Estrogens for the menopause. Maximizing benefits, minimizing risks

Abstract

There is a definite place for estrogen replacement in symptomatic menopausal women. Requisites of such therapy are a through history to establish a real need, a complete gynecologic examination with a Pap smear before therapy begins and annually afterward, use of the smallest daily dose of estrogen that gives the desired effect, and periodic attempts to reduce the dosage or stop the hormone. Endometrial biopsy should be done regularly if this is feasible, and any uterine bleeding should be investigated. If the suggestions outlined are followed, maximal benefit can be achieved with minimal risk to the patient.

PIP: There is a definite need for replacement estrogen therapy in menopausal women exhibiting vasomotor symptoms or osteoporosis, particularly if the woman has had bilateral oophorectomy. There is a less clearly defined need in women complaining of emotional symptoms. Atrophic vaginitis and trigonitis is usually best treated with topical application of estrogen, which does not have systemic side effects if used weekly; more frequent use can lead to vascular absorption. Some of the problems associated with estrogen replacement are dose-related and can be eliminated by using smaller dosages. Uterine bleeding can usually be controlled by administering cyclically with progesterine. Hypertension, thrombosis, and adenocarcinoma are problems associated with administration of exogenous estrogens; use should be undertaken with great care in women exhibiting these conditions and patients should be followed closely to make sure such conditions are not developing. Other conditions which may worsen with estrogen therapy are diabetes mellitus, seizure disorders, migraine, multiple sclerosis, collagen diseases, cholelithiasis, and hyperlipidemia. None except hyperlipidemia is an absolute contraindication but risk/benefit ratios must be considered carefully in these cases.