Current opinions and understandings of menopausal women about hormone replacement therapy (HRT)-the University of Florida experience

OBJECTIVE: This study was designed to assess the opinions and understanding of patients about hormone replacement therapy (HRT) since the release of the Women's Health Initiative (WHI) HRT trial data, which was widely publicized in the lay press. METHODS: All patients between the ages of 45 and 65 years seen in the last 3 years in the University of Florida Women's Clinics were mailed a survey asking about their attitudes and perceptions of HRT. RESULTS: A total of 6468 surveys were mailed with the return of 1076 completed surveys (16.6%); 78% of the respondents were menopausal and 65% had taken HRT. Of the women taking HRT, 70% stated it was for symptom relief and 30% for long-term benefits, including protection from heart disease (10%), Alzheimer's (4%), and osteoporosis (16%). Attitude changes about HRT since the release of WHI results were reported in 42% of respondents. Women currently on HRT had a more positive view of therapy (88%) compared with respondents overall (58%). Despite a great deal of media attention given to the topic of HRT, many women dramatically overestimated the risks of HRT, with 31% believing HRT increases the risk of heart disease 10% to 30% per year and 53% believing HRT increases the risk of breast cancer 10% to 30% per year. Despite this overestimation of risks, only 35% of respondents would not recommend HRT to a friend. CONCLUSION: This study suggests that WHI results did not impact attitudes about HRT in the majority of women taking HRT, as they were usually on therapy for relief of menopausal symptoms. However, there is a great need for consumer education about the attributable risks of HRT, approximately 1 per 1000 per year for heart disease, stroke, DVT, and breast cancer, so they can better weigh the benefits of HRT versus the risks.     

Assessment of the understanding of the risks and benefits of hormone replacement therapy (HRT) in primary care physicians

OBJECTIVE: This study was designed to assess the understanding of primary care physicians who practice in the state of Florida of the risks and benefits of hormone replacement therapy as described in the Women's Health Initiative clinical trial. STUDY DESIGN: All primary care physicians in the state of Florida, including family practice, internal medicine, and Ob/Gyn were identified and mailed an anonymous survey asking about their understanding of the risks and benefits of hormone replacement therapy (HRT), including heart disease, breast cancer, osteoporotic fractures, colon cancer, stroke, and death. Univariate statistics stratified by specialty were performed with Kruskal-Wallis one-way analysis of variance. RESULTS: Six thousand one hundred twenty-five surveys were mailed, with the return of 600 completed surveys, including 203 Ob/Gyn, 145 internal medicine, 219 family practice, and 33 other. Overall, Ob/Gyns had a more positive view of HRT, and internal medicine had a relatively negative view of HRT. In general, respondents overestimated the risk attributable to hormone replacement therapy. Ob/Gyns were significantly more likely to provide accurate assessments of these risks and benefits compared with the other specialties. Respondents correctly identified the magnitude of risks and benefits 28% of the time, 67% of the time overestimated risks and benefits, and 5% of the time misunderstood the direction of risk vs benefit of HRT. CONCLUSION: This study suggests that the findings of the Women's Health Initiative are misunderstood by the majority of primary care specialists, although Ob/Gyns have a better understanding of the risks and benefits compared to other specialties. We hypothesize that respondents that overestimate the increase or decrease in risk were making the error of confusing relative risk with absolute risk difference. There is a great need for physician education about the attributable risks and benefits of HRT.     

激素替代治疗对激素依赖性肿瘤患者生存的影响

激素替代治疗 (HRT)对改善妇女绝经后症状的有益作用已毋庸置疑。但是 ,长期以来HRT被认为可增加激素依赖性肿瘤发生与复发的危险性。通过系统地复习文献 ,不支持HRT增加这类肿瘤的发生及复发的危险性 ,且能提高患者的生活质量 ,对患者的生存也无不利影响。HRT不应该再成为这类肿瘤患者的绝对禁忌证     

子宫内膜异位症根治术后激素替代治疗疗效观察

目的　探讨激素替代治疗Ⅲ～Ⅳ期子宫内膜异位症根治术后 (全子宫及双侧附件切除术后 )的临床疗效与安全性。方法　 2 0 0 1年 3月至 2 0 0 2年 12月将 30例患者随机分成两组 (各 15例 ) :观察组口服戊酸雌二醇0 5～ 1 0mg ,每日 1次。对照组口服利维爱 1 2 5mg ,每日或隔日 1次。治疗前后检查盆腔情况、肝肾功能、体内血清FSH(卵泡刺激素 )、血清E2 (雌二醇 )水平 ,记录治疗期间盆腔痛、性交痛等子宫内膜异位症相关症状和乳房胀痛等不良反应 ,Kupperman评分 (K评分 )每月 1次。 结果　两组用药后围绝经期症状均明显改善 ,无子宫内膜异位症复发表现 ,血浆E2 水平上升 ,治疗前后比较差异有显著性意义 (P <0 0 1)。治疗后E2 水平观察组高于对照组 ,两组比较差异有显著性意义 (P <0 0 1) ,但均在安全范围内。结论　小剂量戊酸雌二醇和利维爱用于Ⅲ～Ⅳ期子宫内膜异位症根治术后患者 ,均能安全、有效地控制围绝经期症状。     

成都市围绝经期和绝经后妇女对激素替代治疗的认知和接受程度

目的 :调查成都市中老年妇女绝经状况和激素替代治疗 (HRT)的使用和认知状况 ,为有针对性地开展生殖健康服务提供依据。方法 :经调查表对成都市市区和郊县的190 6名 4 4岁以上妇女进行横断面研究。结果 :成都市妇女平均绝经年龄为 4 8岁 ,2 5 .4 %的妇女应用过HRT。近 1/3的妇女了解HRT。 5 0 %的妇女希望得到这方面的教育。获得信息的主要途径是医生、亲友、医学书籍和传媒。结论 :成都市中老年妇女的生殖健康知识较为贫乏 ,应将宣传教育和医学服务相结合 ,提高妇女的生活质量     

Joint Position Statement of the Polish Cardiologic Society,the Polish Gynaecological Society and the Polish Menopause and Andropause Society on the effect of postmenopausal hormone replacement therapy on the cardiovascular system

The group of experts representing the Polish Cardiologic Society, the Polish Gynecological Society and the Polish Menopause and Andropause Society has issued this Joint Position Statement based on the review of available literature on the effect of postmenopausal hormone replacement therapy on the cardiovascular system. The results of older clinical and epidemiological studies are confronted with the most recently published data. The importance of type, doses and delivery route of hormones is discussed with respect to the cardiovascular safety of HRT.     

Hormone replacement therapy in postmenopausal women with Alzheimer's disease: a randomized,prospective study

OBJECTIVE: To compare the therapeutic efficacy of hormone replacement therapy (HRT) and tacrine in Alzheimer's disease. DESIGN: Six-month, randomized, open-label study. SETTING: University hospital. PATIENT(S): Fifty-five women with mild to moderate Alzheimer's disease were randomly assigned to tacrine (n = 26) or HRT (n = 29). INTERVENTION(S): In the tacrine group, an initial dose of 40 mg/day was increased up to 160 mg/day. In the HRT group, conjugated equine estrogen was given to patients without uteri (n = 3) or together with micronized progesterone to patients with uteri (n = 26). MAIN OUTCOME MEASURE(S): Mini-Mental State Examination (MMSE), Hopkins Verbal Learning Test, Boston Naming Test, Controlled Oral Word Association Test, Geriatric Depression Scale, Hamilton Depression Scale (HDS), and Instrumental Activities of Daily Living (IADL). RESULT(S): Thirty-three patients who completed the outcome measures (tacrine, 17; HRT, 16) were included in an intent-to-treat analysis. The results did not differ between groups except for IADL, which rated more highly after HRT. Apolipoprotein E genotype effects were assessed. MMSE and HDS scores were improved after tacrine treatment in epsilon 4-negative patients. CONCLUSION(S): Overall efficacy of estrogen plus progesterone combination was similar to tacrine for cognition and mood, but greater for ADL. In epsilon 4-negative patients, tacrine is preferable for cognition and mood.     

Sequential combined transdermal and oral postmenopausal hormone replacement therapies: effects on bleeding patterns and endometrial histology

Objectives: To determine the endometrial response and bleeding patterns in postmenopausal women taking a sequential combined hormone replacement regimen either orally or transdermally. Methods: Seventy-two postmenopausal women with amenorrhea of 6 months or longer with follicle stimulating hormone and estradiol levels in the postmenopausal range and normal endometrium were included in the study. The patients randomly received sequential combined hormone replacement regimen with oral (n=37) or transdermal route (n=35). The total duration of treatment was 6 months (6 cycles of 28 d). The subjects kept daily bleeding diaries, and endometrial biopsies were taken at baseline and after 6 months of therapy. Results: The rates of adequate progestational response (secretory or atrophic) were 83.8% and 82.9% in the oral and transdermal hormone replacement groups, respectively (p>0.05). In the oral hormone replacement group, there were 16.2% of inadequate progestational response, 2.7% had endometrial hyperplasia and 13.5% proliferative endometrium. In the transdermal hormone replacement group, there were 17.1% of inadequate progestational response, 2.9% had endometrial hyperplasia and 14.3% proliferative endometrium. Cyclic bleedings occurred in 92.4% and 92% of all cycles in the oral and transdermal treatment groups, respectively. The mean duration of bleeding per cycle were 3.9±0.9 and 3.8±0.9 d in the oral and transdermal treatment groups, respectively. Conclusion: Sequential combined transdermal hormone replacement therapy is as effective as oral therapy in preventing the development of endometrial hyperplasia. Satisfactory control of bleeding is achieved with both regimens. Received: 6 June 2001 / Accepted: 12 July 2001     

激素替代治疗对绝经后妇女血清脂蛋白(a)的影响

目的 探讨戊酸雌二醇和倍美力对心血管疾病独立危险因子脂蛋白(a)[Lp(a)]的影响。方法 60例绝经后病例,按1:1随机分成两组,行连续序贯方案治疗,其中倍美力组30例口服结合雌激素0.625mg/d加醋酸甲孕酮4mg/d;戊酸雌二醇组30例口服戊酸雌二醇1mg/d加醋酸甲孕酮4mg/d。两组均连续治疗16周,于用药前、用药9周、16周取血测定血Lp(a),同时测血雌二醇水平。结果 两组用药后9周和16周Lp(a)均显著下降(P<0.01);两组间用药各时相Lp(a)水平差异无显著性(P>0.05)。两组用药前后E_2水平均显著升高(P<0.01),达正常月经周期早卵泡期水平。结论 激素替代治疗可使心血管疾病独立危险因子Lp(a)降低。     

A comparative review of the risks and benefits of hormone replacement therapy regimens

The Women's Health Initiative (a large, randomized, placebo-controlled trial) investigated the effect of conjugated equine estrogens combined with medroxyprogesterone acetate on specific potential long-term benefits and risks. A review of the clinical studies that have investigated different types and regimens of estrogens combined with progestins was conducted to assess how applicable the results of the Women's Health Initiative are to hormone replacement therapy regimens in general. The studies that were reviewed were limited to randomized clinical trials and observational studies that have been published over the last 15 years (1987-2002) and to meta-analyses and reviews that may have included the literature before 1987. The increased risks for venous thromboembolism, stroke, coronary heart disease, and breast cancer that were identified in the Women's Health Initiative trial have also been reported with postmenopausal hormone therapies that contain a variety of estrogen and progestin products. The beneficial effects that were noted in the Women's Health Initiative, with respect to reductions in fractures and colorectal cancer, have not been evaluated in large, randomized controlled trials that use different estrogen/progestin combinations; however, observational trials that used a variety of estrogen or hormone replacement therapy products and randomized clinical studies that evaluated bone mineral density (an excellent predictor of fracture risk) with different estrogen/hormone replacement therapy regimens would suggest that results would be similar to those found in the Women's Health Initiative. Although the relief of menopausal symptoms, the primary reason women seek treatment, was not included in the overall benefit/risk analysis of the Women's Health Initiative, numerous trials suggest that all therapies are effective. Overall, these data indicate that the benefit/risk analysis that was reported in the Women's Health Initiative can be generalized to all postmenopausal hormone replacement therapy products.     

Estrogen replacement therapy: What the future holds

Although hormonal replacement therapy has proved beneficial for many postmenopausal women, several issues remain to be resolved through future research. Improved combination therapy, better delivery systems, and optimal dosing may enhance compliance, which is essential for maximum benefit from therapy. Epidemiologic studies are necessary to clarify the role of estrogen in osteoporosis and cardiovascular disease. Additionally, the contribution of hormonal replacement therapy to the development of breast and endometrial cancers needs to be clarified.     

Cardiovascular effects of 6 months of hormone replacement therapy versus placebo: differences associated with years since menopause

OBJECTIVE: In response to post-Women's Health Initiative dialog regarding individualized hormone replacement therapy (HRT), this study evaluates cardiovascular and neuroendocrine effects of HRT versus placebo in postmenopausal women grouped according to time since menopause. STUDY DESIGN: Resting and stress blood pressure (BP), hemodynamic, plasma catecholamine, and cholesterol levels were obtained in 69 women randomly assigned to placebo or active HRT in a 6-month double-blind study. Analyses evaluated if treatment effects differed among those postmenopausal less than 5 years versus 5 years or more. RESULTS: Compared with the placebo-treated and HRT > or =5 groups, the HRT < 5 group showed reduced BP (P<.0007) and trends toward reduced vascular resistance and norepinephrine (P<.07). HRT > or =5 group generally did not differ from placebo. CONCLUSION: Reduced BP and sympathetic tone are evident in some HRT users, with diminishing benefit after the initial postmenopausal years. Time since menopause may be an important consideration in making individualized patient treatment decisions.     

激素补充治疗对绝经后妇女血液流变学的影响

目的探讨不同剂量结合雌激素(倍美力)配伍安宫黄体酮(MPA)的连续联合方案对绝经后妇女血液流变学的影响,以便更合理地为绝经后妇女的激素补充治疗提供指导和咨询.方法将60例绝经1～4年的健康妇女随机分为3组,A、B组分别口服结合雌激素0.625mg/d或0.3mg/d配伍MPA2mg/d,加复方碳酸钙(钙尔奇-D)600mg/d;C组口服复方碳酸钙600mg/d,为期半年,对比3组用药前、后以及用药后各组间血液流变学各项指标的变化.结果治疗前3组血液流变学各项指标比较,差异无显著性(P＞0.05).用药后,A组的全血高切粘度从(5.23±0.37)毫帕@秒(mPa@s)降至(5.03±0.43)mPa@s(P＜0.05),血浆粘度从(1.66±0.19)mPa@s降至(1.58±0.15)mPa@s(P＜0.05),红细胞变形能力从(4.76±0.32)mPa@s降至(4.54±0.34)mPa@s(P＜0.05),有明显改善.B组全血高切粘度从(5.10±0.30)mPa@s降至(4.87±0.30)mPa@s(P＜0.05),红细胞变形能力从(4.65±0.34)mPa@s降至(4.43±0.29)mPa@s(P＜0.05),也有明显改善.C组各项指标无明显变化.治疗后,A组血浆粘度及纤维蛋白原水平低于C组(P＜0.05);B组全血高切粘度、全血低切粘度及血浆粘度低于C组(P＜0.05).血栓弹力图于治疗前及治疗后各组间比较及治疗前后自身对比,差异无显著性(P＞0.05).结论两种剂量结合雌激素配伍MPA连续联合方案,均可降低血浆粘度、提高红细胞变形能力、改善微循环.     

Hormone replacement therapy in menopausal women: Past problems and future possibilities

Oral administration of conjugated equine estrogens (CEE) with and without the synthetic progestin medroxyprogesterone acetate (MPA) in postmenopausal women is associated with side-effects that include increased risk of stroke and breast cancer. The current evidence that transdermal administration of estradiol may provide a safer alternative to orally administered CEE is reviewed. Transdermally administered estradiol has been shown to be an efficacious treatment for hot flushes possibly without the increase in blood clotting that is associated with administration of oral CEE. Further, natural progesterone may have a more beneficial spectrum of physiological effects than synthetic progestins. The substantial differences between CEE compared with estradiol and estriol, as well as the differences between synthetic MPA and natural progesterone, are detailed. Estriol is an increasingly popular alternative hormone therapy used for menopausal symptoms. There is evidence that estriol, by binding preferentially to estrogen receptor-β, may inhibit some of the unwanted effects of estradiol. New clinical trials are needed to evaluate the safety and efficacy of topically or transdermally administered combinations of estradiol, estriol and progesterone. Future studies should focus on relatively young women who begin estrogen supplement use near the start of menopause.