Continuation Rates with Postmenopausal Hormone Therapy
ABSTRACT & COMMENTARY
Synopsis: Both sequential and continuous regimens of postmenopausal hormone therapy have only a 20-25% continuation rate after several years.
Source: Ettinger B, et al. Menopause 1996;3:185-189.
Ettinger and colleagues compared the continuation rate with a cyclic regimen of postmenopausal hormone therapy and a continuous combined regimen. Both regimens used 0.625 mg conjugated estrogens (Premarin) with 5 or 10 mg medroxyprogesterone acetate in the cyclic regimen and 2.5 mg medroxyprogesterone acetate in the daily continuous regimen. The subjects were members of the Kaiser Foundation Health Plan in northern California, where 60% of the women being treated with postmenopausal hormone therapy use the daily continuous combination regimen. In this retrospective study, there were 644 women on the cyclic regimen and 888 on the continuous combination regimen. About 35% of the users of either regimen stopped their therapy after the first prescription, and 76-81% of the women had stopped by the end of the third year. The women using the continuous combination regimen had an 18% higher discontinuation rate. The authors conclude that the continuation rate with postmenopausal hormone therapy is lower than that reported in clinical trials.
COMMENT BY LEON SPEROFF, MD
We are all familiar with the relatively poor continuation rates with postmenopausal hormone therapy. However, the results of this study are surprising in how low that rate is in clinical practice. Perhaps it isn't so surprising that the continuous combination schedule had a higher discontinuation rate. This discontinuation rate was greatest in the first year, and, although the study did not address the reasons for discontinuation, one would expect this to reflect problems with breakthrough bleeding. Obviously, a continuation rate that is so low makes it difficult to achieve the long-term benefits of postmenopausal hormone therapy on cardiovascular disease, osteoporosis, and probably Alzheimer's disease.
These data dramatically point out the lack of success by the medical profession and the pharmaceutical industry in providing a product that achieves long-term, respectable continuation rates. In my view, this can be attributed to two major contributing factors. First, the products that we currently have available are not good enough in achieving amenorrhea as well as freedom from progestational side-effects. Perhaps such a product is not attainable, but I personally believe that, with time, products with different estrogens and different progestins or antiestrogens can produce the desired results. The second contributing factor is our difficulty in achieving the motivation required to sustain a respectable continuation rate. It is now apparent that long-term postmenopausal hormone therapy is a preventive health care action requiring a preventive health care decision. It is difficult to make such a strong decision when one is not threatened with pain, sickness, or even death. It is only with constant and repeated education of our patients (by both the medical profession and the pharmaceutical industry) and repeated counseling efforts that strong preventive health care decisions can be made and continuously supported. This aspect of postmenopausal hormone therapy is further threatened by the time constraints of the managed care system. A five to 10-minute consultation period will simply not do the job. We must develop multiple methods, such as education of the office nurse to support patients, video tapes, and television advertising, and use them all. But when all is said and done, as with screening mammography, it is the interaction between the clinician and the patient that produces the most consistent outcome.