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The team

VIEWS: 5 PAGES: 26

									               Alternatives to HRT

                                                                     Oestrogen




                            Dr Beverley Lawton
                       Women’s Health Research Centre
                        Wellington Menopause Clinic

Women’s Health Research Centre              University of Otago, New Zealand
                         Useful references

    www.otago.ac.nz/whrc
    www.menopause.org.au
    www.nlm.nih.gov/medlineplus/druginfo




Women’s Health Research Centre       University of Otago, New Zealand
                                 Overview

    • Why treat?

    • CAMS

    • Prescription medications
                                                 Woman with fan   Amedeo Modigliani




Women’s Health Research Centre          University of Otago, New Zealand
       The Dilemma…why treat at all?!
    • Common reason for seeking
      medical advice 1
    • Significantly affect QoL
      for 25% of women
    • For 10-20% of women these symptoms
      persist for more than 10 years 2

  1. Haimov-Kochman et al (2005) Acta Obstet Gynecol Scand 84 972-979
  2. Position Statement, Menopause.11(1):11-33, 2004


Women’s Health Research Centre                   University of Otago, New Zealand
                        Sleep Disturbance
    • Increases the risk of
      accidents
    • May decrease work
      place performance
    • Affects family life 1                    Sleeping Woman   Henri Matisse



    • Associated with increased risk of illness such as
    obesity, diabetes, hypertension and diabetes 2, 3
    1. Rosenthal M. Menopause2003;10(1):4-5.
    2. Ayas NT,et al. Arch Intern Med 2003;163(2):205-209.
    3. Gottlieb DJ et al Arch Intern Med 2005;165(8):863-867.



Women’s Health Research Centre                        University of Otago, New Zealand
             “Natural is good marketing ”




Women’s Health Research Centre   University of Otago, New Zealand
                                 “Natural”




Women’s Health Research Centre           University of Otago, New Zealand
    All therapeutic agents have:
    • Risks
    • Benefits
    • Side-effects
    • Interactions
    Dilemma in not treating:
    • Opportunity Costs
    Placebo effect


Women’s Health Research Centre   University of Otago, New Zealand
                         Ginseng example
    • Benefits:. Benefits in mental performance have been seen
      both in healthy young people and in older ill patients.

    • Risks: skin rash or spots, itching, diarrhoea, sore throat, loss
      of appetite, excitability, anxiety, depression, or insomnia.

    • Side effects (Less common): headache, fever,
      dizziness/vertigo, blood pressure abnormalities (increases or
      decreases), chest pain, difficult menstruation, heart
      palpitations, rapid heart rate, leg swelling, nausea/vomiting,
      or manic episodes in people with bipolar disorder.




Women’s Health Research Centre              University of Otago, New Zealand
                         Ginseng example
    • Interactions:
    • may reduce the anticoagulant (blood thinning) effects of
      warfarin

    • Headache, tremors, mania, or insomnia may occur if
      ginseng is combined with prescription anti-depressant
      drugs called monoamine oxidase inhibitors (MAOIs ),
      aloe vera , bilberry, bitter melon, burdock, fenugreek, fish
      oil, gymnema, horse chestnut seed extract (HCSE),
      marshmallow, maitake mushroom, milk thistle, rosemary,
      stinging nettle, and white horehound.

    http://www.nlm.nih.gov/medlineplus/druginfo/natural/patient
       -ginseng.html


Women’s Health Research Centre             University of Otago, New Zealand
        Complementary and Alternative
            Medications (CAMS)




Women’s Health Research Centre   University of Otago, New Zealand
                                 CAMS
    • Increasingly used
    • Surveys in USA estimate approximately
      40% of adults have used CAMS in the last
      year
    • The risks and benefits of many of these
      drugs are unknown
    • Increasing focus for research as we search
      for safe alternatives to HRT


Women’s Health Research Centre          University of Otago, New Zealand
                 What does NOT work ?
    • Dong quai, evening primrose oil, ginseng,
      acupuncture, magnetic therapy, evening primrose
      oil, melatonin,- no affect when compared to
      placebo1
    • Wild yam cream1 Vitamin E 2
    • Exercise - recent evidence suggests exercise may
      increase vasomotor symptoms but improves QoL3
    • Kava improves anxiety but not flushes

    1. Position Statement, Menopause.11(1):11-33, 2004
    2. Fitzpatrick L Med Clin N Am 87 (2003)
    3. Aiello J Menopause 11(4) 2004



Women’s Health Research Centre                           University of Otago, New Zealand
                        No proven benefit
    • Chasteberry, fish oil
    • Flaxseed oil, Ginkgo
    • Gotu kola, liquorice root,                       Fish oil tablets

      omega-3 fatty acids
    • Passion flowers, sage,
      valerian root 1

    1. Fugate SA, Pharmacother 2004; 38: 1482-99        Passion flower




Women’s Health Research Centre                     University of Otago, New Zealand
                         Phyto-oestrogens
• Results from RCTs to date have
  been conflicting.
• GI side-effects, Soy is
  goitrogenic 1
• Possible negative effects on
  breast cell proliferation 2

  • Not to be recommended in breast cancer patients
  1. Fugate S Ann Pharmacother 2004;38:1482-99
  2. http://nccam.nih.gov/news/pastmeetings/blackcohosh_mtngsumm.pdf



Women’s Health Research Centre                  University of Otago, New Zealand
             Black Cohosh (Cimicifuga racemosa)
    • Variable results concerning efficacy in treating
      menopause symptoms 1
    • But recent trials report no benefit above
      placebo2
    • Safety concerns re. reports of fulminant
      hepatitis lead to NIH workshop in 2005 3

    1. Position Statement, Menopause.11(1):11-33, 2004
    2. BMJ 2006 update search black cohosh
    3. http://nccam.nih.gov/news/pastmeetings/blackcohosh_mtngsumm.pdf




Women’s Health Research Centre                  University of Otago, New Zealand
                             Black Cohosh
    •      Experimental breast data
           suggests BC increases the
           toxicity of some cancer
           drugs.
    •      Animal models -
           increased spread cancer in
           mouse mammary cancer                           Black cohosh flower

           model
    http://nccam.nih.gov/news/pastmeetings/blackcohosh_mtngsumm.pdf




Women’s Health Research Centre                 University of Otago, New Zealand
                  Prescription Medicines
                          Antidepressants Venlafaxine,
                            Paroxetine, Fluoxetine
                          • Shown to have variable affect on
                            vasomotor symptoms. Generally fast
                            acting 1
                          • May be useful in breast cancer and/or
                            presence of depression
                          • Nine month RCT - citaloprim and
                            fluoxetine showed no effect on flushes
                            compared to Placebo 1
  1. Suvanto-Luukkonen Menopause.12(1):18-26,2005


Women’s Health Research Centre                 University of Otago, New Zealand
                          Antidepressants
    • Caution as regards side-effects
    • Small numbers and short
      duration of trials to date
    • Venlafaxine has been
      associated with hepatitis 1



    1. Phillips B Ann. (2006) Pharmacoth 40(2): 323-327




Women’s Health Research Centre                      University of Otago, New Zealand
                                 Clonidine
    • May be helpful
    • Side-effects limit use
         –   Drowsiness
         –   Tiredness
         –   Constipation
         –   Dry mouth
         –   Headache
         –   Dizziness


Women’s Health Research Centre           University of Otago, New Zealand
                                 Gabapentin

    • An RCT of 59 women showed reduction of hot
      flushes by 45% compared to 29% placebo 1
      another as effective as oestrogen 3
    • Adverse effects - somnolence, headache,
      dizziness, ataxia, fatigue, disorientation and
      nystagmus (1 in 4)
    • Safe and effective for short term use 2

    1. Guttuso T,Obstet,Gynecol 2003;101:337-345
    2. Fugate S Ann Pharmacother 2004;38:1482-99
    3. Siresha Y, Obstet,Gynecol 2006;108, NO1


Women’s Health Research Centre                     University of Otago, New Zealand
                    Bio-identicals, NHRT
                  www.otago.ac.nz/whrc
    •   Compounded therapies
    •   Often contain mixtures of powerful
        hormones
    •   Efficacy, safety and pharmaco-kinetics
        unknown1
    •   Must be considered experimental therapies

    Position Statement, Menopause.11(1):11-33, 2004




Women’s Health Research Centre                    University of Otago, New Zealand
                     Progesterone Cream
    •   Conflicting efficacy data
    •   Variable uptake
    •   No bone protection
    •   Limited safety data for the uterus
    •   Long term safety data needed

    Davis SR et al, J Endocrinol (2005) 185, 207-222
    www.otago.ac.nz/whrc




Women’s Health Research Centre                         University of Otago, New Zealand
             Don’t forget what we sit on!
      •   Vaginal dryness is common
      •   Intercourse can be painful if not impossible
      •   Vaginal lubricants can help
      •   In most cases topical or oral oestrogen will
          be needed




Women’s Health Research Centre      University of Otago, New Zealand
                                 Summary
    • There is a significant need for appropriate
      treatments for menopause symptoms
    • There are alternative options of varying
      efficacy and safety




Women’s Health Research Centre         University of Otago, New Zealand
                                 Thank you
                    www.otago.ac.nz/whrc


                                              Women’s Health
                                              Research Centre
                                   Research making a difference to women




Women’s Health Research Centre                  University of Otago, New Zealand

								
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