Estrogen Therapy in Postmenopausal Women

1
Estrogen Therapy in Postmenopausal Women

• 3/21/08
• By Lindsey Boll
• Advisor Dr. Hadley
• PAS 646

2
Background

• Many ET studies
• HERS
• WHI
• ET Controversy
• Health risks
• Current perspective
• Uncertain and fluctuating
• Needs clarification

3
Objectives

• Physiology
• HERS and WHI Study Results
• Misconceptions
• Risk and Benefit analysis
• Approach to postmenopausal patient

4
Physiology

• Perimenopause- time of transition characterized
  by irregularity of menstrual cycle
• Ovarian follicular depletion
• ?Fluctuating hormone levels
• ?Sx
• Menopause- permanent cessation of menses
• 51 yo 2 yrs
• Dx by 12 mo ammenorrhea

5
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. gt 50yo (PMP)
• Life expectancy 82 yrs
• ?Many women in need of many yrs of PMP care

6
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

7
Hx of Estrogen Therapy

• Many trials (since 1970s)
• PEPI 1995
• HERS 1998 and 2002
• ERA 2000
• WHI 2002 and 2004
• Others

8
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

9
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

10
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

11
Overall Risks Benefits

• Risks
• Ovarian cancer
• Venous thromboembolic events
• Breast cancer
• Gall bladder disease

• Benefits
• GU atrophy relief
• Decreased risk of fractures
• Favorable lipids effects
• Decreased risk of colorectal cancer
• Decreased risk of diabetes

• CHD event risks addressed by early initiation of
  therapy
• Endometrial hyperplasia/cancer addressed by combo
  therapy with progesterone

12
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

13
Patient Evaluation

• Contraindications
• Unusual vaginal bleeding
• Hx of blood clots
• Hx of breast cancer
• Liver dysfunction
• CHD
• Studies show that women with CHD and women
  without CHD are both at risk for CV events,
  regardless of prior CHD status

14
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.

15
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