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Comment and Controversy

Some women opt to continue HT past 5 years…and more

July 2011 · Vol. 23, No. 7


Some women opt to continue HT past 5 years

When I counsel symptomatic perimenopausal and postmenopausal patients about the use of hormone therapy (HT) for vasomotor symptoms, I let them know that, after 5 years, when it is advisable to taper off and discontinue HT, the hot flushes almost always return. I’ve found that many women refuse to discontinue HT at the 5-year point, even when I’ve counseled them beforehand about the risks.

Any suggestions as to how to further counsel this group?

Sharon Ravenelle, CRNP
Allentown, Pa

Dr. Kaunitz responds:The patient should choose the duration of HT

I appreciate Ms. Ravenelle’s thoughtful clinical query. In my practice, I do not set rigid timelines regarding patients’ use of HT. Rather, I focus on why they are using HT (or wish to initiate it) and what risks are applicable to them. I briefly document this discussion in the patient’s record. Ultimately, the patient (not her physician) chooses whether or not to initiate or continue HT.


Article failed to mention an effective nonhormonal remedy for vaginal atrophy

I really appreciated the series of opinions offered by the OBG Management Virtual Board of Editors concerning HT. It demonstrated the wide variability of doctors’ opinions, as well as the extreme variability of treatment options patients are offered by their doctors.

My primary reason for writing is the last sentence in the article, which stated: “At present, there don’t seem to be any outstanding alternatives to hormonal therapy.”

As director of the Complicated Menopause Program at the University of Massachusetts, I’m constantly weighing the risks and benefits of HT for my patients and regularly suggesting estrogen alternatives, as appropriate. As a result, the makers of Replens vaginal moisturizer have asked my opinion on this issue. In my estimation, the last sentence of the article seems not to reflect the current data.

A recent letter to the editor in Climacteric summarized the data very nicely.1 Replens has been studied in a head-to-head randomized trial with dienestrol hormonal cream and shown to statistically significantly improve the vaginal dryness index (although the hormonal cream did so with a greater effect). Both products:

  • maintained the improvement through 12 weeks of follow-up
  • caused equivalent significant improvements in itching and irritation after the first week of treatment that was maintained for 12 weeks
  • eradicated dyspareunia for 3 months comparably well
  • maintained an effective change in the vaginal pH level.2

Given the fact that many women will not or cannot use estrogen cream for vaginal dryness, and the fact that vaginal dryness and its associated symptom of dyspareunia are so prevalent, it seems that the data support, and our patients require, encouragement to use Replens as a first line of treatment for this problem. This is especially important for your readers, given the aforementioned variability in treatment options offered by the physicians featured in your article.

I hope you will make your readers aware of the availability of an effective alternative to hormone therapy for the treatment of vaginal dryness.

Machelle M. Seibel, MD
Professor of Obstetrics and Gynecology
University of Massachusetts
Director of the Complicated
Menopause Clinic
Former Editor in Chief, Sexuality,
Reproduction, and Menopause

Dr. Seibel reports that he is a consultant to Lil’ Drug Store, the maker of Replens.

Medicolegal risk should not be a deterrent to good care

I was saddened to read the comments of Peyman Zandieh, MD, in the article on hormone therapy. Dr. Zandieh reported that he declines to prescribe HT for any patient out of fear of being sued. I hope that his viewpoint represents a very small minority of ObGyns. Based on his logic, one should not prescribe birth control pills because of the risk of being sued when a patient has a pulmonary embolus, and one should not perform pelvic surgery because of the risk of being sued for a urinary tract injury.

All medical interventions have possible risks. The practice of medicine has always been about balancing the risks and benefits of any treatment in a given patient. A patient who would benefit greatly from HT should not be sent off to suffer solely because of fear of a lawsuit. To paraphrase the late, great President Harry Truman: If you can’t stand the heat, get out of the kitchen.

Thomas W. Powers, MD
Arcadia, Calif

It’s good to hear feedback from peers on HT practices

This article was very helpful! It’s good to hear what’s working for colleagues around the nation. In my practice, I’ve encountered considerable interest in bioidentical hormones and alternatives to HT.

I was surprised that no one mentioned the estradiol vaginal tablet. Many of my patients have asked about it as an alternative to messy cream and the difficulty of inserting a ring (Estring is large!).

Kate W. Adkins, MD
Kent, Ohio

Lifestyle improvements are the best option for menopausal symptoms

The article on HT asked for feedback from readers about how we manage menopausal patients.

I see a large population of menopausal and postmenopausal women in my practice. To manage their vasomotor symptoms, I follow guidelines from the North American Menopause Society, and I work with each individual to find the best treatment—be it HT or an alternative. I also keep up with research and evidence-based guidelines and share the findings and recommendations with my patients. I believe lifestyle improvement is the best therapy, because half of my patients will eventually die of cardiovascular disease.

Stephanie Van Zandt, MD
Clearwater, Fla


History of women in ObGyn is not that old

I almost fell on the ground laughing when I read the comments about gender disparity in Dr. Weinstein’s column and the allegations of sexism in the letters published in response to that column (April and June issues of OBG Management). When I started my training 34 years ago, I was a member of only the third class to allow women, by mandate of the federal government! We were breaking through. It was extremely difficult.

Although I sympathize with any male physicians who have been subject to sexism, I can honestly say that my own gender has worked against me most of the time, as evidenced by a lack of mentorship and other opportunities through the years.

Charlotte Richards, MD
Boston, Mass

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