武功密笈

小黃藏書

å The varied reasons for a woman’s idiosyncratic response to hormonal therapy

include:

- differences in absorption of estrogen and progestins

- the state of the absorbed hormone in plasma

- the way in which the sex steroids bind with the target tissues

- the distribution of a-estrogen or b-estrogen receptors in the patient’s

estrogen-responsive organs

　

– Women who have or are risk for cardiovascular disease, osteoporosis, and

Alzheimer’s disease benefit from its use.

– Cardiovascular disease:

j Coronary artery disease (CAD):

Oral esterified estrogens and transdermal estrogens do not increase plasma

triglycerides and are preferred in women with hypertriglyceridemia.

k Diabetics:

Oral esterified estrogens and transdermal estrogens are also preferable.

è Clinical application:

- Before initiating HRT, evaluate results from a patient’s fasting glucose and a lipid

profile (including total cholesterol, HDL-c, triglycerides, and calculated LDL-c)

- Based on the results of the fasting glucose, lipid profile, and selectively measured

– Osteoporosis:

è Low-dose esterified estrogen therapy increases lumbar spine BMD:

　

ESE Dose
0.3mg/day	0.625mg/day	1.25mg/day
E2 (pg/dL)	22	29	43	64
BMD	-1.6…	-1.2Ú	2.0Ú	3.7Ú
E2 (pg/dL)	14	24	41	58
BMD	-2.0…	1.5Ú	3.0Ú	4.6Ú
E2 (pg/dL)	16	26	40	60
BMD	-2.9…	1.9Ú	3.0Ú	5.0Ú

… p < 0.05 from baseline Ú p < 0.05 from baseline and placebo

è Choosing and adjusting hormone therapy for osteopenia or osteoporosis:

– Alzheimer’s disease:

- Although there is still no consensus, some studies report a 50% reduction in the incidence of

- Clinical application:

1. Identify women at risk for Alzheimer’s disease as early as possible.

2. Determine if the individual’s cognition will respond to estrogen therapy.

3. Decide on the dose and route of estrogen therapy administration.

– The reduction in cardiovascular disease, osteoporosis, and colon cancer associated with HRT is

– Breast cancer:

P Despite more than 40 observational studies, no consensus exists on breast cancer risk with

P Doses of estrogen known to be effective in preventing osteoporosis and cardiovascular

P Clinical application:

– Endometrial cancer:

P Unopposed estrogen increases the risk for endometrial adenocarcinoma 1.7- to 20-fold. This

prescribed has less impact on endometrial protection (cyclic, which results in cyclic bleeding,

and continous)

– Resumption of menstruation:

P When bleeding is problematic enough to undermine the patient’s willingness to continue

with the therapy, amenorrhea can be induced though continuous combined estrogen and

progestin therapy. Depending upon the dose and potency of estrogen, the amount of

progestin can be halved.

ø When 17b estradiol 1mg is ordered, the daily doses for each progestin following can be used: progesterone 100mg, provera 2.5mg, norethindrone 0.5mg.

on this treatment is directly related to the onset and persistence of amenorrhea.

è Continuous combined hormone therapy and amenorrhea:

　

Patients experiencing amenorrhea
3 months	6 months	12 months
Estradiol 1mg + NETA 0.5mg	94	86	94	10
CEE + MPA 2.5mg	52	63	75	40
CEE + MPA 5.0mg	57	72	89	40

NETA: norethindrone CEE: conjugated equine estrogens

P To improve patient acceptability of combined therapy, the progestin can be prescribed

for 2 weeks every 3 months, but higher doses of progestin may be needed.

　

è Estimated serum estradiol and estrone levels and biological potency after

oral estrogen therapy:

cannot be determined by clinically available assays that measure only estradiol and

estrone.

　

¾ Individualize treatment with a comprehensive patient examination and

selective testing.

¾ Use the lowest effective dose of estrogen and progestin/progesterone to

accomplish the therapeutic goal. Recent research shows that ultra low doses of

estrogen can frequently meet the patient’s needs (for example, the control of

vasomotor symptoms, improvement in lipid profile, and prevention of bone

loss).

¾ Monitor the woman’s response to therapy (initially 3 months after starting

therapy and thereafter annually) and adjust the treatment accordingly.

¾ Choose the route and type of estrogen therapy that will optimize compliance.

HRT is effective only as long as the patient takes it. If one regimen is

unsuccessful, try other estrogen formulations instead of discontinuing therapy.

¾ Consider the use of measurable estrogens to mimic the hormonal milieu of

premenopausal (hormonal replacement therapy) or naturally postmenopausal

women (hormonal replenishment therapy).

¾ Educate the patient. Only an educated consumer can make informed decisions.

This leads to improved patient acceptance and continuance with hormonal

therapy.