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Kauffman RP, MacLaughlin EJ, Courtney LA, Vineyard DD. Fear, misinformation, and pharmaceutical messianism in the promotion of compounded bioidentical hormone therapy. FRONTIERS IN REPRODUCTIVE HEALTH 2024; 6:1378644. [PMID: 38486847 PMCID: PMC10937438 DOI: 10.3389/frph.2024.1378644] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Accepted: 02/20/2024] [Indexed: 03/17/2024] Open
Abstract
Compounded bioidentical hormone therapy (cBHT) for menopausal symptoms maintains popularity in western countries despite the availability of hormone products in different formulations and dosages produced by pharmaceutical companies with federal oversight. Akin to many populist therapeutic trends in the history of medicine, cBHT advocates tend to capitalize on consumer fears about existing FDA-approved hormone treatments. Unsubstantiated, exaggerated, or outright false claims are commonplace in promoting cBHT. Given these elements, the basic elements of pharmaceutical messianism continue to drive the cBHT movement.
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Affiliation(s)
- Robert P. Kauffman
- Department of Obstetrics and Gynecology, Texas Tech University Health Sciences Center School of Medicine, Amarillo, TX, United States
| | - Eric J. MacLaughlin
- Department of Pharmacy Practice, Texas Tech University Health Sciences Jerry H. Hodge School of Pharmacy, Amarillo, TX, United States
| | - Lindsay A. Courtney
- Department of Pharmacy Practice, Texas Tech University Health Sciences Jerry H. Hodge School of Pharmacy, Amarillo, TX, United States
| | - David D. Vineyard
- Department of Obstetrics and Gynecology, Texas Tech University Health Sciences Center School of Medicine, Amarillo, TX, United States
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Compounded Bioidentical Menopausal Hormone Therapy: ACOG Clinical Consensus No. 6. Obstet Gynecol 2023; 142:1266-1273. [PMID: 37856860 DOI: 10.1097/aog.0000000000005395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2023]
Abstract
SUMMARY Many compounding pharmacies use the phrase "bioidentical hormone" as a marketing term to imply that these preparations are natural and, thus, safer and more effective than U.S. Food and Drug Administration (FDA)-approved menopausal medications that use bioidentical or synthetic hormones or both. However, evidence to support marketing claims of safety and effectiveness is lacking. Compounded bioidentical menopausal hormone therapy should not be prescribed routinely when FDA-approved formulations exist. Clinicians should counsel patients that FDA-approved menopausal hormone therapies are recommended for the management of menopausal symptoms over compounded bioidentical menopausal hormone therapy. If a patient requests the use of compounded bioidentical menopausal hormone therapy, clinicians should educate them on the lack of FDA approval of these preparations and their potential risks and benefits, including the risks specific to compounding. To truly understand the benefits and harms of compounded bioidentical menopausal hormone therapy, high quality placebo-controlled randomized controlled trials with long-term follow-up comparing custom-compounded products with FDA-approved menopausal hormone therapy are needed.
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Abstract
ABSTRACT Following the release of the Women's Health Initiative data, women began to use compounded bioidentical hormone therapy (cBHT) in the misguided belief of greater safety and efficacy than traditional hormone therapy. New guidelines recommend government-approved hormone therapy for symptomatic healthy menopausal women younger than 60 years or within 10 years of menopause at the time of initiation. For women requesting bioidentical hormones, those similar to the hormones present before menopause, there are many government-approved hormone therapies with extensive pharmacokinetic, safety, and efficacy data provided with package inserts delineating efficacy, safety, and potential risks. For women requesting non-Food and Drug Administration-approved (cBHT), these cBHTs lack data on pharmacokinetics, safety, and efficacy and are not provided a label detailing risk. Their use should be restricted to women with allergies or dosing or formulations not available in government-approved therapies. Pellet therapy providing women with supraphysiologic hormone dosing raises even more safety concerns.
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Flores VA, Pal L, Manson JE. Hormone Therapy in Menopause: Concepts, Controversies, and Approach to Treatment. Endocr Rev 2021; 42:720-752. [PMID: 33858012 DOI: 10.1210/endrev/bnab011] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Indexed: 12/22/2022]
Abstract
Hormone therapy (HT) is an effective treatment for menopausal symptoms, including vasomotor symptoms and genitourinary syndrome of menopause. Randomized trials also demonstrate positive effects on bone health, and age-stratified analyses indicate more favorable effects on coronary heart disease and all-cause mortality in younger women (close proximity to menopause) than in women more than a decade past menopause. In the absence of contraindications or other major comorbidities, recently menopausal women with moderate or severe symptoms are appropriate candidates for HT. The Women's Health Initiative (WHI) hormone therapy trials-estrogen and progestin trial and the estrogen-alone trial-clarified the benefits and risks of HT, including how the results differed by age. A key lesson from the WHI trials, which was unfortunately lost in the posttrial cacophony, was that the risk:benefit ratio and safety profile of HT differed markedly by clinical characteristics of the participants, especially age, time since menopause, and comorbidity status. In the present review of the WHI and other recent HT trials, we aim to provide readers with an improved understanding of the importance of the timing of HT initiation, type and route of administration, and of patient-specific considerations that should be weighed when prescribing HT.
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Affiliation(s)
- Valerie A Flores
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, New Haven, Connecticut, USA
| | - Lubna Pal
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, New Haven, Connecticut, USA
| | - JoAnn E Manson
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Watson CJ, Whitledge JD, Siani AM, Burns MM. Pharmaceutical Compounding: a History, Regulatory Overview, and Systematic Review of Compounding Errors. J Med Toxicol 2021; 17:197-217. [PMID: 33140232 PMCID: PMC7605468 DOI: 10.1007/s13181-020-00814-3] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 09/13/2020] [Accepted: 09/17/2020] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION Medications are compounded when a formulation of a medication is needed but not commercially available. Regulatory oversight of compounding is piecemeal and compounding errors have resulted in patient harm. We review compounding in the United States (US), including a history of compounding, a critique of current regulatory oversight, and a systematic review of compounding errors recorded in the literature. METHODS We gathered reports of compounding errors occurring in the US from 1990 to 2020 from PubMed, Embase, several relevant conference abstracts, and the US Food and Drug Administration "Drug Alerts and Statements" repository. We categorized reports into errors of "contamination," suprapotency," and "subpotency." Errors were also subdivided by whether they resulted in morbidity and mortality. We reported demographic, medication, and outcome data where available. RESULTS We screened 2155 reports and identified 63 errors. Twenty-one of 63 were errors of concentration, harming 36 patients. Twenty-seven of 63 were contamination errors, harming 1119 patients. Fifteen errors did not result in any identified harm. DISCUSSION Compounding errors are attributed to contamination or concentration. Concentration errors predominantly result from compounding a prescription for a single patient, and disproportionately affect children. Contamination errors largely occur during bulk distribution of compounded medications for parenteral use, and affect more patients. The burden falls on the government, pharmacy industry, and medical providers to reduce the risk of patient harm caused by compounding errors. CONCLUSION In the US, drug compounding is important in ensuring access to vital medications, but has the potential to cause patient harm without adequate safeguards.
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Affiliation(s)
- C James Watson
- Harvard Medical Toxicology Program, Boston Children's Hospital, 333 Longwood Avenue, Mailstop 3025, Boston, MA, 02215, USA.
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA.
| | - James D Whitledge
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | | | - Michele M Burns
- Harvard Medical Toxicology Program, Boston Children's Hospital, 333 Longwood Avenue, Mailstop 3025, Boston, MA, 02215, USA
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA, USA
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Abstract
After the results of the Women's Health Initiative trials were published, patient and clinician interest in potential alternatives to conventional hormone therapy (HT) has grown. A commonly used alternative therapy involves custom-compounded steroid hormone preparations, formulated by compounding pharmacies. Many postmenopausal women consider the hormones as natural or bioidentical, in contrast to hormones used in conventional HT, which they consider synthetic. In actuality, the chemical structures of many of the hormones used in bioidentical HT (BHT) are the same as those used in conventional HT. To customize formulations, compounding pharmacies frequently use saliva testing to measure hormones. However, there is a misconception that salivary hormone levels are equivalent to non-protein-bound (free) hormones in blood. Because hormonal custom-compounded formulations are not approved by the Food and Drug Administration (FDA), there are concerns regarding their purity, potency, and quality. Evolving regulatory guidelines by the FDA on oversight of these products should lessen the concerns regarding their safety and efficacy. This review addresses important misconceptions and uncertainties pertaining to BHT, the relationship between salivary and serum/plasma steroid hormone concentrations, the effect of topical progesterone creams on the endometrium, the variability in custom-compounded steroid preparations, and FDA oversight of custom-compounded products.
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Affiliation(s)
- F Z Stanczyk
- Departments of Obstetrics and Gynecology.,Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - H Matharu
- Departments of Obstetrics and Gynecology
| | - S A Winer
- Departments of Obstetrics and Gynecology
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The National Academies of Science, Engineering, and Medicine (NASEM) Report on Compounded Bioidentical Hormone Therapy. ACTA ACUST UNITED AC 2020; 27:1199-1201. [DOI: 10.1097/gme.0000000000001672] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
One of the defining moments of the 80-year evolution of menopausal hormone therapy (MHT) was the 2002 reveal of the initial results of the combined hormone therapy arm of the Women's Health Initiative (WHI) clinical trial. The exodus from regulatory approved MHT was prompt and profound and accompanied by a rapid acceleration of the compounding pharmacy 'bioidentical' hormone therapy industry. Compounders had recruited prescribers and promoted compounded bioidentical hormone therapy (cBHT) well before the WHI, yet the startling results provided a catalyst that enabled a leap in production of compounded hormones that were variably regulated, basically unstudied, and inconsistently labeled. In this review, the story of the rise of cBHT and the regulatory double standard is eclipsed only by the 2020 findings and recommendations of the US National Academies of Science, Engineering, and Medicine. Their investigation, commissioned by the US Food and Drug Administration, was tasked to: provide an evidence-based summary of the clinical utility of cBHT; evaluate whether the evidence of safety and efficacy supports the use of cBHT; and identify patient populations that might need cBHT in lieu of an approved drug product. Their conclusions are consistent with sound science and their recommendations are in harmony with global menopause societies.
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Affiliation(s)
- C A Stuenkel
- University of California, San Diego, School of Medicine, La Jolla, CA, USA
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Del Río JP, Molina S, Hidalgo-Lanussa O, Garcia-Segura LM, Barreto GE. Tibolone as Hormonal Therapy and Neuroprotective Agent. Trends Endocrinol Metab 2020; 31:742-759. [PMID: 32507541 DOI: 10.1016/j.tem.2020.04.007] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2020] [Accepted: 04/24/2020] [Indexed: 12/11/2022]
Abstract
Tibolone (TIB), a selective tissue estrogenic activity regulator (STEAR) in clinical use by postmenopausal women, activates hormonal receptors in a tissue-specific manner. Estrogenic activity is present mostly in the brain, vagina, and bone, while the inactive forms predominate in the endometrium and breast. Conflicting literature on TIB's actions has been observed. While it has benefits for vasomotor symptoms, bone demineralization, and sexual health, a higher relative risk of hormone-sensitive cancer has been reported. In the brain, TIB can improve mood and cognition, neuroinflammation, and reactive gliosis. This review aims to discuss the systemic effects of TIB on peri- and post-menopausal women and its role in the brain. We suggest that TIB is a hormonal therapy with promising neuroprotective properties.
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Affiliation(s)
- Juan Pablo Del Río
- Reproductive Health Research Institute, Santiago, Chile; Translational Psychiatry Laboratory, Clínica Psiquiátrica Universitaria, Hospital Clínico, Universidad de Chile, Santiago, Chile; Millennium Nucleus to Improve the Mental Health of Adolescents and Youths (Imhay), Santiago, Chile
| | | | - Oscar Hidalgo-Lanussa
- Departamento de Nutrición y Bioquímica, Pontificia Universidad Javeriana, Bogotá, Colombia
| | - Luis Miguel Garcia-Segura
- Instituto Cajal, CSIC, Madrid, Spain; Centro de Investigación Biomédica en Red Fragilidad y Envejecimiento Saludable (CIBERFES), Instituto de Salud Carlos III, Madrid, Spain
| | - George E Barreto
- Department of Biological Sciences, School of Natural Sciences, University of Limerick, Limerick, Ireland; Health Research Institute, University of Limerick, Limerick, Ireland.
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Evaluation of clinical meaningfulness of estrogen plus progesterone oral capsule (TX-001HR) on moderate to severe vasomotor symptoms. Menopause 2020; 26:513-519. [PMID: 30516713 PMCID: PMC6493698 DOI: 10.1097/gme.0000000000001261] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Objective: The aim of this study was to determine the clinical meaningfulness of TX-001HR in reducing moderate to severe vasomotor symptoms (VMS) in menopausal women with a uterus. Methods: In the REPLENISH study (NCT01942668), women with moderate to severe hot flushes (≥7/d or ≥50/wk) were enrolled in a VMS substudy and randomized to four doses of daily TX-001HR (17β-estradiol/progesterone) or placebo. Participants assessed improvement of their VMS by the Clinical Global Impression and the Menopause-Specific Quality of Life (MENQOL) questionnaire, which were used to define clinical responders, clinically important differences (CIDs) or minimal CID (MCID) in VMS frequency. Response thresholds were determined by nonparametric discriminant analyses utilizing bootstrapping methods. Results: In the modified intent-to-treat VMS substudy population (n = 726), statistically significantly more Clinical Global Impression–based clinical responders were observed with TX-001HR than placebo for MCID (weekly reduction of ≥25 moderate to severe VMS: 82-88% vs 69%; all, P < 0.05) and CID (weekly reduction of ≥39 VMS: 68%-73% vs 52%; all, P < 0.05) at week 12. Week 4 results were similar. For Menopause Quality of Life–based analysis, significantly more clinical responders were observed with TX-001HR than placebo for MCID (weekly reduction of ≥34 VMS: 74%-81% vs 55%; all, P < 0.01) and CID (weekly reduction of ≥44 VMS: 61%-69% vs 42%; all, P < 0.01) at week 12. Conclusions: TX-001HR provided clinically meaningful improvements (as measured by 2 different methods), in addition to statistically significant reductions, in menopausal VMS frequency. TX-001HR may provide a new option, as a single oral capsule of estradiol and progesterone (identical to the hormones naturally occurring in women) for the treatment of moderate to severe VMS in menopausal women with a uterus.
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12
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Oral 17β-estradiol/progesterone (TX-001HR) and quality of life in postmenopausal women with vasomotor symptoms. Menopause 2020; 26:506-512. [PMID: 30489424 PMCID: PMC6493699 DOI: 10.1097/gme.0000000000001271] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Objective: The aim of the study was to describe the effects of TX-001HR (17β-estradiol [E2] and natural progesterone [P4] in a single oral capsule) on menopause-specific quality of life in women with moderate to severe vasomotor symptoms (VMS). Methods: The REPLENISH study (NCT01942668) was a phase 3, randomized, double-blind, placebo-controlled, multicenter trial which evaluated four E2/P4 doses in postmenopausal women with VMS and a uterus. Women with moderate to severe hot flushes (≥7/d or ≥50/wk) were included in a VMS substudy. Participants self-administered the Menopause-Specific Quality of Life (MENQOL) questionnaire. Baseline changes in MENQOL overall and domains were determined as well as correlations between changes in MENQOL scores and VMS frequency or severity. Results: In the VMS substudy, women treated with E2/P4 had significantly greater improvements from baseline in their MENQOL overall score at week 12, and months 6 and 12, compared with placebo (all, P < 0.05, except the lowest E2/P4 dose at months 6 and 12). Improvements from baseline for the MENQOL vasomotor domain score were significantly greater with TX-001HR doses versus placebo at all time points (all, P < 0.01). Changes in MENQOL vasomotor scores moderately correlated with changes in VMS frequency (r = 0.56, P < 0.0001) and severity (r = 0.55, P < 0.0001). Conclusion: In the REPLENISH trial, women with moderate to severe VMS treated with most E2/P4 doses reported significant improvements in quality of life from baseline to 12 weeks compared with placebo, which were maintained up to 12 months. TX-001HR, if approved, may provide the first oral hormone therapy formulation in a single capsule containing E2 and P4 for the treatment of VMS in postmenopausal women with a uterus.
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Kagan R, Kellogg-Spadt S, Parish SJ. Practical Treatment Considerations in the Management of Genitourinary Syndrome of Menopause. Drugs Aging 2020; 36:897-908. [PMID: 31452067 PMCID: PMC6764929 DOI: 10.1007/s40266-019-00700-w] [Citation(s) in RCA: 46] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Genitourinary syndrome of menopause is a condition comprising the atrophic symptoms and signs women may experience in the vulvovaginal and bladder-urethral areas as a result of the loss of sex steroids that occurs with menopause. It is a progressive condition that does not resolve without treatment and can adversely affect a woman’s quality of life. For a variety of reasons, many symptomatic women do not seek treatment and, of those who do, many are unhappy with their options. Additionally, many healthcare providers do not actively screen their menopausal patients for the symptoms of genitourinary syndrome of menopause. In this review, we discuss the clinical presentation of genitourinary syndrome of menopause as well as the treatment guidelines recommended by the major societies engaged in women’s health. This is followed by a review of available treatment options that includes both hormonal and non-hormonal therapies. We discuss both the systemic and vaginal estrogen products that have been available for decades and remain important treatment options for patients; however, a major intent of the review is to provide information on the newer, non-estrogen pharmacologic treatment options, in particular oral ospemifene and vaginal prasterone. A discussion of adjunctive therapies such as moisturizers, lubricants, physical therapy/dilators, hyaluronic acid, and laser therapy is included. We also address some of the available data on both the patient and healthcare providers perspectives on treatment, including cost, and touch briefly on the topic of treating women with a history of, or at high risk for, breast cancer.
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Affiliation(s)
- Risa Kagan
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, Affiliated with Sutter East Bay Medical Foundation, Sutter East Bay Medical Group, 2500 Milvia Street, Berkeley, CA, 94704, USA.
| | - Susan Kellogg-Spadt
- Drexel University College of Medicine, Philadelphia, PA, USA.,Center for Pelvic Medicine, Bryn Mawr, PA, USA
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Stanczyk FZ, Niu C, Azen C, Mirkin S, Amadio JM. Determination of estradiol and progesterone content in capsules and creams from compounding pharmacies. Menopause 2019; 26:966-971. [PMID: 31453957 PMCID: PMC6738624 DOI: 10.1097/gme.0000000000001356] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Revised: 04/05/2019] [Accepted: 04/05/2019] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To analytically characterize the doses of estradiol and progesterone found in compounded combined forms of oral capsule and transdermal cream formulations, and determine the consistency of the hormone formulations within a batch. METHODS Prescriptions for combined estradiol/progesterone capsules (0.5 and 100 mg, respectively) and creams (0.5 and 100 mg/g, respectively) were sent to 15 custom-compounding pharmacies. Estradiol and progesterone levels were measured by radioimmunoassays. Hormone levels were measured in 2 capsules and 2 creams from each pharmacy; 10 capsules from 3 pharmacies; and top/middle/bottom layer of cream containers to assess consistency. The magnitude and sources of variation for the measurements were examined by analysis of variance models. RESULTS Thirteen pharmacies filled the prescriptions. Measured estradiol levels were 0.365 to 0.551 mg for capsules and 0.433 to 0.55 mg/g for creams, and progesterone levels were 90.8 to 135 mg for capsules and 93 to 118 mg/g for creams. Greater variations in estradiol levels were observed between pharmacies for estradiol in capsules than in creams; however, measured estradiol levels within pharmacies were more consistent in the capsules than the creams. Similar results were obtained for progesterone levels. CONCLUSION The variations in estradiol and progesterone levels observed in compounded hormone therapy formulations justify concerns regarding risks as a result of variability, which have been outlined by The North American Menopause Society, the American College of Obstetricians and Gynecologists, and the US Food and Drug Administration (FDA) in their statements regarding compounded hormone use. These data support the need for an US FDA-approved bioidentical hormone therapy. : Video Summary: Supplemental Digital Content 1, http://links.lww.com/MENO/A425.
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Affiliation(s)
- Frank Z. Stanczyk
- Department of Obstetrics and Gynecology, Keck School of Medicine, University of Southern California, Los Angeles, CA
- Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Chunying Niu
- Department of Obstetrics and Gynecology, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Colleen Azen
- Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA
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Lobo RA, Kaunitz AM, Santoro N, Bernick B, Graham S, Mirkin S. Metabolic and cardiovascular effects of TX-001HR in menopausal women with vasomotor symptoms. Climacteric 2019; 22:610-616. [PMID: 31364889 DOI: 10.1080/13697137.2019.1640197] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Objective: This study aimed to evaluate the effects of TX-001HR (17β-estradiol [E2] and progesterone [P4] in a single oral capsule) on cardiometabolic markers and outcomes. Methods: Four E2/P4 doses (1 mg/100 mg, 0.5 mg/100 mg, 0.5 mg/50 mg, 0.25 mg/50 mg) were compared with placebo in menopausal women with vasomotor symptoms (VMS) and a uterus in the phase 3 REPLENISH (ClinicalTrials.gov, NCT01942668) trial. Changes in lipid and coagulation parameters and blood glucose from baseline at 6, 9, and 12 months as well as cardiovascular events are summarized. Results: A total of 1835 participants took ≥1 capsule of daily E2/P4; 1684 received E2/P4 and 151 received placebo. No clinically significant changes in lipid parameters, coagulation factors, or glucose were observed between treatment groups. Minimal increases of potential clinical importance were observed in total cholesterol, triglycerides, and glucose at month 12 with E2/P4 (1-4%, 6-11%, and 1%, respectively) and placebo (3%, 7%, and 2%, respectively). One episode of deep venous thrombosis and three cases of cardiovascular disease were observed, similar to expected rates of these events in the general population. Conclusions: In the REPLENISH trial, postmenopausal women with VMS treated with E2/P4 had no clinically meaningful effects on lipids, glucose, or coagulation parameters compared with placebo.
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Affiliation(s)
- R A Lobo
- Department of Obstetrics and Gynecology, Columbia University Medical Center , New York , NY , USA
| | - A M Kaunitz
- Department of Obstetrics and Gynecology, University of Florida College of Medicine-Jacksonville , Jacksonville , FL , USA
| | - N Santoro
- Department of Obstetrics and Gynecology, University of Colorado School of Medicine , Aurora , CO , USA
| | - B Bernick
- TherapeuticsMD , Boca Raton , FL , USA
| | - S Graham
- TherapeuticsMD , Boca Raton , FL , USA
| | - S Mirkin
- TherapeuticsMD , Boca Raton , FL , USA
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A long and winding road: reflections on the evolution of menopause medicine over a professional lifetime. Menopause 2018; 25:1395-1400. [PMID: 30489458 DOI: 10.1097/gme.0000000000001205] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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17
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Torres MJ, Ryan TE, Lin CT, Zeczycki TN, Neufer PD. Impact of 17β-estradiol on complex I kinetics and H 2O 2 production in liver and skeletal muscle mitochondria. J Biol Chem 2018; 293:16889-16898. [PMID: 30217819 DOI: 10.1074/jbc.ra118.005148] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Revised: 09/11/2018] [Indexed: 12/14/2022] Open
Abstract
Naturally or surgically induced postmenopausal women are widely prescribed estrogen therapies to alleviate symptoms associated with estrogen loss and to lower the subsequent risk of developing metabolic diseases, including diabetes and nonalcoholic fatty liver disease. However, the molecular mechanisms by which estrogens modulate metabolism across tissues remain ill-defined. We have previously reported that 17β-estradiol (E2) exerts antidiabetogenic effects in ovariectomized (OVX) mice by protecting mitochondrial and cellular redox function in skeletal muscle. The liver is another key tissue for glucose homeostasis and a target of E2 therapy. Thus, in the present study we determined the effects of acute loss of ovarian E2 and E2 administration on liver mitochondria. In contrast to skeletal muscle mitochondria, E2 depletion via OVX did not alter liver mitochondrial respiratory function or complex I (CI) specific activities (NADH oxidation, quinone reduction, and H2O2 production). Surprisingly, in vivo E2 replacement therapy and in vitro E2 exposure induced tissue-specific effects on both CI activity and on the rate and topology of CI H2O2 production. Overall, E2 therapy protected and restored the OVX-induced reduction in CI activity in skeletal muscle, whereas in liver mitochondria E2 increased CI H2O2 production and decreased ADP-stimulated respiratory capacity. These results offer novel insights into the tissue-specific effects of E2 on mitochondrial function.
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Affiliation(s)
- Maria J Torres
- From the East Carolina Diabetes and Obesity Institute.,the Department of Kinesiology, and
| | - Terence E Ryan
- From the East Carolina Diabetes and Obesity Institute.,the Departments of Physiology, and
| | - Chien-Te Lin
- From the East Carolina Diabetes and Obesity Institute.,the Departments of Physiology, and
| | - Tonya N Zeczycki
- From the East Carolina Diabetes and Obesity Institute, .,Biochemistry & Molecular Biology, Brody School of Medicine, East Carolina University, Greenville, North Carolina 27834
| | - P Darrell Neufer
- From the East Carolina Diabetes and Obesity Institute, .,the Department of Kinesiology, and.,the Departments of Physiology, and
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A 17β-Estradiol–Progesterone Oral Capsule for Vasomotor Symptoms in Postmenopausal Women. Obstet Gynecol 2018; 132:161-170. [DOI: 10.1097/aog.0000000000002645] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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Abstract
Vasomotor symptoms are the most common manifestation of the menopause transition and postmenopausal phases of reproductive life. They interfere not only in quality of life, but also contribute to sleep and mood disturbances that potentially compromise home and work effectiveness. Treatment options include hormone therapy (HT), nonhormonal prescription drugs, mind body and behavior therapies, and over-the-counter preparations. Evidence confirms that HT is the most effective option. The initial reticence to prescribe HT immediately following publication of the Women's Health Initiative has been replaced by clear guidelines for confidently identifying women for whom this therapy will be safe.
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Del Río JP, Alliende MI, Molina N, Serrano FG, Molina S, Vigil P. Steroid Hormones and Their Action in Women's Brains: The Importance of Hormonal Balance. Front Public Health 2018; 6:141. [PMID: 29876339 PMCID: PMC5974145 DOI: 10.3389/fpubh.2018.00141] [Citation(s) in RCA: 91] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2017] [Accepted: 04/27/2018] [Indexed: 12/19/2022] Open
Abstract
Sex hormones significantly impact women's lives. Throughout the different stages of life, from menarche to menopause and all stages in between, women experience dramatic fluctuations in the levels of progesterone and estradiol, among other hormones. These fluctuations affect the body as a whole, including the central nervous system (CNS). In the CNS, sex hormones act via steroid receptors. They also have an effect on different neurotransmitters such as GABA, serotonin, dopamine, and glutamate. Additionally, studies show that sex hormones and their metabolites influence brain areas that regulate mood, behavior, and cognitive abilities. This review emphasizes the benefits a proper hormonal balance during the different stages of life has in the CNS. To achieve this goal, it is essential that hormone levels are evaluated considering a woman's age and ovulatory status, so that a correct diagnosis and treatment can be made. Knowledge of steroid hormone activity in the brain will give women and health providers an important tool for improving their health and well-being.
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Affiliation(s)
| | | | | | | | | | - Pilar Vigil
- Reproductive Health Research InstituteSantiago, Chile
- Vicerrectoría de ComunicacionesPontificia Universidad Católica de Chile, Santiago, Chile
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Promotion and marketing of bioidentical hormone therapy on the internet: a content analysis of websites. Menopause 2018; 24:1129-1135. [PMID: 28609391 DOI: 10.1097/gme.0000000000000901] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To evaluate the quality of information presented and claims made on websites offering bioidentical hormone therapy (BHT) products or services. METHODS A quantitative content analysis was completed on 100 websites promoting or offering BHT products or services. Websites were identified through Google search engine from September to October 2013. Search terms included "bioidentical hormone therapy" or "bioidentical progesterone," accompanied by "purchase or buy," "service," or "doctors." The Brief DISCERN instrument was used to determine the quality of the health information. RESULTS Websites were from Canada (59%), United States (38%), and other countries (3%). Almost half of the websites originated from medical clinics (47%), and healthcare professionals offering BHT services included physicians (50%), pharmacists (19%), and naturopaths (16%). Majority of websites promoted BHT as custom-compounded formulations (62%), with only 27% indicating that BHT is also commercially available. Websites overall claimed that BHT had less risk compared with conventional hormone therapy (62%). BHT was described as having less breast cancer risk (40%), whereas over a quarter of websites described BHT as "protective" for breast cancer. Websites mainly targeted women (99%), with males mentioned in 62% of websites. Product descriptors used to promote BHT included individualization (77%), natural (70%), hormone imbalance (56%), and antiaging (50%). The mean Brief DISCERN score was 15, indicating lower quality of information. CONCLUSIONS Claims made about BHT on the internet are misleading and not consistent with current professional organizations' recommendations. Understanding how BHT may be promoted on the internet can help healthcare professionals when educating patients.
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Pickar JH, Archer DF, Kagan R, Pinkerton JV, Taylor HS. Safety and benefit considerations for menopausal hormone therapy. Expert Opin Drug Saf 2017; 16:941-954. [DOI: 10.1080/14740338.2017.1343298] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Affiliation(s)
- James H Pickar
- Department of Obstetrics and Gynecology, Columbia University Medical Center, New York, NY, USA
| | - David F Archer
- Clinical Research Center, Department of Obstetrics and Gynecology, Eastern Virginia Medical School, Norfolk, VA, USA
| | - Risa Kagan
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco and East Bay Physicians Medical Group, Sutter East Bay Medical Foundation, Berkeley, CA, USA
| | - JoAnn V Pinkerton
- Department of Obstetrics and Gynecology, University of Virginia Health System, Charlottesville, VA, USA
| | - Hugh S Taylor
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, New Haven, CT, USA
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L’Hermite M. Custom-compounded bioidentical hormone therapy: why so popular despite potential harm? The case against routine use. Climacteric 2017; 20:205-211. [DOI: 10.1080/13697137.2017.1285277] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- M. L’Hermite
- Service de Gynécologie-Obstétrique, CHU Brugmann, Université Libre de Bruxelles, Bruxelles, Belgium
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Constantine GD, Archer DF, Graham S, Bernick BA, Mirkin S. Prescribing of FDA-approved and compounded hormone therapy differs by specialty. Menopause 2016; 23:1075-82. [PMID: 27648594 PMCID: PMC5028143 DOI: 10.1097/gme.0000000000000683] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2016] [Revised: 03/29/2016] [Accepted: 03/29/2016] [Indexed: 01/27/2023]
Abstract
OBJECTIVE To determine the prescribing patterns of general practitioners (GPs), obstetrician/gynecologists (OB/GYNs), and wellness physicians (WPs) of menopausal hormone therapy (HT) for both compounded (CHT) and Food and Drug Administration (FDA)-approved products, using a survey of US physicians. METHODS Nine thousand one US physicians were invited to participate in a survey to report on their HT-prescribing patterns. Physicians were eligible if they prescribed HT for at least six patients per month. RESULTS The survey was completed by 440 eligible physicians (893 responded of 9,001 invited) including 171 GPs, 170 OB/GYNs, and 84 WPs. Physicians prescribed HT for 15% to 30% of their female patients, with WPs numerically most likely to prescribe HT. Menopausal symptoms were the leading reason for HT prescriptions among all specialties. WPs seemed more likely to prescribe HT for general/cardiovascular health (28%), and for shorter durations, than other specialties. WPs prescribed proportionally more compounded (vs FDA-approved) estrogens/progestogens than GPs or OB/GYNs, but OB/GYNs seemed to prescribe more compounded dehydroepiandrosterone and testosterone (prescribed alone) than did others. OB/GYNs seemed least likely to consider CHT being more safe or effective than FDA-approved HT. Symptom relief was the main determinant of efficacy for all specialties; WPs also used blood (61%) or saliva testing (25%) for dose adjustment. CONCLUSIONS Although all physician specialties surveyed prescribed HT, differences in prescribing CHT versus FDA-approved formulations by medical specialty/practice seemed to exist. Of those surveyed, OB/GYNs and GPs prescribed proportionally more FDA-approved HT, whereas WPs, similarly, prescribed more CHT. More discussion is needed concerning physicians' decisions to prescribe CHT versus FDA-approved formulations.
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Affiliation(s)
| | - David F. Archer
- Clinical Research Center, Department of Obstetrics and Gynecology, Eastern Virginia Medical School, Norfolk, VA
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Bachmann G, Rojas V. Menopausal Hormonal Therapy: More Good News for Women. J Womens Health (Larchmt) 2016; 25:419. [DOI: 10.1089/jwh.2016.5922] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Gloria Bachmann
- Department of Ob/Gyn and Reproductive Sciences, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Veronica Rojas
- Department of Ob/Gyn and Reproductive Sciences, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
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