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Estrogen Therapy inPostmenopausal

Women

3/21/08

By Lindsey BollAdvisor: Dr. Hadley

PAS 646

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Background

Many ET studies

HERS

WHI

ET Controversy

Health risks

Current perspective Uncertain and fluctuating

Needs clarification

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Objectives

Physiology

HERS and WHI Study Results

Misconceptions

Risk and Benefit analysis

Approach to postmenopausal patient

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Physiology

Perimenopause- time of transitioncharacterized by irregularity ofmenstrual cycle

Ovarian follicular depletionFluctuating hormone levels

Sx

Menopause- permanent cessation ofmenses

~51 yo + 2 yrs

Dx by 12 mo ammenorrhea

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Physiology

Postmenopause- stage of life after

menopause

Ovaries inactive

No estrogen/progesterone produced

PMP Sx result from this hormone deficiency

~30% of women in U.S. > 50yo (PMP) Life expectancy: 82 yrs

Many women in need of many yrs of PMP

care

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Physiology

PMP Signs & Symptoms:

GU atrophy w/:

Epithelial thinning, dryness, and inflammation CNS Sx, such as

Insomnia, mood changes, fatigue

Reduced bone mass, increased fx risk

(vasomotor symptoms- perimenopause)

Hot flashes

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Hx of Estrogen Therapy

Many trials (since 1970s)

PEPI 1995

HERS 1998 and 2002 ERA 2000

WHI 2002 and 2004

Others

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HERS Results

Increased risk of venous

thromboembolic events

DVT and PE

Increased incidence of gall bladder

disease

Favorable effects on lipids and

fibrinogen

No sig difference between HT and

placebo concerning CHD events

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WHI Results

Increased risk in nonfatal CHD events in

healthy women

Increased risk of incident breast cancer

Reduction in incidence of fractures

But

only used one drug regimen PMP participants included a wide age range

from 50yo to 79yo.

Time of initiation of therapy was not taken

into consideration

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Misconceptions corrected

Significant public consequences:

2002-03: 43% reduction in ET Rx

HERS Facts

no cardioprotective effects. No difference in CVD events b/t Ht and

placebo

WHI: Facts to consider

Dosing factors affect risks/benefits drug type, route, dosage, administration

Patient profile factors:

Time of HT initiation after menopause, age, and

comorbidies

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Overall Risks & Benefits

Risks

Ovarian cancer

Venousthromboembolicevents

Breast cancer

Gall bladder disease

Benefits

GU atrophy relief

Decreased risk offractures

Favorable lipids effects

Decreased risk ofcolorectal cancer

Decreased risk of

diabetes

CHD event risks addressed by early initiation of therapy

Endometrial hyperplasia/cancer addressed by combo therapy

with progesterone

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Approach to PMP patient

seeking HT

Health Provider role

Patient education

Facts on ET, discount myths True risks and benefits

Patient Treatment with ET

Accurate patient evaluation Patient PMH

Patient complaints

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Patient Evaluation

Contraindications

Unusual vaginal bleeding

Hx of blood clots

Hx of breast cancer

Liver dysfunction

CHD

Studies show that women with CHDand women without CHD are both atrisk for CV events, regardless of priorCHD status

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Patient Evaluation

Sx Indications in PMP

Urogenital atrophy

Osteoporosis

Colorectal cancer

(Absent contraindications)

Early initiation- during perimenopause

Combined with Progesterone-if uterus intact

Tailor HT type, route, dosage, and administration

to individual patient based on age, yrs since

menopause, and comorbid conditions.

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