A guide to hormone therapy Medicine: New research suggests estrogen may not protect the heart. But products containing the hormone proliferate.

October 04, 1998|By Marie McCullough | Marie McCullough,KNIGHT RIDDER/TRIBUNE

The bad news is that weighing the risks and benefits of hormone replacement therapy keeps getting tougher.

In August, startling new research cast doubt on the conventional wisdom that hormones protect the heart. The four-year study found that in postmenopausal women who already had heart disease, taking estrogen and progestin did not prevent further heart attacks or death, and increased the risk of blood clots.

But the good news is that menopausal women who decide that the benefits of taking hormones outweigh the risks have more and more options.

In August, the federal Food and Drug Administration approved Rhone-Poulenc-Rorer's CombiPatch, the first skin patch that combines both estrogen and progestin.

In May, FDA approved Solvay Pharmaceutical's Prometrium, the first pill containing an easily absorbed progesterone (a type of progestin) that is structurally identical to a woman's own pro-gesterone.

And in March, the FDA approved a new, lower dose of Solvay's Estratab, an estrogen pill, for prevention of osteoporosis.

While hormone options are multiplying, Premarin continues to be prescribed most often. Premarin, made by Wyeth-Ayerst Laboratories, is the oldest and most studied estrogen pill, and doctors have come to rely on it.

What are the current products for hormone replacement therapy? Here's an overview.

When choosing a hormone, keep in mind your symptoms.

For relief of vaginal dryness and improvement in bladder function, Estring, a vaginal ring similar to a diaphragm, releases very low doses of estrogen over three months. The hormone works on the targeted tissues, but not the rest of the body.

For relief of menopausal miseries such as hot flashes, or for long-term therapy to ward off heart disease and osteoporosis, pills, skin patches and vaginal creams are helpful.

Whatever the delivery system, a woman who has a uterus must take both estrogen and progestin.

Progestin - either progesterone derived from plants or a synthetic cousin - prevents the uterine lining, or endometrium, from growing out of control. Progestin wasn't routinely prescribed until the 1980s, after women discovered the hard way that estrogen alone can trigger endometrial cancer.

Unfortunately, progestins also tend to interfere with estrogen's good effects on cholesterol, and may renew the irritability, mood swings and bloating of premenstrual syndrome.

Brand names of estrogen pills besides Premarin include Ogen, Ortho-Est, Estratab, Estrace and Menest. Brand names of progestin pills include Provera, Cycrin, Aygestin, Micronor, Norlutate and the newest, Prometrium. There are also combined estrogen/progestin pills, called Prempro and Premphase.

Estrogen patches - such as Climara, Estraderm, Vivelle, FemPatch and Alora - send estrogen through the skin, directly into the bloodstream, bypassing the liver and intestines. This makes the patch a good choice for women with clotting problems, liver disease or gastrointestinal disorders. Some doctors also recommend it for patients who don't get a steady enough estrogen dose from pills to suppress all hot flashes.

The downside to the patch, which is worn on the abdomen or hip, is that some women find it itchy and irritating.

Until now, an estrogen patch had to be combined with a progestin pill. (There are two newer progestin products that are not oral: Crinone releases progesterone through a vaginal gel. Progestasert releases progesterone into the uterus for a year from an intrauterine device.)

Now, a woman can get both estrogen and progestin from the skin patch CombiPatch, which she changes every three to four days.

David Archer, an obstetrician-gynecologist at Eastern Virginia Medical School in Norfolk, Va., and president of the North American Menopause Society, said the FDA had concluded the various estrogen formulations all improve bone-mineral density and reduce hot flashes.

"There may be some variation in their effects on lipids [blood fats]," Archer said. "Can you tease out the difference? No."

When it comes to progestin, however, there is evidence that progesterone may have advantages over synthetic alternatives - which is why doctors say Prometrium, the first progesterone pill, is a welcome option.

The 1994 PEPI study (Postmenopausal Estrogen/Progestin Intervention) showed that progesterone in an easily absorbed pill had a better effect on lipids than the synthetic progestin found in Provera.

Some doctors say their patients seem to suffer fewer PMS miseries with progesterone.

"Natural progesterone doesn't cause as much ... bloating, depression, headaches," Kelly said. "That is very clear in my practice."

The one problem with progesterone - it is not easily absorbed - has been solved by fine grinding, called "micronizing."

Pub Date: 10/04/98

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