Efficacy, Safety, and Tolerability of Low-Dose Hormone Therapy in Managing Menopausal Symptoms

Abstract

The primary indication for postmenopausal hormone therapy (HT) is to relieve the vasomotor symptoms (hot flashes, night sweats) and vaginal dryness and discomfort that often accompany the menopausal transition and beyond. These symptoms, which are attributed to the natural decline in estrogen during and after menopause, can be remedied with HT. The loss of bone mineral density (BMD) and associated skeletal fragility and increased risk of fracture are also effectively mitigated by HT in postmenopausal women.1-3 In women with a uterus, a progestin is used to oppose estrogen-stimulated endometrial proliferation and protect against endometrial cancer. The safety and tolerability of therapeutic agents must be considered in balance with their clinical efficacy. Reports from the Women's Health Initiative (WHI) trials raised concerns about venous thromboembolic events (VTEs), coronary heart disease (CHD), breast cancer, and stroke in women who were an average of 12 years postmenopause and received estrogen plus progestin (EPT) when compared with women who received placebo (Table 1).2,4 -10 The estrogen-alone (ET) arm in women without a uterus found increased risks of thromboembolic events and stroke with treatment but no increase in CHD or breast cancer (Table 2). 3,4,[11][12][13] Both trials found reduced risks for major fracture and colorectal cancer, the latter particularly in women randomized closer to menopause. 2,3However, given that the WHI study population may have been at greater risk for adverse events by virtue of age and years since menopause, the relevance of WHI data to the management of the typical symptomatic woman has been questioned. Consistent with the most commonly prescribed treatment options at the time the WHI trials were designed, HT doses of 0.625 mg conjugated equine estrogen (CEE) with or without 2.5 mg medroxyprogesterone acetate (MPA) were used. Publication of the initial results from the WHI EPT trial focused attention on the adoption of lower HT doses in clinical practice.14 Today, the use of lower starting doses for treatment of postmenopausal symptoms is increasingly recommended.14,15Currently, oral doses as low as 0.3 mg/day of CEE and 0.5 mg/day of 17␤-estradiol (E 2 ) are available to treat menopausal symptoms, and transdermal patches are available with estradiol doses as low as 0.014 mg/day. The purpose of this article is to describe what is known about the efficacy, safety, This article was externally peer reviewed.

On Postpartum Depression, Hormonal Problems, and Practice Management for Medical Home Implementation

“…Getting sufficient long-term data about the multiple different medications over a significant length of time in a generally healthy population has been part of the difficulty. Langer et al 14 review what we know about low-dose therapy. Several current national recommendations suggest low-dose therapy for as little time as necessary for symptoms of menopause.…”

Nurse practitioner use of patient-centered care to improve the quality of life of women experiencing vasomotor symptoms of menopause

“…Results of the WHI trial revealed an increased risk of breast cancer in women who used HT; however, the women enrolled in the study were on average 12 years post menopausal (Langer, 2009). The findings of the trial are not necessarily generalizable to a younger population, but fears of adverse effects remain .…”

“…Conventional HT consists of estrogen replacement with the addition of progestin for those who retain their uterus (Langer, 2009). The goal in prescribing HT is to determine the lowest dose that effectively alleviates bothersome perimenopausal and menopausal VMS (Langer, 2009 showed a similar reduction in the number of hot flashes at the 12 week period of therapy 37 compared to higher doses.…”

“…The findings of the trial are not necessarily generalizable to a younger population, but fears of adverse effects remain . Breast cancer is a major concern for women and the evidence suggests that increased rates are positively correlated with the duration of time a woman uses HT (Langer, 2009). The metabolic changes that occur as a result of taking HT may influence the incidence of venous thromboembolism (VTE) (Stevenson, 2009).…”

“…The goal in prescribing HT is to determine the lowest dose that effectively alleviates bothersome perimenopausal and menopausal VMS (Langer, 2009 showed a similar reduction in the number of hot flashes at the 12 week period of therapy 37 compared to higher doses. The reduction in number of flashes per week fell from greater than 30 to less than 5 in 12 weeks.…”