John E. Buster

Transdermal menopausal hormone therapy: delivery through skin changes the rules

Importance to the field: Transdermal hormone therapy is replacing oral estrogens and androgens as safe enhancements of life quality for postmenopausal women. Estradiol and testosterone are dosed into the microvascular circulation directly through skin so there is no first-pass hepatic transformation or deactivation of the dosed estradiol or testosterone. Areas covered in this review: This review critically examines recent clinical trials describing experience with transdermal estradiol and testosterone in postmenopausal women. Transdermal estradiol is effective in the treatment of vasomotor symptoms (VMS) and can provide its benefits at higher levels of safety than have been heretofore possible with oral estrogens. Transdermal testosterone is effective in the treatment of hypoactive sexual desire disorder (HSDD) documented in multiple, well-powered randomized clinical trials with demonstrated high levels of safety. What the reader will gain: The reader will learn that transdermal estradiol and testosterone, in properly selected postmenopausal women, significantly and safely enhance life quality, are likely to become increasingly popular, and will probably replace oral hormone therapy. Take home message: Transdermal delivery of native estradiol for VMS and testosterone for HSDD has significant advantages in safety and efficacy over traditional oral preparations which are now available for clinical use.

Hypoactive sexual desire disorder in premenopausal women: case studies.

Abstract Hypoactive sexual desire disorder (HSDD) is the most common female sexual dysfunction (FSD) and is thus frequently encountered in the primary care provider and OB/GYN practices. Causes of low sexual desire may be hormonal, neurologic, vascular, psychologic, or a result of illness/surgery or medications. The condition is often left untreated because both women and clinicians feel embarrassed to bring up the topic and believe that there is no available treatment. The use of short, validated questionnaires, such as the Decreased Sexual Desire Screener, to be completed in the waiting room, can open up discussion between provider and patient. In addition, 2 other algorithms are designed for clinicians who are not specifically trained in FSD and can help in diagnosing and managing a broad range of conditions related to FSD. Treatment for low desire consists primarily of patient education and counseling, as well as treatment of underlying comorbid conditions, such as diabetes, obesity, or cancer. While testosterone products are approved in Europe for use in surgically postmenopausal women with HSDD, in the United States, no pharmacologic treatments are approved for the treatment of HSDD or any FSD. Testosterone products are being used off–label, but questions remain about their efficacy and safety in pre– and postmenopausal women. This article gives an overview of HSDD in clinical practice and provides 3 case descriptions to illustrate the treatment of low sexual desire in women with diverse histories.

Nonclassic 21-hydroxylase deficiency presenting as endometrial hyperplasia with uterine bleeding in a 67-year-old woman.

OBJECTIVE To report for the first time a case of postmenopausal endometrial hyperplasia caused by nonclassic 21-hydroxylase deficiency (NC21OHD). The specific combination of mutations associated with this case has never before been reported. DESIGN Case report. SETTING Private academic practice. PATIENT(S) A 67-year-old woman with uterine bleeding due to endometrial hyperplasia was found to have premenopausal gonadotropins with elevated estrogens. Endocrine workup revealed increased 17-hydroxyprogesterone (17-OHP), which led to molecular testing to establish a diagnosis of NC21OHD. INTERVENTION(S) Trial of suppression with low-dose oral dexamethasone. MAIN OUTCOME MEASURE(S) Resolution of postmenopausal bleeding. RESULT(S) Total estrogens normalized with treatment, and the endometrial stripe became normal. CONCLUSION(S) This is an unusual case of NC21OHD in which the sole presentation was persistent endometrial hyperplasia, with bleeding past the normal age for menopause. In women with unusual endometrial hyperplasias of this type, we suggest endocrine testing before proceeding to hysterectomy.