ALTERNATIVES TO ORAL ESTROGEN REPLACEMENT

The Er:YAG vaginal laser for management of women with genitourinary syndrome of menopause (GSM)

The purpose of our study was to investigate the effects of vulvovaginal erbium laser on the genitourinary syndrome of menopause (GSM) and sexual function of postmenopausal women. We conducted a retrospective study of sixty-four postmenopausal women with GSM, and these patients were scheduled for three times of vulvovaginal erbium laser treatment. A baseline and post-treatment vaginal status was assessed by measuring vaginal pH, patients' subjective vulvovaginal atrophy (VVA) symptoms, which included dryness, dyspareunia, itching, and burning. The urinary response to treatment was assessed using ICIQ-SF, UDI-6, IIQ-7, OABSS, and POPDI-6. Sexual function was evaluated using the Female Sexual Function Index (FSFI) before and after vulvovaginal laser therapy. Patient follow-ups were scheduled for 12 months after treatment. A total of sixty-four patients were enrolled in the study. We observed the significant improvement in the percentage of negative symptoms (dryness/dyspareunia/itching/burning) and in lower urinary tracts symptoms evaluated with ICIQ-SF, UDI-6, IIQ-7, OABSS, and POPDI-6 (P < 0.05). Patients' overall satisfaction regarding their sexual life, assessed via Female Sexual Function Index (FSFI), showed significant improvement in its six domains of sexual function (P < 0.05). The pH level of vaginal secretions significantly decreased. No long-term complications were found post-treatment. The Er:YAG vaginal laser procedure is associated with a significant improvement in GSM and sexual function of postmenopausal women. Our result demonstrates that it can be a safe and efficacious treatment for patients with GSM without any serious adverse effects up to 1-year post-treatment. The long-term effects of using vulvovaginal laser in the treatment of GSM should be investigated.

Association between hormone replacement therapy and carpal tunnel syndrome: a nationwide population-based study

OBJECTIVE

Carpal tunnel syndrome (CTS) is the most common compressive focal mononeuropathy, and the increased incidence in postmenopausal and pregnant women suggests its association with oestrogen. The objective of this study is to evaluate the relationship between hormone replacement therapy (HRT) and the occurrence of CTS.

DESIGN

Population-based case-control study.

SETTING

Nationwide health insurance programme operated by the government with a near 100% coverage rate.

PARTICIPANTS

We identified women ≥45 years old in the Health Insurance Research Database of Taiwan, which contains data on a representative sample of one million enrollees. After exclusion of those who were diagnosed with CTS before the prescription of HRT, a total of 118 309 participants were included and followed up for 15 years starting from 1 January 1996. Both HRT and occurrence of CTS were identified using the insurance claims.

MAIN OUTCOME MEASURES

We identified incident patients of CTS and evaluated the association between HRT and CTS by calculating the OR.

RESULTS

Of the 4535 participants who developed CTS during the study period, 2334 (51.5%) were HRT recipients. In participants without CTS, the proportion of HRT recipients was 28.1%, yielding an OR of 2.72 with a 95% CI of 2.56 to 2.88. After adjustment for age, diabetes, rheumatoid arthritis, hypothyroidism, gout and obesity, the OR of CTS associated with HRT was 2.04 (95% CI 1.91 to 2.17). While HRT, diabetes, rheumatoid arthritis and gout had similar effects on CTS across all age groups, hypothyroidism and obesity had different effects on different groups.

CONCLUSION

This study observed a positive association between HRT and CTS, independent of age, diabetes, rheumatoid arthritis, hypothyroidism, gout and obesity. While the ORs of CTS associated with HRT were similar across age groups, those associated with hypothyroidism and obesity were not, indicating effect modifications by age.

Establishment of a Mucin Secreting Cell Line Cx-03 from an Uterine Carcino Sarcoma

PURPOSE

The identification of novel cell lines which combine the most important properties of mucosal membranes in terms of drug absorption, transmembrane transport and mucus secretion can help to establish improved and meaningful test systems for pharmacological and infectiological studies.

METHODS

We have established a novel mucus secreting tumor cell line (Cx-03) derived from a female patient who underwent radical hysterectomy after diagnosis of a large malignant carcino sarcoma (Muellerian mixed tumor). Via xenotransplantation in SCID beige mice, recultivation and subcloning a stable cell line was established from primary tumor cells.

RESULTS

Human origin and novelty of the cell line was determined by karyotype analysis and STR fingerprint. During growth cells produce considerable amounts of a PAS positive viscoelastic mucus. Immunostaining revealed expression of mucins and the mucin modifier CLCA1. We demonstrate in initial electrophysiological experiments that confluent, polarized monolayers of Cx-03 are formed (on PCF-filter supports) that exhibit stable electrical resistance (> 600 Ω cm²). Confluent Cx-03 monolayers express barrier-forming tight junction proteins claudin-1 and -4 which co-localize with zonula occludens protein-1 (ZO-1) at cell-cell contacts.

CONCLUSIONS

Mucus secretion is a rare property among mammalian cell lines. In combination with its ability to form polarized monolayers Cx-03 might contribute as a novel cell based model for drug absorption, transport and barrier studies.

Shared decision making in endocrinology: present and future directions

In medicine and endocrinology, there are few clinical circumstances in which clinicians can accurately predict what is best for their patients. As a result, patients and clinicians frequently have to make decisions about which there is uncertainty. Uncertainty results from limitations in the research evidence, unclear patient preferences, or an inability to predict how treatments will fit into patients' daily lives. The work that patients and clinicians do together to address the patient's situation and engage in a deliberative dialogue about reasonable treatment options is often called shared decision making. Decision aids are evidence-based tools that facilitate this process. Shared decision making is a patient-centred approach in which clinicians share information about the benefits, harms, and burden of different reasonable diagnostic and treatment options, and patients explain what matters to them in view of their particular values, preferences, and personal context. Beyond the ethical argument in support of this approach, decision aids have been shown to improve patients' knowledge about the available options, accuracy of risk estimates, and decisional comfort. Decision aids also promote patient participation in the decision-making process. Despite accumulating evidence from clinical trials, policy support, and expert recommendations in endocrinology practice guidelines, shared decision making is still not routinely implemented in endocrine practice. Additional work is needed to enrich the number of available tools and to implement them in practice workflows. Also, although the evidence from randomised controlled trials favours the use of this shared decision making in other settings, populations, and illnesses, the effect of this approach has been studied in a few endocrine disorders. Future pragmatic trials are needed to explore the effect and feasibility of shared decision making implementation into routine endocrinology and primary care practice. With the available evidence, however, endocrinologists can now start to practice shared decision making, partner with their patients, and use their expertise to formulate treatment plans that reflect patient preferences and are more likely to fit into the context of patients' lives. In this Personal View, we describe shared decision making, the evidence behind the approach, and why and how both endocrinologists and their patients could benefit from this approach.

Unintended positive and negative effects of drugs on lipoproteins

PURPOSE OF REVIEW

Dyslipidaemia is an important cardiovascular disease risk factor. Many drugs affect lipid profile and lipoprotein metabolism. We reviewed unintended effects of nonlipid modifying, commonly used medications on lipid profile and lipoprotein metabolism.

RECENT FINDING

Several detrimental effects of many drug classes such as diuretics, antidepressant, anticonvulsant and antiretroviral drugs have been reported, whereas other drug classes such as antiobesity, alpha 1-blockers, oestrogens and thyroid replacement therapy were associated with positive effects.

SUMMARY

Dyslipidaemia is a common side-effect of many medications. This should be taken into consideration, especially in patients at high risk of cardiovascular disease. Other drugs demonstrated positive effects on circulating lipids and lipoproteins. The impact of these unintended effects on atherosclerotic disease risk and progression is unclear.

Exogenous pubertal induction by oral versus transdermal estrogen therapy

Hypogonadal adolescent girls need estrogen therapy for the induction of puberty. For years, oral conjugated estrogens have been used for this purpose, starting at a very low dose, with gradual increments over time, to allow for the maturation of the reproductive organs, in order to mimic physiologic conditions. Several concerns, mainly due to first pass through the liver, are manifest with oral estrogen therapy. With the advent of transdermal estrogens and its improved efficacy profile as well as reduced side effects, it seems reasonable to consider it for pubertal induction. The primary objective of this study was to compare and contrast oral versus transdermal estrogen with regard to metabolism and physiology and to review current available data on transdermal estrogens with respect to exogenous pubertal induction.

Alzheimer's disease treatment: assessing caregiver preferences for mode of treatment delivery

INTRODUCTION

Management of patients with Alzheimer's Disease (AD) can exert a substantial burden upon caregivers. As new modes of treatment administration are developed, it is important to assess caregiver satisfaction and preference in a standardized manner. This study describes the development of the Alzheimer's Disease Caregiver Preference Questionnaire (ADCPQ) to assess AD caregivers' satisfaction with and preference for patch or capsule treatments in AD patients.

METHODS

Twenty-five published articles (1987-2002) were reviewed to identify potential ADCPQ domains. Three caregiver focus groups (n=24) were conducted to develop a first draft of the questionnaire. After evaluating the acceptance of ADCPQ to caregivers through in-depth interviews (n=10), its psychometric properties were assessed using data from 986 patients enrolled in a multicenter, randomized, double-blind, four-arm, placebo- and active-controlled, 24-week trial.

RESULTS

Focus groups indicated that caregivers expressed dissatisfaction with current AD treatment routines including limitations related to: efficacy, administration schedule, number of pills, adherence to treatment, side effects, and taking pills. In-depth interviews with caregivers found the ADCPQ to be comprehensible with an acceptable layout. The resultant ADCPQ comprises three modules: A) baseline, 11 items assessing treatment expectations; B) week 8, 33 items on satisfaction and preferences with treatment options; C) week 24, 10 items assessing overall opinions of treatment options. Missing data per item was low (<or=0.3%) and domain internal consistency reliability was good (0.71-0.91). Preference items were also valid when evaluating concordance and discordance between convenience and satisfaction patch and capsule domain scores.

CONCLUSION

AD treatment puts a significant strain on caregivers. New modes of treatment delivery may be less burdensome to caregivers, thereby increasing satisfaction and potential treatment adherence. The ADCPQ was well accepted by AD caregivers and its domains demonstrated satisfactory psychometric properties. The ADCPQ is a useful tool to understand caregiver preferences for patch versus oral therapies in AD.

Vaginal oestrogen therapy after breast cancer: is it safe?

The increasing number of breast cancer patients who suffer from menopausal symptoms is mainly due to the extensive use of adjuvant treatments in the younger women. Both short and long-term side effects of oestrogen deficiency may severely impact on the quality of life of these women and should not be underestimated. Hormonal treatments are contraindicated in breast cancer survivors mainly due to the concern that dormant micrometastases may be stimulated to grow. Alternative non-hormonal remedies are now available to alleviate symptoms and to prevent chronic diseases associated with oestrogen deficiency. Urogenital atrophy is an important consequence of oestrogen deprivation that can be effectively treated by vaginal estrogens, although systemic absorption occurs with conventional doses. Preliminary data suggest that much lower doses of vaginal estrogens can alleviate urogenital atrophy without influencing serum estrogenic levels. Further research is warranted to confirm whether vaginal estrogens are safe in symptomatic breast cancer patients who are non-responsive to alternative treatments.

Treatment of menopausal symptoms: what shall we do now?

During the past few years, many women and doctors have revised their opinions of hormone replacement therapy (HRT) for menopausal symptoms, and a substantial number of individuals have discontinued its use because of concerns about side-effects. Numerous alternatives to HRT are promoted, and assessment of the quality of evidence about the safety and effectiveness of these compounds can be difficult. In this Review, we summarise the data from studies addressing the efficacy, risks, and benefits of frequently prescribed treatments, and offer evidence-based clinical guidelines for the management of menopausal symptoms. Although few comparative studies exist, oestrogen alone or combinations of oestrogen and progestagen are likely to be the most effective treatments for menopausal hot flushes and vaginal dryness. Tibolone is as effective as HRT, however, and might also improve libido. For those who wish to avoid hormonal treatments, there are few effective options. Selective serotonin reuptake inhibitors might be effective in the very short term (less than 12 weeks) and are well tolerated. There is not enough evidence that any of the complementary therapies available are any better than placebo for menopausal vasomotor symptoms, and few safety data exist.

Treatment of urogenital atrophy with low-dose estradiol: preliminary results

OBJECTIVE

To determine the lowest dosage of vaginally administered estradiol (E2) that reverses signs and symptoms of urogenital atrophy but does not substantially increase plasma E2 levels.

DESIGN

Single-blind, single-arm study to determine the effects of de-escalating doses of vaginal estrogen on symptoms of urogenital atrophy, vaginal pH, and vaginal and urethral cytology. A questionnaire was used to assess subjective vaginal and urethral symptoms. Objective measurements included vaginal and urethral cytology, pH, endometrial biopsy, and 24-h circulating plasma luteinizing hormone, follicle-stimulating hormone (FSH), E2, and estrone levels obtained in a Clinical Research Unit. Circulating E2 levels were assayed with an ultrasensitive yeast bioassay with a detection limit of 0.02 pg/mL. Measurements were obtained over a 24-h period after administration of vehicle alone, on day 1 after the initial vaginal E2 dosage, after 3 weeks of daily E2 administration, and after an additional 9 weeks of twice weekly administration.

RESULTS

From the first seven subjects studied at a 10-microg dose of E2, 100% responded according to predefined criteria. Vaginal cytology showed statistical improvement at 3 and 12 weeks. Urethral cytology was statistically improved after 12 weeks. Vaginal pH decreased from postmenopausal to premenopausal levels at both 3 and 12 weeks. Eighty-two percent of symptoms were cured or improved. Endometrium remained atrophic. Circulating E2 levels remained within the postmenopausal range of 3-10 pg/mL.

CONCLUSION

A 10-microg dose of vaginal E2 effectively treated urogenital atrophy in seven women and did not cause endometrial hyperplasia or increase E2 levels.

Drug-Induced lipid changes: a review of the unintended effects of some commonly used drugs on serum lipid levels

Many drugs besides lipid-lowering drugs affect serum lipid levels in either a potentially harmful or beneficial way, and may therefore increase or decrease the risk of cardiovascular disease. Diuretics, beta-blocking agents, progestogens, combined oral contraceptives containing 'second generation' progestogens, danazol, immunosuppressive agents, protease inhibitors and enzyme-inducing anticonvulsants adversely affect the lipid profile. They increase total cholesterol, low density lipoprotein cholesterol and triglycerides by up to 40, 50 and 300%, respectively, and decrease high density lipoprotein cholesterol by a maximum of 50%. Conversely, alpha-blocking agents, estrogens, hormone replacement therapy, combined oral contraceptives containing 'third generation' progestogens, selective estrogen receptor modulators, growth hormone and valproic acid show mostly beneficial effects on the lipd profile. Some drugs, for example, isotretinoin, acitretin and antipsychotics, mainly elevate triglyceride levels. Adverse or beneficial effects on serum cholesterol levels do not always translate into a higher or lower, respectively, incidence of cardiovascular disease. because these drugs may influence cardiovascular risk through multiple pathways. In some cases, excessive cholesterol levels occur, for example, with protease inhibitor therapy, and several cases of pancreatitis attributable to drug-induced hypertriglyceridaemia have been reported. Some general guidelines on the management of drug-induced dyslipidaemia can be given. Replacement of the dyslipidaemia-inducing drug by an equivalent alternative therapy is preferred. However, such alternatives are often difficult to find. If there is no equivalent alternative and treatment with the dyslipidaemia-inducing drug must be initiated, monitoring of serum lipid levels is important. If drug use is expected to be long term, the existing guidelines for the management of dyslipidaemia in the general population can be applied to drug-induced dyslipidaemia. In cases of extreme hyperlipidaemia, medication use should be reassessed.

Effect of an estradiol gel with monthly or quarterly progestogen on menopausal symptoms and bleeding

OBJECTIVE

To assess the acceptability, efficacy and endometrial safety of transdermal estradiol gel (Divigel/Sandrena) combined with monthly or quarterly oral progestogen (medroxyprogesterone acetate).

METHODS

This 12-month, multicenter, open-label study was carried out at 12 study centers in Finland and Sweden. A total of 395 postmenopausal women received 1 mg estradiol in 1 g gel, daily, with oral medroxyprogesterone acetate 10 mg for the first 12 days every month (groups I and III) or every 3 months (group II). The main outcome measures were relief of climacteric symptoms, bleeding patterns and endometrial safety.

RESULTS

All regimens reduced the severity of hot flushes, sweating episodes and vaginal dryness. In groups I and III, approximately 80% and 70% of women, respectively, had regular monthly withdrawal bleeding (excepting the first cycle), with irregular bleeding in 8.3% and 5.3% of treatment months. In group II, approximately 94% of women had regular tri-monthly withdrawal bleeding, with irregular bleeding in 10.7% of the treatment months. Endometrial hyperplasia was observed in 0.3% of women. More than 87% of subjects completed the study, and 97% of these rated the gel as acceptable or convenient.

CONCLUSIONS

Both the 1- and 3-month regimens were equally effective in controlling climacteric symptoms and protecting against endometrial hyperstimulation. The bleeding patterns were comparable between groups and were similar to those reported for oral estrogens. Estradiol gel was highly acceptable to the majority of women.

Women's health care during the perimenopause

OBJECTIVE

To review the perimenopause, its associated symptoms, and current management options.

DATA SOURCES

Published articles identified through MEDLINE (1966-2000) using the search terms perimenopause and treatment. Additional articles and books were identified from the bibliographies of the retrieved articles.

DATA SYNTHESIS

The perimenopause is the transition period from normal ovulatory cycles to menopause. It is associated with erratic fluctuations in reproductive hormone levels, often leading to irregular menstrual cycles, vasomotor symptoms, changes in mood or cognition, and sexual dysfunction. The perimenopause is an ideal time to evaluate a woman's health risks for such common chronic midlife conditions as heart disease, osteoporosis, and some cancers, and to initiate appropriate preventive health measures. Low-dose oral contraceptives and other hormonal therapies are often effective in managing perimenopausal symptoms.

CONCLUSION

The transition to menopause is an important time in the female life span that is associated with varied physical and psychological symptoms. Pharmacists should be prepared to provide education about the perimenopause and counsel women on the benefits and risks of various pharmacologic and nonpharmacologic treatments that can ease their passage through this often difficult transition. Pharmacists also are well-positioned to educate and encourage perimenopausal women to initiate lifestyle changes that can enhance their health for the rest of their lives.

Comparison of Alora estradiol matrix transdermal delivery system with oral conjugated equine estrogen therapy in relieving menopausal symptoms. Alora Study Group

OBJECTIVE

To compare the efficacy of two strengths of an estradiol matrix transdermal delivery system with daily oral doses of conjugated equine estrogens in reducing the frequency of moderate-to-severe hot flushes in postmenopausal women.

DESIGN

The design of the study provided for the following treatment regimens: an estradiol transdermal delivery system (Alora 0.05 or 0.1 mg/day) administered twice weekly or oral doses of conjugated equine estrogens (CEE 0.625 or 1.25 mg) administered daily were given to 321 highly symptomatic postmenopausal women for 12 weeks following a randomized, parallel-group, double-blind, double-dummy design.

RESULTS

Results indicate no statistically significant differences at any time point in mean frequency or mean percentage reduction in frequency of moderate-to-severe hot flushes between patients given Alora 0.1 mg/day and those receiving CEE 1.25 mg/day. Similarly, no significant differences were observed at any time in mean frequency of moderate-to-severe hot flushes between the Alora 0.05 mg/day and CEE 0.625 mg/day groups, although the group receiving CEE 0.625 mg/day exhibited a statistically greater percentage reduction than the Alora 0.05 mg/day group at weeks 3, 4 and 8. By week 12, these two treatments were statistically indistinguishable. There were no serious or unexpected adverse events with the two transdermal systems and local skin tolerability was excellent. Other estrogenic effects such as restoration of vaginal cytology, breast tenderness and unexpected vaginal bleeding were comparable between transdermal and oral administration groups except for a lower incidence of bleeding in those women receiving the lower dose transdermal regimen.

Vaginal estrogen creams: use patterns among a cohort of women

OBJECTIVE

To assess the prevalence, amount, and duration of use of vaginal estrogen cream among several birth cohorts of women from 1983 through 1992.

DESIGN

Analyses are based on automated membership, pharmacy, and hospital discharge databases from Group Health Cooperative (GHC) of Puget Sound, a large health maintenance organization in Seattle, Washington.

PARTICIPANTS

A total of 33,822 women, aged 45 years and older as of December 31, 1983, who were enrolled in GHC from 1983 to 1992 or who were enrolled at baseline and died in the following decade.

RESULTS

About 24% of the cohort had filled at least one prescription for vaginal estrogen cream during 1983 through 1992, and about 60% of the users had more than one prescription filled. The annual birth cohort-specific prevalence of having filled one or more prescriptions for vaginal estrogen creams ranged between 1.6 and 8.2% across birth cohorts, whereas the average annual prevalence for the cohort was between 5.3 and 6.8%. The total amount, duration of use, and proportion of total estrogen exposure from creams increased with age of the birth cohort. Among the 733 women with intact uteri who were long-term cream users, 60.4% had no progestin prescriptions while averaging 22.1 tubes of estrogen cream.

CONCLUSION

The prescription-filling patterns for estrogen in this cohort show an increase in the amount, years of use, and proportion of estrogen exposure from creams with the age of the birth cohort and extensive unopposed cream use among a small proportion of women with intact uteri. The systemic effects of vaginal estrogen cream among older postmenopausal women with urogenital atrophy deserve closer scrutiny.

Menopause: when hormone replacement therapy is not an option. Part I

Although the perimenopausal period is often experienced as a positive life transition, it is frequently accompanied by a variety of distressing physical and emotional sequelae. Hormone replacement therapy (HRT) has been hailed as the first-line treatment for many of these symptoms. A significant number of women, however, are unable to take exogenous hormones because of absolute or relative contraindications to therapy. Other women are unwilling to use this treatment for a variety of reasons, including reluctance to use unnatural exogenous hormones and fear of unknown risks of HRT. This two-part review discusses the physiology of menopause and its related symptoms, as well as the risks and benefits of both oral and non-oral routes of hormone administration. Self-help measures and alternative therapeutic options are recommended for the treatment of menopausal symptoms, which include vasomotor instability, urogenital atrophy, psychologic disturbances, and risk of osteoporosis and cardiovascular disease.

[Estrogens for prevention of coronary heart disease?]

In recent years, reports of favourable effects of estrogen therapy on cardiovascular morbidity and mortality have led to enthusiasm for widespread use of estrogens by postmenopausal women. Guidelines for estrogen therapy issued by the American College of Physicians include the statement "Women who have coronary heart disease are likely to benefit from hormone therapy". What evidence support this recommendation? More than 30 observation studies have examined the effect of estrogen replacement therapy on cardiovascular event and all cause mortality. In addition there have been 13 case controlled studies. The majority showed lower morbidity and mortality from coronary heart disease among users of postmenopausal estrogens than among non-users. Recently, 2 meta-analyses estimated the reduction in coronary heart disease associated with estrogen use to be in the range of 35 to 44%, respectively. All of these observational studies share a fatal flaw: Women who take estrogens are different from women who do not. Some differences have been measured, others have not. Women who take estrogens are on average better educated, healthier, have higher incomes and have better access to health care. These difference rather than the estrogens may account for much of the lower risk of heart disease. At this time we cannot tell from these observational studies what the real benefit of estrogens on coronary heart disease might be. Estrogen replacement therapy is not without risk. Estrogens increase the risk of endometrial carcinoma approximately 6-fold, an effect that is eliminated by the addition of progestins. Controversy continues over whether estrogen replacement increases the risk of breast cancer. A number of prospective randomized studies are now under way that will establish whether estrogen replacement therapy definitely reduces the risk of cardiovascular disease in women with and without coronary lesions and whether it increases the risk of breast cancer. Until the results of these trials are available claims on the definite usefulness of hormone supplementation to prevent coronary heart disease in postmenopausal women remain premature. In the light of the probable usefulness estrogen replacement therapy for the prevention of cardiovascular events should be recommended for women with increased risk for or definitively proven coronary heart disease.

New developments in topical estrogen therapy

OBJECTIVE

To review new developments in transdermal E2 therapy in postmenopausal women.

DESIGN

A bibliographic search (Medline) of the medical literature from 1966 through 1995 was used to identify new studies evaluating transdermal E2.

PATIENT(S)

Menopausal and postmenopausal women.

RESULT(S)

Like oral estrogen, transdermal E2 relieves menopausal symptoms, reverses urogenital atrophy, and conserves bone economy. Initial studies have demonstrated beneficial effects of transdermal E2 on cardiovascular function. Quality of life, patient satisfaction, and compliance also improve with transdermal E2. Advances in transdermal delivery continue to emerge, including low-dose systems and patches that maintain serum E2 levels for a full 7-day period.

CONCLUSION(S)

New developments in transdermal administration have the potential to increase the number of postmenopausal women who accept and are compliant with long-term estrogen replacement therapy.

Hormone replacement therapy: management of common problems

OBJECTIVE

To describe common pitfalls associated with hormone replacement therapy (HRT) and recommendations to prevent or ameliorate them.

DESIGN

After pertinent articles and texts were reviewed, we outlined the available regimens of HRT, the commonly encountered side effects, and the management options.

RESULTS

HRT is frequently prescribed for elderly women. Vaginal bleeding, nausea, breast tenderness, migraine headaches, mood alterations, and abdominal bloating are common occurrences with HRT. These problems often can be managed by changing the dose, using another preparation or regimen, or altering the route of administration. For example, transdermal administration of estradiol may be tolerated better than oral therapy in patients with nausea. Irregular bleeding warrants endometrial biopsy to rule out hyperplasia.

CONCLUSION

With simple measures, common side effects of HRT can easily be managed by primary-care physicians. Gynecologic referral is recommended when endometrial biopsy is necessary or when symptoms fail to respond to adjustments in hormone therapy.