Prescribing menopausal hormone therapy: an evidence-based approach

Figures & data

Figure 1 Schematic representation of the natural history of coronary atherosclerosis in US women.

Notes: Reprinted from Mikkola TS, Clarkson TB, Notelovitz M. Postmenopausal hormone therapy before and after the Women’s Health Initiative study: what consequences? Ann Med. 2004;36:407.⁷⁸ Copyright © 2004, Informa Healthcare. Reproduced with permission of Informa Healthcare.
Abbreviations: ET, estrogen therapy; HT, hormone therapy.

Table 1 Nonoral estrogen and progestogen products available in the US

Nonoral estrogen and progestogen products
Systemic					Local (vaginal)
Patch		Cream/gel/spray	Vaginal ring	Brand name	Cream	Tablet	Ring	Brand name
Estrogen	Progestogen	Estrogen			Estrogen
17β-estradiola				Alora®	17β-estradiol			Estrace®
				Vivelle® Vivelle-Dot® Climara® Estraderm® Fempatch™ Esclim®	Conjugated equine estrogen			Premarin®
		17β-estradiol topical emulsion/topical gel		Estrasorb™ EstroGel®		Estradiol hemihydrate		Vagifem®
				Divigel® Elestrin®			17β-estradiol	Estring®
		17β-estradiola spray		Evamist®
	17β-estradiol and norethindrone acetate			Combipatch®
	17β-estradiol and norgestimate			Ortho-Prefest®
			Estradiol acetate	Femring®

Notes:

a Bioidentical. Copyright © 2013 by The North American Menopause Society, adapted with permission. Hormone Products for Postmenopausal use in the US and Canada, November 2012. Accessed at http://www.menopause.org/docs/professional/htcharts.pdf?sfvrsn=6.⁸⁰ Alora, Watson Pharmaceuticals Inc., Dublin, Ireland; Vivelle/Vivelle-Dot, Novartis Pharmaceuticals Corporation, Basel, Switzerland; Climara, Bayer HealthCare Pharmaceuticals Inc., Montville, NJ, USA; Estraderm, Novartis; Fempatch, Parke-Davis, Pfizer, Pharmaceuticals Inc., New York, NY, USA; Esclim, Fournier Pharma Inc., Montreal, QC, Canada; Estrasorb, Medicis Pharmaceutical Corp, Scottsdale, AZ, USA; Estrogel, ASCEND Therapeutics, Inc., Herndon, VA, USA; Divigel, Upsher-Smith Laboratories, Inc., Maple Grove, MN, USA; Elestrin, Meda Pharmaceuticals Inc., Somerset, NJ, USA; Evamist, Ther-Rx Corporation, St. Louise, MO, USA; Combipatch, Novartis Pharmaceuticals Corporation; Ortho-Prefest, Janssen Pharmaceuticals, Inc., Titusville, NJ, USA; Femring, Warner Chilcott (US) Inc., Parsippany, NJ, USA; Estrace (Vaginal), Warner Chilcott (US) Inc.; Premarin, Wyeth Pharmaceuticals Inc., Madison, NJ, USA; Vagifem - Novo Nordisk, Bagsvaerd, Denmark; Estring, Pharmacia and Upjohn Company, Somerset Country, NJ, USA.

Table 2 Oral estrogen and progestogen products available in the US

Estrogen products		Progestogen products		Estrogen plus progestogen products
Composition	Brand name	Composition	Brand name	Composition	Brand name
Conjugated equine estrogens	Premarin®	MPA	Cycrin® Provera®a	Conjugated estrogen + MPA	Prempro® Premphase®
Synthetic conjugated estrogen, A	Cenestin®	Norethindrone acetate	Aygestin® Norlutate®	Ethinyl estradiol + norethindrone acetate	Femhrt®a
Synthetic conjugated estrogen, B	Enjuvia®	Progesterone USP (in peanut oil)	Prometrium®a	17β-estradiol + norethindrone acetate	Activella®
Esterified estrogens	Menest®			17β-estradiol + drospirenone	Angeliq®
17β-estradiol	Estrace®a			17β-estradiol + norgestimate	Prefest®a
Estradiol acetate	Femtrace®a
Estropipate	Ortho-est® Ogen®

Notes:

a Bioidentical. Copyright © 2013 by The North American Menopause Society, adapted with permission. Hormone Products for Postmenopausal use in the US and Canada, November 2012. Accessed at http://www.menopause.org/docs/professional/htcharts.pdf?sfvrsn=6.⁸⁰ Premarin, Wyeth Pharmaceuticals Inc., Madison, NJ, USA; Cenestin, Teva Women’s Health Inc., North Wales, PA, USA; Enjuvia, Duramed Pharmaceuticals Inc., Cincinnati, OH, USA; Menest, Monarch Pharmaceuticals Inc, Bristol, TN, USA; Estrace, Warner Chilcott (US), LLC, Parsippany, NJ, USA; Femtrace, Warner Chicott (US), LLC; Ortho-Est, Women First HealthCare, Inc., San Diego, CA, USA; Ogen, Pharmacia and Upjohn Company, Somerset Country, NJ, USA; Cycrin - Esi Pharmaceuticals Inc., Malvern, PA, USA; Provera, Pharmacia and Upjohn Company; Aygestin, Teva Women’s Health, Inc.; Norlutate, Parke-Davis, Pfizer, Pharmaceuticals Inc., New York, NY, USA; Prometrium, AbbVie Inc., North Chicago, IL, USA; Prempro, Wyeth Pharmaceuticals Inc.; Premphase, Wyeth Pharmaceuticals Inc.; Femhrt, Warner Chilcott, (US), LLC; Activella, Novo Nordisk, Bagsvaerd, Denmark; Angeliq, Bayer HealthCare Pharmaceuticals Inc., Montville, NJ, USA; Prefest, Teva Women’s Health, Inc.; Prefest, Duramed Pharmacueticals, Inc.; Provera, Pharmacia and Upjohn Company; Aygestin, Teva Women’s Health; Norlutate, Parke-Davis; Prometrium, Abbvie Inc.

Abbreviations: MPA, medroxyprogesterone acetate; USP, United States Pharmacopeia.

Table 3 Comparative effects of oral versus transdermal estrogens

	Oral estrogen	Transdermal estrogen
Pharmacokinetics	Serum level peaks and troughs	Serum level remains relatively constant
Inflammatory markers (eg, C-reactive protein)	Increased synthesis	Neutral
Lipid effects	Increased triglycerides Increased HDL Decreased LDL	Decreased triglycerides Neutral effects on HDL and LDL
Blood pressure	Increased	Decreased
Insulin-like growth factor 1	Decreased (may lead to decreased lean body mass and increased body fat)	Neutral
Sex hormone-binding globulin	Strongly increased	Minimally increased
Clotting protein synthesis (hepatic enzyme induced)	Increased (may increase risk of venous thromboembolism)	Neutral (no increase in risk of venous thromboembolism at low doses)

Note: Data from Goodman.⁶⁴

Abbreviations: HDL, high-density lipoprotein; LDL, low-density lipoprotein.

Figure 2 (A) Risks and benefits of MHT (expressed as attributable or excess risk) in women starting MHT between the ages of 50 and 59 years or less than 10 years after the start of menopause. Figure expanded from panel B for clear visualization. (B) Number of women expected to get hot flashes and vaginal dryness symptom benefit per 1,000 women taking MHT for 5 years. Design of panels A and B is the same. Panel B compares the number of women benefiting from relief of symptoms of hot flashes and vaginal atrophy with the number of women experiencing other risks and benefits.

Notes: Republished with permission of Endocrine Society, from Santen RJ, Allred Dc, Ardoin SP, et al. Postmenopausal hormone therapy: an Endocrine Society scientific statement. J. Clin Endocrinol Metab. 2010 Jul;95(7 Suppl 1):s1–s66. doi:10.1210/jc.2009–2509. Epub Jun 21, 2010.⁷⁹ Permission conveyed through Copyright Clearance Center, Inc.
Abbreviations: MHT, menopause hormone therapy; E, estrogen; E+P, estrogen + progestogen.

MikkolaTSClarksonTBNotelovitzMPostmenopausal hormone therapy before and after the Women’s Health Initiative study: what consequences?Ann Med200436640241315513292

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The North American Menopause Society (menopause.org) [homepage on the Internet]Hormone Products for Postmenopausal Use in the United States and Canada Available from http://www.menopause.org/docs/professional/htcharts.pdf?sfvrsn=6Accessed December 11, 2013

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GoodmanMPAre all estrogens created equal? A review of oral vs transdermal therapyJ Womens Health (Larchmt)201221216116922011208

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SantenRJAllredDcArdoinSPPostmenopausal hormone therapy: an Endocrine Society scientific statementJ Clin Endocrinol Metab20107957 Suppl 1s1s6610.1210/jc.2009-2509 Epub Jun 21, 201020566620

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