Additionally, females with hypogonadism, like Ashley, are at increased risk of cardiovascular disease. Numerous studies link oral estrogen therapy to increased cardiovascular risk. This is thought to be due to the first-pass effect, which theorizes that after oral consumption, the bolus of estrogen travels through and is metabolized by the liver. There, it stimulates biochemical factors that result in an increase in C-reactive protein (CRP). Elevated CRP levels have been observed in patients on long-term oral ERT; women with cardiovascular disease; and healthy women as well.17
Studies using transdermal estradiol-17β have not duplicated these findings, possibly because it is not first metabolized through the liver. Transdermal estrogen offers other advantages over oral formulations: (1) Therapeutic effects are achieved at lower peak doses because first-pass hepatic metabolism and enzymatic degradation in the GI are avoided. (2) Serum hormone levels remain constant. (3) Rapid cessation of drug administration is possible with removal of the transdermal system.18
We reviewed the pros and cons of oral versus transdermal estradiol (Table 3) with Ashley and her family. Given the information at hand, it seemed clear to every member of the team that transdermal estradiol was the best choice for Ashley.
Cost. One last question remained: Was the newer drug covered by Ashley’s family’s insurance plan? And, if not, what was the out-of-pocket cost? Each insurance carrier and individual policy is different, but to get an idea of how ERT is covered in my state, I checked with one of the largest carriers in California (Table 4).
Empowering patients and families
Researching and sharing all the information we could gather with our patient and her family validated their concerns and empowered them as team members. Our work together served not only to increase the likelihood of therapy adherence but also provided education about the potential side effects. At her return visit three months later, Ashley reported almost 100% adherence and no side effects. Moreover, she preferred the patch versus having to remember to take another oral medication.