Why are physicians reluctant to use estrogens for anything – or do they prefer ‘PROFOX’?

The reluctance of physicians to use estrogens in women with hormone responsive disorders is a tragic result of the 2002 WHI study. Although their hostility to estrogen therapy antedated these studies, the flawed data is now used as justification for the denial of estrogens for treatment of low bone density and various types of hormone responsive depression in women. Estrogens should be first choice therapy for osteoporosis in women under the age of 60 years, but in practice bisphosphonates, with its increasing number of long-term side-effects, has become first-line therapy for physicians. These side-effects include osteonecrosis of the jaw, mid-shaft femoral fractures and the need for proton pump inhibitors, which further reduce bone density and add to the fracture risk. Pyschiatrists fail to use transdermal estradiol for postnatal depression, premenstrual depression and perimenopausal depression in spite of randomized trials demonstrating their efficacy. Selective serotonin reuptake inhibitor therapy for depression independently decreases bone density and is also responsible for loss of libido, loss of mental acuity and dependence. Thus postmenopausal women with vasomotor symptoms, depression, loss of libido, vaginal dryness or low bone density are frequently denied effective estrogen therapy and given a combination of low-cost generic prozac and fosamax, which is in danger of becoming a post-WHI nightmare drug PROFOX (PROzacFOsamaX). This can only be avoided if advisory bodies review the reassuring evidence concerning estrogen therapy in women under the age of 60 years and advise accordingly.

Testosterone for low libido in postmenopausal women not taking estrogen

BACKGROUND

The efficacy and safety of testosterone treatment for hypoactive sexual desire disorder in postmenopausal women not receiving estrogen therapy are unknown.

METHODS

We conducted a double-blind, placebo-controlled, 52-week trial in which 814 women with hypoactive sexual desire disorder were randomly assigned to receive a patch delivering 150 or 300 microg of testosterone per day or placebo. Efficacy was measured to week 24; safety was evaluated over a period of 52 weeks, with a subgroup of participants followed for an additional year. The primary end point was the change from baseline to week 24 in the 4-week frequency of satisfying sexual episodes.

RESULTS

At 24 weeks, the increase in the 4-week frequency of satisfying sexual episodes was significantly greater in the group receiving 300 microg of testosterone per day than in the placebo group (an increase of 2.1 episodes vs. 0.7, P<0.001) but not in the group receiving 150 microg per day (1.2 episodes, P=0.11). As compared with placebo, both doses of testosterone were associated with significant increases in desire (300 microg per day, P<0.001; 150 microg per day, P=0.04) and decreases in distress (300 microg per day, P<0.001; 150 microg per day, P=0.04). The rate of androgenic adverse events - primarily unwanted hair growth - was higher in the group receiving 300 microg of testosterone per day than in the placebo group (30.0% vs. 23.1%). Breast cancer was diagnosed in four women who received testosterone (as compared with none who received placebo); one of the four received the diagnosis in the first 4 months of the study period, and one, in retrospect, had symptoms before undergoing randomization.

CONCLUSIONS

In postmenopausal women not receiving estrogen therapy, treatment with a patch delivering 300 microg of testosterone per day resulted in a modest but meaningful improvement in sexual function. The long-term effects of testosterone, including effects on the breast, remain uncertain. (ClinicalTrials.gov number, NCT00131495.)

Prevention and treatment of osteoporosis in women

Osteoporosis affects one in three women. There has been some confusion among women and health professionals about the management of osteoporosis since the publication of the Women's Health Initiative and Million Women studies. This guidance regarding estrogen-based and non-estrogen-based treatments for osteoporosis responds to the controversies about the benefits and risks of individual agents. Treatment choice should be based on up-to-date evidence and targeted to individual women's needs.

A comparison of 19th century and current attitudes to female sexuality

The 19th century medical attitude to normal female sexuality was cruel, with gynecologists and psychiatrists leading the way in designing operations for the cure of the serious contemporary disorders of masturbation and nymphomania. The gynecologist Isaac Baker Brown (1811-1873) and the distinguished endocrinologist Charles Brown-Séquard (1817-1894) advocated clitoridectomy to prevent the progression to masturbatory melancholia, paralysis, blindness and even death. Even after the public disgrace of Baker Brown in 1866-7, the operation remained respectable and widely used in other parts of Europe. This medical contempt for normal female sexual development was reflected in public and literary attitudes. Or perhaps it led and encouraged public opinion. There is virtually no novel or opera in the last half of the 19th century where the heroine with 'a past' survives to the end. H. G. Wells's Ann Veronica and Richard Strauss's Der Rosenkavalier, both of which appeared in 1909, broke the mould and are important milestones. In the last 50 years new research into the sociology, psychology and physiology of sexuality has provided an understanding of decreased libido and inadequate sexual response in the form of hypoactive sexual desire disorder. This is now regarded as a disorder worthy of treatment, either by various forms of counseling or by the use of hormones, particularly estrogens and testosterone.

Variations on hormone replacement therapy: an answer to the 'one dose fits all' Women's Health Initiative study

The Women's Health Initiative study worked on the assumption that one dose would fit all asymptomatic postmenopausal women. The investigators therefore often used the wrong dose, of the wrong hormones, on the wrong patients and therefore came to many wrong conclusions. Different combinations of different hormones are necessary for different symptoms and different age groups. Hormone replacement therapy may be commenced in the perimenopausal phase, the early postmenopause, the late postmenopause or after hysterectomy and bilateral salpingo-oophorectomy or a premature menopause. These all require different treatments. Similarly, various indications such as vasomotor symptoms, sexual problems, depression or the treatment/prevention of osteoporosis all need different combinations of estradiol and possibly progestogen and testosterone, according to the specific requirements of the patient.

Does retention of the ovaries improve long-term survival after hysterectomy? Prophylactic oophorectomy

The controversy surrounding prophylactic oophorectomy is discussed. The importance of adequate hormone replacement with estradiol and particularly testosterone is discussed as is the severe limitation of considering publications which describe the unacceptable practice of hysterectomy and bilateral salpingo-oophorectomy without hormone replacement therapy. There remains a good argument for removal of ovaries at hysterectomy in women over the age of 40 with full discussion, consent and appropriate hormone replacement.

Ovariotomy for menstrual madness and premenstrual syndrome--19th century history and lessons for current practice

Ovariotomy--the removal of normal ovaries, known as Battey's Operation--began in 1872 and became the fashionable treatment of menstrual madness, neurasthenia, nymphomania, masturbation and "all cases of insanity". This practice was supported by distinguished gynecologists and psychiatrists, becoming one of the great medical scandals of the 19th century. In modern times, if menstrual madness is considered to be premenstrual dysphoric disorder (PMDD), and ovariotomy, the surgical equivalent of ovulation suppression of GnRH analogues, it can be argued that the surgery would have been effective for this limited indication, although the side effects of long-term estrogen deficiency would have made the treatment unacceptable. Currently, the successful hormonal treatment of PMDD is one of suppression of ovulation and removal of the cyclical hormonal changes in the luteal phase, probably progesterone, which is the essential cause of PMDD. Such therapy would be by GnRH analogues, transdermal estradiol and, in a few cases, the surgical option of hysterectomy and bilateral salpingo-oophorectomy with adequate hormone replacement. A study of medical history can help us prevent the mistakes of over-enthusiasm but positive lessons can be learned.

Bleeding profiles and effects on the endometrium for women using a novel combination of transdermal oestradiol and natural progesterone cream as part of a continuous combined hormone replacement regime

OBJECTIVE

Many women are seeking alternatives to conventional forms of hormone replacement. This study evaluates the endometrial effects of natural progesterone cream used in conjunction with transdermal oestradiol.

DESIGN

Open plan study conducted over 48 weeks.

SETTING

Tertiary referral London teaching hospital.

POPULATION

Women at least two years postmenopausal.

METHODS

Women were recruited nationally. They applied 40 mg transdermal natural progesterone cream and 1 mg transdermal oestradiol daily.

MAIN OUTCOME MEASURES

Endometrial histology, assessed by pipelle endometrial biopsy, ultrasound assessment of endometrial thickness and bleeding diaries.

RESULTS

Fifty-four women were recruited of which 41 completed the study. Mean age was 57.4 years. Thirty-two percent of women had evidence of inadequate endometrial opposition (proliferative or hyperplastic) at the end of 48 weeks. At baseline, women had a mean endometrial thickness of 3.3 mm, which had significantly thickened to a mean of 5.3 mm by 24 weeks (P < 0.001). By 48 weeks, there was significantly greater increase in endometrial thickness from baseline in those women who displayed inadequate endometrial opposition, compared with those women who had adequate endometrial opposition (P= 0.004). At 24 weeks, 48% of women had remained entirely amenorrhoeic. By the end of the study, 35% of women had been entirely amenorrhoeic and 50% had had either no bleeding or spotting alone. The number of bleeding episodes did not reduce with time.

CONCLUSIONS

The dose of natural progesterone cream in this study was insufficient to fully attenuate the mitogenic effect of oestrogen on the endometrium. We would not recommend this combination of hormones to be used by postmenopausal women.

A study to look at hormonal absorption of progesterone cream used in conjunction with transdermal estrogen

Natural progesterone creams are gaining popularity as a possible treatment for menopausal symptoms, and many women may be using them with estrogen. We planned to evaluate, using an open plan study, the systemic absorption of a combination of transdermal estrogen and progesterone. Women applied transdermal progesterone 40 mg and transdermal estrogen 1 mg daily over 48 weeks. Women were assessed at intervals of 12 weeks. Significant increases in plasma levels of progesterone and estradiol were seen after 12 weeks, although only low plasma progesterone levels were found (median 2.5 nmol/l) and no further increase was noted over the remainder of the study period. A significant correlation was found between plasma levels of the two hormone (r = 0.315, p = 0.045). Women reported significant reductions in menopausal symptoms, as measured by the Green Climacteric Scale, after 24 and 48 weeks of combined treatment. There may be similar mechanisms of absorption of the two hormones, although the doses used in our study produced sub-luteal levels of progesterone. There was no evidence of accumulation of progesterone with time, and further study is needed to assess the efficacy and safety of this combination of hormones.