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| |  DG DISPATCH - ACOG: Multiple Treatment Options Available For Women In Menopause By Katherine Hasal Special to DG News PHILADELPHIA, PA -- May 19, 1999 -- With nearly 50 million American women reaching menopause by the year 2000, hormone replacement therapy is a significant area of research. The average time of menopause is about 50 to 51 years. Researchers discussed the multiple treatment options available for women in menopause during a telebriefing. Given today's extended life expectancies, many women can expect to live an average of 30 years after menopause and HRT can be an important determinant of their health during these years, said Robert Rebar, MD, professor and chairman, department of obstetrics and gynecology University of Cincinnati College of Medicine. Menopause is associated with a number of symptoms, including hot flashes, vaginal dryness, sleep and mood disturbances and poor concentration. A number of disease processes, including osteoporosis, cardiovascular disease, breast cancer and Alzheimer's disease, dramatically increase after menopause. Simply put, estrogen maintains bone density. It relieves vasomotor symptoms, such as hot flashes and night sweats. In retrospective studies, it seems to reduce the incidence of heart attack and stroke, maintains skin quality and appears to improve mood and cognition. On the other hand, some studies have suggested that estrogen may be associated with an increased risk of breast cancer. Approximately 75 percent of women do not take hormone replacement therapy. In fact, more than 60 percent have never had HRT prescribed. Of those that do begin taking HRT, less than 50 percent are still taking HRT at the end of one year and at the end of three years, only about 20 percent continue with therapy. Reasons for discontinuation include concerns regarding the associated risks as well as side effects, such as breast tenderness, weight gain, uterine bleeding and bloating. Bruce Ettinger, MD, senior investigator, division of research, Kaiser Permanente, described the results of a study designed to evaluate the impact of switching from the standard 0.625 mg dose of conjugated estrogen to an estrogen-light, low-dose (0.3 mg) therapy-in other words, cutting estrogen levels in half. The drug used in this study, Estrotab, is a plant-based, esterified estrogen. This study included 138 long-term HRT users, with an average age of 60 years and an average HRT use of nine years. At the outset, the half-dose was perceived as safer. Satisfactory symptom control was achieved and negative psychological symptoms, such as mood and anxiety, were reduced. Some participants (five to 10 percent) reported an increased number of hot flashes. In this study, nine percent of women experienced breakthrough bleeding, while only six percent had experienced breakthrough bleeding on the prior dosage. Although this half-dose will require further testing for safety, it appears to be an innovative new option for women that is more convenient, offers lower side effects and maintains the same long-term benefits in terms of preventing bone loss and being cardioprotective. This lower dose would be ideal to switch women who have been on HRT for a couple of years who are still having periods. It may be more easily tolerated especially by elderly women. Finally, Lorraine Fitzpatrick, MD, Professor of Internal Medicine, Endocrine Research Unit, Mayo Clinic and Mayo Foundation, described the use of a new progestogen that is a natural, plant-based micronized progesterone. This drug (Prometrium) is structurally identical to the progesterone produced by the human body and, according to Dr. Fitzpatrick's research, is better tolerated than the synthetic compounds. Using several different surveys and a historical control population, Prometrium was associated with increased quality-of-life and satisfaction with therapy. On one study, 45 percent indicated that it was the best progesterone they have ever taken. Similar results were obtained across the board in terms of reduced depression and anxiety and reduction in somatic symptoms. In this study, 34 percent said that they had better symptom control and 32 percent reported improved bleeding control. Each of the speakers emphasised the importance of trying different doses, different formulations and even different drug combinations that provides the best symptom control and the fewest side effects, while maintaining the bone loss prevention, cardioprotective and other effects associated with HRT.
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