HRT: 4 experts chart a new course
To clarify the issues raised by the Women’s Health Initiative, OBG Management asked 4 experts the inevitable: Now what? Here, the physicians discuss the findings and detail how this will affect the way they—and you—treat menopausal women.
Luciano: Most studies have reported that lowdose therapy offers adequate relief of vasomotor symptoms, with fewer side effects such as bleeding, mastodynia, or bloating, and usually with adequate protection against bone loss. I find that the lowest effective dose is better tolerated and associated with fewer side effects and drop-out rates. However, that dose varies from patient to patient according to the severity of symptoms and the woman’s ability to absorb and/or metabolize hormones. For this reason, I usually start with a lower dose—50% of the recommended therapeutic dose—and increase or decrease it according to the patient’s response and tolerance. Smokers who are unwilling to quit may require the usual therapeutic dose, since they metabolize estrogen at a faster rate. In contrast, obese women or women who consume a moderate amount of alcohol may require lower HRT doses.
My preference is to start with CEE (0.3 mg daily) or micronized estradiol (0.5 mg daily) with progesterone (50 to 100 mg daily), administered at bedtime to take advantage of the hypnotic effects of micronized progesterone and to minimize nocturnal vasomotor symptoms. For patients who prefer transdermal preparations or who have gastrointestinal (GI) symptoms, I start with 0.035 to 0.05 mg of transdermal estradiol daily plus the same dose of progesterone (50 to 100 mg) at bedtime. If a patient’s symptoms are not relieved by these doses, I may increase the dosage by 50%. If patients develop mastodynia or bleeding, I decrease the dosage by 50%.10
Fitzpatrick: There have been numerous studies suggesting that lower doses of estrogen or estrogen-progestin combinations are beneficial in the postmenopausal woman.9,11 Most of these studies have used BMD as an endpoint. Lower doses of estrogen (0.3 mg or 0.5 mg oral equivalents or 0.025 mg transdermal) provide bone protection, albeit at a lower level than the “standard” doses. These lower doses also attenuate hot flushes and may be nearly equivalent or slightly lower in efficacy, depending on the actual dose employed.
The skeleton is very sensitive to estrogen. Even small doses can provide protection, especially in individuals who have relatively well-preserved bone mass. In patients who are older and have been on ERT or HRT for many years, I usually offer the option of stepping down the dose.
Dr. Fitzpatrick reports receiving a fellowship educational grant from Solvay Pharmaceuticals. Dr. Kaunitz reports receiving funding for clinical trials from Barr Laboratories, Berlex, Eli Lilly, Galen, NIH, Organon, Parke-Davis/Pfizer, Pharmacia, and R.W. Johnson Pharmaceutical Research Institute. He also reports conducting CME presentations and publications for Organon, Ortho-McNeil, Pharmacia, and Wyeth. In addition, Dr. Kaunitz serves as a consultant for ACOG, APOG, ARHP, Barr Laboratories, Berlex, Eli Lilly, Johnson & Johnson, Organon, and Pharmacia. He holds stock in Johnson & Johnson, Ostex International, and Cytyc. Dr. Luciano reports receiving grant support from ML Labs, Pfizer, Pharmacia, Proctor & Gamble, and TAP Pharmaceuticals. He is on the speaker’s bureau for Eli Lilly, Pharmacia, and Wyeth, and serves as a consultant to Pharmacia. Dr. Randolph reports no financial relationship with any companies whose products are mentioned in this article.
