Ask the Pharmacist

Q: I have been taking an estrogen patch for a few years now to control the hot flashes that were killing my sleep. How long should I stay on them?

A: Last week, we discussed who is, or is not, a good candidate to try Hormone Replacement Therapy (HRT) to control the many possible symptoms of menopause and try to improve their quality of life.

Once the decision is made that the benefits of HRT are likely to outweigh the downsides, there are a host of questions that arise. The answers to these seem to keep changing as ongoing studies shine new light upon the issues. One of these queries pertains to just how long the treatment should continue if it proves to be successful in resolving your symptoms.

Like many medical-related questions, there is no clearly-defined answer that can be rubber-stamped for everyone. Theories, such as treating for five years or until a specified age, have been shot down by experts who state that the answer depends upon immeasurable variables that exist within the individual.

The current recommendation is to, at least annually if not more often, evaluate whether to continue with the therapy or attempt to get off it. If the latter course of action is chosen, rather than stopping it “cold turkey,” success is far more likely to occur if the dose is gradually lowered over months to help decrease the likelihood of rebound-type symptoms.

While this may frustrate those who want to execute their decision immediately, the tapering process will make for a much easier path forward and in the long-run, whether you stopped taking estrogen in October versus December, it's not going to change the course of your life in any meaningful way.

We do suggest people try to get off these drugs from time to time as they have known risks (see last week’s article) that increase as we age. However, there are also more subtle risks we incur when we are not sleeping (depression, cardiovascular issues, etc.) due to an unending wave of hot flashes.

Note that the above applies only to systemic HRT (i.e. pills and patches) and not the vaginal products used for dryness and irritation. These can be safely continued indefinitely for those who benefit.

Another question that arises is which type of treatment to use. The answer to that depends upon the symptoms being treated and individual characteristics and preferences.

For hot flashes, the pills and the patch/cream (known as topicals) seem to work well (and better than the non-hormonal treatments such as antidepressants, clonidine and the assorted natural products out there), but a case can be made that the topicals have some advantages. These include less chance of having the therapy upset your stomach, convenience (some of the patches are changed only once or twice a week as opposed to taking a pill daily) and of greater importance, a possibly lower risk of suffering from a blood clot or stroke.

On the downside, the topicals tend to be more expensive and come with the potential for skin reactions for those with sensitive skin, so they are definitely not for everyone. Regardless of which form is chosen, a low dose should be attempted first and patience needs to be exercised as it may take up to 12 weeks for the medication to “kick in” and control your symptoms adequately. For those with a uterus, a progesterone has to be added to guard against the potential for the estrogen to cause cancer of the uterus.

One new product that just appeared on the market is Duavive (pronounced DOO-ah-veev) which combines the traditional conjugated estrogen with a new drug called bazedoxifene. Bazedoxifene is not a progesterone but a selective estrogen receptor modulator which prevents uterine cancer by blocking the effects of estrogen in the uterus.

At this point, the drug is being targeted only for those women who cannot take a progesterone product - this is relatively uncommon but includes those with liver disease, systemic lupus erythematosus, and those taking very specific anticonvulsants, antiretroviral drugs (used in AIDS) or antibiotics typically used in tuberculosis therapy – but who still need to be protected from using estrogens on their own.

The drug comes with a big price ticket (approximately $90 per month which is far more than most of its competitors) and the uncertainty which always come when using a drug that is relatively new to the market.

For the treatment of vaginal-only symptoms (such as dryness, burning, painful intercourse, frequent urinary tract infections, incontinence, etc.) the use of products inserted into or applied to the vagina, such as the estrogen cream (Premarin), Vagifem (a small tablet that is deposited into the vagina twice weekly) or Estring (a ring that is placed within the vagina and left for three months), are far preferred to systemic therapies.

This is because they do not come with the same risks and do not require an accompanying progesterone ingredient since so little of the estrogen ever makes it into your bloodstream.

For more information about this or any other health-related questions, contact the pharmacists at Gordon Pharmasave, Your Health and Wellness Destination. Also check the website at www.gordon-pharmasave.com/ and the Facebook page at www.facebook.com/GordonPharmasave/?fref=ts