Hormone replacement therapy: The right choice for your patient?

TABLE 1

Absolute risks of HRT

Menopausal symptoms

Dr. Leong: Because estrogen is the most effective treatment for menopausal symptoms, Mrs JC may yet consider taking it on a short-term basis, if her symptoms are debilitating. We should use the lowest dose required to control symptoms. She has already stopped her therapy, of course. But had she still been taking ET and told you she wished to discontinue it, you could have advised her that, often times, tapering estrogen over several months results in fewer symptoms than when quitting “cold turkey” (TABLES 2 AND 3).

If Mrs JC is absolutely against taking estrogen, several other drugs have been shown to reduce hot flashes. The selective serotonin reuptake inhibitors (SSRIs) were effective in several randomized trials using venlafaxine (Effexor),⁴ paroxetine (Paxil), and, less effectively, fluoxetine (Prozac).⁵ Clonidine (Catapres) was effective at reducing hot flushes in some, but not all, clinical trials.⁶Gabapentin (Neurontin) and megestrol acetate (Megace) are other possible choices.

Complementary and alternative therapies have been very popular among some postmenopausal women as they look for symptom relief. There are mixed data on soy compounds (phytoestrogen and isoflavone), with only 3 of 8 trials demonstrating a beneficial effect.^7-9 Black cohosh showed modest benefits, but ginseng, dong quai, red clover, evening primrose oil, vitamin E, acupuncture, wild yam, and progesterone cream were ineffective. The main cautions with these products are that safety and efficacy are not well established and quality control of the products is often lacking.

Dr Erickson:Urinary problems most commonly associated with menopause are incontinence and recurrent urinary tract infections. Fortunately, both of these problems can be reduced with topical estrogen, which has minimal systemic absorption (TABLE 4). For example, a recent study of intravaginal estradiol (25 μg) vs placebo showed that the estrogen-treated group had significant reduction in symptoms (including dysuria, frequent voiding, and incontinence) and urodynamic findings, but no increase in serum estradiol levels or endometrial growth.¹⁰ Thus, a topical estrogen could provide the urologic benefits without the risks of systemic treatment. If she wants to avoid estrogen altogether, she has other options.

TABLE 2

Possible tapering schedules for estrogen regimens

TABLE 3

HRT dosing options

Urinary tract symptoms

TABLE 4

Vaginal products for genitourinary atrophy

Stress incontinence. For stress incontinence, pelvic floor muscle exercises are helpful. These can be done without any assistance if the patient is able to do the exercises and is motivated. For patients with marginal ability or motivation, options include biofeedback training, vaginal weights, electric stimulation, or magnetic stimulation.

Alpha-adrenergic agonists have also been used,¹¹although treatment of stress incontinence is an off-label use for these drugs and they have risks including hypertension and tachycardia. Phenylpropa-nolamine (eg, Entex LA) is the alpha-adrenergic agent with the most reported studies for stress incontinence, but it was withdrawn from the market due to increased risk of cerebrovascular accident.¹²The alternative now contains pseudoephedrine (eg, Entex PSE) but there are no published trials of pseudoephedrine for stress incontinence.

More recent studies have shown duloxetine (Cymbalta) to be effective,^{13, 14} although incontinence is currently an offlabel use for it.

Fem-Soft urethral inserts are used by some patients and are covered by Medicare. These soft inserts are held in place by a unique balloon, which expands automatically after insertion and compresses when the patient pulls on the insert to remove it (ie, the balloon does not need to be inflated or deflated in the office). They are similar in width to Foley catheters (16 or 18 Fr) but are shorter, extending only about 1 cm out from the urethral meatus.