Trends in oral and vaginally administered estrogen use among US women 50 years of age or older with commercial health insurance

Weissfeld, Joel L.; Liu, Wei; Woods, Corinne; Zhang, Rongmei; Li, Jie; Vlugt, Theresa H. van der; Slaughter, Shelley R.

doi:10.1097/gme.0000000000001054

Cited by 27 publications

(28 citation statements)

References 15 publications

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“…[1][2][3][4] Over a third of HT prescriptions in the US in 2015 were written for women over age 60, when the prevalence of systemic HT among women in the United States (US) with commercial health insurance ranged from 6.8 percent in women 60-64 years and 1.6 percent in women over age 74. [5] Similar prevalence data have been reported in northern European countries. [6] The US data underestimated HT prevalence due to omission of Medicare insurance data and because prescriptions for vaginal estrogen and compounded hormones were not included.…”

Section: Introductionsupporting

confidence: 74%

"I’m going to stay young": Belief in anti-aging efficacy of menopausal hormone therapy drives prolonged use despite medical risks

2020

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BackgroundOver a third of menopausal hormone therapy (HT) prescriptions in the US are written for women over age 60. Use of HT more than 5 years is associated with increased risk for cardiovascular disease; breast, ovarian, and endometrial cancers; thromboembolic stroke; gallbladder disease; dementia; and incontinence. ObjectivesTo explore older women's perceptions of the benefits and risks of long-term HT and examine factors influencing their decisions to use HT > 5 years despite medical risks. MethodsA qualitative approach was selected to broadly explore thought processes and social phenomena underlying long-term users' decisions not to discontinue HT. Interviews were conducted with 30 women over age 60 reporting use of systemic HT more than 5 years recruited from an urban area in California and a small city in the Rocky Mountain region. Transcripts of interviews were analyzed using conventional grounded theory methods. ResultsWomen reported using HT to preserve youthful physical and mental function and prevent disease. Gynecologists had reassured participants regarding risk, about which all 30 expressed little concern. Participants, rather than providers, were the principal drivers of long-term use. ConclusionsParticipants perceived estrogen to have anti-aging efficacy, and using HT imparted a sense of control over various aspects of aging. Maintaining this sense of control was prioritized over potential risk from prolonged use. Our findings provide an additional perspective on

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Section: Introductionsupporting

confidence: 74%

"I’m going to stay young": Belief in anti-aging efficacy of menopausal hormone therapy drives prolonged use despite medical risks

2020

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“…Although use of vaginal estrogens almost doubled from 2000 to 2009 (Fig. 2) and later decreased from 2011 through 2015, 25,31 clinical trials and observational studies of vaginal estrogen use have not found an association with endometrial cancer. 27–30,32 Therefore, it is unlikely that vaginal estrogens contribute to the increase in endometrial cancer observed between 2002 and 2009.…”

Section: Resultsmentioning

confidence: 99%

Increased Incidence of Endometrial Cancer Following the Women's Health Initiative: An Assessment of Risk Factors

Constantine¹,

Kessler²,

Graham

et al. 2019

Journal of Women's Health

127

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Background: The Surveillance, Epidemiology, and End Result (SEER) database shows a variable increase in endometrial cancer incidence over time. The objective of this review was to examine published endometrial cancer rates and potential etiologies. Methods: Endometrial cancer incidence was obtained from the SEER Program database from 1975 through 2014, and a test for trend in incidence was calculated. Changes in risk factors thought to be associated with endometrial cancer, including age, obesity, diabetes, diet and exercise, reproductive factors, and medications (hormone therapy [HT] including Food and Drug Administration [FDA]-approved and non-FDA–approved [compounded] estrogens and progestogens, tamoxifen, and hormonal contraceptives) were found through PubMed searches. Temporal trends of risk factors were compared with endometrial cancer trends from SEER. Results: Although endometrial cancer rates were constant from 1992 to 2002 (women 50–74 years of age), they increased 2.5% annually with a 10% increase from 2006 to 2012 (trend test 0.82). Use of approved prescription estrogen–progestogen combination products decreased after the publication of the Women's Health Initiative (WHI) data, whereas other risk factors either remained constant or decreased during the same time; however, compounded bioidentical HT (CBHT) use increased coincident with the endometrial cancer increase. Conclusion: Endometrial cancer rate increases after the first publication of WHI data in 2002 may be associated with the decreased use of approved estrogen–progestogen therapy, the increase in CBHT use, and the prevalence of obesity and diabetes; potential relationships require further evaluation.

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“…[1][2][3][4] Published data indicate that low-dose vaginal estrogens minimally increase plasma estradiol and clearly not to levels observed with oral or transdermal estrogen products. Use of vaginal estrogens has increased since publication of the results from the Women's Health Initiative (WHI), [5][6][7][8] presumably from concerns about the adverse effects of increased systemic estrogen levels. Notably, local administration of vaginal estrogens minimizes systemic estrogen exposure, 9 compared with that of oral or transdermal estrogens.…”

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confidence: 99%

Systemic estradiol levels with low-dose vaginal estrogens

et al. 2019

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Objectives: To critically evaluate published systemic estradiol levels during use of low-dose vaginal estrogens considering detection method and estrogen dose; describe challenges with accurately measuring estradiol; and determine the normal estradiol level range in postmenopausal women. Methods: PubMed was searched for studies reporting systemic estradiol levels with lower-dose vaginal estrogens (25 mg estradiol or 0.3 mg conjugated equine estrogens). Estradiol levels at baseline and during treatment, area under the curve, and maximum estradiol concentrations were summarized by dose within assay type. A proposed range of systemic estradiol in normal, untreated, postmenopausal women was estimated by conservatively pooling means and standard deviations from published studies. Results: Mean basal estradiol levels were 3.1 to 4.9 pg/mL using liquid or gas chromatography/mass spectroscopy (LC or GC/MS/MS) with a range of undetectable to 10.5 pg/mL using radioimmunoassay. Systemic estradiol levels with vaginal estrogens reflected their doses as measured with LC or GC/MS/MS in different studies: 7.1 to 9.1 pg/mL and 16.7 to 22.7 pg/mL with a 25-mg softgel capsule insert and a tablet insert, respectively; 4.6 to 7.4 pg/mL and 6.6 to 14.8 pg/mL with a 10-mg softgel capsule and a tablet insert, respectively; and 3.6 to 3.9 pg/mL with a 4-mg softgel capsule insert. A mean systemic estradiol concentration ranging from undetectable to 10.7 pg/mL is proposed as an estimate for basal estradiol levels in normal, untreated, postmenopausal women. Systemic estradiol absorption may be influenced by the placement of estradiol higher (as with an applicator) versus lower (as without an applicator) in the vagina, as estradiol transport to the uterus would be more likely further away than closer to the introitus. Conclusion: Serum estradiol concentrations were generally lower when measured with more specific and sensitive assays. Estradiol absorption was dose-dependent, and may be influenced by dose, formulation, and positioning in the vagina. Very low systemic estradiol absorption with low/ultralow-dose vaginal estrogens may potentially decrease any adverse events that may be associated with higher doses of vaginal estrogens used for treating moderate to severe VVA due to less estradiol exposure.

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Trends in oral and vaginally administered estrogen use among US women 50 years of age or older with commercial health insurance

Abstract: Analyses of US prescription claims data between 2006 and 2015 for women 50 years of age or older showed declining use of oral estrogen generally and vaginally administered estrogen products specifically in age groups less than 65 years of age.

Cited by 27 publications

References 15 publications

"I’m going to stay young": Belief in anti-aging efficacy of menopausal hormone therapy drives prolonged use despite medical risks

"I’m going to stay young": Belief in anti-aging efficacy of menopausal hormone therapy drives prolonged use despite medical risks

Increased Incidence of Endometrial Cancer Following the Women's Health Initiative: An Assessment of Risk Factors

Systemic estradiol levels with low-dose vaginal estrogens

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