There are many products for HRT, including synthetically manufactured hormones available commercially and bioidentical hormone products compounded specifically to meet the patient's needs. Both come in a variety of dosage forms, including tablets, patches, and vaginal creams and rings. Compounded products may come in additional dosage forms, such as transdermal creams, troches (small lozenges), and capsules. Topical creams are applied to the wrist or behind the knee, where the skin is thin with high blood perfusion. Troches are dissolved in the mouth, allowing the hormone to be absorbed without being altered by digestion. In compounding HRT, the compounder can alter the concentration of each hormone to target the patient's specific symptoms while avoiding the side effects of some commercial preparations.
The first step in choosing an HRT product is to identify which hormone or hormones need to be supplemented or replaced. Age is another factor to consider with HRT, as most adverse effects seen in the WHI trials occurred in women older than 60 years. Most women experience menopause in their 40s or 50s, however, so this is when HRT would be most beneficial. Young, healthy patients going through menopause should be reassured that the risk is very low when using HRT for a duration of 5 years. In clinical practice, patients have been known to use HRT for up to 10 years. The HRT product is then gradually titrated to the lowest effective dosage possible while avoiding symptoms of hormone deficiency.
Common symptoms in patients with declining estrogen include hot flashes, dry skin and hair, night sweats, vaginal dryness, and incontinence. Since estrogen therapy is not without its risks, it is important to start with the lowest dosage and slowly titrate to an effective dosage. Options for estrogen-only products include Estrace oral tablets (estradiol), Vivelle-Dot patches (estradiol), and Premarin tablets (conjugated estrogen). For more localized vaginal symptoms, Premarin cream is an effective option that avoids other symptoms of increased estrogen, such as weight gain, mood swings, and breast tenderness.
The presence or absence of the uterus is another important factor to consider when an HRT product is being selected. Unopposed estrogen—estrogen therapy alone without progesterone—has been shown to increase the risk of endometrial hyperplasia and endometrial cancer, so women with a uterus should avoid receiving estrogen without progesterone to prevent the risk of uterine hyperplasia.[7,8] The presence of a uterus should not be considered an absolute contraindication to HRT, although therapy should be limited to 5 years based on the increased risk of breast cancer. Another risk associated with prolonged estrogen therapy is the development of blood clots leading to pulmonary embolism and stroke. As with all prescriptions, the risks versus benefits of HRT should be discussed with the patient before initiation. Many women using HRT report improvements in sleep, sexual functioning, and vasomotor symptoms and experience an overall improvement in quality of life.[9,10] In the WHI trials, the risk-versus-benefit ratio was more favorable in younger patients receiving conjugated estrogens who had a previous hysterectomy, compared with patients receiving conjugated estrogen and medroxyprogesterone acetate.
Progestin, a synthetic progesterone, is often administered together with estrogen to negate the effects of long-term estrogen therapy. Medroxyprogesterone acetate, a common progestin, was used in the WHI trials. Commercially available combination estrogen and progestin products include Prempro (conjugated estrogens and medroxyprogesterone) and Femhrt (ethinyl estradiol and norethindrone). Medroxyprogesterone alone as a separate tablet in addition to estrogenonly tablets is also an appropriate option to prevent the risks associated with unopposed estrogen.
Supplementation of testosterone is usually limited to the improvement of sexual function in menopausal women. However, many women with low levels of testosterone experience depression, headaches, and fatigue, in addition to the typical symptoms of decreased sex drive and trouble reaching climax. In clinical practice, testosterone supplementation is often used to eliminate these symptoms, and it should be considered a part of the overall hormone balance. In addition, a study of 51 women using testosterone replacement for androgen deficiency caused by hypopituitarism reported free testosterone levels that reached the upper limit of normal, increased bone mineral density of the hip and radius, greater fat-free mass, and increased thigh muscle, but there was also an increase in acne.
DHEA replacement is another consideration, as DHEA is converted to testosterone. However, based on available data, the Endocrine Society recommends against the use of DHEA in women for improvement of sexual function. Some experts suggest a trial of DHEA in menopausal and postmenopausal women with significantly impaired mood or sense of well-being despite treatment with optimal glucocorticoid and mineralocorticoid replacement therapy. Since DHEA is available OTC, pharmacists can provide education on symptoms and replacement therapy to women interested in purchasing this product.
US Pharmacist. 2015;40(9):33-37. © 2015 Jobson Publishing