Estrogen Therapy in

Postmenopausal
Women
3/21/08
By Lindsey Boll
Advisor: Dr. Hadley
PAS 646
Background
Many ET studies
HERS
WHI
ET Controversy
Health risks
Current perspective
Uncertain and fluctuating
Needs clarification

Objectives
Physiology
HERS and WHI Study Results
Misconceptions
Risk and Benefit analysis
Approach to postmenopausal patient
Physiology
Perimenopause- time of transition
characterized by irregularity of
menstrual cycle
Ovarian follicular depletion
Fluctuating hormone levels
Sx
Menopause- permanent cessation of
menses
~51 yo + 2 yrs
Dx by 12 mo ammenorrhea
Physiology
Postmenopause- stage of life after
menopause
Ovaries inactive
No estrogen/progesterone produced
PMP Sx result from this hormone deficiency

~30% of women in U.S. > 50yo (PMP)
Life expectancy: 82 yrs
Many women in need of many yrs of PMP
care
Physiology
PMP Signs & Symptoms:
GU atrophy w/:
Epithelial thinning, dryness, and inflammation
CNS Sx, such as
Insomnia, mood changes, fatigue
Reduced bone mass, increased fx risk
(vasomotor symptoms- perimenopause)
Hot flashes

Hx of Estrogen Therapy
Many trials (since 1970s)
PEPI 1995
HERS 1998 and 2002
ERA 2000
WHI 2002 and 2004
Others
HERS Results
Increased risk of venous
thromboembolic events
DVT and PE
Increased incidence of gall bladder
disease
Favorable effects on lipids and
fibrinogen
No sig difference between HT and
placebo concerning CHD events

WHI Results
Increased risk in nonfatal CHD events in
healthy women
Increased risk of incident breast cancer
Reduction in incidence of fractures

But
only used one drug regimen
PMP participants included a wide age range
from 50yo to 79yo.
Time of initiation of therapy was not taken
into consideration
Misconceptions corrected
Significant public consequences:
2002-03: 43% reduction in ET Rx
HERS Facts
no cardioprotective effects.
No difference in CVD events b/t Ht and
placebo
WHI: Facts to consider
Dosing factors affect risks/benefits
drug type, route, dosage, administration
Patient profile factors:
Time of HT initiation after menopause, age, and
comorbidies
Overall Risks & Benefits
Risks
Ovarian cancer
Venous
thromboembolic
events
Breast cancer
Gall bladder disease


Benefits
GU atrophy relief
Decreased risk of
fractures
Favorable lipids effects
Decreased risk of
colorectal cancer
Decreased risk of
diabetes
CHD event risks addressed by early initiation of therapy
Endometrial hyperplasia/cancer addressed by combo therapy
with progesterone
Approach to PMP patient
seeking HT
Health Provider role
Patient education
Facts on ET, discount myths
True risks and benefits
Patient Treatment with ET
Accurate patient evaluation
Patient PMH
Patient complaints
Patient Evaluation
Contraindications
Unusual vaginal bleeding
Hx of blood clots
Hx of breast cancer
Liver dysfunction
CHD
Studies show that women with CHD
and women without CHD are both at
risk for CV events, regardless of prior
CHD status



Patient Evaluation
Sx Indications in PMP
Urogenital atrophy
Osteoporosis
Colorectal cancer
(Absent contraindications)

Early initiation- during perimenopause
Combined with Progesterone-if uterus intact
Tailor HT type, route, dosage, and administration
to individual patient based on age, yrs since
menopause, and comorbid conditions.

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