MENOPAUSE

Transdermal estrogen is as effective as oral therapy

Like oral estrogen therapy, transdermal therapy effectively treats vasomotor symptoms, prevents loss of bone density, and treats genital atrophy.

Because transdermal menopausal estrogen therapy does not increase hepatic production of procoagulant factors, as does oral estrogen, it is biologically plausible that transdermal therapy is safer than oral therapy in terms of the risk of VTE.⁶

Combined with other evidence, the findings of this important French study suggest that ObGyns should consider transdermal therapy when helping menopausal women select a HT regimen.

Micronized progesterone might not raise the risk of breast cancer

Fournier A, Berrino F, Clavel-Chapelon F. Unequal risks for breast cancer associated with different hormone replacement therapies: results from the E3N cohort study. Breast Cancer Res Treat. 2008;107:103–111.

In contrast to estrogen-only therapy, long-term use of combination estrogen– progestin HT is associated with a modestly elevated risk of breast cancer.^7-10

In France, micronized progesterone is the progestin most commonly used in HT. In 2008, results from a large French case-control study suggested that—in contrast to combination HT that contains MPA or norethindrone acetate—use of combination HT formulated with micronized progesterone was not associated with an elevated risk of breast cancer.

In women taking menopausal estrogen, the appropriate dosage of micronized progesterone to prevent endometrial hyperplasia is 100 mg nightly or 200 mg for 12 or more nights each month.

Avoid micronized progesterone in patients with peanut allergy

Because micronized progesterone contains peanut oil, patients with a history of peanut allergy should not use it.

Estrogen’s effects on cognition depend on, again, age at use

Rocca WA, Bower JH, Maraganore DM, et al. Increased risk of cognitive impairment or dementia in women who underwent oophorectomy before menopause. Neurology. 2007;69:1074–1083.

Rocca WA, Bower JH, Maraganore DM, et al. Increased risk of parkinsonism in women who underwent oophorectomy before menopause. Neurology. 2008;70:200–209.

One intriguing possibility entertained in recent years is that HT prevents dementia, although data so far have been conflicting. A large, high-quality observational study performed in Utah and published in 2002 provided evidence that HT use by young menopausal women prevents cognitive decline later in life, particularly when HT is used over the long term.¹¹

In contrast, the WHI Memory Study found that HT increases the risk of mild cognitive impairment and dementia.¹² However, that study enrolled an older subgroup of WHI participants (65 to 79 years old at randomization).

Very young estrogen-deprived women stand to benefit from HT

Over the past year, Rocca and colleagues at the Mayo Clinic in Minnesota published two reports assessing the risk of neurologic disease among several thousand Midwestern women who had undergone oophorectomy (unilateral or bilateral) before reaching menopause. A history of oophorectomy, especially in women younger than 38 years, was associated with a significantly increased risk of cognitive impairment and dementia. However, when estrogen therapy was prescribed until at least 50 years of age following bilateral oophorectomy, no increased risk of cognitive impairment was found.

Using similar methods, the same research group at Mayo found that oophorectomy before menopause was associated with a significantly increased risk of parkinsonism (symptoms that did not meet the formal criteria for Parkinson’s disease) as well as an increased risk, which did not attain statistica significance, of Parkinson’s disease itself.

Taken in totality, the evidence suggests that when HT is initiated in young menopausal women, protection against dementia and other neurologic disease may result. These findings parallel the evidence on the risk of CAD during HT use presented at the beginning of this article.