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Stopping Estrogen Treatment (Sometimes called “HRT”)

by Dr. Jerilynn C. Prior, Scientific Director, Centre for Menstrual Cycle and Ovulation Research

In July 2002, the largest randomized placebo-controlled study of “Hormone Replacement Therapy” for healthy menopausal women was stopped early because it showed that estrogen plus very low dose medroxyprogesterone therapy caused serious harm. Women, when they learned of these results, suddenly stopped their hormone therapy. Many found themselves dealing with severe night sweats and hot flushes. The Centre for Menstrual Cycle and Ovulation Research believes you can stop estrogen and avoid the hot flushes. Here's how:

Slowly Does It

Some women who abruptly stop estrogen therapy will have bad hot flushes that can be very hard to treat. Tapering the medication over time can prevent this.

Note: If you have osteoporosis, you should ask your doctor for a prescription for Etidronate as Didrocal®. This works like estrogen to prevent bone loss. Start taking Etidronate before you begin tapering estrogen treatment

Steps To Coming Off Slowly

A. Increase to a full dose of progesterone:

  • 300 mg of oral micronized progesterone (Prometrium® or compounded progesterone pills) per day, taken at night, OR
  • 10 mg of medroxyprogesterone acetate (Provera) per day

You can try progesterone cream, but the appropriate dose is not yet known. The dose will be approximately 150 mg twice a day.

I recommend oral micronized progesterone (Prometrium® or compounded progesterone pills) because it will help with hot flushes as well as aid sleep.

B. Gradually decrease the estrogen you are taking.

Ideally, switch to a transdermal (patch or gel form) of estrogen, which allows you to decrease more gradually. This is especially important if you have ever had hot flushes. However, this is slightly more expensive than the pill form. If you can't afford the patch or gel, see the pill schedule below. Decrease over about four months. You can cut the patch to decrease the dose. Be sure to save the pieces you cut off for later use.

1. Here is an example of how to decrease the estrogen using a patch, over 14 weeks.

Weeks 1-2

7/8 of a patch

Weeks 3-4

3/4 of a patch

Weeks 5-6

5/8 of a patch

Weeks 7-8

1/2 a patch

Weeks 9-10

3/8 of a patch

Weeks 11-12

1/4 of a patch

Weeks 13-14

1/8 of a patch

Week 15

off estrogen

2. Here is an example of how to decrease Conjugated Estrogen (Premarin (CEE) or CES) over 3 months:

Ask your health care provider for a three-month prescription of the lowest dose (0.3 mg, green tablet) of Conjugated Estrogen. Most women have been taking the standard dose (0.625 mg, burgundy tablet).

Week 1: 0.625 on 6 days, 0.3 on 1 day

Week 2: 0.625 on 5 days, 0.3 on 2 days

Space out the pills. Rather than having all 0.625 mg pills in a row, then all 0.3 mg, space them out evenly. For example:

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

0.625

0.625

0.3

0.625

0.625

0.3

0.625


Week 3: 0.625 for 4 days, 0.3 for 3 days

Week 9: 0.3 for 5 days

Week 4: 0.625 for 3 days, 0.3 for 4 days

Week 10: 0.3 for 4 days

Week 5: 0.625 for2 days, 0.3 for 5 days

Week 11: 0.3 for 3 days

Week 6: 0.625 for 1 day, 0.3 for 6 days

Week 12: 0.3 for 1 day

Week 7: 0.3 for 7 days

Week 13: Off estrogen

Week 8: 0.3 for 6 days

 

3. Here's an example of how to taper and stop estrogen therapy in a gel form (Estragel®).

If you have been on a high dose of pill estrogen (more than 0.625 mg/day) you will need to start with two pumps of Estragel® each day. For the two weeks use two pumps per day, except that one day a week decrease to one pump. The next two weeks use one pump every third day. Then alternate one and two pumps a day for a couple of weeks. Now use one pump a day for two weeks.

You are now ready to taper down to less than one pump a day. To do this you need to figure the length of gel in a full pump so you can gradually decrease by about 10% every couple of weeks. First, slowly push out one full pump of estradiol gel making an even bead on a heavy piece of paper. You want to stretch out the gel as evenly and as far as you can. Then mark the beginning and the end of this line of gel with a pen—it will be about 6 cm or a little over two inches. That is 100% of a dose. Now take a ruler and divide that line into 10 parts. You will decrease from 100% to 90% and take this for two weeks before decreasing to 80%. Keep on this schedule until you are off of Estragel® entirely.

C. What to do if the hot flushes start again as you taper estrogen therapy

If you start getting increased hot flushes or night sweats as you are lowering your dose of estrogen, go back up to the level of estrogen at which hot flushes were totally gone. Maintain that dose for several weeks longer before beginning to gradually reduce the dose again.

D. What to do about the progesterone therapy when you are off estrogen

If you have successfully stopped estrogen and have no hot flushes, you may wish to stop progesterone also. Progesterone does not need to be tapered. If the hot flushes start, then you need to continue. Try stopping progesterone once a year. Or you may decide that progesterone is also helping your bones (see ABCs of Osteoporosis Treatment) and stimulating osteoblasts to build new bone. You may also find it helps your sleep and that you would like to continue it. You can safely do that (see Progesterone Therapy for Menopausal Women). Natural progesterone does not cause blood clots and, based on its scientific actions in tissues, it is more likely to prevent breast cancer and heart disease than to cause them.

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