Hormone therapy adverse effects

Since both raloxifene and the non-hormonal drug alendronate reduce the incidence of osteoporotic fractures in postmenopausal women it is relevant to determine which approach is better tolerated and thus most likely to promote long-term adherence to therapy. Adverse effects and compliance have been studied in a direct randomized comparison over 12 months in 902 women attending 154 treatment centres in Spain (21). They took either raloxifene 60 mg/day or alendronate 10 mg/day. Those who took raloxifene reported significantly better compliance than those who took alendronate more patients discontinued alendronate prematurely than raloxifene (26% versus 16%. The main reason for premature discontinuation was adverse reactions, particularly gastrointestinal reactions (9.9% with alendronate, 3.4% with raloxifene). 

Antithyroid drugs for long-term therapy (C). Thiourea-derivatives (thioamides) inhibit peroxidase and, hence, hormone synthesis. To restore a euthyroid state, two therapeutic principles can be applied in Graves disease (a) monotherapy with a thioamide, with gradual dose reduction as the disease abates (b) administration of high doses of a thioamide, with concurrent administration of thyroxine to offset diminished hormone synthesis. Adverse effects of thioamides are rare, but the possibility of agranulocytosis has to be kept in mind. 

List the monitoring parameters necessary to assess therapeutic outcomes and adverse effects in patients receiving growth hormone therapy. 

List the adverse effects of and contraindications to hormone-replacement therapy. 

Educate a patient regarding the proper use and potential adverse effects of hormone-replacement therapy. 

Hormone-replacement therapy remains the most effective treatment for vasomotor symptoms and vulvovaginal atrophy and should be considered for women experiencing these symptoms. The goals of treatment are to alleviate or reduce menopausal symptoms and to improve the patient s quality of life while minimizing adverse effects of therapy. The appropriate route of administration should be chosen based on individual patient symptoms and should be continued at the lowest dose for the shortest duration consistent with treatment goals for each patient. 

A number of non-hormonal therapies have been studied for symptomatic management of vasomotor symptoms, including antidepressants [e.g., selective serotonin reuptake inhibitors (SSRIs) and venlafaxine], herbal products (e.g., soy, black cohosh, and dong quai), and a group of miscellaneous agents (e.g., gabapentin, clonidine, and megestrol). The choice of therapy depends on the patient s concomitant disease states, such as depression and hypertension, and the risk for potential adverse effects. 

Options for adjuvant hormonal therapy in postmenopausal women include aromatase inhibitors (e.g. anastrozole, letrozole, or exemestane) either in place of or after tamoxifen. Adverse effects with aromatase inhibitors include hot flashes, myalgia/arthralgia, vaginal dryness/atrophy, mild headaches, and diarrhea. 

Non-compliance is a serious problem in the prevention of osteoporosis and osteoporotic fractures. This is due to adverse effects, lack of noticeable benefit and ignorance. It is difficult to convince regular intake of oral calcium, biphosphonates, vitamin D and in post-menopausal women hormone replacement. Long-term compliance to hormone replacement is worse in developing countries. The most cost-effective therapy for osteoporosis is primary prevention. 

In patients with longstanding hypothyroidism and those with ischemic heart disease, rapid correction of hypothyroidism may precipitate angina, cardiac arrhythmias, or other adverse effects. For these patients, replacement therapy should be started at low initial doses, followed by slow titration to full replacement as tolerated over several months. If hypothyroidism and some degree of adrenal insufficiency coexist, an appropriate adjustment of the corticosteroid replacement must be initiated prior to thyroid hormone replacement therapy. This prevents acute adrenocortical insufficiency that could otherwise arise from a thyroid hormone-induced increase in the metabolic clearance rate of adrenocortical hormones. 

L All of the following are common adverse effects associated with drug overdose of thyroid hormone replacement therapy EXCEPT... 

Oral contraception and hormone replacement therapy are dealt with specifically in separate monographs. Here the general adverse effects of estrogens for any indication are reviewed. 

Well-designed studies of local, topical, and intradermal forms of estrogen as a means of attaining a general systemic effect have tended to show that when doses are therapeutically equivalent to those used orally the adverse effects are similar (219). However, this is a complex issue, which is discussed more extensively in connection with hormone replacement therapy. 

The evidence of adverse effects emerging from randomized trials in and around 2002 has resulted in a dramatic fall in the use of hormone replacement therapy, the use of some formulations falling by two-thirds (21). Continuing debate on the benefit to harm balance of hormonal therapy at the time of the menopause or subsequently has in the recent past hardly yielded new conclusions (22). 

Tibolone is an agonist at estrogen and progestogen receptors, with weak androgenic activity. It is given as an alternative to hormone replacement therapy, without added progestogen, and has been in use for some 30 years to treat bone loss in post-menopausal women. Some long-term studies (for example over 10 years) appear to have confirmed its safety and relative freedom from adverse effects (1). In particular there is little or no increase in thrombotic events and the incidence of breast tenderness is low. 

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