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:
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.
Note: If you have osteoporosis, you should ask your doctor for a prescription for Etidronate as Didrocal®, for calcitonin nasal spray or for another medication that can prevent bone loss. The reason is that stopping estrogen allows a rapid increase in bone resorption (which means bone loss). These work like estrogen to prevent bone resorption. Start taking Etidronate or that other osteoporosis medicine before you begin tapering estrogen treatment.
Ideally, switch to a transdermal (patch or gel form) of estrogen, which allows you to decrease more gradually (and is safer in terms of risks for blood clots). Transdermal forms of estrogen are more expensive than the pill form. If you really can't afford the patch or gel, see the pill schedule below.
Estrogen patches come in two types: the original “gel-type” ones had a sticky backing with a centre gel that released the estrogen into the skin; the other is a “matrix” patch that has the glue and hormone together as part of the patch. You can tell that you have the gel-type if it has a bump in the centre; if you have the matrix estrogen patch it will be totally flat. If you’re switching, ask for a prescription for the matrix kind of patch.
Estrogen gel is delivered as a clear thick liquid for rubbing on arms or legs or abdomen. It usually comes in a pump-type container but may also be dispensed in a tube like toothpaste. Instructions for decreasing a gel estradiol treatment are below.
It is important decrease estrogen levels very gradually, especially if you have ever had hot flushes or you started estrogen therapy for the treatment of hot flushes and night sweats (called vasomotor symptoms.)
Decrease by about 10% every two weeks. You may be able to stop over about four months but sometimes it takes longer. If you start to get night sweats again as you decrease your estrogen dose, go back up to the dose where you were fine (without night sweats) and stay there for another two weeks before again trying to decrease the dose. Keep taking progesterone 300 mg at bedtime the whole time.
If you have a matrix kind of estrogen patch (see above) you can cut the patch to decrease the dose. Be sure to save the pieces you cut off for later use as your dose decreases. If you already have the gel kind of estrogen patch, then you need to switch to get a prescription so you can switch to the matrix patch or estrogen gel.
1. Here is an example of how to decrease the estrogen using a patch, over 14 weeks.
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Weeks 1-2
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7/8 of a patch
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Weeks 3-4
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3/4 of a patch
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Weeks 5-6
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5/8 of a patch
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Weeks 7-8
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1/2 a patch
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Weeks 9-10
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3/8 of a patch
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Weeks 11-12
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1/4 of a patch
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Weeks 13-14
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1/8 of a patch
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Week 15
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off estrogen
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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:
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Monday
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Tuesday
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Wednesday
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Thursday
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Friday
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Saturday
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Sunday
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0.625
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0.625
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0.3
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0.625
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0.625
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0.3
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0.625
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Week 3: 0.625 for 4 days, 0.3 for 3 days
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Week 9: 0.3 for 5 days
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Week 4: 0.625 for 3 days, 0.3 for 4 days
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Week 10: 0.3 for 4 days
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Week 5: 0.625 for2 days, 0.3 for 5 days
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Week 11: 0.3 for 3 days
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Week 6: 0.625 for 1 day, 0.3 for 6 days
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Week 12: 0.3 for 1 day
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Week 7: 0.3 for 7 days
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Week 13: Off estrogen
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Week 8: 0.3 for 6 days
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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.
