Drug update: hormone replacement therapy.

Management of the menopausal woman is more of an art than a science. For patients plagued by urogenital atrophy or vasomotor symptoms, such as hot flashes, night sweats, and insomnia, female hormones are among the most effective treatments.

Norra MacReady

They come in a variety of pills, creams, and patches that contain a range of active ingredients in a wide array of dosages.

Until recently, hormone replacement therapy (HRT) was also used to help prevent other conditions that become common in older women, such as cardiovascular disease or osteoporosis. However, the results of several recent studies showed that women who took a widely prescribed estrogen-progestin combination had an increased risk of breast cancer and cardiovascular events, compared with women treated with placebo, especially after 5 or more years. This forced physicians and patients to reevaluate their use of these products. Currently they are recommended primarily to treat the vasomotor symptoms of menopause or atrophy of urogenital tissue. For most women at risk of heart disease or osteoporosis, other treatments are available.

The variety of hormone types and vehicles makes comparison across products difficult. Most physicians take a trial-and-error approach. Currently experts recommend that a woman use HRT for up to 2-3 years and then start tapering her use. Exogenous estrogen by itself increases the risk of endometrial cancer, so women with an intact uterus who take estrogen must take progesterone to counter that risk.

A menopausal woman also needs an overall management strategy tailored to her unique needs, including counseling on diet and exercise and recommendations on the use of over-the-counter items such as soy products and vaginal lubricating agents.

 
HORMONE COMBINATIONS 
 
Drug                 Dosage                Cost/Day 
 
Products that 
combine 
estrogen and 
progestin in one 
pill or patch are 
convenient but 
lack the 
flexibility of 
single-hormone 
preparations. 
 
conjugated equine    0.625 mg estrogen     $1.18 * 
estrogen and         and 2.5 mg 
medroxyprogesterone  medroxyprogesterone/ 
acetate (Prempro)    day 
 
 
 
 
 
 
 
 
 
 
 
 
estradiol and        1 mg estradiol        $0.93 * 
norethindrone        and 0.5 mg 
acetate (Activella)  norethindrone/day 
 
 
 
 
 
 
 
 
 
ethinyl estradiol    5 [micro]g ethinyl    $0.93 * 
and                  estradiol and 1 mg 
norethindrone        norethindrone/day 
acetate (femhrt) 
 
 
 
estradiol and        0.05 mg estradiol     $1.20 ** 
norethindrone        and 0.14 mg 
acetate              norethindrone/day 
(CombiPatch) 
 
 
 
 
 
 
 
 
 
 
 
 
estradiol and        1 mg estradiol/day    $0.89 * 
norgestimate         and 0.09 mg 
(Ortho-              norgestimate/day for 
Prefest)             3 days, followed by 
                     3 days off 
 
 
 
 
 
 
 
 
 
conjugated equine    0.625 mg estrogen     $1.09 * 
estrogen and         for 14 days; then 
medroxyprogesterone  0.625 mg estrogen 
                     plus 5 mg 
acetate (Premphase)  medroxyprogesterone 
                     for 14 days 
 
 
 
 
 
 
 
 
esterified           1.25 mg estrogen      $1.60 * 
estrogen             and 2.5 mg 
and                  methyltestosterone/ 
methyltestosterone   day 
(Estratest) 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
SINGLE-HORMONE 
PREPARATIONS 
 
For women who have 
had a hysterectomy 
or for those who do 
not respond to 
combination 
products and 
require more 
customization. 
Most estrogens are 
formulated as a 
vaginal cream 
as well as an 
oral tablet. 
Although the 
topical 
formulations 
avoid systemic 
adverse 
effects and are 
effective for 
treating vaginal 
dryness, some 
women consider 
them too messy for 
regular use. 
Space limitations 
prevent separate 
listings for the 
oral formulations 
of conjugated 
estrogen and 
estradiol and the 
transdermal 
formulation of 
estradiol. The 
advantages and 
disadvantages of 
these 
single-hormone 
formulations are 
similar to the 
analogous 
combination 
formulations 
listed above. 
 
estropipate          0.75-3 mg/day         $0.60 
 
                                           (1.5 mg/day) * 
 
 
 
 
 
 
 
 
 
estradiol in         7.5 [micro]g/day      $0.97 *** 
vaginal              continuously 
ring (Estring) 
 
 
 
 
medroxyprogesterone  2.5-10 mg/day         $0.36 (5 mg) * 
acetate 
 
 
 
Drug                 Comment + 
 
Products that 
combine 
estrogen and 
progestin in one 
pill or patch are 
convenient but 
lack the 
flexibility of 
single-hormone 
preparations. 
 
conjugated equine    Contains estrogen from the 
estrogen and         urine of pregnant mares. Last 
medroxyprogesterone  summer, results from the 
acetate (Prempro)    Women's Health Initiative 
                     study showed this tablet 
                     formulation led to an excess 
                     risk of breast cancer, 
                     cardiovascular events, and 
                     blood clots after a mean of 5 
                     years of use. The women in the 
                     study averaged 63 years old; 
                     risk faced by younger women is 
                     not clear. Also formulated 
                     with a 5-mg dose of 
                     progesterone. 
 
estradiol and        Contains synthetic, plant-based 
norethindrone        sterol. Some women prefer this 
acetate (Activella)  tablet formulation as more 
                     "natural" or "organic", but 
                     there's no evidence it differs 
                     clinically from mammalian- 
                     derived products. Effects of 
                     long-term use are unknown, but 
                     precautions are similar to 
                     those for equine estrogen are 
                     advised. 
 
ethinyl estradiol    ...