An Overview of Estrogen Replacement Therapy in Postmenopausal Women

Women's perceptions of hormone replacement therapy: risks and benefits (1980–2002). A literature review

OBJECTIVES

Many postmenopausal women are reluctant to take hormone replacement therapy (HRT) and those who do are likely to discontinue within 1 year. Setting aside the beliefs and prejudices of the prescriber, women's own perceptions of risks and benefits may influence their willingness to accept and then persevere with HRT. We conducted a systematic literature review relating women's beliefs about HRT to acceptance and adherence.

METHODS

Using standard guidelines for systematic search procedures, we identified 112 papers (published during 1980-2002) from databases such as Medline, PsycINFO and the NHS and Cochrane libraries.

RESULTS

Women hold both positive and negative beliefs about HRT. Their perceptions of benefits are often countered by concerns over potential adverse effects, beliefs that are sometimes at odds with the clinical evidence. The use and discontinuation of HRT are influenced more by short-term symptom relief than by considerations of long-term benefits. Many women who refuse HRT believe that the menopause is a natural event that does not warrant 'chemical' intervention. Doctors and nurses are not used to their full capacity as an education and information resource to counter the possibility of unbalanced stories in the media.

CONCLUSIONS

Addressing women's preconceptions about HRT should be an important part of the process of prescribing and review. Such an approach will help ensure that a woman's decision to start or continue HRT is informed by an understanding of the known risks and benefits, rather than by myths or mistaken beliefs about the menopause or HRT.

Knowledge and use of hormone replacement therapy among Polish women: estimates from a nationally representative study—HORTPOL 2002

OBJECTIVES

To evaluate the knowledge about hormone replacement therapy (HRT) and the prevalence of its current use in Polish female population.

METHODS

Cross-sectional survey on a representative sample of 1544 women between 18 and 87 years of age.

RESULTS

Almost half of the Polish women have heard of HRT. Depending on the education level, 26-38% of women knew that HRT alleviates the physical and psychological symptoms of menopause and 18-32% knew that HRT reduces the risk of developing osteoporosis. Forty-three percent of all the women with a higher level of education were aware that HRT increases the risk of breast and uterine cancer. The prevalence of current HRT use among women aged 45-64 was 12%. Women who had only basic education were less likely to use HRT than those with a medium and higher education level. Lack of information about HRT was the main cause of not using it. Forty-four percent of the perimenopausal women (age range 45-54 years) have never heard of HRT and 36% were never told by their healthcare providers that they could use it. Nineteen percent of perimenopausal women were not using HRT because they were afraid of the HRT related risks. Sixty-four percent of women who were using HRT were prescribed oral HRT preparations.

CONCLUSIONS

A fairly small proportion of Polish women currently uses HRT, largely because most remain poorly informed about the therapy.

Long-term trends in cancer mortality in the United States, 1930-1998

BACKGROUND

Progress against cancer can be examined by analyzing long-term trends in cancer incidence and mortality. The recent directive from the U.S. Department of Health and Human Services to adopt the 2000 U.S. standard population for the age adjustment of death rates prompted the American Cancer Society to update historical cancer mortality statistics using the new standard.

METHODS

Mortality data were abstracted by race, gender, year, and age at death for 1930 through 1959 from annual volumes of Vital Statistics of the United States. For 1960 through 1998, these data were obtained from data tapes provided by the National Center for Health Statistics. Two U.S. standard million populations (1970 and 2000) were used to calculate age-adjusted rates. Average annual percent change was estimated for each decade by site, gender, and age, and the statistical significance of the change was assessed at p < 0.05.

RESULTS

After long-term increases or mostly level trends that date from the 1930s for some sites, death rates for cancers of the lung (in males), prostate, female breast, colon-rectum, pancreas, leukemia, and ovary were decreasing in the 1990s. Liver cancer death rates were increasing in the 1990s. Throughout the study period, death rates for female lung cancer increased, while death rates for stomach and uterine cancers declined.

CONCLUSIONS

The trends of decreasing cancer death rates for the leading cancer sites in the 1990s are encouraging. However, surveillance researchers must continue to monitor these declines to assess whether the progress seen in this decade persists. Efforts also must be made to study the sites with increasing trends and identify potential underlying causes.

Midlife women making hormone therapy decisions

This study focuses on midlife women aged 40-65 years who were in transition to menopause, were menopausal or had a hysterectomy, to examine and better understand hormone therapy (HT) choices women make. Among the nationally representative sample of women in the Commonwealth Fund 1998 Survey of Women's Health (n = 884), 39% of the menopausal women reported current HT use. The two primary reasons for initiating HT are following a doctor's recommendation and seeking relief of menopausal symptoms. Age, education, race, hysterectomy status, having health insurance, use of calcium supplements and comfort in communicating with a doctor are important factors associated with HT use. This study underscores the importance of physicians and other health professionals providing accurate HT information to assist women in making HT decisions.

Selective estrogen receptor modulators: the ideal estrogen replacement?(2)(2)

The ultimate estrogen for replacement therapy should exert beneficial actions upon the skeletal, cardiovascular, and central nervous systems while displaying minimal side effects in the uterus and breast. Selective estrogen receptor modulators (SERMs), such as tamoxifen and raloxifene, have recently been studied to achieve these aims. Not only are these agents potentially effective in reducing a patient's risk of breast carcinoma but they have also been shown to increase bone mineral density and prevent osteoporosis. Displaying favorable effects on lipid metabolism, SERMs also may be protective against coronary heart disease and myocardial infarction. Tamoxifen's adverse side effects on the uterus have not been noted with raloxifene, because the latter behaves as an estrogen antagonist in the endometrium. Ongoing studies, such as the Study of Tamoxifen and Raloxifene and the Raloxifene Use for the Heart trials, may help to further determine whether SERMs are the ideal estrogen for the postmenopausal female patient.

Hormone replacement therapy: knowledge, attitudes, self-reported use - and sales figures in Nordic women

OBJECTIVES

To evaluate knowledge about, attitudes towards and use of hormone replacement therapy (HRT) in Norwegian women - and to compare self-reported use with sales statistics of HRT in the Nordic countries during recent years.

MATERIAL AND METHODS

Random samples of Norwegian women age 16-79 were interviewed by the Central Bureau of Statistics in 1994 (n=737), in 1996 (n=665) and in 1998 (n=680). Statistics on the sale of estrogen were provided by the Norwegian Medical Depot and Nordic Council on Medicines.

RESULTS

One in three women had received information about HRT during the last 2 years (1994), mainly through weekly magazines and physicians. The proportion answering in accordance with the prevailing view of HRT's effects ('correct knowledge') varied from 36.4 to 47.2%. Those informed by a physician possessed correct knowledge, had positive attitudes towards HRT and were willing to use HRT more often than women informed through other channels. Women with a high level of education had received information and had correct knowledge more often than others, but they were still less willing to use HRT and did not use HRT more often than the less educated. In the age group 45-69 years the use of HRT was 16.3% in 1994, 19.1% in 1996 and 19. 1% in 1998 (P=0.421, trend). In addition to received information, attitudes towards and knowledge about estrogen were the most important factors predicting use of HRT after adjusting for other variables. According to sales figures, the use of systemic estrogen in Norway has increased more than 360% since 1990. Although no other Nordic country has experienced a corresponding increase, Iceland had the highest sales figures in 1997.

CONCLUSIONS

Based on the limited proportion of women receiving information on HRT and the ambivalence found in groups of educated women, we suggest that more and better information should be given middle-aged women to make them better able to make informed choices regarding use of HRT.

Clinical efficacy of raloxifene in postmenopausal women

A new class of compounds known as selective estrogen receptor modulators (SERMs) may possess the optimal combination of characteristics desirable in a drug designed for use in postmenopausal women. Among this class of compounds, raloxifene is the most studied and is currently available for clinical use in some countries for the prevention of osteoporosis in post-menopausal women. Raloxifene is a non-steroidal benzotiophene derivative shown to prevent bone loss at axial and appendicular sites and reduce serum cholesterol, like estrogen, in oophorectomized rats and in postmenopausal women. In animal models, unlike estrogen, raloxifene does not stimulate breast or uterine tissues. These appealing attributes make raloxifene a potential treatment for osteoporosis and other menopause related risks in middle aged and elderly women. Multicenter studies have been performed in early postmenopausal women, randomly assigned to receive raloxifene 30, 60, or 150 mg/day or placebo. All subjects received a calcium supplement. Bone mineral density, which was measured twice a year over 24 months by dual X-ray absorptiometry, decreased significantly at all skeletal sites with placebo, and significantly increased with raloxifene at the spine, hip, and total body at the three doses. At 24 months, the mean increase with raloxifene 60 mg compared with placebo was 2.4% at the lumbar spine and at the total hip, and 2% at the total body. Markers of bone formation (serum osteocalcin and bone specific alkaline phosphatase) and of resorption (urinary CrossLaps) decreased significantly to the premenopausal range within 3-6 months of treatment with raloxifene. In addition, total serum and low-density lipoprotein cholesterol decreased significantly in all raloxifene therapy groups in a dose-related fashion. Serum HDL-cholesterol and triglycerides were not significantly changed by therapy. The most commonly observed side-effect was hot flushes, with patients taking raloxifene reporting a slightly higher rate of flushes (25%) than those on placebo (18%). This adverse event usually occurred within the first few months of therapy, was generally mild, and did not result in excess study dropout (raloxifene 1.5%, placebo 2.1%). Preliminary 2-year data indicated that raloxifene is not associated with an increased risk of breast cancer. In summary, the clinical efficacy and safety of raloxifene is very promising and this compound will offer a particularly attractive choice for postmenopausal women.

Behavioral and neurobiological effects of estrogen replacement therapy and a history of triphasic oral contraceptive exposure

The effects of contraceptive steroids and estrogen replacement therapy on behavior and neuroendocrine function were evaluated in adult female cynomolgus monkeys. During the 'premenopausal' phase of the experiment, the animals were assigned to either treatment with a triphasic oral contraceptive (OC) for 24 months or the untreated control group. The monkeys were then ovariectomized and half of each of the premenopausal groups were randomly assigned to either treatment with conjugated equine estrogens (ERT) or the untreated control group for 12 months (the 'postmenopausal' phase). All evaluations were completed during the postmenopausal phase of the experiment. Both types of exogenous steroid treatments appeared to increase cardiovascular and hypothalamic-pituitary-adrenal responses to stress in socially dominant but not socially subordinate females. A history of triphasic OC administration increased contact aggression received, and reduced the prolactin response to fenfluramine, suggesting reduced serotonergic activity, for at least a year following the cessation of triphasic OC treatment.

Fracture risk following bilateral oophorectomy

To assess fracture risk following bilateral oophorectomy, we conducted a population-based retrospective cohort study among the 463 Rochester, Minnesota women who underwent bilateral oophorectomy for benign ovarian conditions in 1950-1979. During 7220 person-years of observation, there appeared to be a modest increase in the risk of distal forearm fractures (standardized morbidity ratio [SMR] 1.4; 95% CI 1.0-2.0) and vertebral fractures (SMR 1.9; 95% CI 1.3-2.8) but not hip fractures (SMR] 1.1; 95% CI 0.6-1.9). Although our statistical power was quite limited, there was a suggestion that women who became estrogen deficient at a young age were at greater risk of fracture. However, the youngest women were more likely to be on estrogen replacement therapy, and for longer durations, so that the average age at the onset of estrogen deficiency in this population was 47 years.

Estrogen replacement therapy in practice: trends and issues

Since their availability in 1926, estrogens and their use in postmenopausal women have met with both acceptance and alarm by the medical profession and potential estrogen users. It was not until the 1980s that long-term research began to demonstrate the beneficial effects of estrogen, thus contributing to a significant increase in use during the past decade. This article provides information on current use of estrogen replacement therapy and describes factors influencing continuance. Poor continuance remains a barrier to the full potential of estrogen replacement therapy for postmenopausal women. The role of the physician in improving continuance is discussed.

Clinical experience with a seven-day estradiol transdermal system for estrogen replacement therapy

OBJECTIVE

To describe the efficacy, safety, and wearability of estrogen replacement therapy of a 7-day estradiol transdermal system (Climara), developed using new drug-in-adhesive technology.

STUDY DESIGN

The pharmacokinetics of the 7-day system were investigated in single- and multiple-dose studies, a relative bioavailability study of the two patch sizes, and comparative studies with the twice-weekly transdermal system (Estraderm). Safety and efficacy in the treatment of vasomotor symptoms compared with conjugated equine estrogens (Premarin) and placebo were evaluated in two 11-week, randomized, double-blind, multicenter trials in 603 women; the data are combined in this report. Irritation and adhesion were also evaluated in comparative studies with Estraderm, Micropore (an inert once-weekly tape), and placebo controls.

RESULTS

Blood levels were sustained for the full 7 days of patch wear, there was no drug accumulation, and a physiologic estrone to estradiol ratio was maintained. Pharmacokinetics studies showed dose proportionality of the 0.05 and 0.1 mg/day patches. Both patch sizes significantly decreased the frequency of hot flushes compared with placebo and were comparable with conjugated equine estrogens. There was a statistically significant difference between the two patch sizes. The mean overall decline in the hot flush rate was 74.6% for the 0.1 mg patch versus 64.5% for the 0.05 mg patch (p < or = 0.05). The combined data also showed that the onset of efficacy is within 1 to 2 weeks after the start of therapy and that efficacy is fully sustained during the 7-day patch wear period with some diminution of effect during the treatment-free week of each cycle. Treatment was well tolerated. Adverse events led to withdrawal from the studies in 8.9% of subjects. In most of these (6.8% of subjects), the cause was adverse skin reactions. Skin irritation was similar to Estraderm in comparative studies, whereas adhesion was significantly better with Climara.

CONCLUSION

The Climara patch delivers estradiol for a full 7 days. Clinical efficacy of both patch sizes is comparable with currently accepted therapy and is sustained for the entire week of patch wear. A significant difference in response between the two doses supports dose titration. The patch is well tolerated and has excellent adhesion.