HORMONE REPLACEMENT THERAPY CONTROVERSY

Womens Hormone Replacement Controversy

Presente! to C"eryl #$nea$% &r' PH% RN% (NP)C THE *N+VERS+TY O( TE,AS SCHOOL O( N*RS+N- AT -ALVESTON

+n Part.al ($l/.llment O/ t"e Re0$.rements /or t"e Co$rse -NRS 1223 (NP Ol!er A!$lt C"ron.c +llness

4y L.sa 4a5er RN% 4SN W.ll.am 4yr! RN% 4SN Natal.e Corm.er RN% 4SN Aman!a &ay RN% 4SN La$ra &ay RN% 4SN

Octo6er 71% 7819

WOMENS HORMONE REPLACEMENT Introduction

Hormone replacement t"erapy /or :omen .s a controvers.al top.c 6et:een or;an.<at.ons an! prov.!ers% o/ten leav.n; t"e pat.ent $ns$re o/ t"e 6est treatment opt.on /or "er' T"e most lo;.cal approac" to present.n; t"e controversy 6ase! on Hormone Replacement T"erapy =HRT> /or :omen .s to /.rst $n!erstan! t"e rat.onale /or :".c" .t :as !evelope!' +n t"e 1?38s% .t :as ev.!ent t"at m$c" o/ t"e researc" on any part.c$lar !.sease :as con!$cte! on :".te men% ne;at.n; 6ot" :omen an! m.nor.t.es .n t"e *n.te! States =*S>' T"e Nat.onal +nst.t$te o/ Healt" =N+H> create! t"e O//.ce o/ Researc" on Womens Healt"% :".c" later .n t"e early 1??8s !evelope! t"e Womens Healt" +n.t.at.ve =WH+>' T"e "ypot"es.s :as prem.se! on t"e .!ea t"at estro;en !e/.c.ency may play a role .n t"e !evelopment o/ cancer% car!.ovasc$lar !.sease% !ement.a% an! osteoporos.s .n postmenopa$sal :omen' +n terms o/ 6ene/.cence% t"e .n!.cat.on /or HRT .s an .mprovement .n lon;)term "ealt" an! to prevent or !elay t"e e//ects o/ c"ron.c !.sease on :omen =ACO-% 7819>' &$e to t"e WH+s o6l.;at.on to non)male/.cence% t"e estro;en@pro;est.n arm o/ t"e st$!y :as s"$t !o:n !$e to ev.!ence o/ .ncreas.n; car!.ovasc$lar !.sease% p$lmonary em6ol.sm% stro5e% an! 6reast cancer .n 7887 =An!reol.% 4enAam.n% -r.;;s% B W.n;'% 7818>' Later .n 788C% t"e estro;en only arm o/ t"e st$!y :as !.ssolve! 6eca$se estro;en lac5e! e//.cacy .n car!.ovasc$lar !.sease an! :as l.n5e! to an .ncrease .n cere6rovasc$lar acc.!ents =An!reol. et al'% 7818>' W".le t"e act.ve arms o/ researc" :ere concl$!e! .n WH+% an o6servat.onal st$!y .s st.ll 6e.n; con!$cte! an! !ata .s cont.n$o$sly ;at"ere!' More .mportantly% t"o$san!s o/ st$!.es .n :omens "ealt" can 6e trace! to t"e or.;.nal e//orts o/ t"e WH+ =An!reol. et al'% 7818>' T"e WH+ !re: maAor cr.t.c.sm o/ :".c" rema.ns% even t"o$;" t"e pop$lat.on cr.ter.a :as :omen a;es 18)D? :.t" t"e mean a;e o/ :omen rece.v.n; HRT to 6e 2C =ACO-% 7819>' Most

WOMENS HORMONE REPLACEMENT

:omen enter .nto menopa$se at a mean a;e o/ 17 =ACO-% 7819>% mean.n; t"e e//ects o/ t"e HRT :ere on postmenopa$sal :omen' ($rt"er% t"e Amer.can Con;ress o/ O6stetr.c.ans an! -ynecolo;.sts =ACO-> =7819> s$;;ests Et"at Estro;en T"erapy =ET> may re!$ce Coronary Heart &.sease =CH&> r.s5 /actors an! may prov.!e car!.ovasc$lar protect.on /or :omen :"o recently eFper.ence! menopa$se'G ACO- recommen!s t"at HRT s"o$l! not 6e $se! /or t"e pr.mary or secon!ary prevent.on o/ "eart !.seaseH "o:ever% ACO- also .n!.cates an! .nv.tes /$rt"er researc" .nto estro;en alone t"erapy' T".s .s 6ase! on t"e t.m.n; o/ menopa$se an! t"e pla$s.6.l.ty o/ pos.t.ve o$tcomes .n re!$c.n; car!.ovasc$lar !.sease' W".le t"e controversy may seem at 6ay .n t"e *S% ne: researc" /rom t"e 4r.t.s" Menopa$se Soc.ety =RCO-% 7819> .n!.cates t"ere .s researc" s$pport.n; a$tonomo$s !ec.s.on ma5.n; /or HRT 6y t"e pat.entH .n.t.at.n; t"erapy 6e/ore a;e 28 s"o:.n; 6ene/.c.al "ealt" e//ectsH .n.t.at.n; t"erapy :.t" lo:er !osesH an! to set ar6.trary l.m.ts% alt"o$;" HRT may eFten! as lon; as .t .s 6ene/.c.al' Lastly% HRT .s st.ll cons.!ere! a treatment /or per.menopa$se symptoms =ACO-% 7819>' +/ t"e pat.ent rema.ns on estro;en :.t" or :.t"o$t pro;est.n over a;e 21 6ase! on .n!.v.!$al treatment% .ns$rance may not cover t"e cost o/ t"e me!.cat.on as t"e c$rrent recommen!at.on /rom t"e Amer.can -er.atr.c Soc.ety !oes not s$pport t"e $se o/ system.c estro;en replacement =ACO-% 7819>' Clinical Case &4 .s a 1? year ol! H.span.c /emale present.n; to cl.n.c to esta6l.s" care :.t" a ne: Pr.mary Care Prov.!er =PCP> an! .nvest.;ate a les.on t"at "as 6een present on "er /orearm /or approF.mately t"ree mont"s' &4 reports .nterm.ttent pa.n to les.onH "o:ever% s"e reports prev.o$s les.ons s.m.lar .n "er 6reast an! t".;" t"at "ave 6een remove! .n t"e past' &4 !en.es any /ever@c".lls% ras"es% re!ness% or .tc".n; to t"e area'

WOMENS HORMONE REPLACEMENT

&4 "as a ".story o/ a t"yro.! no!$le t"at :as 6.ops.e! .n 7817' 4.opsy note! Has".moto T"yro.!.t.s' +n t"e past% TPO :as a6 pos.t.ve' &4 "as 6een /ollo:e! 6y en!ocr.ne /or t".sH last T"yro.! ($nct.on Tests =TST> :ere normal .n 87@7819' S"e also "as a ".story o/ Esop"a;eal Re/l$F an! "yperl.p.!em.a% :".c" s"e .s try.n; to control :.t" Enat$ral s$pplementsG% :".c" .ncl$!e V.tam.n C% (ol.c Ac.!% Pro6.ot.cs% an! V.tam.n 4 CompleF' &4 reports a ".story o/ osteopen.a' Last &E,A Scan% late 7817% reveale! osteopen.a' S"e .s c$rrently on Calc.$m an! V.tam.n &9' &4 also reports a ".story o/ 6loo! !yscras.a% /or :".c" s"e .s c$rrently ta5.n; ASA% 31m;% t:.ce !a.ly' &4 reports EMy 6loo! .s eFtremely t".c5 an! + :as tol! + nee!e! to 6e ca$t.o$s o/ 6loo! clotsG' &4 reports a ".story o/ en!ometr.os.s t"at :as resolve! 6y a total "ysterectomy .n 1?3?' &4 "as c$rrently 6een on estra!.ol% 1m;% !a.ly /or 7C years s@p total "ysterectomy' S"e reports s"e "as never "a! Emenopa$sal symptomsG% 6$t "er O4-YN sa.! s"e nee!e! to 6e on estro;en to prevent menopa$sal symptoms' Ot"er ".story .ncl$!esI Hetero<y;o$s /or Met"yenetetra"y!ro/olate re!$ctase =MTH(R>% "eart m$rm$r% a6normal mammo;rams% m$lt.ple cyst eFc.s.ons% an! s"o$l!er art"roplasty' &4 .s c$rrently marr.e! :.t" 9 c".l!ren' S"e !en.es ever smo5.n;% !r.n5.n; or .ll.c.t !r$; $se' &4 reports s"e "as not "a! a /ollo:)$p :.t" ;ynecolo;y .n 78J yearsH rat"er% "er care "as 6een mana;ement 6y a PCP% :"o "as s.nce ret.re!' S"e a!m.ts s"e .s /ear/$l to !.scont.n$e estra!.ol !$e to poss.6.l.ty o/ menopa$sal symptoms' &4 .s $p to !ate on all .mm$n.<at.ons an! .s c$rrently !$e /or a colonoscopy an! mammo;ram' &4 reports mot"er "er passe! a:ay /rom 6reast cancer% :".c" s$6se0$ently metastas.<e! to l$n; an! 6ra.n' Her /at"er .s st.ll l.v.n; :.t" a me!.cal ".story o/ &.a6etes Mell.t$s Type ++ =&M ++>% "yperl.p.!em.a% an! oral cancer' &4s 6rot"er an! s.ster are st.ll l.v.n; an! "ave a me!.cal ".story o/ &M ++' Maternal ;ran!mot"er an! ;ran!/at"er are 6ot" !ecease! :.t"

WOMENS HORMONE REPLACEMENT

;ran!mot"er pass.n; /rom a Cere6rovasc$lar Acc.!ent =CVA> an! ;ran!/at"er s$//er.n; a CVA% !y.n; o/ colon cancer' Paternal ;ran!mot"er an! ;ran!/at"er are also !ecease! :.t" ;ran!mot"er "av.n; a ".story o/ &M ++ an! ;ran!/at"er "av.n; &M ++ an! coronary "eart !.sease' &4s maternal $ncle .s also !ecease! /rom test.c$lar cancer t"at metastas.<e! to t"e colon' Her v.tals an! c$rrent la6 !ata revealI 4PI 171@3CH HRI 31H TempI ?2'7H HtI 1DH WtI 1D2l6H 4M+I 7D'2% TSHI 1'C1% C"olesterolI 773% L&LI C1% H&LI 21% Tr.;lycer.!esI ?8% an! H;6 A1CI 1'7' *pon eFam% &4 .s alert an! or.ente! :.t" no apparent !.stress' No masses% les.ons% ten!erness% or a6normal.t.es note! to "ea!' Normal eFternal eye :.t" corneas clear% conA$nct.va an! sclera normal an! p$p.ls e0$al% ro$n!% react.ve to l.;"t an! accommo!at.on' Nares are patent :.t" sept$m m.!l.ne an! m$cosa p.n5 an! mo.st :.t" no !ra.na;e' Mo.st m$c$s mem6ranes% no eryt"ema or tons.llar enlar;ement% poster.or p"arynF clear an! l.ps% teet" an! ;$ms normal o6serve! .n orop"arynF' Nec5 .s s$pple :.t" no lymp"a!enopat"y% t"yrome;aly% an! no t"yro.! ten!erness' Heart tones S1 an! S7 a$sc$ltate! :.t" re;$lar rate an! r"yt"m' No m$rm$rs or cl.c5s .!ent./.e!' 4.lateral l$n; /.el!s are clear to a$sc$ltat.on an! perc$ss.on' Non)palpa6le no!es .n nec5 an! clav.c$lar re;.ons note! A6!omen .s so/t% non)ten!er% non)!.sten!e!% :.t" no l.ver% spleen or a6normal masses palpate!' No cl$66.n;% cyanos.s% or e!ema o6serve!' Normal ROM% :.t" stren;t" 1@1 t"ro$;"o$t 6o!y' Normal ;a.t an! stat.on% !eep ten!on re/leFes symmetr.c% an! central nerves are ++ ) ,++ .ntact' T"ere .s a one cent.meter mo6.le% cyst)l.5e% les.on note! to r.;"t /orearm' Analyzed Risks & Benefits of HRT HRT can 6e a compl.cate! an! m$lt.)!.mens.onal !ec.s.on /or most :omen !$r.n; per. an! post menopa$se' A conversat.on m$st 6e .n.t.ate! 6et:een t"e pat.ent an! t"e prov.!er 6ase! on a synt"es.s o/ c$rrently ava.la6le ev.!ence' No:% :e :.ll !.sc$ss t"e ev.!ence to s$pport t"e

WOMENS HORMONE REPLACEMENT $se o/ an! r.s5s o/ HRT 6e.n; prescr.6e! /or o$r pat.ent'

One 6ene/.t o/ HRT .s .ts e//ect.ve met"o! o/ controll.n; tro$6lesome menopa$sal symptoms' O$r pat.ent :as place! on estro;en 6y "er prev.o$s O4-YN .n or!er to prevent menopa$sal symptoms' T"e pr.mary .n!.cat.on /or HRT .s t"e treatment o/ mo!erate to severe vasomotor symptoms% :".c" .ncl$!e "ot /las"es an! s:eat.n;' Com6.nat.on estro;en)pro;est.n or estro;en only t"erapy .s e//ect.ve treatment /or t"ese symptoms% an! ot"er menopa$sal symptoms =sleep !.sor!ers% $ro;en.tal atrop"y> =C"le6o:s5.% et al'% 788?% p'1D9>' Some pract.t.oners a!! HRT .nto a cl.ents plan o/ care to /orestall var.o$s compla.nts t"at accelerate a/ter menopa$se% pr.mar.ly vasomotor symptoms' T"e latest ev.!ence s"o:s t"at HRT Ere!$ces "ot /las"es 6y 38K to ?8KG =(err.% 7817% p'C?8>' Vasomotor symptoms are a common compla.nt !$r.n; menopa$seH t"ere/ore% .t .s :.se /or HRT 6e cons.!ere!' A common compla.nt t"at .s o/ten poorly !.sc$sse! .s 6ene/.t t"at HRT plays .n com6at.n; Et"e Ls.lentL symptom o/ va;.nal !.scom/ortG =0$ote! .n A6ernet"y% 7819% p' 798>' Accor!.n; to a Coc"rane rev.e: o/ 12 cl.n.cal tr.als% Eall types o/ local estro;en are e//ect.ve /or rel.e/ o/ va;.nal atrop"y symptomsG =0$ote! .n A6ernet"y% 7819% p'798>' T"e mana;ement o/ trans.t.on.n; a cl.ent t"ro$;" menopa$se var.es ;reatly as symptom .ntens.ty% !$rat.on% an! e//ects on 0$al.ty o/ l./e !.//er' &$r.n; t"e v.s.t% &4 eFpresses concerns a6o$t stopp.n; "er me!.cat.on% as menopa$sal symptoms are "er 6.;;est :orry' T"e pat.ents percept.on o/ menopa$se .s a very /r.;"ten.n; !.sor!er .n :".c" "er 0$al.ty o/ l./e may 6e a//ecte!' Anot"er 6ene/.t o/ HRT .s t"e prevent.on o/ 6one loss t"at lea!s to osteoporos.s' W".le a.!.n; :.t" menopa$se trans.t.on% .t .s .mportant /or t"e pract.t.oner to cons.!er 6e;.nn.n; a preventat.ve re;.men o/ 6.sp"osp"onates or a select.ve estro;en receptor mo!$lator =A6ros.a B Mr.e6s% 788D% p'389>' T"e c$rrent ev.!ence s"o:s t"at Eestro;en slo:s t"e a;.n;)relate! 6one

WOMENS HORMONE REPLACEMENT

loss eFper.ence 6y most menopa$sal :omenG =Manson B 4ass$5% 7883% p' 98C1>H t"ere/ore% &4 "as rece.ve! anot"er 6ene/.t o/ HRT to re!$ce 6one t$rnover an! a.! .n t"e prevent.on o/ osteoporos.s' Alt"o$;" ev.!ence s"o:s t"at HRT .s 6ene/.c.al /or re!$c.n; osteoporos.s% one m$st cons.!er "er /am.ly ".story relate! to 6reast cancer an! personal ".story o/ a6normal mammo;rams' T"e latest ev.!ence s"o:s t"at Eselect.ve estro;en receptor mo!$lators =SERM> select.vely .n".6.t or st.m$late estro;en l.5e act.on .n var.o$s t.ss$esH "o:ever% RaloF./ene =Ev.sta> s"o$l! 6e $se! .n postmenopa$sal :omen :"o cannot tolerate 6.sp"osp"onates an!@or t"ose :"o are at r.s5 o/ .nvas.ve 6reast cancerG =4l$m"o/er B Potts% 7819% p' 31D>' Ev.sta s"o$l! 6e cons.!ere! as an alternat.ve opt.on /or t"e cl.ent an! Ecan 6e cons.!ere! .n t"e conteFt o/ .n!.v.!$al r.s5s an! 6ene/.tsG =A6ros.a B Mr.e6s% 788D% p'389> /or prevent.n; osteoporos.s' +t .s also .mportant to re.n/orce t"at Econt.n$e! eFerc.se an! appropr.ate !.etary s$pplements are also recommen!e!G =A6ros.a B Mr.e6s% 788D% p'389>H s$c" as t"e v.tam.n s$pplementat.on s"e .s c$rrently ta5.n;' Anot"er 6ene/.t o/ HRT .s lo:er.n; ones r.s5 /or colon cancer' Accor!.n; to t"e latest ev.!ence% an analys.s o/ 12%D99 postmenopa$sal :omen too5 part .n a 11) year /ollo:)$p st$!y o/ t"e 4reast Cancer &etect.on &emonstrat.on ProAect' T"ere :ere n.ne)"$n!re! an! s.Fty :omen :"o :ere !.a;nose! :.t" 6o:el cancer over t"e co$rse o/ t"e st$!yH "o:ever% t"e most startl.n; res$lt :as t"at :omen :"o too5 a com6.nat.on o/ estro;en an! pro;esto;en)HRT /or at least 1 years "a! a C1K re!$ct.on .n t"e.r c"ance o/ !evelop.n; 6o:el cancer' =EEv.!ence /or "ormoneG% 788?>' T"ose :"o too5 estro;en)only HRT /or t"e !$rat.on o/ t"e tr.al "a! a 71K re!$ce! r.s5 o/ !evelop.n; 6o:el cancer =EEv.!ence /or "ormone% 788?>' &$e to o$r pat.ents eFtens.ve me!.cal ".story an! /am.ly ".story% .t .s .mportant to

WOMENS HORMONE REPLACEMENT

cons.!er r.s5 /actors an! "er a;e as a !om.nant r.s5 /actor /or colorectal cancer' Accor!.n; to Strayer an! R.c"man% colorectal cancer .s t"e Esecon! lea!.n; ca$se o/ !eat" 6y cancer% an! "ormone replacement t"erapy $se! .n menopa$sal :omen .s assoc.ate! :.t" re!$ce! r.s5 o/ colorectal cancer =7819>' T"e cl.ents maternal ;ran!/at"er an! maternal $ncle 6ot" "ave a ".story o/ colon cancer an! .t .s .mperat.ve t"at s"e .s m.n!/$l o/ "er r.s5 /actors an! :ays to a.! .n prevent.n; colon cancer% s$c" as colonoscop.es' T".s po.nt .s re.n/orce! :.t" a recent st$!y t"at s"o:e! HRT Eo//ere! t"e ;reatest r.s5 re!$ct.on amon; :omen :.t" /.rst)!e;ree /am.ly ".story o/ colorectal cancer =Strayer B R.c"man% 7819>' We can re.n/orce :ays to prevent colon cancer 6y pra.s.n; "er /or not smo5.n;% enco$ra;.n; !a.ly eFerc.se% l.m.t.n; amo$nt re! meat cons$mpt.on% an! sc"e!$l.n; "er colonoscopy' HRT can poss.6ly act as a car!.oprotect.ve a;ent' T".s :o$l! 6e an a!!e! 6ene/.t /or o$r pat.ent as s"e "as "yperl.p.!em.a' T"e Heart an! Estro;en@Pro;est.n Replacement st$!y =HERS>% !one .n :omen :.t" esta6l.s"e! coronary "eart !.sease =CH&>% !emonstrate! E.mprovements .n t"e l.p.! pro/.les o/ :omen on HRT% 6$t t"e overall r.s5 o/ vasc$lar mortal.ty !.! not !ecl.neG =4l$m"o/er B Potts% 7819% p' 31D>' S.nce HRT "as s"o:n to .mprove l.p.! pro/.les% :e can enco$ra;e o$r cl.ent to a!! ot"er non)p"armacolo;.c .ntervent.ons s$c" as ra: /r$.ts an! ve;eta6les% eFerc.se% an! not smo5.n; to "elp re!$ce "er r.s5 o/ "eart !.sease' &$e to "er eFtens.ve /am.l.al ".story o/ "eart !.sease% me!.cal ".story% an! .ncreas.n; a;e% HRT co$l! also "elp to lo:er "er r.s5 as Emore t"an C8 years o/ cl.n.cal tr.als report s.;n./.cant car!.ovasc$lar protect.on /rom estro;en)only t"erapy .n menopa$sal :omenG =S"o$pe% 7817% p'12> an! t".s :as ".;"ly recommen!e! /or t"e past t:o !eca!es !$e to all o/ t"e pos.t.ve cl.n.cal tr.als' Yet% t"ere :as cl.n.cal controversy as to :"et"er .t "a! $n/avora6le e//ects /or a lon;er per.o! o/ t.me' Alt"o$;" more researc" .s nee!e!% a recent &an.s" st$!y p$6l.s"e! .n

WOMENS HORMONE REPLACEMENT

Octo6er 7817 .n t"e 4r.t.s" Me!.cal #o$rnal concl$!e! E:omen :"o ta5e HRT /or 18 years /ollo:.n; menopa$se "ave a s.;n./.cantly re!$ce! r.s5 o/ !eat"% "eart /a.l$re% an! "eart attac5 :.t"o$t any .ncrease! r.s5 o/ cancer% 6loo! clots% or cere6rovasc$lar acc.!entsG =E+s "ormone t"erapy sa/eG% 7819>' +t .s also .nterest.n; to researc" t"at t"e ro$te o/ t"e HRT can also a//ect t"e e//.cacy an! a!verse e//ects o/ $s.n; HRT to lo:er t"e r.s5 o/ "eart !.sease' Women :.t" car!.ovasc$lar or t"rom6ot.c r.s5 /actors% s$c" as o$r pat.ent% :"o "ave starte! t"erapy a/ter a;e 28 or more t"an 18 years a/ter t"e onset o/ menopa$se Emay6e can!.!ates /or lo:)!ose trans!ermal estro;en 6eca$se t"e trans!ermal ro$te "as 6een s"o:n to "ave a lo:er r.s5 o/ veno$s t"rom6oem6ol.sm =VTE> t"an oral a!m.n.strat.onG =S"o$pe% 7817% p'1D>' T".s alternat.ve s"o$l! 6e cons.!ere! /or o$r pat.ent as s"e "as r.s5 /actors /or !evelop.n; "eart !.sease an! "as not "a! a t"oro$;" conversat.on :.t" a prov.!er to !.sc$ss r.s5@6ene/.ts o/ "er c$rrent plan o/ care' +n contrast% :"en loo5.n; at menopa$se an! "ormone replacement t"erapy% .t .s .mportant to remem6er t"at menopa$se .s not a !.sease% 6$t a normal p"ys.olo;.c c"an;e .n t"e /emale levels o/ "ormones =&$np"y% W.nlan!)4ro:n% Porter% B T"omas% 7811>' W".le many :omen are a6le to ma5e t"e trans.t.on t"ro$;" menopa$se% some eFper.ence symptoms severe eno$;" to see5 me!.cal treatment =&$np"y% et al'% 7811>' T"ere "ave 6een many st$!.es !one to eval$ate t"e pros an! cons o/ "ormone replacement t"erapy' T"ese st$!.es o/ten "ave con/l.ct.n; res$lts' Ho:ever% t"e *'S' Prevent.ve Serv.ces Tas5 /orce "as most recently recommen!e! a;a.nst t"e $se o/ "ormonal t"erapy /or c"ron.c pro6lems =Moyer% 7819>' ET"e *SPST( concl$!es :.t" ".;" certa.nty t"at t"e c"ron.c !.sease prevent.on 6ene/.ts o/ N"ormone replacement t"erapyO !o not o$t:e.;" t"e "arms on most post)menopa$sal :omenG =Moyer% 7819>' (or menopa$sal symptoms s$c" as "ot /las"es or va;.nal !ryness% t"ere are ot"er opt.ons ava.la6le /or

WOMENS HORMONE REPLACEMENT 18 symptomat.c treatment' (or t"e pat.ent presente! .n t".s paper% t"ere are concerns a6o$t "er overall "ealt" t"at s"o$l! 6e cons.!ere! :"en prescr.6.n; "ormone replacement t"erapy' M$c" o/ "er overall "ealt" :o$l! .n!.cate t"at cont.n$e! t"erapy may not 6e .n "er 6est .nterest' +t s"o$l! 6e note! t"at t"e $se o/ "ormone replacement t"erapy .s a recommen!e! treatment /or post)s$r;.cal menopa$se' E(ollo:.n; s$r;.cal menopa$se% symptoms can "ave a more s$!!en onset an! "e.;"tene! .ntens.tyG =Cro:e% 4$rrell% B W".te"ea!% 7811>' T".s pat.ent "a! a "ysterectomy 7C years a;o% 6$t at a;e 1? s"e s"o$l! 6e ta5en o// o/ "ormone t"erapy !$e to reasons !escr.6e! 6elo:' One concern /or t".s pat.ent .s t"e r.s5 /or car!.ovasc$lar events' Her 4M+ .s calc$late! to 6e 7D'2% :".c" places "er .n t"e m.!!le o/ t"e over:e.;"t cate;ory an! .n!.cates t"at s"e may not 6e ;ett.n; eno$;" eFerc.se on a ro$t.ne 6as.s' T".s pat.ent also states t"at s"e "as a 6loo! clott.n; !.sor!er an! "yperl.p.!em.a' T"ese are s.;n./.cant r.s5 /actors /or a car!.ovasc$lar event' T"ere "as 6een researc" to s"o: t"at t"e $se o/ HRT .n menopa$sal :omen can act$ally .ncrease t"e r.s5 o/ t"ese car!.ovasc$lar events' EWomens r.s5 /or stro5e .s stat.st.cally

s.;n./.cantly .ncrease! :.t" t"e $se o/ postmenopa$sal "ormone t"erapyG =Moyer% 7819>' +t s"o$l! also 6e note! E6ot" com6.ne! t"erapy an! estro;en alone are assoc.ate! :.t" a stat.st.cally s.;n./.cantly .ncrease! r.s5 /or &VTG =Moyer% 7819>' T"e WH+ also reports t"at t"ere .s an .ncrease! r.s5 /or clott.n; :"en ta5.n; HRT =S"o$pe% 7817>' W"en cons.!er.n; t".s pat.ents ".story o/ car!.ovasc$lar r.s5s% .t .s pro6a6ly 6est not to .ncrease "er r.s5s :.t" "ormone t"erapy' T"e secon! concern /or t".s pat.ent .s "er ".story relate! to 6reast cancer' Her /am.ly ".story .ncl$!es t"at "er mot"er "a! 6reast cancer t"at metastas.<e! to t"e l$n; an! 6ra.n' T"e pat.ents personal ".story .ncl$!es a6normal mammo;rams' HRT "as 6een l.n5e! as a /actor /or

WOMENS HORMONE REPLACEMENT 11 .ncrease! rates o/ 6reast cancer =S.n"a% Coyle% B R.n;% 7819>' EHRT alone can .ncrease t"e r.s5 o/ 6reast cancer s.;n./.cantly' T".s ;reater r.s5 r.ses :.t" .ncreas.n; a;e an! :.t" t"e len;t" o/ t.me t"at HRT cont.n$es% alt"o$;" any e//ect .s lost 6y /.ve years a/ter treatment stopsG =Scott.n; B Ho:ar!% 7819>' Car!.ovasc$lar events an! r.s5 /or 6reast cancer are t"e most concern.n; .ss$es /or t".s pat.ent' Ho:ever% t"ere are also ot"er concerns t"at s"o$l! 6e !.sc$sse! :.t" t".s pat.ent re;ar!.n; t"e ne;at.ve aspects o/ "ormone replacement t"erapy' T"e *'S' Prevent.ve Serv.ces Tas5 (orce =*SPST(> "as /o$n! ev.!ence t"at HRT .s also assoc.ate! :.t" more mo!erate e//ects .ncl$!.n; !ement.a% ;all6la!!er !.sease% an! $r.nary .ncont.nence =Moyer% 7819>' T"ere "as also 6een a l.n5 6et:een HRT an! $lcerat.ve col.t.s =-astro.ntest.nal N$rs.n;% 7817>' T"e pat.ent eFpresse! concerns a6o$t stopp.n; "er me!.cat.on' S"e state! t"at

menopa$sal symptoms :ere "er 6.;;est concern' T"ree o/ t"e maAor menopa$sal symptoms .ncl$!e "ot /las"es% n.;"t s:eats% an! va;.nal !ryness =A6ernet"y% 7819>' T"ere are sa/er alternat.ves to rel.eve all o/ t"ese symptoms' W".le Eless e//ect.ve t"an estro;en% selecte! ant.!epressants =paroFet.ne% venla/aF.ne% /l$oFet.ne% an! sertral.ne> an! ;a6apent.n may 6e reasona6le opt.onsG .n t"e treatment o/ "ot /las"es an! n.;"t s:eats =(.les% Mayer% B Pr$t".% 7817>' Va;.nal !ryness can 6e rel.eve! :.t" ot"er non)"ormone opt.ons' T"ere are l$6r.cants an! mo.st$r.<ers ava.la6le 6ot" over t"e co$nter an! 6y prescr.pt.on t"at can 6e $se!' ET"e 6est l$6r.cants to $se are t"ose t"at :omen /.n! easy an! pleasant to $se% :".c" ma.nta.n a nat$ral pH% an! are e//ect.veG =A6ernet"y% 7819>' Professional, Legal, and Ethical Attri utes +n t"e case o/ t"e pat.ent presente!% s"e "as s.;n./.cant r.s5 /actors /or car!.ovasc$lar events% 6reast cancer% as :ell as ot"er less severe "ealt" concerns' EOn t"e 6as.s o/ a systemat.c

WOMENS HORMONE REPLACEMENT 17 rev.e: o/ ev.!ence p$6l.s"e! t"ro$;" Novem6er 7811% t"e *SPST( concl$!e! :.t" mo!erate to ".;" certa.nty t"at t"e "arms o/ "ormone t"erapy o$t:e.;" t"e 6ene/.ts :"en .t .s $se! /or c"ron.c !.sease prevent.onG =-$allar% Manson% La.ne% B M$lro:% =7819>' T"e pat.ent "as val.! concerns a6o$t menopa$sal symptomsH "o:ever% t"ere are sa/er alternat.ves to treat t"e most common symptoms' (rom a pro/ess.onal an! et".cal stan!po.nt% one "as to cons.!er :"o $lt.mately stan!s to ;a.n /rom "ormone replacement t"erapy' W".le t"ere .s most certa.nly controversy s$rro$n!.n; t"e $se o/ HRT% t"ere appears to 6e a ;eneral consens$s t"at p"armace$t.cal compan.es are at t"e /ore/ront o/ campa.;n.n; .n /avor o/ .ts $se' W.t" t"e .n.t.al 6el.e/ t"at HRT lo:ere! t"e r.s5s o/ cancer% "eart !.sease% osteoporos.s% !epress.on% .n a!!.t.on to !ecreas.n; t"e vasomotor symptoms o/ menopa$se% .ts no :on!er p"ys.c.ans an! t"e.r /emale pat.ents :ere so ea;er to try .t' A/ter report.n; a ;lo6al pro/.t over P7 6.ll.on !ollars .n 7881% Wyet" P"armace$t.cals .nveste! over P73 m.ll.on t"e /ollo:.n; year on mar5et.n; strate;.es /or Premar.n alone =Sc"$l5.n% 7883>' +t :as a!vert.se! as HRT "elp.n; :omen rema.n yo$t"/$l an! /em.n.ne 6y 5eep.n; t"em yo$n; an! 6ea$t./$l t"ro$;"o$t menopa$se =Sc"$l5.n% 7883>' A/ter st$!.es 6e;an to ".;"l.;"t t"e more a!verse e//ects o/ HRT .ncl$!.n; an .ncrease! r.s5 /or 6reast cancer an! car!.ovasc$lar an! t"rom6olyt.c events% many p"ys.c.ans an! :omen 6e;an to !o$6t .ts e//.cacy an! 6ene/.t' T"e s"./t t"en 6ecame more a6o$t "ealt"% rat"er t"an 6ea$ty' As "ealt" care pro/ess.onals% :e "ave a !$ty to o$r pat.ents to !o no "arm% maF.m.<e 6ene/.ts% an! eFam.ne t"e r.s5s' T"e Nonmale/.cence Pr.nc.ple states t"at t"e prov.!er "as a !$ty not to .n/l.ct "arm or ev.l =Mar.c et al% 788?>' +n re/erence to HRT% t".s pr.nc.ple .mpl.es t"at .t .s eFcl$s.vely t"e prov.!ers respons.6.l.ty to 5no: every r.s5 an! potent.al r.s5 t"at t"ese me!.cat.ons pose to t"e pat.ent' A!!.t.onally% 6ene/.cence .s !e/.ne! as Ea /$n!amental et".cal

WOMENS HORMONE REPLACEMENT 19 pr.nc.ple t"at see5s to prevent "arm an! eFplo.tat.on o/% an! maF.m.<e 6ene/.tsG =Pol.t B 4ec5% 7882>' Researc" .n!.cates t"at :".le s"ort)term $se o/ HRT may allev.ate many o/ t"e symptoms o/ menopa$se% t"e lon;)term $se o/ HRT "as 6een assoc.ate! :.t" several "ealt" r.s5s' As prov.!ers% :e m$st as5% E!o t"e 6ene/.ts o$t:e.;" t"e r.s5sQG +/ t"e ans:er to t".s 0$est.on .s yes% t"en t"e treatment s"o$l! 6e eFplore! as a poss.6.l.tyH "o:ever% t".s !oes not .mply t"at treatment cannot 6e cons.!ere! an opt.on ./ t"e ans:er .s no' (or eFample% ./ t"e r.s5s !o .n /act o$t:e.;" t"e 6ene/.ts% t"e prov.!er "as t"e !$ty an! o6l.;at.on to not only eFpla.n t"ese r.s5 to t"e pat.ent .n :ay t"at t"ey are a6le to compre"en! completely% 6$t t"ey m$st also eFplore an! !.sc$ss alternat.ve treatment plans :.t" t"e pat.ent :".c" may present less r.s5s to t"e pat.ent' +n a!!.t.on to eFplor.n; t"e r.s5s an! 6ene/.ts to t"e pat.ent% prov.!ers s"o$l! 6e consc.ent.o$s o/ :"et"er or not t"e pat.ent .s l.5ely to a!"ere to t"e prescr.6e! treatment plan' Recent an! c$rrent researc" "as 6e;$n to po.nt to t"e e//ects an! 6ene/.ts o/ HRT on c"ron.c !.sease accor!.n; to t"e pat.ents a;e an! t.me .n "er l./e cycle' St$!.es are !emonstrat.n; t"at early s"ort)term treatment may .n /act "ave some 6ene/.t on t"e nat$re an! pro;ress.on o/ c"ron.c !.sease' Researc"ers are no: po.nt.n; o$t t"at /ormer researc" "as $se! pat.ents :"o are /$rt"er a!vance! .n t"e sta;e o/ per. menopa$se an! post menopa$se an! t"ere/ore rece.ve less 6ene/.t /rom HRT as oppose! to :omen :"o are starte! at a yo$n;er a;e =&erry% 7883>' T".s .s re/erre! to as t"e T.m.n; Hypot"es.s =&erry% 7883>' +n 788D% one st$!y reports a ".;"er .ncrease! .nc.!ence o/ car!.ovasc$lar events .n :omen a;es 18)28 years ol!H t"e a;e ;ro$p .n :".c" o$r pat.ent /allsH an! s$;;ests t"at t"ese r.s5s may 6e l.m.te! an! HRT may 6ene/.t t"e pat.ent% 6y start.n; HRT nearer to menopa$se as oppose! to a/ter t"e act$al cessat.on o/ menses =&ar6y% 7883>' Accor!.n; to T"e Nort" Amer.can Menopa$se Soc.ety =NAMS>% estro;en t"erapy =ET> rema.ns t"e most e//ect.ve treatment /or 6ot" vasomotor an! va;.nal

WOMENS HORMONE REPLACEMENT 1C symptoms o/ menopa$se =Sc"m.!t% 7817>' T"e latest ev.!ence .n!.cates t"at t"ere may 6e a protect.ve nat$re o/ HRT an! osteoporos.sH "o:ever% t".s protect.on .s lost :"en stopp.n; t"e HRT =Sc"m.!t% 7817>' HRT researc" "as also .n!.cate! a poss.6le l.n5 6et:een HRT an! lo:er.n; r.s5 o/ colon cancer an! car!.ovasc$lar events' +n contrast% st$!.es are $nclear as to t"e act$al t"reat o/ car!.ovasc$lar r.s5% 6$t .t appears t"at many researc"ers a;ree t"at t"e r.s5 o/ car!.ovasc$lar events ;oes $p a/ter lon;)term $se o/ t"erapy% an! !rops !ramat.cally :.t" !.scont.n$at.on o/ t"erapy =&erry% 7883>' HRT also poses a r.s5 /or 6reast cancer' T"ere .s no ev.!ence to con/.rm t"at t"e $se o/ HRT .ncreases t"e 0$al.ty o/ l./e .n any ot"er :ay t"an 6y controll.n; t"e symptoms o/ menopa$se =Sc"m.!t% 7817>' Plan of Care for !B O$r pat.ent "as 6een ta5.n; HRT /or 7C years' Alt"o$;" s"e .s 1? years% s"e "as m$lt.ple r.s5 /actors t"at are o/ maAor concern /or "er "ealt"' S"e "as a s.;n./.cant /am.ly ".story o/ car!.ovasc$lar events% .ncl$!.n; stro5e% an! 6reast cancer' 4ase! on "er /am.ly ".story an! "er personal ".story o/ a6normal mammo;rams% a 6loo! clott.n; !.sor!er% an! "yperl.p.!em.a% o$r ;ro$p /eels t"at t"ese place "er at too ;reat o/ a r.s5 to A$st./y cont.n$ance o/ HRT' O$r pat.ent .s open to t"e !.scont.n$at.on o/ HRT 6$t .s concerne! a6o$t t"e symptoms o/ menopa$se% alt"o$;" s"e "as never s$//ere! /rom symptoms s.nce s"e :as place! on HRT prop"ylact.cally a/ter s$r;.cal .n!$ct.on o/ menopa$se' Researc" "as s"o:n t"at symptoms $s$ally !ecrease ./ not s$6s.!e completely .n most :omen :.t".n 18 years =&erry% 7883>' Symptom mana;ement can also 6e accompl.s"e! :.t" t"e $se o/ ot"er alternat.ve t"erap.es s$c" as p"ytoestro;ens .ncl$!.n; soy .so/lavene% "er6al t"erap.es s$c" as 6lac5 co"os" an!@or re! clover% an! compl.mentary me!.c.nes s$c" as "ypnos.s =-ara! et al% 7811>' -ara! et al% 7817% also ment.ons prom.s.n; treatment /rom a synt"et.c stero.! calle! T.6olone% :".c" appears to

WOMENS HORMONE REPLACEMENT 11 "ave no .ncrease! r.s5 /or 6reast or ovar.an cancers =-ara!% 7811>' T".s ne:er !r$; reporte!ly !ecreases mastal;.a an! a6normal $ter.ne 6lee!.n; :".le .mprov.n; va;.nal !ryness% seF$al !.scom/ort% 6one !ens.ty% an! t"e r.s5 o/ /ract$reH "o:ever% more researc" .s nee!e! =-ara!% 7811>' T"ere are also ne:er !r$;s calle! 6.o).!ent.cal "ormones% :".c" are s.m.lar to convent.onal "ormones% 6$t more researc" .s nee!e! to !eterm.ne e//.cacy an! sa/ety o/ t"ese !r$;s =-ara!% 7811>' T"ere are many t"erape$t.c opt.ons ava.la6le to o$r pat.ent t"at :e /eel are .mportant to !.sc$ss :.t" "er' +n a!!.t.on to t"e alternat.ve t"erap.es alrea!y ment.one!% .t .s cr$c.al t"at :e teac" o$r pat.ent a6o$t t"e .mportance o/ :e.;"t 6ear.n; eFerc.se an! :al5.n; 1 "o$r per !ay to !ecrease "er r.s5 o/ osteoporos.s' +n a!!.t.on% s"e can re!$ce "er .nc.!ence o/ "ot /las"es% sleep !.st$r6ances% "ea!ac"es% !epress.on% /at.;$e% loss o/ concentrat.on% or any symptoms t"at ar.se a/ter !.scont.n$at.on o/ "er HRT :.t" l./estyle mo!./.cat.ons s$c" as !.etary c"an;es% avo.! smo5.n;% $s.n; va;.nal l$6r.cants% ta5.n; s$pplements s$c" as v.tam.n E% an! :e.;"t mana;ement' Sa/er alternat.ve p"armacot"erap.es are also ava.la6le s$c" as v.tam.n &% calc.$m% an! ma;nes.$m /or osteoporos.s prevent.on an! SSR+s /or !epress.on' +t .s also .mportant to note t"at a!!.t.onal researc" .s nee!e! Eto clar./y t"e 6ene/.ts an! r.s5s o/ !.//erent "ormone /orm$lat.ons an! to 6etter $n!erstan! "o: treatment m.;"t "elp :.t" 0$al.ty)o/)l./e symptomsG =EHormone t"erapy $p!ateG% 7819>' E0$ally as .mportant% :e /eel t"at .t .s .mportant to a!!ress any soc.al or personal st.;mas t"at o$r pat.ent may 6e "av.n; a6o$t menopa$se' W".le &4 .s not a can!.!ate /or HRT% some :omen may re0$est t"erapy /or t"e.r vasomotor symptoms% osteoporos.s% or ;en.to$r.nary symptoms' *t.l.<.n; Epocrates% estro;ens $nconA$;ate! cost PD8'88@mont"H estro;ens conA$;ate! :.t" me!roFypro;esterone cost P31'88@mont"H Va;./em .n.t.al mont" costs P1C8'88% 6$t t"en !ecreases to PC8'88@mont"H t"e SSR+s ran;e .n cost /rom P1C'88)P788'88@mont"H t"e over)t"e)co$nter s$pplements ran;e /rom

WOMENS HORMONE REPLACEMENT 12 P1'88)P11'88 mont"ly =va;.nal l$6r.cant% 6lac5 co"os"% soy .so/lavene>' Alternat.vely% "ypnos.s t"erapy cons.sts o/ a teac".n; sess.on :.t" ;$.!e! .ma;ery t"at .s !one /.ve t.mes a :ee5 /or C1 m.n$tes =4oyles% 7817>' Re;ar!less o/ t"e plan o/ t"erapy% .t m$st 6e :ell !oc$mente! t"at 6ene/.ts an! r.s5s :ere !.sc$sse!H !eta.l.n; eac" po.nt a!!resse!% an! t"at t"e pat.ent $n!erstan!s t"e e//ects o/ s$c" care' We :o$l! as5 &4 to ret$rn to t"e cl.n.c .n 2 mont"s a/ter s"e "as 6een o// "er estro;en t"erapy' &$r.n; t".s t.me% s"e :.ll 5eep a lo; o/ postmenopa$sal symptoms to .ncl$!e

vasomotor symptoms% sleep@moo! !.st$r6ances% an! ;en.to$r.nary symptoms' S.nce s"e .s osteopen.c on estro;en t"erapy% :e :o$l! !.sc$ss poss.6le p"armacolo;.c .ntervent.ons% s$c" as t"e 6.sp"osp"onates% to prevent osteoporos.s an! sc"e!$le "er neFt &E,A scan .n 781C' We also nee! to a!!ress "er L&L level o/ 1C1% even t"o$;" "er H&L level o/ 21 .s car!.oprotect.ve' Alt"o$;" estro;en t"erapy a.!s .n lo:er.n; L&L an! .ncreas.n; H&L% s"e .s a!vance! a;e an! "as /am.ly ".story r.s5 /actorsH t"ere/ore% "er ;oal L&L s"o$l! 6e less t"an 198' +/ s"e :as res.stant to c"olesterol or osteoporos.s me!.cat.ons% :e :o$l! enco$ra;e l./estyle mo!./.cat.ons an! rescreen a l.p.! panel .n 1 year' Lastly% :e :.ll ass.st sc"e!$l.n; "er mammo;rap"y screen.n; an! colonoscopy' W".le &4 presente! to esta6l.s" care :.t" a c".e/ compla.nt not spec./.c to HRT% as pract.t.oners :e m$st al:ays ta5e a "ol.st.c approac" to pat.ent ".story an! assessment' *lt.mately% o$r role m$st rema.n t"at o/ e!$cator an! present t"e latest ev.!ence' Pat.ents are t"en ena6le! to ma5e .n/orme! !ec.s.ons a6o$t "o: to 6est mana;e t"e.r "ealt" care'

References A6ernet"y% M' =7819>' Mana;.n; va;.nal !ryness .n menopa$se' Pract.ce N$rs.n;% 7C=1>% 798)

WOMENS HORMONE REPLACEMENT 1D 79C' ACO-' =7819>' Comm.ttee op.n.onI Hormone t"erapy an! "eart !.sease' Retr.eve! on Septem6er 73% 7819% retr.eve! /romI "ttpI@@:::'aco;'or;@R@me!.a@Comm.ttee K78Op.n.ons@Comm.tteeK78onK78-ynecolo;.cK78Pract.ce@co121'p!/Q !mcS1BtsS78198?73T78C7799D?2 ACO-' =7819>' Pat.ent e!$cat.on /act s"eetI Hormone t"erapy' Retr.eve! on Septem6er 73% 7819 /rom "ttpI@@:::'aco;'or;@(or Pat.ents@Searc" (ATs@!oc$ments@Hormone T"erapy Am6ros.a% T' B Mr.e6s% #'M =788D>' M$sc$los5eletal con!.t.ons' +n 4' Hac5ley% #'M' Mr.e6s% B M'E' Ro$ssea$ =E!s'>% Primary care of women: A guide for midwives and women's health providers =pp'D31)383>' S$!6$ry% Massac"$settsI #ones an! 4artlett P$6l.s"ers' An!reol.% T'% 4enAam.n% +'% -r.;;s% R'% B W.n;% E' =7818>' An!reol.s an! CarpentersI Cec.l essent.als o/ me!.c.ne =3t" e!'>' P".la!elp".aI Sa$n!ers Elsev.er' 4l$m"o/er% R' B Potts% S'E' =7819>' Menopa$se' +n (' #' &om.no =E!'>% The 5 minute clinical consult =71st e!'% pp' 312)31D>' P".la!elp".a% PAI L.pp.ncott% W.ll.ams% B W.l5.ns' 4oyles% S' =7817>' Hypnos.s "alts "ot /las"es /or some :omen' Retr.eve! on Octo6er 11% 7819 /rom "ttpI@@:::':e6m!'com@menopa$se@ne:s@78171871@"ypnos.s "alts "ot /las"es' C"le6o:s5.% R'T'% M$ller% L'H'% Prent.ce% R'L'% Ste/an.c5% M'L'% Manson% #'E'% -ass% M'% Ara;a5.% A'M'% Oc5ene% #'M'% Lane% &'S'% Sarto% -'E'% RaA5ov.c% A'% Sc"en5en% R'% Hen!r.F% S'L'% Rav!.n% P'M'% Ro"an% T'E'% Yasmeen% S'% B An!erson% -' =788?>' 4reast cancer a/ter $se o/ estro;en pl$s pro;est.n .n postmenopa$sal :omen' The New England Journal of Medicine !"#=2>% 1D9)3D' !o.I18'1812@NE#Moa838D23C Cro:e% M'% 4$rrell% 4'% B W".te"ea!% L' =7817>' L./estyle r.s5 mana;ementUa 0$al.tat.ve

WOMENS HORMONE REPLACEMENT 13 analys.s o/ :omens !escr.pt.ons o/ ta5.n; "ormone t"erapy /ollo:.n; s$r;.cally .n!$ce! menopa$se' #o$rnal o/ A!vance N$rs.n;% 23=3>% 131C)1379' &erry% P' S' =7883>' *p!ate on "ormones% menopa$se% an! "eart !.seaseI Eval$at.n; pro/ess.onal responses to t"e :omens "ealt" .n.t.at.ve' $ealth %are for &omen 'nternational' 7?I D78)D9D' &$np"y% L' M'% W.nlan!)4ro:n% #' E'% Porter% 4' O'% B T"omas% &' #' =E!s'>' =7811>' Pr.mary care t"e art an! sc.ence o/ a!vance! pract.ce n$rs.n; =9r! e!'>' P".la!elp".aI ('A' &av.s' Ev.!ence /or "ormone replacement t"erapy' =788?>' -astro.ntest.nal N$rs.n;% D=1>% C+NAHL Pl$s :.t" ($ll TeFt% E4SCO"ost' Retr.eve! Octo6er 11% 7819% /rom "ttpI@@:e6'e6sco"ost'com'l.6$F'$tm6'e!$@e"ost@p!/v.e:er@p!/v.e:erQ v.!S?Bs.!S/73e/98c)e681)C976)?C16)D673/9cC?!66KC8sess.onm;r118B".!S11D (err.% (re! (' =7817>' Hot (las"es' (erri's clinical advisor: 5 )oo*s in + =7817 e!.t.on% p'C?8>' P".la!elp".a% P'AI Elsev.er Mos6y' (.les% #'% Mayer% A'% B Pr$t".% S' =7817>' Anyt".n; ;oesI &.scont.n$at.on o/ "ormone t"erapy' #o$rnal o/ Womens Healt" 71=1>% 12D)123' -ara!% R' 4$r;er% H'% &av.!son% S' =7811>' EFplor.n; t"e "ormone replacement t"erapy !e6ate% Australian Nursing Journal' 1?=1>I 98)99' -astro.ntest.nal N$rs.n; =7817>' HRT l.n5e! to !evelopment o/ $lcerat.ve col.t.s' -astro.ntest.nal N$rs.n; 18=3>% 17' -$allar% E'% Manson% #'% La.ne% C'% B M$lro:% C' =7819>' Postmenopa$sal Hormone T"erapyI T"e Heart o/ t"e Matter' Annals o/ +nternal Me!.c.ne% 113=1>% 2?)D8' Hamr.c% A' 4'% &el;a!o% S' A' =788?>' Et".cal !ec.s.on ma5.n;' +n Hamr.c% A' 4'% Spross% #' A'% an! Hanson% C' M' =E!s'>' A!vance! pract.ce n$rs.n;I an .nte;rat.ve approac" =Ct" e!'% pp

WOMENS HORMONE REPLACEMENT 1? 97C>' St' Lo$.s% MOI Elsev.er Sa$n!ers' Hormone t"erapy $p!ate' =7819>' Harvar! WomenLs Healt" Watc"% 78=D>% 9' C+NAHL Pl$s :.t" ($ll TeFt% E4SCO"ost' Retr.eve! Octo6er 11% 7819 /rom "ttpI@@:e6'e6sco"ost'com'l.6$F'$tm6'e!$@e"ost@p!/v.e:er@p!/v.e:erQ v.!S1Bs.!S/73e/98c)e681)C976)?C16)D673/9cC?!66KC8sess.onm;r118B".!S11D #o"nson% #'% T"omas% &'% Porter% 4' =7811>' Womens Healt" Pro6lems' +n L' &$np"y% #' W.nlan!)4ro:n% 4' Porter% B &' T"omas =E!s'>% Pr.mary CareI T"e Art an! Sc.ence o/ A!vance! Pract.ce N$rs.n; =pp' D18)D1D>' P".la!elp".a% PAI ('A' &av.s Company' Manson% #'E B 4ass$5% S'S =7883>' T"e menopa$se trans.t.on an! postmenopa$sal "ormone t"erapy' +n &'L' Lon;o% &' L' Masper% S' L' Ha$ser% #' L' #ameson% A'S' (a$c.% #' Loscal<o =E!s'>% $arrison's principles of internal medicine =13t" e!'% pp' 98C8)98C2>' Ne: Yor5 C.ty% NYI Mc-ra: H.ll P$6l.s"ers' Moyer% V' =7819>' Menopa$sal "ormone t"erapy /or t"e pr.mary prevent.on o/ c"ron.c con!.t.onsI *'S' preventat.ve serv.ces tas5 /orce recommen!at.on statement' Annals of 'nternal Medicine, 113=1>I CD)1C% 2?)D8' Pol.t% &' ('% 4ec5% C' T' =7882>' Essent.als o/ n$rs.n; researc"I Met"o!s% appra.sal% an! $t.l.<at.on =2t" e!'% pp 3D)33>' P".la!elp".a% PAI L.pp.ncott W.ll.ams B W.l5.ns' RCO-' =7819>' RCO- an! t"e "ormone replacement t"erapy =HRT>' Retr.eve! on Septem6er 73% 7819 /rom "ttpI@@:::'rco;'or;'$5@:"at):e)!o@campa.;n.n;)an!)op.n.ons@6r.e/.n;s) an!)0as)@rco;)an!)"rt)!e6ate' Sc"m.!t% P' =7817>' T"e 7817 "ormone t"erapy pos.t.on statement o/ t"e nort" Amer.can menopa$se soc.ety% Menopause, 1?=9>I 71D)7D1' Scott.n;% P' B Ho:ar!% P' =7819>' T"e ca$ses o/ cancer' %ancer Nursing Practice% 17=1>% 79)73'

WOMENS HORMONE REPLACEMENT 78 S"o$pe% &' =7817>' +n!.v.!$al.<.n; "ormone t"erapyI We.;".n; r.s5s an! 6ene/.ts' %ontemporary -./01N 1D=3>% 12)7C' S.n"a% R'% Coyle% C'% B R.n;% A' =7817>' 4reast cancer .n ol!er pat.entsI nat.onal cancer re;.stry !ata' The 'nternational Journal of %linical Practice% 2D=D>% 2?3)D88' Strayer% &'% B R.c"man% S' =7819>' Menopa$seI R.s5 /or Colorectal Cancer' C+NAHL Pl$s :.t" ($ll TeFt% E4SCO"ost'Retr.eve! Octo6er 11% 7819 /rom "ttpI@@:e6'e6sco"ost'com'l.6$F'$tm6'e!$@e"ost@p!/v.e:er@p!/v.e:erQs.!S/73e/98c)e681) C976)?C16)D673/9cC?!66KC8sess.onm;r118Bv.!S2B".!S11D