 weeks or progesterone 200 mg, hs on days 1225 of each month $12.88/2 weeks ii. Intact uterus, continuous therapy conjugated estrogens 0.625 mg, once daily $2.32/30 days or conjugated equine estrogens 0.625 mg, once daily $3.65/30 days or estropipate 0.625 mg, once daily $4.26/30 days or estradiol-17b (micronized) 1 mg, once daily $6.50/30 days AND, with any of the above medroxyprogesterone 2.5 mg, once daily $2.46/30 days iii. Intact uterus, continuous estrogen therapy and cyclic progestin therapy conjugated estrogens 0.625 mg, once daily $2.32/30 days or conjugated equine estrogens 0.625 mg, once daily $3.65/30 days or estropipate 0.625 mg, once daily $4.26/30 days or estradiol-17b (micronized) 1 mg, once daily $6.50/30 days AND, with any of the above, 1 of the following medroxyprogesterone 5-10 mg, once daily on days 1 to 10 or 14 of each month $1.60-4.98/10 days or norethindrone 0.35-0.70 mg, once daily on days 1 to 10 or 14 of each month $4.40-8.80/10 days or progesterone 200 mg, hs on days 1 to 10 or 14 of each month $9.20/10 days iv. Absent uterus, continuous therapy conjugated estrogens 0.625 mg, once daily $2.32/30 days or conjugated equine estrogens 0.625 mg, once daily $3.65/30 days or estropipate 0.625 mg, once daily $4.26/30 days or estradiol-17b (micronized) 1 mg, once daily $6.50/30 days or estradiol 50-100 µg patch, twice weekly $19.70-22.16/4 weeks 1. Topical agents for vaginal (and possibly urethral) atrophy dienestrol 0.1 mg/g vaginal cream $8.27/75 g Initial dose 2 g (1 application) once daily for 1 week Maintenance 2 g (1 application) 1-3 times/week or conjugated equine estrogens 0.625 mg/g vaginal cream $14.82/42.5 g Initial dose 2 g once daily Maintenance 2 g 1-3 times/week or estradiol-17b vaginal ring 2 mg (releases 7.5 µg/24 h) replacement every 3 months by patient $60.00/ring Second-line therapies: 1. When estrogen therapy is contraindicated, progestins are often helpful for flushes even if used alone medroxyprogesterone 5-10 mg, once daily $4.86-9.81/30 days or norethindrone acetate 2.5-5 mg, once daily $11.40-22.50/30 days or megestrol 20 mg, bid $27.16/30 days 2. Where estrogen therapy is contraindicated or when hormonal supplements not desired clonidine 50 µg, bid $5.40/30 days Additional Instructons and Notes -HRT is contraindicated in women who have breast cancer or undiagnosed vaginal bleeding and in those who have a past history of thromboembolic disease occurring on previous hormone therapy. The risk of venous thromboembolism is increased in current users of HRT, but the increased risk is still small, e.g., in a cohort of women aged 50-59 there would be 5 additional cases per 100 000 person-years. -If topical therapy is required daily on a continuing basis, then it should be cyclic (3 weeks on, 1 week off) and a progestin should be added. -Compliance with HRT seems to be better with transdermal therapy. -In the presence of active liver disease, the transdermal route is preferable. -To date, there are no data to demonstrate any advantage of continuous HRT over sequential HRT in terms of patient compliance, incidence of PMS-like side effects, reduction in vasomotor symptoms, improvement of lipid profile or maintenance of bone density. Reference

Category

Cardiovascular Dermatology Ears Nose and Throat Endocrinology Gastroenterology Genitourinary System HIV Hematology Musculoskeletal System Neurology Opthalmology Obstetrics and Gynecology Palliative Care Psychiatry and Behaviour Respiratory System

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http://oscarmcmaster.org:25300/oscarResource-Pl...

1. Systemic therapy for menopausal flushing
2. Intact uterus, cyclical therapy
3. Oral therapy

conjugated estrogens 0.625 mg, once daily on days 1-25 of each month $1.94/25 days

or conjuated equine estrogens 0.625 mg, once daily on days 1-25 of each month $3.04/25 days

or estropipate 0.625 mg, once daily on days 1-25 of each month $3.55/25 days

or estradiol 17b(micronized) 1 mg, once daily on days 1-25 of each month $5.41/25 days

AND, with any of the above, 1 of the following

medroxyprogesterone 5-10 mg, once daily on days 12 or 14 to 25 of each month $2.27-4.58/2 weeks

or norethindrone 0.35-0.70 mg, once daily on days 12 or 14 to 25 of each month $6.16-12.32/2 weeks

or progesterone 200 mg, hs on days 12 or 14 to 25 of each month $12.88/2 weeks

4. Transdermal therapy

estradiol 50 µg patch, twice weekly for first 2 weeks of each month then $20.65/4 weeks

estradiol-norethindrone 50 µg/250 µg patch, twice weekly for next 2 weeks

5. Combined oral and transdermal therapy

estradiol 50-100 µg patch, twice weekly on days 1 to 25 of each month $19.70-22.16/25 days

AND, 1 of the following

medroxyprogesterone 5-10 mg, once daily on days 12 or 14 to 25 of each month $2.27-4.58/2 weeks

or norethindrone 0.35-0.70 mg, once daily on days 12 or 14 to 25 of each month $6.16-12.32/2 weeks

or progesterone 200 mg, hs on days 1225 of each month $12.88/2 weeks

ii. Intact uterus, continuous therapy

conjugated estrogens 0.625 mg, once daily $2.32/30 days

or conjugated equine estrogens 0.625 mg, once daily $3.65/30 days

or estropipate 0.625 mg, once daily $4.26/30 days

or estradiol-17b (micronized) 1 mg, once daily $6.50/30 days

AND, with any of the above

medroxyprogesterone 2.5 mg, once daily $2.46/30 days

iii. Intact uterus, continuous estrogen therapy and cyclic progestin therapy

conjugated estrogens 0.625 mg, once daily $2.32/30 days

or conjugated equine estrogens 0.625 mg, once daily $3.65/30 days

or estropipate 0.625 mg, once daily $4.26/30 days

or estradiol-17b (micronized) 1 mg, once daily $6.50/30 days

AND, with any of the above, 1 of the following

medroxyprogesterone 5-10 mg, once daily on days 1 to 10 or 14 of each month $1.60-4.98/10 days

or norethindrone 0.35-0.70 mg, once daily on days 1 to 10 or 14 of each month $4.40-8.80/10 days

or progesterone 200 mg, hs on days 1 to 10 or 14 of each month $9.20/10 days

iv. Absent uterus, continuous therapy

conjugated estrogens 0.625 mg, once daily $2.32/30 days

or conjugated equine estrogens 0.625 mg, once daily $3.65/30 days

or estropipate 0.625 mg, once daily $4.26/30 days

or estradiol-17b (micronized) 1 mg, once daily $6.50/30 days

or estradiol 50-100 µg patch, twice weekly $19.70-22.16/4 weeks

1. Topical agents for vaginal (and possibly urethral) atrophy

dienestrol 0.1 mg/g vaginal cream $8.27/75 g

Initial dose 2 g (1 application) once daily for 1 week
Maintenance 2 g (1 application) 1-3 times/week

or conjugated equine estrogens 0.625 mg/g vaginal cream $14.82/42.5 g

Initial dose 2 g once daily
Maintenance 2 g 1-3 times/week

or estradiol-17b vaginal ring 2 mg (releases 7.5 µg/24 h) replacement every 3 months by patient $60.00/ring

Second-line therapies:

1. When estrogen therapy is contraindicated, progestins are often helpful for flushes even if used alone

medroxyprogesterone 5-10 mg, once daily $4.86-9.81/30 days

or norethindrone acetate 2.5-5 mg, once daily $11.40-22.50/30 days

or megestrol 20 mg, bid $27.16/30 days

2. Where estrogen therapy is contraindicated or when hormonal supplements not desired

clonidine 50 µg, bid $5.40/30 days

Additional Instructons and Notes

-HRT is contraindicated in women who have breast cancer or undiagnosed vaginal bleeding and in those who have a past history of thromboembolic disease occurring on previous hormone therapy. The risk of venous thromboembolism is increased in current users of HRT, but the increased risk is still small, e.g., in a cohort of women aged 50-59 there would be 5 additional cases per 100 000 person-years.

-If topical therapy is required daily on a continuing basis, then it should be cyclic (3 weeks on, 1 week off) and a progestin should be added.

-Compliance with HRT seems to be better with transdermal therapy.

-In the presence of active liver disease, the transdermal route is preferable.

-To date, there are no data to demonstrate any advantage of continuous HRT over sequential HRT in terms of patient compliance, incidence of PMS-like side effects, reduction in vasomotor symptoms, improvement of lipid profile or maintenance of bone density.

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