Dr Dedeshya Holowenko
none
Indications for estrogen therapy
Risks of estrogen therapy
Transdermal vs oral estrogen
Atrophic vaginitis
◦ very common in the post menopausal woman
◦ Causes decreased libido, urinary irritability,
dysparenia and relationship discord
Natural Menopause
◦ Peri and early post menopause (65 years
Coronary Events with HT
Younger Vs. Older Women
Less than 60 years old
Decreased risk CHD by 30%
OR 0.68 (0.48 – 0.95)
Greater than 60 years old
First year increased risk CHD
OR 1.47 (1.12 – 1.92)
2nd year decreased risk of CHD
by 20%
OR 0.79 (0.67 – 0.93)
Salpeter, JGIM 2006; 21:363-366
Coronary Events with HT
Younger Vs. Older Women
Take Home Message:
“Hormone Therapy reduces the risk
(protects) of CHD events in younger
postmenopausal women. In older
women HT increases, then decreases
risk over time”
Salpeter, JGIM 2006; 21:363-366
Consider transdermal estrogen
Oral estrogens have a higher risk of
thromboembolic events than transdermal
estrogen
Oral Therapy
Tablet must pass through
the digestive system and
liver before reaching
circulation
Transdermal therapy
Hormone has immediate access to
the circulation without concerns for
the liver and digestion
Oral estrogens can induce
the production of numerous
hepatic proteins, such as:
◦ angiotensinogen
◦ sex-hormone-binding globulin
◦ Increased clotting factors
High estrogen concentrations
in the liver increases metabolic burden
◦ increases biologically active metabolites
Impaired hepatic function can lead to
hyperestrogenism
◦ may have substantial estrogenic side effects
Mueck AO: Münchner Medizinische Wochenschrift 1997; 139:495–9.
• Smoking reduces endogenous
estrogen levels
• Nicotine may increase hepatic
metabolism of estrogen via CYP 450
enzymes
• Smoking increases SHBG
• Consider transdermal delivery to
avoid first-pass liver metabolism (if
they are already on an estrogen)
Lobo, JRM 37:77,1992
Can. Cons. Men. Osteo. JSOGC:20, 1998
Oral Transdermal
Decreased libido x
High TG w/ caution
Hypertension w/ caution
Smokers w/ caution
Post thromboembolism x ?
Thyroid disorders w/ caution
Disorders of the liver w/ caution
Disorders of the gall bladder w/ caution
Disorders of the pancreas w/ caution
Disorders of the stomach or intestine w/ caution
Mueck AO: Münchner Medizinische Wochenschrift 1997; 139:495–9.
FDA approved Bioidentical Hormones