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GDS_70000_Title_v1 1
HRT : An Update of Evidence
Hesham Al-Inany, M.D, PhD
Outline
• Menopausal transition
• HRT modalities
• Risks & Benefits
• Emerging concept
What is Menopausal transition?
• Menopause : permanent cessation of menstruation resulting from loss of
ovarian follicular...
AMH & Menopausal transition (2014)
• prediction of age of menopause using AntiMullerian Hormone
• Both AMH and mother's AN...
Signs and Symptoms
During the Menopausal Transition
Adapted from Bungay G et al. Br Med J 1980;281:181–3;
Van Keep PA et a...
Prevalence of Vasomotor Symptoms by Years
to/from the Final Menstrual Period (2008)
• Meta-analysis of six studies to esti...
• Penn Ovarian Aging Study 2007
• Data on 404 women who were
followed for a span of 9 years
– 50% White
– 50% African Amer...
Figure modified with permission from Obermeyer CM, Menopause Across Cultures: A Review of the Evidence, Menopause, 7, 3:18...
HRT Remains the Most Effective Therapy for
Vasomotor Symptoms 2006
• No significant efficacy of botanicals in reducing vas...
Outline
• Menopausal transition
• HRT modalities
• Risks & Benefits
• Emerging concept
Uterus
Sequential therapy without tablet break
Regular bleeding at end of cycle
How is HRT Given?
Continuous Sequential HR...
Estrogens Used in HRT 2007
Equivalent dose for bone endpoints*
Estrogen Ultra Low Low Standard High
Conjugated equine estr...
Estradiol: Benefits on Vasomotor Symptoms
• Dose–response effect for reducing moderate-to-severe hot flushes (n=333)
Figur...
Role of Progestogens in HRT
• Estrogen provides the benefits of HRT on menopausal symptoms
• For women who have not had a ...
Progestogens: Receptor Binding Activity
Progestogen Progestogenic Estrogenic Androgenic
Anti-
androgenic
Glucocorticoid
An...
2013 IMS Recommendations on Menopausal
Hormone Therapy – General Principles for Use
• HRT remains the most effective thera...
Outline
• Menopausal transition
• HRT modalities
• Risks & Benefits
• Emerging concept
HRT Risks and Benefits
Benefits
Relief of
Menopause
Symptoms
Risks
Breast
Cancer
Odds ratio (fixed)
95% CI
1.00 [0.68, 1.46]
1.02 [0.06, 16.44]
0.92 [0.41, 2.07]
0.98 [0.78, 1.22]
0.50 [0.04, 5.54]
0.32 ...
HRT and the Risk of Ischemic Stroke (WHI)
Risk of Ischemic Stroke
• The use of estrogen-only and estrogen-progestogen ther...
Risk of Stroke Associated with Route of
Administration (2010)
• Case-control study from the UK General Practice Research D...
Risk of Thromboembolism Associated with
Different Progestogens (2007)
ESTHER case-control study
271 consecutive VTE cases ...
Breast Cancer with HRT: Risk Perception vs. Reality
Figure reproduced with permission from http://www.keepstudy.org/why_ke...
Growth
1 cm
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Years
2.5 cm1 mm
Pre-mammographic Mammographic
Window
Clinically detected
B...
Is HRT Associated with Increased Breast Cancer Risk?
Evidence from WHI
1. Rossouw JE et al. JAMA 2002;288:321–33; 2. Lange...
HRT and Breast Cancer Risk - WHI
US WHI studies – additional risk of breast cancer after 5 years’ use
Age range
(years)
In...
HRT and Breast Cancer Risk – Million Women Study
Million Women Study – Estimated additional risk of breast cancer after 5 ...
Choice of Progestogen and Breast Cancer Risk:
E3N French Cohort Study 2008
Fournier A et al. Breast Cancer Res Treat 2008;...
Choice of Progestogen and Breast Cancer Risk:
Finnish Cohort Study 2009
Lyytinen H et al. Obst Gyn 2009;113:65–73.
Estradi...
Statements from International Societies 2013
International Menopause Society Statement on Breast Cancer1
• Women should be...
Outline
• Menopausal transition
• HRT modalities
• Risks & Benefits
• Emerging concept
Sequential Estradiol/Dydrogesterone:
Endometrial Safety and Bleeding
• In a comparison of 1/5 or 1/10 vs. 2/10 or 2/20 (n=...
Continuous Estradiol/Dydrogesterone:
Endometrial Safety and Bleeding Patterns 2010
• In an open, multicenter study of 1/5 ...
The emerging concepts in HRT
• Timing (window of opportunity)
• Early start
• Maintenance of estrogenic benefits
• Patient...
Conclusion
Used by the right woman, at the right dose, HRT can:
• Relieve vasomotor and other menopausal symptoms
• Provid...
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2014 :Updated information on Hormone Replacement Therapy

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New information have been raised on HRT. It seems that with selecting the right regimn and right candidate, HRT could be back again

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Transcript of "2014 :Updated information on Hormone Replacement Therapy"

  1. 1. GDS_70000_Title_v1 1 HRT : An Update of Evidence Hesham Al-Inany, M.D, PhD
  2. 2. Outline • Menopausal transition • HRT modalities • Risks & Benefits • Emerging concept
  3. 3. What is Menopausal transition? • Menopause : permanent cessation of menstruation resulting from loss of ovarian follicular activity (WHO, 2002) • Menopausal transition: from the first features of approaching menopause until up to 1 year after final menstrual period • Associated with significant hormonal variability over time • Overall, decline in estrogen levels over the menopausal transition Burger HG et al. Hormonal changes in the menopause transition. J Clin Endocrinol Metab 2002;84:4025–30. Copyright 2002, The Endocrine Society. Years around menopause Estradiol(pmol/L) FSH(iu/L) 0 1 2 3 4 5-1-2-3-4 0 20 40 60 80 100 120 0 50 100 150 200 250 300
  4. 4. AMH & Menopausal transition (2014) • prediction of age of menopause using AntiMullerian Hormone • Both AMH and mother's ANM have added value in forecasting TTM for the daughter based on her age (Dólleman M et al, 2014)
  5. 5. Signs and Symptoms During the Menopausal Transition Adapted from Bungay G et al. Br Med J 1980;281:181–3; Van Keep PA et al. Maturitas 1990;12:163–70. Vasomotor Symptoms Sleep Disorders Mood Changes Urogenital Atrophy Dyspareunia Osteoporosis Atherosclerosis Coronary Heart Disease Cerebrovascular Disease 40 yrs 50 yrs Menopause 60 yrs Menstrual Disorders
  6. 6. Prevalence of Vasomotor Symptoms by Years to/from the Final Menstrual Period (2008) • Meta-analysis of six studies to estimate the natural progression of vasomotor symptoms during the menopause transition : 4- 8 yrs Figure reproduced with kind permission from Springer Science+Business Media: J Gen Intern Med, Revisiting the duration of vasomotor symptoms of menopause: a meta-analysis. 23, 2008, 1507–13, Politi MC, Schleinitz MD, Col NF, Figure 2. Menopause 0 10 20 30 40 50 60 70 80 90 100 Percentagewithvasomotor symptomsvv Years to/from final menstrual period Y-8 Y-7 Y-6 Y-5 Y-4 Y-3 Y-2 Y-1 Y0 Y1 Y2 Y3 Y4 Y5 Y6 Y7 Y8 Y9 Y10 Y11 Y12 Y13 Y14 Y15 Y16 McKinlay (1974) Gutherie (2003) Thompson (1973) Oldenhave (1993) Berg (1988) Nedstrand (1996)
  7. 7. • Penn Ovarian Aging Study 2007 • Data on 404 women who were followed for a span of 9 years – 50% White – 50% African American Prevalence and Severity of Symptoms by Menopausal Stage Freeman EW, Sammel MD, Lin H, Gracia CR, Pien GW, Nelson DB, Sheng L. Symptoms associated with menopausal transition and reproductive hormones in midlife women. Obstet Gynecol 2007;110:230–40. 73% Subjects(%) Aches Subjects(%) Decreased libido Subjects(%) Depression 80 60 40 20 0 Subjects(%) Vaginal dryness Subjects(%) Hot flushes Subjects(%) Poor sleep Menopausal stage Menopausal stage Mild Moderate or severe 80 60 40 20 0 80 60 40 20 0 80 60 40 20 0 80 60 40 20 0 80 60 40 20 0
  8. 8. Figure modified with permission from Obermeyer CM, Menopause Across Cultures: A Review of the Evidence, Menopause, 7, 3:184-92. Comparative Frequencies of Hot Flushes in Different Parts of the World • A review of cross-cultural evidence on vasomotor symptoms from available studies
  9. 9. HRT Remains the Most Effective Therapy for Vasomotor Symptoms 2006 • No significant efficacy of botanicals in reducing vasomotor symptoms Newton KM et al. Ann Intern Med 2006;145:869–79. Reprinted from Annals of Internal Medicine, 145, Newton et al, Treatment of Vasomotor Symptoms of Menopause with Black Cohosh, Multibotanicals, Soy, Hormone Therapy, or Placebo, 869-879, Copyright (2006), with permission from American College of Physicians. Baseline 3 months 6 months 12 months 0 1 2 3 4 5 6 7 8 Vasomotorsymptomsperday Black Cohosh Multibotanical Multibotanical + soy HRT: CEE +/- MPA Placebo
  10. 10. Outline • Menopausal transition • HRT modalities • Risks & Benefits • Emerging concept
  11. 11. Uterus Sequential therapy without tablet break Regular bleeding at end of cycle How is HRT Given? Continuous Sequential HRT Estrogen Progestogen Day 14 De Villiers TJ et al. Climacteric 2013;16:316–337. . Continuous Estrogen Estrogen No tablet break No bleeding as no uterus Uterus Continuous Combined HRT Estrogen Progestogen Day 14 Combined therapy without tablet break No bleeding at end of cycle
  12. 12. Estrogens Used in HRT 2007 Equivalent dose for bone endpoints* Estrogen Ultra Low Low Standard High Conjugated equine estrogens (mg) 0.151 0.3 0.625 1.25 Micronized 17β-estradiol (mg) 0.52 1 2 4 Estradiol valerate (mg) 1 2 Transdermal 17β-estradiol (μg) 143 25 50 100 *Estrogenic effects may vary for other endpoints Table reproduced from Maturitas, 40, Gambacciani M, Genazzani AR. Hormone replacement therapy: the benefits in tailoring the regimen and dose. 195–201, Copyright (2001), with permission from Elsevier. 1. Lindsay R et al. Obstet Gynecol 1984;63:759–63; 2. Panay N et al. Climacteric 2007;10:120–31; The Estrogen Dose Counts
  13. 13. Estradiol: Benefits on Vasomotor Symptoms • Dose–response effect for reducing moderate-to-severe hot flushes (n=333) Figure reproduced with permission from Notelovitz M, Lenihan JP, Mcdermott M, Kerber IJ, Nanavati N, Arce JC. Initial 17β-Estradiol Dose for Treating Vasomotor Symptoms. Obstet Gynecol 2000;95:726–31. *p<0.05, ***p<0.001 vs. placebo * * Meannumberofmoderate-to- severehotflushesperweek Weeks 0 10 20 30 40 50 60 70 80 0 1 2 3 4 5 6 7 8 9 10 11 12 Placebo 0.25 mg Estradiol 0.5 mg Estradiol 1 mg Estradiol 2 mg Estradiol *** *** *** * * *
  14. 14. Role of Progestogens in HRT • Estrogen provides the benefits of HRT on menopausal symptoms • For women who have not had a hysterectomy, the addition of a progestogen to HRT is necessary to protect the endometrium from the stimulatory effects of unopposed estrogen Writing Group for the PEPI Trial. JAMA 1996;275:370–5. PEPI Trial: multicenter RCT : Results of Endometrial Biopsy Conclusion: Adding a progestogen is needed to safeguard the endometrium Placebo CEE alone CEE+MPA sequential CEE+MPA continuous N 119 119 118 120 Normal 98% 38% 95% 99% Simple hyperplasia 1% 28% 3% 1% Complex hyperplasia 1% 23% 2% 0% Atypia 0% 12% 0% 0% Adenocarcinoma 1% 0% 0% 0%
  15. 15. Progestogens: Receptor Binding Activity Progestogen Progestogenic Estrogenic Androgenic Anti- androgenic Glucocorticoid Anti-mineralo- corticoid Progesterone + – – ± + + Dydrogesterone + – – ± – ± Drospirenone + – – + – + MPA + – ± – + – Norethisterone + + + – – – Table reproduced from Maturitas, 46 (S1), Schindler AE, Campagnoli C, Druckman R, Huber J, Pasqualini JR, Schweppe KW, Thijssen JHH. Classification and pharmacology of progestins. 7–16. Copyright (2003), The Progestogen Counts • All progestogens have a protective effect on the endometrium • However, not all progestogens have the same receptor binding effect + Effective; ± Weakly effective; – Not effective
  16. 16. 2013 IMS Recommendations on Menopausal Hormone Therapy – General Principles for Use • HRT remains the most effective therapy for vasomotor symptoms • Use lowest effective dose of estrogen • More favorable if treatment is started earlier in menopause De Villiers TJ et al. Climacteric 2013;16:316–337. .
  17. 17. Outline • Menopausal transition • HRT modalities • Risks & Benefits • Emerging concept
  18. 18. HRT Risks and Benefits Benefits Relief of Menopause Symptoms Risks Breast Cancer
  19. 19. Odds ratio (fixed) 95% CI 1.00 [0.68, 1.46] 1.02 [0.06, 16.44] 0.92 [0.41, 2.07] 0.98 [0.78, 1.22] 0.50 [0.04, 5.54] 0.32 [0.01, 8.24] 0.97 [0.06, 15.82] 2.64 [0.10, 66.41] 0.33 [0.01, 8.21] 0.97 [0.54, 1.72] 1.79 [0.42, 7.67] 1.26 [0.96, 1.64] 0.97 [0.78, 1.21] Total 1.03 [0.91, 1.16] HRT Reduced the Risk of CHD events in Younger Postmenopausal Women (2006)In a meta-analysis of data from 23 studies (n=39,049) • HRT reduced CHD events by 32% in younger* women • In older women**, there was no reduction in CHD with HRT (OR 1.03; CI 0.91 to 1.16) *<10 years post-menopause or <60 years; **≥10 years post-menopause or ≥60 years CHD, coronary heart disease; OR, odds ratio Odds ratio (fixed) 95% CI 3.03 [0.12, 75.28] 0.16 [0.01, 4.12] 3.03 [0.12, 75.06] 1.00 [0.06, 16.10] 0.33 [0.01, 3.19] 1.25 [0.06, 26.10] 0.33 [0.01, 8.12] 0.31 [0.01, 8.29] 0.05 [0.00, 1.16] 0.12 [0.00, 2.93] 0.87 [0.53, 1.41] 0.56 [0.30, 1.03] Total 0.68 [0.48, 0.96] 0.001 Favors HT Favors control Favors HT 0.01 0.1 1 10 100 Favors control Older women** 1000.01 0.1 1 10 Younger women* Figure reproduced with kind permission from Springer Science+Business Media: J Gen Intern Med, Coronary Heart Disease Events Associated with Hormone Therapy in Younger and Older Women, 21, 2006, 363-66, Salpeter SR, Walsh JME, Greyber E, Salpeter EE, Figures 1 & 2.
  20. 20. HRT and the Risk of Ischemic Stroke (WHI) Risk of Ischemic Stroke • The use of estrogen-only and estrogen-progestogen therapy is associated with an up to 1.5-fold increased relative risk of ischemic stroke. The risk of hemorrhagic stroke is not increased during use of HRT. This relative risk is not dependent on age or on duration of use, but as the baseline risk is strongly age-dependent, the overall risk of stroke in women who use HRT will increase with age US WHI studies combined - additional risk of ischemic stroke1 over 5 years’ use Age range (years) Incidence per 1,000 women in placebo arm over 5 years Risk ratio (95% CI) Additional cases per 1,000 HRT users over 5 years (95% CI) 50–59 8 1.3 (1.1–1.6) 3 (1–5) 1No differentiation was made between ischemic and hemorrhagic stroke
  21. 21. Risk of Stroke Associated with Route of Administration (2010) • Case-control study from the UK General Practice Research Database Renoux C et al. BMJ 2010;340:c2519. • Low-dose transdermal HRT did not appear to increase stroke risk (1.15– 3.11) (0.62– 1.05) (1.12– 1.40) (1.16– 1.90) AdjustedRRvs.never-use ofHRT(95%CI)
  22. 22. Risk of Thromboembolism Associated with Different Progestogens (2007) ESTHER case-control study 271 consecutive VTE cases (mean age: 61.6 years) and 610 controls (mean age: 61.5 years) Canonico M. Circulation 2007;115:840–5. AdjustedORs(95%CI)for VTEwithoralandtransdermal estrogenvs.non-users (e.g. Dydrogesterone)  Micronized progesterone and dydroprogesterone appear to have an acceptable thrombotic risk profile 4.2 (1.5–11.6) 0.7 (0.3–1.9) 0.9 (0.4–2.3) 3.9 (1.5–10.0) (e.g. Nomegestrol acetate)
  23. 23. Breast Cancer with HRT: Risk Perception vs. Reality Figure reproduced with permission from http://www.keepstudy.org/why_keeps/keeps_causeDeath.pdf. Accessed 1 November 2012 PERCEPTION Leading causes of death perceived by women REALITY Actual causes of death among US women Old age (1%) Heart disease (18%) Other cancer (13%) Breast cancer (39%) Lung cancer (2%) Ovarian cancer (9%) Stress (2%) Smoking (1%) Other/don’t know (16%) Heart disease (45%) Other (25%) Lung cancer (5%) Ovarian cancer (<2%) COPD (4%) Pneumonia (4%) Other cancer (11%) Breast cancer (4%)
  24. 24. Growth 1 cm 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Years 2.5 cm1 mm Pre-mammographic Mammographic Window Clinically detected Breast Tumor Chronological Development of Breast Cancer 2011 Fritz MA and Speroff L. Clinical Gynecologic Endocrinology and Infertility (8th edn) Wolters Kluwer 2011; pp. 667–8.
  25. 25. Is HRT Associated with Increased Breast Cancer Risk? Evidence from WHI 1. Rossouw JE et al. JAMA 2002;288:321–33; 2. Langer R et al. Climacteric 2012;15:206–12; 3. Stefanik M et al. JAMA 2006;295:1647–57; 4. Santen R et al. J Clin Endocrinol Metab 2010;95(Suppl 1):s1–66; 5. Gompel A et al. Climacteric 2012;15:241–9. WHI evidence WHI RR for breast cancer: 1.26 (95% CI 1.00–1.59) for current use of HRT (CEE + MPA)1 Relative risk of 1.26 with combined HRT translates to an excess (attributable) risk of 4 per 1000 women taking HRT for 5 years4 Excess risk of breast cancer from HRT increases with increase in underlying risk5 Determination of risk should underlie decision to use HRT • No increased risk was identified for women who had had hysterectomy receiving CEE alone 2012
  26. 26. HRT and Breast Cancer Risk - WHI US WHI studies – additional risk of breast cancer after 5 years’ use Age range (years) Incidence per 1,000 women in placebo arm over 5 years Risk ratio (95% CI) Additional cases per 1,000 HRT users over 5 years (95% CI) CEE estrogen-only 50–79 21 0.8 (0.7–1.0) -4 (-6–0)1 CEE + MPA 50–79 14 1.2 (1.0–1.5) +4 (0–9) When the analysis was restricted to women who had not used HRT prior to the study there was no increased risk apparent during the first 5 years of treatment: after 5 years the risk was higher than non-users 1 WHI study in women with no uterus, which did not show an increase in risk of breast cancer Netherlands Summary of Product Characteristics (SmPC) , estradiol/dydrogesterone 2/10, 1/10, 1/5, 0.5/2.5 issued 13 April 2012.
  27. 27. HRT and Breast Cancer Risk – Million Women Study Million Women Study – Estimated additional risk of breast cancer after 5 years’ use Age range (years) Additional cases per 1,000 never users of HRT over a 5 year period1 Risk ratio (95% CI) # Additional cases per 1,000 HRT users over 5 years (95% CI) Estrogen only HRT 50–65 9–12 1.2 1–2 (0–3) Combined estrogen-progestogen 50–65 9–12 1.7 6 (5–7) # Overall risk ratio. The risk ratio is not constant but will increase with increasing duration of use Note: Since the background incidence of breast cancer differs by EU country, the number of additional cases of breast cancer will also change proportionately 1Taken from baseline incidence rates in developed countries Netherlands Summary of Product Characteristics (SmPC) , estradiol/dydrogesterone 2/10, 1/10, 1/5, 0.5/2.5 issued 13 April 2012.
  28. 28. Choice of Progestogen and Breast Cancer Risk: E3N French Cohort Study 2008 Fournier A et al. Breast Cancer Res Treat 2008;107:103–11; Fournier A et al. J Clin Oncol. 2008 ;26:1260–1268. Risk of all breast cancer Risk elevation may not be uniform for all progestogens N = 80,377 women, for an average treatment duration of 8.1 years Overall 77.7% were ductal breast cancers vs. 22.3% lobular breast cancers Estrogen/other progestogens (0.83– 1.22) (0.94– 1.43) (1.50– 1.91) 1.16 1.00 Estrogen/ progesterone Baseline risk without HRT Estrogen/ dydrogesterone 1.69 0 0.2 0.4 0.8 1.2 1.6 1.0 2.2 2.0 1.8 1.4 0.6 Relativerisk(95%CI) ≥5 years (0.8– 1.5) (0.8– 2.7) (1.2– 3.8) 1.5 1.1 ≥5 years<5 years <5 years 2.1 0 0.2 0.4 0.8 1.2 1.6 1.0 2.2 2.0 1.8 1.4 0.6 Ductal carcinoma Lobular carcinoma 1.1 (0.8– 1.17) Risk of breast cancer subtypes with E/D Significantly different from the risk without HRT Not statistically significantly different from risk without HRT
  29. 29. Choice of Progestogen and Breast Cancer Risk: Finnish Cohort Study 2009 Lyytinen H et al. Obst Gyn 2009;113:65–73. Estradiol/ MPA Estradiol/other progestogens Standardincidenceratio(95%CI) 0 0.2 0.4 0.8 1.2 1.6 1.0 2.2 2.0 1.8 1.4 0.6 2.072.03 1.64 1.13 Estradiol/ dydrogesterone Estradiol/ NETA (0.49– 2.22) (1.49– 1.79) (1.88– 2.18) (1.76– 2.04) Baseline risk without HRT Risk elevation may not be uniform for all progestogensRisk elevation may not be uniform for all progestogens N = 50,210 women >50 years of age, treatment duration 5 years
  30. 30. Statements from International Societies 2013 International Menopause Society Statement on Breast Cancer1 • Women should be reassured that the possible increased risks of breast cancer associated with HRT are small • an incidence of <1.0 per 1000 women per year of use • Less than the increased risks associated with common lifestyle factors such as reduced physical activity, obesity and alcohol consumption • Micronized progesterone or dydrogesterone used with estradiol may be associated with a better risk profile for breast cancer than synthetic progestogens 1. De Villiers TJ et al. Climacteric 2013;16:316–337. 2. Santen R et al. J Clin Endocrinol Metab 2010;95(Suppl1):S1–S66. USA Endocrine Society Scientific Statement on Breast Cancer2 • Emerging data from 2 independent studies suggest that progesterone (and perhaps dydrogesterone) in combination with estrogen does not increase breast cancer risk if given for 5 years or less
  31. 31. Outline • Menopausal transition • HRT modalities • Risks & Benefits • Emerging concept
  32. 32. Sequential Estradiol/Dydrogesterone: Endometrial Safety and Bleeding • In a comparison of 1/5 or 1/10 vs. 2/10 or 2/20 (n=579)1 – Endometrial safety was recorded across groups • No cases of hyperplasia or malignancy with 1/10 and 2/10 • 1 polyp occurred with 1/10 – Cyclic bleeding patterns were seen • Percentage of women with cyclic bleeding was 79% with 1/10 and 91% with 2/10 • E 1 mg associated with less cyclic and intermittent bleeding vs. E 2 mg • Higher doses of D associated with higher incidence of bleeds and later day of onset • In a comparison of 2/5, 2/10, 2/15 or 2/20 (n=371):2 – Endometrial safety was recorded across groups • No cases of hyperplasia or malignancy with 1/10 and 2/10 – Cyclic bleeding patterns found at all doses (83%, 90%, 87%, 93%, respectively) • Percentage of women with cyclic bleeding was 90% with 2/10 1. Ferenczy A et al. Climacteric 2002;5:26–35; 2. Burch DJ et al. Brit J Obst Gynaecol 1995;102:243–8.
  33. 33. Continuous Estradiol/Dydrogesterone: Endometrial Safety and Bleeding Patterns 2010 • In an open, multicenter study of 1/5 for 1 year (n=290):1 • 1 case of simple hyperplasia without atypia (treatment failure rate of 0.4%) • Women without bleeding increased from 71% (cycle 1) to ~80% by end of the study • ~50% of bleeding episodes were spotting • 41% women were amenorrheic throughout the study • 7 women withdrew prematurely due to uterine bleeding • In an open, multicenter study of ultra-low-dose 0.5/2.5 over 1 year (n=446):2 • 1 case of simple hyperplasia (incidence: 0.27%) • 68% experienced amenorrhea (88% during months 10–12) • 14% had 1 or 2 bleeding/spotting episodes • Spotting alone was the most prevalent bleeding intensity; heavy bleeding was rare 1. Quereux C et al. Maturitas 2006;53:299–305; 2. Bergeron C et al. Maturitas 2010;66:201–5.
  34. 34. The emerging concepts in HRT • Timing (window of opportunity) • Early start • Maintenance of estrogenic benefits • Patient selection • Avoiding generalized prescribing • Personalization • Tailoring dose to patient • Continuation and tapering the dose with age
  35. 35. Conclusion Used by the right woman, at the right dose, HRT can: • Relieve vasomotor and other menopausal symptoms • Provide protection against bone loss (second line) • Provide acceptable bleeding patterns
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