hormone replacement therapy: the evidence and the clinicians dilemma victor s. sierpina, md alvah...
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Hormone Replacement Therapy: The Evidence and the Clinician’s Dilemma
Victor S. Sierpina, MD
Alvah Cass, MD
Daniel Freeman, PhD
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Bio-identical Hormones
• Hormones that are identical to those produced in the human body (may be synthetically produced)– Estrone, estradiol, estriol (Ortho-
Est,Estrace, Estraderm, Climara)– Progesterone (ProGest, Fem-Gest,
Progonol)– Testosterone– DHEA
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Natural Progesterones?Compounding Pharmacies
• Mexican Wild Yam• (Must add UPS Progesterone to topical
cream to be bioavailable)
• Compounding pharmacies: Bi-Est, Tri-Est, Micronized Progesterone
• 800-927-4227; www.iacprx.com… • www.womensinternational.com…
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Ovarian Steroidogenesis
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Altered and“Natural Hormones”
• Conjugated or otherwise modified from the original structure
• May have multiple components, bioactivity, bioavailability, metabolites
• Premarin®, conjugated equine estrogen has 90 different hormonal components
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Differences in Function/Structure
Testosterone Estradiol
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Differences in Structure
Methylated ProgesteroneProgesterone
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Basics of Menopausal Care
• Regular exercise• Social support• Meditation, relaxation, sleep • Quit smoking/alcohol• Dietary phytoestrogens
– Soy– Celery, fennel, parsley– Nuts, seeds– Flaxseed
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Phytoestrogens
• Soy• Black Cohosh
• Dong Quai• Red Clover• Chaste Berry Tree• Licorice• Evening Primrose Oil• Ginseng
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Botanicals
• Cimcifuga racemosa (Black cohosh) 1-2 g tid; 2 mg bid (27-deoxyacteine)
• Angelica sinensis (Dong quai) 1-2 g tid• Glycyrrhiza glabra (Licorice) 1-2 g tid• Vitex agnus-castus (Chaste berry)1-2
g tid• Ginseng 500-1000 mg/d
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Conclusions
• Jury still out on safety of HRT
• Bio-identical HRT has not been evaluated in clinical trials
• Are risks of HRT due to the hormones, their metabolites, methods of administration
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Conclusions
• Botanical medicines useful to treat menopausal sx
• ? Effect on osteoporosis, CV dz
• Progesterone alone may tx both menopausal sx and osteoporosis (controversial for osteoporosis when used alone)
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BOTTOM LINE
– HRT for menopausal sx is likely safe for up to 4-5 yrs
– Longer use (10-15 yrs) may create increased risk for some women
– Don’t HRT as CV tx or preventive– Individualize risk/benefit ratio and choice for
each pt.
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