By Ranel Larsen, PharmD, RPh, PCCA Clinical Compounding Pharmacist

This is the saying that comes to mind of when we think about Las Vegas. But, in the case of PCCA’s HRT Symposium, what happens in Vegas does not, in fact, stay there. 

“HRT Vegas,” as we often call it, happens each year in February and focuses on hormone replacement therapy (HRT). It is the compounding industry’s biggest hormone replacement event, and this year was no exception. The same can be said of all PCCA Education. At each event, we ask for feedback on suggested topics, speakers and ideas to make the next event bigger and better. This year, HRT Vegas was exceptional, with engaging topics and an incredible line-up of speakers tailored to the needs of our attendees. One of the advantages of compounded HRT is being able to customize the therapy for each patient’s specific needs because, as we know, one size does not fit all. HRT is also a complex topic and should not be considered without a thorough understanding of how all the body’s hormones interact with each other. This is what attendees learn at HRT Vegas, plus much more. Let’s look at some highlights.

HRT and Safety 
When we talk about hormones, one of the first things that is usually brought up is safety. Estradiol may improve cognition¹ and lower the risk of Alzheimer’s disease,^2,3 cardiovascular disease, osteoporosis and other comorbidities in postmenopausal women. With heart disease being the number one cause of death in women, why are more not using HRT? There are two reasons: A poor understanding of the science by physicians and the general public, and a fear of breast cancer. Let’s take a minute to look at a few key studies.

We will start with the Women’s Health Initiative (WHI) study. It is important to have a thorough understanding of this study, as it contains valuable information, and it had and still has a huge impact on the use of hormones. If you look at the estrogen-only arm involving conjugated equine estrogen (CEE), the results showed a decreased risk of breast cancer, coronary heart disease, colorectal cancer and death.⁴ In addition, the WHI 18-year follow-up data showed a significant reduction in breast cancer incidence with CEE alone, and a significant increase in breast cancer incidence with CEE plus medroxyprogesterone.⁵ So it seems that medroxyprogesterone is likely the suspect here.

The Journal of the American College of Cardiology published a study that concluded that natural progesterone, not medroxyprogesterone acetate, enhances the beneficial effect of estrogen on exercise-induced myocardial ischemia in postmenopausal women.⁶ This suggests that there is a major difference between progesterone and medroxyprogesterone. Just take a look at the chemical structure of each, and you can see how truly different they are. Then, compare the structures of estradiol and testosterone. Look at how a small change can drastically change the chemical. It’s not too surprising that progesterone and medroxyprogesterone have such different actions.

And finally, one of the most substantial pieces of evidence that hormones are safe is the North American Menopause Society (NAMS) Hormone Therapy Position Statement, 2017. It concluded that hormone therapy is the most effective treatment for vasomotor symptoms and genitourinary symptom management and has been shown to prevent bone loss and fracture. In addition, they state, “The risks of hormone therapy differ depending on type, dose, duration of use, route of administration, timing of initiation, and whether a progestogen is used.”⁷

The Route Is Important 
The Kronos Early Estrogen Prevention Study (KEEPS), which involved more than 700 women, looked at transdermal estradiol and oral progesterone and found no increase in breast cancer risk. It also concluded that the therapy relieved many of the symptoms of menopause, improved mood and improved several markers of cardiovascular risk.⁸ Another study showed that oral but not transdermal estrogen replacement therapy is associated with risk of venous thromboembolism in postmenopausal women, suggesting that transdermal therapy might be safer than oral therapy with respect to thrombotic risk.⁹ A recent study also highlighted that the transdermal route avoids the hepatic first‐pass metabolism, resulting in fewer adverse effects on coagulation markers compared to oral estrogens and does not increase risk of deep vein thrombosis.¹⁰

It’s a Symphony
PCCA’s HRT Symposium has evolved to a more functional medicine approach over the years, looking at the body as a whole and working to treat the cause instead of simply treating the symptoms. So not only did we learn about estrogen, progesterone and testosterone, but also about thyroid, adrenals and the gut, and how it is all connected. 

Why Patients Need a Compounding Pharmacy
Compounders have something that is not offered anywhere else. We have the ability to customize and to use estriol and testosterone, which are not commercially available. We can make different strengths and dosage forms of estrogen and progesterone, and we can make it easy for patients by combining multiple active pharmaceutical ingredients into one dosage form. And most of the time, this means increased compliance and affordability, which means happy patients. “Happy wives equal happy lives,” right? Well I say that happy menopausal patients make for happy pharmacists and practitioners!

This is just a small sampling of what HRT Vegas provided. In addition, our speakers presented many formulas, compounding tips and tricks, and updates on public affairs and regulatory issues. The event brings together pharmacists, marketers and practitioners from all over the U.S. and Canada, building lasting professional relationships and empowering each other. HRT Vegas brings us together, helps us make connections and increases our knowledge to better serve our patients. When you come to PCCA’s HRT Symposium in Las Vegas, what happens in Vegas does not stay in Vegas!

Can’t wait until next year? PCCA members can join us for our Nashville HRT Symposium from August 8–10, 2019. They can also earn their HRT Specialist designation by taking our C4 HRT Online Course, which starts May 13, 2019, and attending the Nashville HRT Symposium.

    
Ranel A. Larsen, PharmD, RPh, PCCA Clinical Compounding Pharmacist, is a graduate of the Roseman University School of Pharmacy, where she obtained her Doctor of Pharmacy degree in 2006. After working in retail pharmacy for three years, she transitioned to a compounding-only pharmacy, where she worked for over four years. Ranel joined the PCCA staff in April 2014. Her areas of interest include hormone replacement therapy for men and women, veterinary medicine, pain management and dermatology.

References
1.    Hogervorst, E., Williams, J., Budge, M., Riedel, W., & Jolles, J. (2000). The nature of the effect of female gonadal hormone replacement therapy on cognitive function in post-menopausal women: A meta-analysis. Neuroscience, 101(3), 485–512.
2.    Nilsen, J., Irwin, R. W., Gallaher, T. K., & Brinton, R. D. (2007). Estradiol in vivo regulation of brain mitochondrial proteome. Journal of Neuroscience, 27(51), 14069–14077. https://doi.org/10.1523/JNEUROSCI.4391-07.2007
3.    Wharton, W., Gleason, C. E., Lorenze, K. R., Markgraf, T. S., Ries, M. L., Carlsson, C. M., & Asthana, S. (2009). Potential role of estrogen in the pathobiology and prevention of Alzheimer's disease. American Journal of Translational Research, 1(2), 131–147. 
4.    Anderson, G. L., Limacher, M., Assaf, A. R., Bassford, T., Beresford, S. A., Black, H., … Wassertheil-Smoller, S. (2004). Effects of conjugated equine estrogen in postmenopausal women with hysterectomy: The Women's Health Initiative randomized controlled trial. JAMA, 291(14), 1701–1712. https://doi.org/10.1001/jama.291.14.1701
5.    Manson, J. E., Aragaki, A. K., Rossouw, J. E., Anderson, G. L., Prentice, R. L., LaCroix, A. Z., … Wactawski-Wende, J. (2017). Menopausal hormone therapy and long-term all-cause and cause-specific mortality: The Women's Health Initiative randomized trials. JAMA, 318(10), 927–938. https://doi.org/10.1001/jama.2017.11217
6.    Rosano, G. M., Webb, C. M., Chierchia, S., Morgani, G. L., Gabraele, M., Sarrel, P. M., … Collins, P. (2000). Natural progesterone, but not medroxyprogesterone acetate, enhances the beneficial effect of estrogen on exercise-induced myocardial ischemia in postmenopausal women. Journal of the American College of Cardiology, 36(7), 2154–2159.
7.    The NAMS 2017 Hormone Therapy Position Statement Advisory Panel. (2017). The 2017 hormone therapy position statement of The North American Menopause Society. Menopause, 24(7), 728–753. https://doi.org/10.1097/GME.0000000000000921
8.    Cobin, R. H., & Goodman, N. F. (2017). American Association of Clinical Endocrinologists and American College of Endocrinology position statement on menopause–2017 update. Endocrine Practice, 23(7), 869–880. https://doi.org/10.4158/EP171828.PS
9.    Scarabin, P. Y., Oger, E., & Plu-Bureau, G. (2003). Differential association of oral and transdermal oestrogen-replacement therapy with venous thromboembolism risk. Lancet, 362(9382), 428–432. https://doi.org/10.1016/S0140-6736(03)14066-4
10.    Mikkola, T. S., Savolainen-Peltonen, H., Venetkoski, M., & Ylikorkala, O. (2017). New evidence for cardiac benefit of postmenopausal hormone therapy. Climacteric, 20(1), 5–10. https://doi.org/10.1080/13697137.2016.1262839

These statements are provided for educational purposes only. They have not been evaluated by the Food and Drug Administration, and are not to be interpreted as a promise, guarantee or claim of therapeutic efficacy or safety. The references cited did not necessarily evaluate PCCA products or formulas included in these statements. The information contained herein is not intended to replace or substitute for conventional medical care, or encourage its abandonment.