Transdermal estrogen replacement: The pros
By Ivy M. Alexander, MS, C-ANP
Adult Nurse Practitioner
Assistant Professor
Yale University School of Nursing
Adult and Family Nurse Practitioner Specialty
New Haven, CT
(Editor’s note: This is the first of a two-part series on transdermal estrogen replacement therapy. In this issue, we explore the potential benefits. Next month, we’ll discuss the potential risks and disadvantages.)
As more women experience and live beyond menopause, interest in risks and benefits associated with estrogen replacement therapy (ERT) has increased. Initially, interest focused on relief of menopausal symptoms. Now that more research and experiential data are available, systemic effects related to estrogen deficiency and replacement are being recognized. Systemic benefits associated with ERT include reducing osteoporosis and coronary heart disease (CHD) and possibly some protection from colorectal cancer, Alzheimer’s disease, and senile dementia.1,2
Estrogen can be administered via oral, parenteral, intravaginal, and transdermal routes. Oral administration is most common, followed by the transdermal route.1 The purpose of this column is to review the advantages of transdermal estrogen delivery systems.
The most common reason for estrogen administration is relief of menopausal symptoms. Trans dermal therapy effectively reduces hot flashes, night sweats, headaches, mood changes, irritability, insomnia, and subjective sleep disturbances.1-5 Likewise, genitourinary symptoms such as vaginal dryness, pruritis, stress incontinence, urinary frequency, and dyspareunia are decreased with transdermal ERT. Potential benefits include:
• Offers hepatic effects.
In addition to relieving classic menopausal symptoms, transdermal ERT offers several other systemic benefits. The transdermal route of delivery bypasses the liver, so serum estradiol and estrone levels are closer to the 1:1 ratio seen before menopause.1 Additionally, transdermal estrogen does not affect angiotensin, sex hormone-binding globulin, or thyroid binding globulin, all of which are increased with oral estrogen administration.1,6 Finally, oral estrogens can affect bile composition and increase the risk of lithogenesis. Since transdermal estrogen does not appear to affect bile composition, it may be a safer option for women at risk for gallbladder disease.1
• Improves lipid profile and cuts CHD risk.
Transdermal estrogens affect the lipid profile differently than orally administered estrogens. Both decrease total cholesterol and low-density lipoproteins (LDL) and increase high-density lipoproteins (HDL). The changes seen with oral administration are greater than those occurring with transdermal delivery. Conversely, triglyceride levels increase with oral therapy and decrease with transdermal administration.1,2,5 With either type of administration, CHD risks may be reduced through improved lipid profile, reduced fasting insulin levels, increased left ventricular function, decreased vascular resistance, and reduced LDL oxidation.1,2,5
Despite the general belief that ERT is cardioprotective, a recent study found no benefit and a small increase in CHD during the first year of combination oral therapy in women who had cardiac disease prior to initiating HRT. Long-term treatment appeared to offer some benefit.2
• Lessens osteoporosis risk.
Osteoporosis risk is decreased with transdermal and oral ERT. This benefit is conferred by decreasing the rate of bone resorption and slowing turnover. Oral and transdermal delivery systems have been equally effective in reducing osteoporosis and reducing fracture risk.1,2
• Is easy to use.
Several estrogen and estrogen/progesterone combination patches are available. Patches are placed on the lower abdomen or buttock and replaced once or twice weekly.6 Studies indicate higher compliance in women using transdermal delivery as compared with oral estrogen.1
References
1. Connell EB. Transdermal estrogen therapy. Postgrad Med 1997;101-130.
2. Wenger NK. HRT and coronary heart disease: Answers to your top 12 questions. Women’s Health in Primary Care 1999; 2:305-321.
3. Lubbert H, Nauert C. Continuous versus cyclic transdermal estrogen replacement therapy in postmenopausal women: Influence on climacteric symptoms, body weight, and bleeding pattern. Maturitas 1997; 28:117-125.
4. Polo-Kantola P, Erkkola R, Irjala K, et al. Effect of short-term transdermal estrogen replacement therapy on sleep: A randomized, double-blind crossover trial in postmenopausal women. Fertil Steril 1999; 71:873-880.
5. Rozenberg S, Ylikorkala O, Arrenbrecht S. Comparison of continuous and sequential transdermal progestogen with sequential oral progestogen in postmenopausal women using continuous transdermal estrogen: Vasomotor symptoms, bleeding patterns, and serum lipids. Int J Fertil Womens Med 1997; 42(Suppl 2):376-387.
6. Anderson B, Mattesson LA. The effect of transdermal estrogen replacement therapy on hyperandrogenicity and glucose homeostasis in postmenopausal women with NIIDM. Acta Obstet Gynecol Scand 1999; 78:260-261.
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