Why women choose compounded bioidentical hormone therapy: lessons from a qualitative study of menopausal decision-making

Health Disparities and Hormone Therapy Prescribing for Early, Peri-, and Postmenopausal Women: A Scoping Review

OBJECTIVES

Menopause hormone therapy has improved the quality of life for perimenopausal and early postmenopausal women, yet women may not be prescribed or use this treatment option. The purpose of this study was to conduct a scoping review to assess whether health disparities existed in hormone therapy prescription rates and use for peri- and postmenopausal care based on demographic and clinical characteristics in real-world, observational studies conducted in the USA.

METHODS

A chief librarian conducted a search strategy from 1940 to 10/31/2023 in five bibliographic databases. One hundred eighty-four articles were found through database and handsearching. After removing duplicates and excluding articles that did not meet study criteria, 14 articles were included in this review. Data were independently extracted and charted using a data extraction form, which was developed based on the study aims. Reviewers met to confirm agreement and discuss disagreements.

RESULTS

Sixteen health disparities, in menopause hormone therapy prescribing or use, were found in this scoping review. Differences between ethnic groups were found in 9 of 14 articles. Education level, menopause route, medical conditions, and practitioner specialization were in 4 of the 14 articles. The remaining 11 health disparities were categorized under chronic medical conditions and social constructs.

CONCLUSIONS

Health disparities have existed for decades in menopause hormone therapy prescribing and use for peri- and postmenopausal women. Identification of health disparities for underserved groups can help reshape educational initiatives for practitioners in all relevant disciplines.

Survey of patient experience and management of vasomotor symptoms due to menopause from the PatientsLikeMe community

OBJECTIVE

This study aimed to describe menopause and treatment experiences of women with vasomotor symptoms due to menopause in the United States.

METHODS

A cross-sectional survey was administered to women 40-65 years of age recruited from PatientsLikeMe, a dedicated online platform for patients.

RESULTS

A total of 196 women (mean age 55.7 years; 81.2% White) completed the survey and were included in the analyses. The majority (87.2%) reported experiencing bothersome symptoms; 54.3% (100/184) had daytime hot flashes, and 59.2% (109/184) had nighttime sweats and hot flashes, up to 5 times per day on average. Mean postmenopause duration was 10.8 years. Although most (68.5%, 126/184) reported having vasomotor symptoms for less than 5 years, some (14.1%, 26/184) had symptoms for more than a decade. Only 35.2% (69/196) were treated for their symptoms; the most frequently reported prescription treatment was hormone therapy (58%; 40/69), which was administered for less than 3 years in most cases (67.5%, 27/40). Although women were generally satisfied with their interactions with healthcare providers, 23.0% reported inadequate support. Sleep, personal relationships, and physical, emotional, and mental well-being were the most affected by vasomotor symptoms. Healthcare professionals with training in women's health were the most valued resource for dealing with the symptoms associated with menopause.

CONCLUSIONS

Not all women with symptoms were treated. In those whose concerns were addressed by providers, a reluctance to pursue treatment was still observed. A need persists to ensure that this population has the resources and support needed to effectively manage symptoms.

A Preliminary Qualitative Analysis of women's Experiences With Vaginal Fractional CO2 Laser Treatments

Background

Menopause involves a range of bodily changes, with impacts on physical and psychological well-being. Around half of the postmenopausal women experience genitourinary syndrome of menopause (GSM). Fractional CO2 laser treatment can promote tissue regeneration in the vaginal wall to potentially assist with managing GSM. However, the results from clinical trials of this treatment have been mixed, and the personal perceptions and experiences of women receiving this treatment have been largely unexplored.

Objectives

To qualitatively explore the motivations and outcomes of women who have undergone vaginal fractional CO2 laser treatment.

Methods

Fourteen postmenopausal women were involved in the study. These women had undergone vaginal fractional CO2 laser treatment between 2 and 48 months earlier (M = 32.1, standard deviation = 14.9 months). Telephone interviews were conducted to explore women's motivations and their experiences after treatment. Interviews were recorded and transcribed verbatim. Deductive and inductive thematic analysis was conducted to analyze interviews.

Results

Analyses produced 4 major themes. First, motivations mostly revolved around participants seeking relief from menopausal symptoms. Second, some participants noted positive sexual outcomes, including improved sexual pleasure after treatment. Third, participants noted positive physical and psychological effects, including improvements in incontinence and overall confidence. Lastly, a subset of participants reported no discernible changes.

Conclusions

This novel qualitative exploration of women's motivations and outcomes of fractional CO2 laser therapy demonstrates the multifaceted impact of treatment. These findings highlight the importance of considering the holistic effects of fractional CO2 laser therapy on women's health during midlife, particularly amid menopausal changes.

Level of Evidence 4

Women's perceptions and experiences with cannabis use in menopause: a qualitative study

OBJECTIVES

Since the legalization of recreational cannabis in 2018, the use of cannabis for medical reasons has increased in Canada. The aim of this study was to explore the experiences and perceptions of midlife women using cannabis for medical purposes coinciding with menopause symptom management.

METHODS

Semistructured, one-on-one interviews were conducted using a qualitative description method. This was the second phase of a mixed methods study, where interviewees were purposefully selected from a sample of women (ages 35 and over, located in Alberta) surveyed during the first phase of the study. Interviews were by phone or virtual meeting, audio-recorded, and transcribed verbatim. Qualitative content analysis was applied to analyze the data collected.

RESULTS

Twelve interviews were conducted between December 2020 and April 2021. Menopause was perceived as a complex experience for women. Cannabis was described as a therapeutic agent, providing symptom relief through the menopause transition. Women reported similarities in their menopause and cannabis use experiences in the lack of information available, limited role of healthcare providers, feelings of stigmatization, and emphasis on self-education. Women self-managed their cannabis use, learning from their own experiences or the anecdotal sharing of others', accessed cannabis from a variety of medical and nonmedical sources, and relied on experimentation, and a range of supports were described.

CONCLUSION

Midlife women pursued the use of cannabis medically to manage symptoms that overlap with menopause. Understanding how and why midlife women use cannabis medically can provide insight for future research and the development of educational resources to support women in menopause.

The Effect of Hormonal Contraceptive Use on Skeletal Muscle Hypertrophy, Power and Strength Adaptations to Resistance Exercise Training: A Systematic Review and Multilevel Meta-analysis

BACKGROUND

Resistance exercise training is widely used by general and athletic populations to increase skeletal muscle hypertrophy, power and strength. Endogenous sex hormones influence various bodily functions, including possibly exercise performance, and may influence adaptive changes in response to exercise training. Hormonal contraceptive (HC) use modulates the profile of endogenous sex hormones, and therefore, there is increasing interest in the impact, if any, of HC use on adaptive responses to resistance exercise training.

OBJECTIVE

Our aim is to provide a quantitative synthesis of the effect of HC use on skeletal muscle hypertrophy, power and strength adaptations in response to resistance exercise training.

METHODS

A systematic review with meta-analysis was conducted on experimental studies which directly compared skeletal muscle hypertrophy, power and strength adaptations following resistance exercise training in hormonal contraceptive users and non-users conducted before July 2023. The search using the online databases PUBMED, SPORTDiscus, Web of Science, Embase and other supplementary search strategies yielded 4669 articles, with 8 articles (54 effects and 325 participants) meeting the inclusion criteria. The methodological quality of the included studies was assessed using the "Tool for the assessment of study quality and reporting in exercise".

RESULTS

All included studies investigated the influence of oral contraceptive pills (OCP), with no study including participants using other forms of HC. The articles were analysed using a meta-analytic multilevel maximum likelihood estimator model. The results indicate that OCP use does not have a significant effect on hypertrophy [0.01, 95% confidence interval (CI) [- 0.11, 0.13], t = 0.14, p = 0.90), power (- 0.04, 95% CI [- 0.93, 0.84], t =  - 0.29, p = 0.80) or strength (0.10, 95% CI [- 0.08, 0.28], t = 1.48, p = 0.20).

DISCUSSION

Based on the present analysis, there is no evidence-based rationale to advocate for or against the use of OCPs in females partaking in resistance exercise training to increase hypertrophy, power and/or strength. Rather, an individualised approach considering an individual's response to OCPs, their reasons for use and menstrual cycle history may be more appropriate.

REGISTRATION

The review protocol was registered on PROSPERO (ID number and hyperlink: CRD42022365677).

[Andean women: Attitudes towards the use of plants for the treatment of gynecological eventsMulheres andinas: atitudes em relajo ao uso de plantas para o tratamento de eventos ginecológicos]

Introduction

Diseases often represent physiological changes that require immediate action depending on the severity. Faced with these changes, Andean women put into practice their ancestral knowledge and attitudes to find a solution, as they are the most immediate means at their disposal.

Objective

To interpret the attitudes of Andean women in the province of Hualgayoc, Peru, towards using plants for treating some gynecological events.

Materials and Methods

A qualitative, exploratory, hermeneutic phenomenological design study was conducted with 16 Andean women through a semi-structured interview based on an interview guide with optimal content validity. The results emerged from open, axial, and selective coding and were organized into subcategories and categories.

Results

The categories obtained were favorable attitudes towards using plants and gynecological situations for using plants. The subcategories include satisfaction with the results achieved, safety to continue using plants, aptitude to advise on the use of plants, knowledge of plant's therapeutic effects, events for using plants, and methods of preparing them.

Discussion

Several international studies converge on similar attitudes, manifested in greater trust in traditional medicine, favorable acceptance behavior, belief in its effects, a mental projection of getting well, and willingness to continue its use.

Conclusion

The women were satisfied with the results obtained from the use of medicinal plants because they were beneficial, indigenous to their region, and did not involve any expense. The frequent use of plants was to alleviate pain during menstruation, vaginal infections, and labor.

To clot, or not to clot: The dilemma of hormone treatment options for menopause

Untreated menopause may have serious health implications, but treatments can have dangerous side effects. We evaluate menopausal symptoms as well as available treatments -the routes of administration and their effect on blood coagulation. Menopausal females may experience hot flushes, vulva- and vaginal atrophy and osteoporosis. Many treatments are available to relieve these symptoms such as Conjugated Equine Estrogen and bioidentical hormones. The routes of administration include oral and transdermal. Hormones that are administered orally undergo a hepatic first pass metabolism. The by-products have a lower efficacy and possibly enhanced side effects. Furthermore, hormone treatments influence the coagulation cascade through coagulation factors or their regulators. Increased coagulation poses a risk for venous thromboembolism. Currently a definite conclusion on whether the side effects from hormone treatments exceed the risk of untreated menopause cannot be made. However, a more individualised approach to hormone treatments may be the most feasible solution to this dilemma.

The Menopause Management Vacuum

ABSTRACT

The burden of untreated menopause symptoms in midlife women is substantial and can result in reduced quality of life as well as lost work productivity, lost opportunities for advancement at work, and increased health care costs. Unfortunately, the health care system is largely unprepared to help women manage these symptoms, which have a mean duration of 7 to 9 years. Hormone therapy usage rates have plummeted following publication of the results of the Women's Health Initiative trials due to safety concerns. In addition, postgraduate medical training programs include minimal to no training on menopause management. These and other factors have contributed to what is essentially a menopause management vacuum. This vacuum created a market opportunity, particularly given the fact that midlife women are potent drivers of the global economy. In this review, we outline the menopause management gaps and discuss a multipronged approach to close these gaps and improve the care of midlife women.

Compounded bioidentical hormone products, a path forward

OBJECTIVE

To describe the widespread use of compounded bioidentical hormone therapies (cBHT). To define the term clinical utility and present why there is insufficient evidence to support the overall clinical utility of cBHT products. To recommend actions that pharmacists and regulators can take to promote safer cBHT use.

SUMMARY

Nationwide, millions of men and women use cBHT products. Use of these products appears to be increasing year-to-year, according to the limited data reported by the 503 A and 503 B pharmacies that formulate and dispense these products. Although use appears to be widespread, the safety, efficacy, and clinical utility of these products remains unproven. This commentary provides examples of what draws consumers to these products, comparative costs, and formulation challenges. Actions to promote the safe use of cBHT and approaches to begin the study of these products are provided.

CONCLUSION

While significant progress was made via the Drug Supply Chain Security Act in 2013 to improve the safety of compounding practice in general, efforts to further improve the safety and transparency of cBHT dispensing and use must continue, at both the local and national level.

Improving online clinical sexual and reproductive health information to support self-care: A realist review

Self-care is the ability of individuals, families and communities to promote health, prevent disease, maintain health, and cope with illness and disability with or without the support of a healthcare provider. In the field of sexual and reproductive health options for self-care predominantly include ordering contraceptives online, or testing and treating genital infections outside a healthcare setting. The shift to digitally facilitated self-care consequently requires information that was previously used by clinicians to be made available to those managing their own sexual and reproductive health. This review was specifically interested in how to optimise this informational enabling environment as self-care becomes more complex. Using a realist approach to facilitate collation, analysis and synthesis of research from multiple disciplines this review sought to enable the generation of a programme theory to inform service development. The majority of research we identified studied information to support the choice to self-care and access to self-care. In contrast to established areas of self-care, for example, the management of diabetes or hypertension, studies of the self-care process in sexual and reproductive health are lacking. There is significant potential to expand digital information resources to support sexual and reproductive health self-care, however, there are currently significant unmet informational needs. This review proposes six key recommendations for providers and key stakeholders involved with sexual and reproductive healthcare for the improvement of digital self-care services.

Long term impact of the WHI studies on information-seeking and decision-making in menopause symptoms management: a longitudinal analysis of questions to a medicines call centre

BACKGROUND

While women are taking a greater role in decisions about menopause symptom management, the legacy of the Women's Health Initiative (WHI) studies persist. Despite hormone therapy (HT) being effective in reducing all-cause mortality, many women seeking relief of menopausal symptoms exaggerate HT harms and overstate the perceived benefits or ignore the risks of alternative therapies. We aimed to explore the longitudinal impact of the widely-publicised WHI 2002 study on women's information-seeking and describe determinants of decision-making about managing menopausal symptoms.

METHODS

In a longitudinal analysis of both quantitative and qualitative data, we explored consumer questions about menopause-related medicines received by two Australian medicines call centres (1996-2010) before, during, and after WHI 2002. We analysed calls by age and gender of caller and patient, their relationship, postcode, enquiry type, and motivation to help-seek. We compared calls regarding HT and herbal medicines (HM) with the rest of calls, and thematically analysed question narratives across the three time-periods.

RESULTS

There were 1,829 menopause-related calls received of over this time-period, with a call surge, primarily from women in their mid-fifties, in the two months after the WHI 2002 publication. Two in three calls were motivated by negative media reports as women sought support for decision-making, primarily reassurance to cease HT. While HT safety concerns persisted for eight years post-publication, the nature of information-seeking changed over time. Callers subsequently sought reassurance to use menopause treatments together with their other medicines; and pursued HT substitutes, including HM, in response to HT product discontinuation.

CONCLUSIONS

Women sought information or reassurance to support a decision, based on dynamic changes in internal (symptom or risk intolerance, attitude towards menopause and treatment preferences) and external factors (perceived source trust and changes in treatment availability). In assessing HT benefit versus risk, women tend to overestimate risk with HT safety concerns persisting over time. Decision-making in managing menopause symptoms is complex and dynamic. Reassurance to reach or justify decisions from a perceived trusted source can support informed decision-making.

Women's Experiences of Diagnosis and Treatment of Early Menopause and Premature Ovarian Insufficiency: A Qualitative Study

Early menopause (EM) and premature ovarian insufficiency (POI) affect an estimated 10% of women and can precipitate a wide range of physiological and personal impacts. Receiving a diagnosis of EM/POI and navigating treatment can be complex experiences for women; however, qualitative research exploring these aspects of the condition is limited. Our study aimed to increase understanding of women's lived experiences of EM/POI encompassing its medical, social, and emotional dimensions. We conducted narrative interviews with 30 women aged 28 to 51 years with spontaneous and iatrogenic EM/POI and menopausal symptoms resulting from ovarian suppression therapy, and analyzed transcripts thematically. This article examines the prominent and under-researched themes of women's experiences of navigating "diagnosis" and treatment. Diagnosis emerged as a complex and changeable process wherein women had to negotiate a diagnosis of spontaneous EM/POI and grasp the meaning and probability of iatrogenic EM/POI. Navigating treatment entailed further complexity as women grappled with the risks and efficacy of hormonal and non-hormonal medications. The findings underline the intricacies of EM/POI as a biomedical phenomenon and highlight the need for health practitioners to recognize and respond to the challenges women face in coming to terms with the condition and managing its embodied effects.

Compounding for women's health: a compounder's perspective - need, regulations, and future

Compounding medicine involves various health-care professionals working together to produce medications that treat patient conditions including menopause and other women's health-related illnesses. These medications are compounded under the standards and guidelines mandated by individual state pharmacy boards, the US Food and Drug Administration, and other professional organizations. Contrary to commercial medications, the personalized medicine aspect of compounding medications ensures that the patient's allergies, doses, and drug delivery preferences are addressed during formulation. In the foreseeable future, compounders will continue to formulate medications that are unavailable in the commercial sector, following strict safe-practice guidelines. More importantly, the application of pharmacogenomics and three-dimensional printing to compounding medications could revolutionize compounding formulations and generate new approaches for personalized medicine.

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.

Equol Decreases Hot Flashes in Postmenopausal Women: A Systematic Review and Meta-Analysis of Randomized Clinical Trials

Soy isoflavones may benefit some, but not all, menopausal women, and the ability of the women to produce equol may be the major determinant of effectiveness. We assessed the efficacy of soy isoflavones and equol for alleviating menopausal symptoms, especially vasomotor symptoms, in postmenopausal women who were equol producers and nonproducers by using systematic review and meta-analysis of randomized clinical trials (RCTs). We searched 12 English, Korean, and Chinese language scientific and medical databases. We selected all available RCTs that assessed the effect of equol, either equol itself or soy isoflavone in equol producers, on menopausal symptoms in peri- or postmenopausal women. The primary outcome was the effect on hot flashes. The severity of hot flashes was determined by the scores, and sensitivity and risk of bias analyses were conducted. Other outcomes of the review, but not meta-analysis, included depression and adverse events. Six studies (779 total subjects) met all criteria for the systematic review, 5 of those could be included in the meta-analysis (728 total subjects). Two studies included in the meta-analysis reported no statistically significant benefits of equol; the other three did report significant benefits of equol. Meta-analysis revealed a significant benefit of equol for lowering hot flash scores and revealed a generally low risk of bias. In conclusion, this study found that supplementing equol to equol nonproducers significantly lowered the incidence and/or severity of hot flashes in menopausal women.