Continuing decline in hormone therapy use: population trends over 17 years

Compounded bioidentical menopausal hormone therapy - a physician perspective

One of the defining moments of the 80-year evolution of menopausal hormone therapy (MHT) was the 2002 reveal of the initial results of the combined hormone therapy arm of the Women's Health Initiative (WHI) clinical trial. The exodus from regulatory approved MHT was prompt and profound and accompanied by a rapid acceleration of the compounding pharmacy 'bioidentical' hormone therapy industry. Compounders had recruited prescribers and promoted compounded bioidentical hormone therapy (cBHT) well before the WHI, yet the startling results provided a catalyst that enabled a leap in production of compounded hormones that were variably regulated, basically unstudied, and inconsistently labeled. In this review, the story of the rise of cBHT and the regulatory double standard is eclipsed only by the 2020 findings and recommendations of the US National Academies of Science, Engineering, and Medicine. Their investigation, commissioned by the US Food and Drug Administration, was tasked to: provide an evidence-based summary of the clinical utility of cBHT; evaluate whether the evidence of safety and efficacy supports the use of cBHT; and identify patient populations that might need cBHT in lieu of an approved drug product. Their conclusions are consistent with sound science and their recommendations are in harmony with global menopause societies.

Trends in Prescribing Menopausal Hormone Therapy and Bisphosphonates in Australia and Manitoba, Canada and Adherence to Recommendations

Background: Recommendations for using menopausal hormone therapy (MHT) and bisphosphonates for postmenopausal osteoporosis management have changed over time. After the release of the Women's Health Initiative (WHI) trial results in 2002, new evidence on risks and benefits of MHT became available, and newer guidelines generally specify that MHT should not be prescribed for prevention of chronic disease, including osteoporosis. This raises the question of whether bisphosphonate prescribing changed over time to compensate for the decrease in MHT use. Materials and Methods: We examined trends in dispensed prescriptions in Australia (national) and Canada (province of Manitoba) in relation to prescribing recommendations. Administrative data were used to describe dispensing patterns and changes for persons of all ages from 1996 to 2008, and for women aged 50 to ≥80 years from 2003 to 2008 in Australia and 1996 to 2008 in Canada. Results: In both geographic settings, MHT dispensing increased 1996-2001, peaked in 2001, and declined substantially thereafter (67% reduction in MHT prescriptions for Australia; 64% reduction for Manitoba, Canada to 2008). From 2003 to 2008, the number of MHT prescriptions declined among all age groups in both settings, with the highest declines among women in their 50s. Concurrently, bisphosphonate dispensing increased until 2005 (2001-2005: 260% increase in the number of prescriptions in Australia; 125% increase in Manitoba) and stabilized thereafter, in both settings. Annual bisphosphonate dispensing rates increased 4.1-10.9% for women in their 70s and 80s in Australia and Manitoba during the period studied. Conclusions: Based on dispensed prescriptions data, more recent guidelines for MHT and bisphosphonates use for postmenopausal osteoporosis, which were updated during the study period (and are still consistent with the current guidelines), appear to have been broadly adhered to in both settings.

Menopausal Hormone Therapy use and breast cancer risk by receptor subtypes: Results from the New South Wales Cancer Lifestyle and EvaluAtion of Risk (CLEAR) study

Breast cancer risk is increased with current Menopausal Hormone Therapy (MHT) use, with higher risks reported for ER+ (Estrogen Receptor positive), and ER+/PR+ (Estrogen and Progesterone Receptor positive) breast cancers than those of ER- and ER-/PR- status, respectively. There is limited evidence to suggest MHT use is associated with the specific subtype characterised as ER+/PR+/HER2- (Estrogen and Progesterone Receptor positive and Human Epidermal growth factor Receptor2 negative) status. This study aims to investigate the MHT-breast cancer relationship for breast cancer tumor receptor subtypes defined by ER expression alone, by ER and PR expression only and by joint expression of ER, PR, and HER2. Analyses compared 399 cancer registry-verified breast cancer cases with receptor status information and 324 cancer-free controls. We used multinomial logistic regression to estimate adjusted odds ratios (aORs) and 95% Confidence Intervals (CI) for current and past versus never MHT use, for subgroups defined by tumor receptor expression. Current, but not past, use of MHT was associated with an elevated risk of ER+ breast cancer (aOR = 2.04, 95%CI: 1.28-3.24) and ER+/PR+ breast cancer (aOR = 2.29, 1.41-3.72). Current MHT use was also associated with an elevated risk of the ER+/PR+/HER2- subtype (aOR = 2.30, 1.42-3.73). None of the other subtypes based on ER, ER/PR or ER/PR/HER2 expression were significantly associated with current MHT use in this analysis. Current, but not past, use of MHT increases the risk of breast cancer, with consistently higher risks reported for ER+ and ER+/PR+ subtypes and mounting evidence regarding the specific ER+/PR+/HER2- subtype. Our findings contribute to quantification of the effects of MHT, and support efforts to articulate the receptor-mediated mechanisms by which MHT increases the risk of breast cancer.

Estetrol, a Fetal Selective Estrogen Receptor Modulator, Acts on the Vagina of Mice through Nuclear Estrogen Receptor α Activation

The genitourinary syndrome of menopause has a negative impact on quality of life of postmenopausal women. The treatment of vulvovaginal atrophy includes administration of estrogens. However, oral estrogen treatment is controversial because of its potential risks on venous thrombosis and breast cancer. Estetrol (E4) is a natural estrogen synthesized exclusively during pregnancy by the human fetal liver and initially considered as a weak estrogen. However, E4 was recently evaluated in phase 1 to 2 clinical studies and found to act as an oral contraceptive in combination with a progestin, without increasing the level of coagulation factors. We recently showed that E4 stimulates uterine epithelial proliferation through nuclear estrogen receptor (ER) α, but failed to elicit endothelial responses. Herein, we first evaluated the morphological and functional impacts of E4 on the vagina of ovariectomized mice, and we determined the molecular mechanism mediating these effects. Vaginal epithelial proliferation and lubrication after stimulation were found to increase after E4 chronic treatment. Using a combination of pharmacological and genetic approaches, we demonstrated that these E4 effects on the vagina are mediated by nuclear ERα activation. Altogether, we demonstrate that the selective activation of nuclear ERα is both necessary and sufficient to elicit functional and structural effects on the vagina, and therefore E4 appears promising as a therapeutic option to improve vulvovaginal atrophy.

Pharmacokinetics of the first combination 17β-estradiol/progesterone capsule in clinical development for menopausal hormone therapy

Objective:

This study aims to compare the pharmacokinetics and oral bioavailability of a capsule combining 17β-estradiol and progesterone in a non–peanut oil–containing formulation with those of widely used and approved separate formulations of estradiol and progesterone coadministered to healthy postmenopausal women.

Methods:

This was an open-label, balanced, randomized, single-dose, two-treatment, three-period, three-sequence, cross-over, partial-replicate, reference-scaled study. Postmenopausal women (aged 40-65 y) were randomly assigned to one of three dosing sequences of test and reference products (TRR, RTR, or RRT, where T is the test drug and R is the coadministered reference product), with each of the three periods separated by a 14-day washout. The primary pharmacokinetic endpoints were C_max, AUC_(0-t), and AUC_(0-inf) for the test and reference products, assessed for bioequivalence using the scaled average bioequivalence or unscaled average bioequivalence method. Safety was assessed by clinical observation, participant-reported adverse events, and laboratory data, including blood levels of hormones.

Results:

Sixty-six women were randomly assigned, and 62 women (94.0%) completed all three study periods. All AUC and C_max parameters met bioequivalence criteria for all analytes (estradiol, progesterone, and estrone), except C_max for total estrone. The extent of estradiol and progesterone absorption was similar between the test product and the reference products. Four adverse events—all considered mild and unrelated to the study drugs—were reported.

Conclusions:

The combination 17β-estradiol/progesterone product demonstrates bioavailability similar to those of the respective reference products of estradiol and progesterone. If regulatory approval is obtained, this new hormone therapy would be the first treatment of menopause symptoms to combine progesterone with 17β-estradiol in an oral formulation.

Compounded bioidentical hormone therapy: identifying use trends and knowledge gaps among US women

OBJECTIVE

Two surveys (Harris and Rose surveys) were conducted to quantify the use of compounded hormone therapy (CHT; or bioidentical hormone therapy) among perimenopausal and postmenopausal women in the United States, to assess women's knowledge of CHT versus Food and Drug Administration (FDA)-approved hormone therapy, and to gather information on menopausal experience.

METHODS

The Harris survey was administered to 801 women aged 45 to 60 years who had experienced at least one menopausal symptom. The Rose survey was administered to 2,044 women aged 40 years or older who were ever users of hormone therapy. Women were queried about menopausal symptoms, hormone therapy use, and knowledge of CHT. Findings from the Rose survey were extrapolated using US Census Bureau data and prescription claims for FDA-approved hormone therapy to estimate the prevalence of CHT use.

RESULTS

According to extrapolations using Rose data, up to 2.5 million US women aged 40 years or older may use CHT annually, accounting for 28% to 68% of hormone therapy prescriptions. Harris data showed that 86% of women surveyed were unaware that CHT products are not FDA-approved. The Rose survey asked a subset of 1,771 women whether their hormone therapy had been personalized based on hormone levels; 21% (378) answered "yes" whereas 27% (476) did not know. In both surveys, most hormone therapy users stated that their physician had recommended the treatment.

CONCLUSIONS

We estimate that 1 million to 2.5 million US women aged 40 years or older use CHT. The data suggest that many women are unaware that compounded hormones have not been evaluated or approved by the FDA. Providers have an educational opportunity to ensure that women considering hormone therapy understand the risks and benefits of inadequately regulated CHT.

Compounded non-FDA-approved menopausal hormone therapy prescriptions have increased: results of a pharmacy survey

OBJECTIVE

From a survey of compounding pharmacists, specific questions regarding compounded menopausal hormone therapy were used to estimate compounded hormone therapy (CHT) prescribing in the United States.

METHODS

A national online survey was conducted by Rose Research--a market research company consisting of 12,250 US pharmacists from independent community pharmacies (ICPs) and compounding pharmacies (CPs). Pharmacists who completed the survey and met the prespecified criteria were eligible. Data from the survey were extrapolated to estimate overall CHT prescription volume and annual costs of CHT prescriptions for the United States based upon industry data from the National Community Pharmacists Association and IBISWorld.

RESULTS

Surveys were completed by 483 pharmacies, including 365 ICPs and 118 CPs. On the basis of the survey responses and extrapolated industry data, an estimated 26 to 33 million CHT prescriptions were filled annually, with total sales estimated at $1.3 to $1.6 billion. CPs (vs ICPs) accounted for a higher proportion of CHT prescriptions. More than half of the ICPs (52%) and CPs (75%) expected continued compounding business growth, with most predicting 5% to 25% growth within 2 years, despite the potential effect of restrictive legislation regarding compounding.

CONCLUSIONS

On the basis of extrapolated data from numbers of prescriptions reported by pharmacists participating in the survey, the volume of CHT seems to approach that of Food and Drug Administration (FDA)-approved menopausal hormone therapy, and growth in the CHT market is expected. Thus, physicians should educate themselves and the women consulting them about the differences between the FDA-approved and the less-tested CHT formulations. More research on the efficacy, safety, and consistency of non-FDA-approved CHT is needed.

Use of Menopausal Hormone Therapy and Bioidentical Hormone Therapy in Australian Women 50 to 69 Years of Age: Results from a National, Cross-Sectional Study

Menopausal Hormone Therapy (MHT) use in Australia fell by 55% from 2001 to 2005, following the release of large-scale findings on its risks and benefits. Comprehensive national data, including information on overall prevalence of MHT use as well as information on duration of use in Australia have not been reported since the 2004–5 National Health Survey, when 11% of women aged 45+ years were estimated to be current MHT users. No national data are available on prevalence of use of “bioidentical” hormone therapy (BHT). The objective of this study was to determine recent prevalence of MHT and BHT use. A cross-sectional, national, age-stratified, population survey was conducted in 2013. Eligible women, aged 50–69 years, resident in Australia were randomly sampled in 5-year age groups from the Medicare enrolment database (Australia’s universal health scheme). The response rate was 22% based on return of completed questionnaires, and analyses were restricted to 4,389 women within the specified age range. The estimated population-weighted prevalence of current use of MHT was 13% (95%CI 12–14), which was broadly similar to the previously reported national figures in 2004–5, suggesting that the use of MHT in Australia has largely stabilised over the past decade. A total of 39% and 20% of current-users with an intact uterus reported use of oestrogen-progestagen MHT and oestrogen-only MHT, respectively, whereas 77% of hysterectomised current-users used oestrogen-only MHT. Almost three-quarters of current-users [population-weighted prevalence 9% (95%CI 8–10)] had used MHT for ≥5 years. In regard to BHT, estimated population-weighted prevalence of ever use was 6% (95%CI 6–7) and 2% (95%CI 2–3) for current use. The population-weighted prevalence of MHT and BHT combined, in current users in their fifties and sixties was 15% (95%CI 14–16). These data provide a recent national “snapshot” of Australian women’s use of both conventional MHT and of BHT.

Behaviours and attitudes influencing treatment decisions for menopausal symptoms in five European countries

Objective

To assess women’s behaviours and attitudes regarding the treatment of menopausal symptoms in five European countries.

Study design

Women aged ≥45 years in France, Germany, Italy, Spain, and the United Kingdom participated in an internet survey. Completers were those who reported menopausal symptoms and had treated their symptoms. Women were equally stratified by age (45–54 years, 55–64 years, ≥65 years).

Main outcome measures

Behaviours, attitudes, and experiences regarding treatment of menopausal symptoms.

Results

Of 3890 peri- to postmenopausal women screened, 67% experienced symptoms and 54% sought either medical input or some treatment concerning their symptoms. Hot flushes, the most common symptom, decreased with age but remained prevalent after age 64. Roughly 75% of women who sought relief consulted a physician, mostly a gynaecologist or a general practitioner (GP) as in the United Kingdom. The decision to seek treatment was influenced by age, number, and severity of symptoms. Approximately 79% visiting a physician received prescription therapy. Of the women who received non-hormone therapy (HT) treatment instead of HT: patients refused HT (20–44%), physicians did not discuss HT (32–46%), or advised against HT (24–43%). Women in the United Kingdom were most familiar with and favorable to HT. Interest in a new HT (34–50%) was higher than use (19–28%).

Conclusions

Menopausal symptoms are common, persistent, and bothersome, but many fail to seek treatment. Sources and types of treatment vary among age groups and countries. Education regarding women’s attitudes toward treatment should be provided to those physicians who treat menopausal symptoms in each country.

Dietary licorice root supplementation reduces diet-induced weight gain, lipid deposition, and hepatic steatosis in ovariectomized mice without stimulating reproductive tissues and mammary gland

SCOPE

We studied the impact of dietary supplementation with licorice root components on diet-induced obesity, fat accumulation, and hepatic steatosis in ovariectomized C57BL/6 mice as a menopause model.

MATERIALS AND METHODS

We evaluated the molecular and physiological effects of dietary licorice root administered to ovariectomized C57BL/6 mice as root powder (LRP), extracts (LRE), or isolated isoliquiritigenin (ILQ) on reproductive (uterus and mammary gland) and nonreproductive tissues important in regulating metabolism (liver, perigonadal, perirenal, mesenteric, and subcutaneous fat). Quantitative outcome measures including body weight, fat distribution (magnetic resonance imaging), food consumption, bone density and weight (Dual-energy X-ray absorptiometry), and gene expression were assessed by the degree of restoration to the preovariectomized health state. We characterized histological (H&E and oil red O staining) and molecular properties (expression of certain disease markers) of these tissues, and correlated these with metabolic phenotype as well as blood levels of bioactives.

CONCLUSION

Although LRE and ILQ provided some benefit, LRP was the most effective in reducing body weight gain, overall fat deposition, liver steatosis, and expression of hepatic lipid synthesis genes following ovariectomy. Our data demonstrate that licorice root provided improvement of multiple metabolic parameters under conditions of low estrogen and high-fat diets without stimulating reproductive tissues.

Critical review of complementary and alternative medicine use in menopause: focus on prevalence, motivation, decision-making, and communication

OBJECTIVE

This study aims to undertake the first critical review of complementary and alternative medicine (CAM) use among menopausal women (a term here used to include premenopausal, perimenopausal and postmenopausal women) by focusing on the prevalence of CAM use and CAM users' characteristics, motivation, decision-making, and communication with healthcare providers.

METHODS

A comprehensive search of 2002-2012 international literature in the Medline, CINAHL, AMED, and SCOPUS databases was conducted. The search was confined to peer-reviewed articles published in English with abstracts and reporting new empirical research findings regarding CAM use and menopause.

RESULTS

A considerable level of CAM use was observed among women in menopause. Many menopausal women use CAM concurrently with their conventional medicine. However, communication regarding CAM between menopausal women and healthcare providers seems less than optimal, with a demand for further information on the safety and efficacy of medicines. Existing literature is of variable methodological rigor, often presenting small sample sizes and low-quality data collection. Further rigorous research on this topic-including quantitative and qualitative methods using large national samples, where relevant-is required.

CONCLUSIONS

The findings of this critical review provide insights for those practicing and managing health care in this area of women's health. Healthcare providers should prepare to inform menopausal women about all treatment options, including CAM, and should be aware of the possible adverse effects of CAM and potential interactions between CAM and conventional medicine among women in menopause who are under their care.

A critical review of traditional Chinese medicine use amongst women with menopausal symptoms

OBJECTIVES

To provide the first critical review of traditional Chinese medicine (TCM) use amongst symptomatic menopausal women, drawing upon work examining the perspectives of both TCM users and TCM practitioners.

METHODS

A search was conducted in three English-language databases (MEDLINE, CINAHL and AMED) and three Chinese-language databases (CNKI, VIP and CBM Disc) for 2002-2013 international peer-reviewed articles reporting empirical findings of TCM use in menopause.

RESULTS

A total of 25 journal articles reporting 22 studies were identified as meeting the review inclusion criteria. Chinese herbal medicine appears to be the most common therapy amongst symptomatic menopausal women, and vasomotor symptoms and emotional changes are the most frequent symptoms for which TCM is sought. However, evidence regarding the prevalence of TCM use and users' profile in menopause is limited. Existing studies are of varied methodological quality, often reporting low response rate, extensive recall bias and a lack of syndrome differentiation.

CONCLUSIONS

This review provides insights for practitioners and health policy-makers regarding TCM care to symptomatic menopausal women. More nationally representative studies are required to rigorously examine TCM use for the management of menopausal symptoms. Syndrome differentiation of menopausal women is an area which also warrants further attention.

Factors associated with successful discontinuation of hormone therapy

BACKGROUND

Careful management of symptoms, particularly sleep and mood disturbances, may assist women in discontinuing hormone therapy (HT). We sought to describe characteristics associated with successful HT cessation in women who attempted to discontinue estrogen pills/patches with or without progestin.

METHODS

We invited 2,328 women, aged 45-70, enrolled January 1, 2005, to May 31, 2006, at Group Health in Washington State and Harvard Vanguard Medical Associates in Massachusetts, to participate in a telephone survey about HT practices. For the sample, we selected 2,090 women with estrogen dispensings (pharmacy data) during the study period, 200 women without HT dispensing after January 2005, and 240 women with no estrogen dispensings; 1,358 (58.3%) completed the survey. These analyses are based on survey responses.

RESULTS

Among 802 women who attempted HT discontinuation, the mean age was 50 years, 93% were postmenopausal, 90% were white, 30% had had a hysterectomy, and 75% experienced hot flashes after discontinuation. Those who did not succeed had greater trouble sleeping (74% vs. 57%) and mood disturbances (51% vs. 34%) than those who succeeded. In multivariable analyses, factors associated with successful discontinuation included doctor advice (odds ratio [OR] 2.62, 95% confidence interval [CI] 1.68-4.08), lack of symptom improvement (OR 4.21, CI 1.50-12.17), vaginal bleeding (OR 5.96, CI 1.44-24.6), and learning to cope with symptoms (OR 3.36, CI 2.21-5.11). Factors associated with unsuccessful HT discontinuation included trouble sleeping (OR 0.40, CI 0.26-0.61) and mood swings or depression (OR 0.63, CI 0.42-0.92).

CONCLUSIONS

Doctor advice is strongly associated with successful HT discontinuation. Symptom management, particularly sleep and mood disturbances, may help women discontinue HT.

Modeling of steroid estrogen contamination in UK and South Australian rivers predicts modest increases in concentrations in the future

The prediction of risks posed by pharmaceuticals and personal care products in the aquatic environment now and in the future is one of the top 20 research questions regarding these contaminants following growing concern for their biological effects on fish and other animals. To this end it is important that areas experiencing the greatest risk are identified, particularly in countries experiencing water stress, where dilution of pollutants entering river networks is more limited. This study is the first to use hydrological models to estimate concentrations of pharmaceutical and natural steroid estrogens in a water stressed catchment in South Australia alongside a UK catchment and to forecast their concentrations in 2050 based on demographic and climate change predictions. The results show that despite their differing climates and demographics, modeled concentrations of steroid estrogens in effluents from Australian sewage treatment works and a receiving river were predicted (simulated) to be similar to those observed in the UK and Europe, exceeding the combined estradiol equivalent's predicted no effect concentration for feminization in wild fish. Furthermore, by 2050 a moderate increase in estrogenic contamination and the potential risk to wildlife was predicted with up to a 2-fold rise in concentrations.

Bioidentical progesterone cream for menopause-related vasomotor symptoms: is it effective?

OBJECTIVE

To evaluate the efficacy of bioidentical progesterone cream in the treatment of menopause-related vasomotor symptoms.

DATA SOURCES

A systematic search (from time of inception to September 2012) of PubMed, EMBASE, International Pharmaceutical Abstracts, International Journal of Pharmaceutical Compounding, Cochrane, and CINAHL was conducted using the terms progesterone, vasomotor symptoms, night sweats, hot flash or flush, and randomized controlled trials (RCTs). Hand-searching of citations from relevant articles was also performed.

STUDY SELECTION AND DATA EXTRACTION

Articles selected for inclusion described RCTs evaluating the use of bioidentical progesterone cream for the treatment of menopause-related vasomotor symptoms. Studies included were placebo controlled and participants were postmenopausal women experiencing vasomotor symptoms.

DATA SYNTHESIS

Searching identified 3 published RCTs. Only one study, which used a bioidentical progesterone cream specifically compounded for the trial, found that the bioidentical progesterone was more effective than placebo in relieving menopause-related vasomotor symptoms. The 2 studies using manufactured bioidentical progesterone creams found that the creams were no more effective than placebo. Vaginal bleeding and headaches were the most commonly reported adverse effects in the studies.

CONCLUSIONS

Available evidence from RCTs does not support the efficacy of bioidentical progesterone cream for the management of menopause-related vasomotor symptoms. Adverse effects appear to be mild and self-limiting.

Trends in hip fracture incidence and in the prescription of antiosteoporosis medications during the same time period in Belgium (2000-2007)

OBJECTIVE

To examine the secular trend of hip fracture incidence in Belgium between 2000 and 2007 and the concomitant change in the prescriptions of antiosteoporosis medications.

METHODS

The incidence of hip fractures and the number of prescriptions were determined using national databases. A logistic regression including years and 5-year age range was performed to assess the secular trend of hip fracture incidence, and Pearson's correlation coefficient was calculated to examine the relationship between hip fracture incidence and the prescriptions of antiosteoporosis medications.

RESULTS

The annual number of hip fractures increased in Belgium from 13,512 in 2000 to 14,744 in 2007, with a more marked increased in men (20.4%) than in women (5.7%). The age-adjusted incidence of hip fractures was significantly decreased by 1.12% per year in women, but declined nonsignificantly by 0.34% per year in men. An increase in the prescriptions of antiosteoporosis medications in women was observed during the same time period.

CONCLUSION

Despite an increase in the number of hip fractures in Belgium between 2000 and 2007, there was a significant decrease in age-adjusted incidence in women but not in men. Although our results suggest that the decrease may be related to the extent of antiosteoporosis medications, a causal relationship cannot be ascertained and many other factors may have contributed to the decrease in age-adjusted incidence.

Menopausal hormone therapy and subsequent risk of specific invasive breast cancer subtypes in the California Teachers Study

BACKGROUND

Although it is well established that combined estrogen-progestin therapy (EPT) increases breast cancer risk, questions remain regarding the effect of different formulations of hormones, whether certain women are at particularly high risk, and whether risk varies by tumor subtype.

METHODS

We investigated hormone therapy (HT) use in relation to breast cancer risk in the California Teachers Study cohort; after a mean follow-up of 9.8 years, 2,857 invasive breast cancers were diagnosed.

RESULTS

Compared with women who had never used HT, women who reported 15 or more years of estrogen therapy (ET) use had a 19% greater risk of breast cancer (95% confidence interval, 1.03-1.37), whereas women using EPT for 15 or more years had an 83% greater risk (95% confidence interval, 1.48-2.26). Breast cancer risk was highest among women using continuous combined EPT regimens. Risks associated with EPT and ET use were increased with duration of HT use for women with a body mass index (BMI) of <29.9 kg/m(2) but not for women with BMI of >or=30 kg/m(2). Elevated risks associated with EPT and ET use were confined to tumors that were positive for both estrogen and progesterone receptors and those that were HER2+ but were slightly diminished for HER2- tumors.

CONCLUSIONS

Breast cancer risks increased with longer duration of ET and EPT use, and risks were highest for continuous-combined EPT use. Furthermore, risks varied by BMI and tumor subtype.

IMPACT

These findings underscore the need for personalized risk-benefit discussions with women contemplating HT use.

Laser acupuncture does not improve menopausal symptoms

OBJECTIVE

Acupuncture is commonly used to treat menopausal symptoms and other gynecological conditions. Laser acupuncture, more accurately named "laser acupoint stimulation," has the advantages of being noninvasive, reproducible, and convenient. A few studies of conventional acupuncture have suggested a beneficial effect in treating menopausal symptoms. This study sought to investigate the effectiveness of laser acupoint stimulation in relieving symptoms associated with menopause.

METHODS

A double-blind, randomized, placebo-controlled study was conducted in 40 women experiencing active symptoms of menopause. Outcome variables were numbers of diurnal and nocturnal flushes and symptom score, determined using a previously validated scale. A laser acupoint stimulation device was altered to produce identical flashing lights whether or not the laser was operating to allow for a placebo ("laser off") control. Participants received either active or placebo treatment on a fortnightly basis for 12 weeks. The acupoint selection in both groups was individualized to each participant, selected from a set of 10 acupoints.

RESULTS

There were no significant differences between the active and placebo treatment groups in numbers of diurnal or nocturnal flushes or in nonflushing symptom scores.

CONCLUSIONS

Laser acupoint stimulation chosen from a fixed set of acupoints is no more efficacious than manual stimulation with an inert laser probe in altering menopausal symptoms.

Relationships between menstrual and menopausal attitudes and associated demographic and health characteristics: the Hilo Women's Health Study

The objective of this study was to examine the relation of menstrual attitudes to menopausal attitudes and the demographic and health characteristics associated with each. This cross-sectional study consisted of a randomly selected sample of 1,824 respondents aged 16 to 100 years in multi-ethnic Hilo, Hawai'i. Women completed questionnaires for demographic and health information, such as age, ethnicity, education, residency in Hawai'i, menopausal status, exercise, and attitudes toward menstruation and menopause. Women more often chose positive terms, such as "natural," to describe menstruation (60.8%) and menopause (59.4%). In bivariate analyses, post-menopausal women were significantly more likely to have positive menstrual and menopausal attitudes than pre-menopausal women. Factor analyses were used to cluster attitudes followed by linear regression to identify demographic characteristics associated with factor scores. Asian-American ethnicity, higher education, reporting more exercise, and growing up outside of Hawai'i were associated with positive menstrual attitudes. Higher education, older age, post-menopausal status, growing up outside of Hawai'i and having hot flashes were associated with positive menopausal attitudes. Bivariate correlation analyses suggested significant associations between factor scores for menstrual and menopausal attitudes. Both negative and positive menstrual attitudes were positively correlated with the anticipation of menopause, although negative attitudes toward menstruation were negatively correlated with menopause as a positive, natural life event. Demographic variables, specifically education and where one grows up, influenced women's attitudes toward menstruation and menopause and should be considered for inclusion in subsequent multi-ethnic studies. Further research is also warranted in assessing the relationship between menstrual and menopausal attitudes.