Is hrt a replacement medication

Is HRT a Replacement medication?

by

Manuel Neves-e-Castro, MD(Lisbon, Portugal)

10 th World Congress on the Menopause

June 2002

Berlin

Hormone

HRT = Replacement

Therapy

Physiology of the ovary

endocrine function

exocrine function

Endocrine Function

Birth (+) Infancy + + Adolescence + + + Adulthood + + + + Menopause + + Postmenopause +

Exocrine Function

Birth 0

Infancy 0

Adolescence (+)

Adulthood +

Menopause (+)

Postmenopause 0

Symptoms of the pre and postmenopause

- hormone related

- age related

Risk factors after menopause

Related to: - hormones - age - life style - nutrition - exercise

Diseases with higher incidence after menopause

- CV (dyslipidemias)- Bone (osteopenia, osteoporosis)- CNS (brain dysfunctions and

degenerations )

Objectives

Good quality of life:

a) maintain and improve Health

b) prevent diseases

Health

“Is a condition of physical, mental and social wellbeing and not only the absence of disease”

WHO

Strategies

- change life style

- proper nutrition

- exercise

- pharmacologic interventions. hormonal. non hormonal

Nurses’s Health Study (NEJM, 2000)

from 1980 to 1994 CHD 31%

Smoking 13% Obesity 8% THS 9% Better nutrition 16%

Pharmacologic interventions (hormonal)

- estrogens- SERM’s- androgens (?)- thyroid (?)

Menopausal hormonal treatments are very good.

but

Treatments without hormones may also be very good for a woman’s health

“When hormone replacement therapy is not possible”

Neves-e-Castro M in “The Management of the Menopause; The Millennium Review 2000” Ed.John Studd; Parthenon, NY 2000

Pharmacologic interventions(non hormonal)

- Statins - ß blockers - Calcium – channel blockers - Diuretics - Angiotensin C.E. inhibitors - Bisphosphonates/calcium - Tranquilizers - Serotonin and noradrenalin reuptake inhibitors - Metformin - etc

“Recently revised NCEP guidelines indicate that for women aged 45 to 75, the favorable effects of therapy with “statins” in clinical trials make a cholesterol-lowering drug preferable to HRT for CAD risk reduction”.

Cleeman J. JAMA 2001;285(19):2486-97

Lipid-lowering therapy promotes clinically stable plaque

- Prolonged intensive lipid-lowering therapy is associated with a markedly decreased lipid content in carotid atherosclerotic plaques

- The clinical implication of this is that the low plaque lipid composition would predict greater plaque stability, and would thus reduce clinical ischemic events such as myocardial infarction or stroke.

Zhao X-Q et al. Arterioscler Thromb Vasc Biol 2001;21:1623-1629,1563-1564

“Lovastin together with continuous combined HRT seems to be more effective in the secondary prevention of coronary heart disease not only due to lipid lowering properties but also related to several other additive effects such as modification of endothelial function and inflammatory responses”

El-Swefy SE et al. Pharmacological Research, 2002;45:167-173

Hormone Replacement Therapy concept

To add hormones that should physiologically be present at any time in life

Examples:

- insulin (type I diabetes)- cortisone (Addison’s disease)- thyroid (hypothyrodism)- growth hormone (dwarfism)- androgens (orchidectomy)- estrogens (surgical or premature

menopause, gonadal agenesis)

HRT must be changed to Postmenopause Hormone

Treatments (PMHT)

If Hormone Replacement Therapy is accepted that would mean that all postmenopausal women must be given hormones.

If Hormone Replacement Therapy was a correct designation then this was no therapy at all but simply a replacement. It would not be a treatment for a disease but a restoration of what would be physiologic, which is not the case in the natural postmenopause.

PostMenopause Hormonal Treatments (PMHT)

They are not substituive

They are important for:- symptom relief- disease prevention (primary and secondary)

It must be made clear that HRT does not mean that all women must be under hormonal treatments.

- The important issue, after all, is not HRT

- What is important is the best possible approach to preventive medicine in a middle-aged woman

What is physiologic in the postmenopause is a decline in the endocrine function of the ovary (hypoestrogenism).

Therefore, there is nothing to replace !

Thus, it is not physiologic to give estrogens to all women, although estrogens are very important pharmacologic agents to specifically treat symptoms and to prevent diseases that are associated with/or caused by the decrease of estrogens in the postmenopause

“Pharmaceutical companies are actively involved in sponsoring the definition of diseases and promoting them to both prescribers and consumers”

Moynihan R et al.BMJ 2002;324:886-90

“The social construction of illness is being replaced by the corporate construction of disease”

Moynihan R et al.BMJ 2002;324:886-90

“Extending therapy to un-diseased population may also have important ethical implications, as treatment with statins may lead to perceptions of illness”

Freemand X et al.BMJ 1998;316:1241

“IHD deaths are much more frequent in the USA than in Italy, whereas CeVD deaths are more common in Italy”

Ricci S et al.J Clin Basic Cardiol 2002;5:105-108

“In the light of these differences, long-term HRT should yield larger benefits in North American women – with higher IHD mortality and lower incidence of fatal CeVD – and probably less beneficial effects in Italian women, who exhibit a lower IHD mortality and a higher CeVD mortality”.

Ricci S et al.J Clin Basic Cardiol 2002;5:105-108

“Our analysis of age group mortality indicates that in the 40-49 age group for each woman dying of IHD, 5 will die of BC in Italy but only 2 in the USA”

Ricci S et al.J Clin Basic Cardiol 2002;5:105-108

“Women who are to receive long-term HRT, should be selected much more carefully than in countries where IHD mortality is altogether higher and more frequent in younger women”

Ricci S et al.J Clin Basic Cardiol 2002;5:105-108

Postmenopause (PMHT) Hormone Treatment is a concept that means that estrogens (and androgens) are to be used when indicated, in conjunction with other non hormonal treatments and non pharmacological strategies.

The gynecologists, or the endocrinologists are, above all, the internists of the middle-aged women they accept to help.

Either they know how to select and manipulate several treatments, in adition to hormones, or they must cooperate closely with internists.

HRT

is a misnomer !

This discussion is important because there is a tendency to consider that there is nothing but estrogens to offer to a postmenopausal woman, and that such treatments are obligatory for every woman and for very long time.

This is wrong !

Neves-e-Castro M-Tthe Queen is naked-Maturitas 2001;38:235-7