Options in Hormone Delivery

By Lee P. Shulman, MD.

Menopause management is a “work in progress” and clinicians must remain informed about the latest advances in HRT formulations in order to identify the right therapy for each woman.

The menopausal population of the United States will double between 1990 and 2020,¹ inevitably changing the way clinicians provide care to women. The increasing number of menopausal women will require diagnostic, counseling, and therapeutic interventions different from those routinely used for reproductive-aged women. Clinicians now have more options for the treatment of menopause, and in fact, for the general medical management of mature women. Nevertheless, for the foreseeable future our first-line therapy to help most women cope with the vasomotor symptoms and other estrogen-deprivation symptoms

associated with the menopausal transition, and to promote their well-being thereafter, is hormone replacement therapy (HRT).

Despite considerable evidence demonstrating the benefits of HRT, the majority of women choose not to use HRT or to discontinue its use shortly after starting therapy.² This is due, in part, to the continual trickle of well-publicized studies reporting that HRT is either unsafe or ineffective, even in the face of a considerable body of literature that attests to the opposite.

Lack of compliance with HRT also can be attributed to insufficient training of many women’s health-care providers concerning the needs of menopausal women and the potential nongynecologic impact of HRT. Women’s health-care providers often focus on the gynecologic issues of menopause, such as vulvovaginal atrophy and urovaginal problems, and fail to assess the more global issues of the menopause. The loss of endogenous estrogen leads to multi-organ changes and problems for women, affecting their overall health, quality of life, and longevity. In addition to the urinary and reproductive tracts, estrogen-sensitive tissues include skin, bone, vascular lining, the brain, and central nervous system. Even dental health is affected; menopausal women who are not treated with HRT are at increased risk for tooth loss.³ Unfortunately, many obstetrician-gynecologists receive little to no training on counseling women about HRT use, advising patients on sexuality, cardiovascular and central nervous system health, or providing information on health maintenance efforts such as diet and exercise—all issues of considerable importance to the mature woman.

This lack of training affects the care and management of even younger menopausal women. Mood and sleep disturbances are often the first problems to manifest, but women don’t spontaneously volunteer complaints about them. Only after reviewing her overall health, a woman may report, “You know what? I have had increasing problems with sleeping over the past several months. I wake up sometimes at 3:00 in the morning.” After the appropriate assessment of sleep and urinary problems, many clinicians will start prescribing sleep aids, when in fact the patient is experiencing the very early signs of vasomotor instability associated with dropping or widely fluctuating estrogen and progestin levels. It is important to be cognizant of these nuances to provide better counseling, diagnosis, and treatment for those conditions that have a negative impact on patients.