Another Blow Against Oral Estrogen

If you'll recall the Global Consensus Statement on Menopausal Hormone Therapy (MHT) that I reviewed last month, statement #7 (my numbering) noted that transdermal MHT is associated w/lower risk of deep venous thromboembolism (DVT) compared to oral replacement options.  Seven international societies & medical groups came together to arrive at this statement, including the Endocrine Society and the North American Menopause Society.  Of note, the American College of Obstetricians and Gynecologists (ACOG) was not represented, at least not in print.

However, in Committee Opinion #556 published in this month's green journal, Obstetrics & Gynecology, ACOG has formally come out in favor of transdermal estrogen if MHT is warranted since it appears to be much less prothrombotic than oral estrogen, even comparable to placebo.  

Of note, the authors stated that average risk for DVT is 54/100,000 per year for women in their 40s, 62-122/100,000 per year for women in their 50s, 300-400/100,000 per year for women in their 70s, and 700/100,000 per year for women in their 80s.

Amazingly enough, the authors even admitted that there is "adequate evidence" that natural progesterone (sold as branded Prometrium) is not linked to an increase DVT risk while the commonly prescribed synthetic (their word!) progestin, medroxyprogesterone acetate (sold separately as Provera or in combination as -Pro), is linked to an increase DVT risk.  And finally, the authors stated that there was not enough evidence on the risks & benefits of compounded transbuccal options, such as lozenges & troches.  I applaud them for just admitting their existence!

So what's the bottom line for symptomatic women in need of MHT?  Try any version of transdermal estradiol as noted yesterday, including the plant-derived version.  And if a progestational agent is needed due to an intact uterus, consider Prometrium rather than Provera; along those lines, Climara is ok but Climara-Pro is not.

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