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. > 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. 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 Overall Risks & Benefits • 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.

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