What are the risks of using an estradiol patch in an 82-year-old female with a history of heart disease (HD), osteoporosis, Alzheimer's disease, and irritable bowel syndrome (IBS)?

From the Guidelines

Using an estradiol patch in an 82-year-old female with heart disease, osteoporosis, Alzheimer's disease, and IBS is not recommended due to the significant risks associated with hormone therapy in this population. The most concerning risk is worsening of her existing heart disease, as estrogen therapy increases the risk of stroke, blood clots, and cardiovascular events, particularly in women over 65 with pre-existing heart conditions 1. For her osteoporosis, while estrogen can help bone density, safer alternatives like bisphosphonates (alendronate, risedronate) or denosumab would be more appropriate at her age. Regarding cognitive function, estrogen therapy may actually worsen cognitive impairment in women with existing Alzheimer's disease rather than help it. For her IBS, estrogen might potentially exacerbate symptoms through effects on gut motility and sensitivity. Additionally, estradiol patches can cause side effects like breast tenderness, vaginal bleeding, headaches, and nausea that could complicate her care.

Some key points to consider in this patient's care include:

• The increased risk of cardiovascular events associated with estrogen therapy, particularly in women over 65 with pre-existing heart conditions 1
• The potential for estrogen to worsen cognitive impairment in women with existing Alzheimer's disease
• The availability of safer alternatives for managing osteoporosis, such as bisphosphonates or denosumab
• The potential for estrogen to exacerbate symptoms of IBS

Current medical guidelines strongly discourage initiating hormone therapy in women over 65, especially those with cardiovascular disease or dementia, as the risks substantially outweigh any potential benefits 1. Therefore, hormone therapy with estradiol is not recommended for this patient, and alternative management strategies should be considered to address her osteoporosis, IBS, and other health concerns.

From the FDA Drug Label

The estrogen plus progestin substudy of the Women's Health Initiative (WHI) reported increased risks of myocardial infarction, stroke, invasive breast cancer, pulmonary emboli, and deep vein thrombosis in postmenopausal women (50 to 79 years of age) during 5.6 years of treatment with oral conjugated estrogens (CE 0.625 mg) combined with medroxyprogesterone acetate (MPA 2. 5 mg) per day, relative to placebo. The estrogen-alone substudy of the WHI reported increased risks of stroke and deep vein thrombosis (DVT) in postmenopausal women (50 to 79 years of age) during 6.8 years and 7.1 years, respectively, of treatment with oral conjugated estrogens (CE 0. 625 mg) per day, relative to placebo. The Women's Health Initiative Memory Study (WHIMS), a substudy of the WHI study, reported increased risk of developing probable dementia in postmenopausal women 65 years of age or older during 4 years of treatment with CE 0.625 mg combined with MPA 2.5 mg and during 5.2 years of treatment with CE 0. 625 mg alone, relative to placebo.

The risks of using an estradiol patch in an 82-year-old female with a history of heart disease (HD), osteoporosis, Alzheimer's disease, and irritable bowel syndrome (IBS) include:

• Increased risk of stroke and deep vein thrombosis (DVT) 2
• Increased risk of myocardial infarction and pulmonary emboli 2
• Increased risk of invasive breast cancer 2 2
• Increased risk of developing probable dementia 2 It is essential to weigh these risks against the potential benefits of estradiol patch therapy and consider the individual woman's treatment goals and risks. Estradiol should be prescribed at the lowest effective dose and for the shortest duration consistent with treatment goals and risks for the individual woman 2.

From the Research

Risks of Estradiol Patch in an 82-year-old Female

The use of an estradiol patch in an 82-year-old female with a history of heart disease (HD), osteoporosis, Alzheimer's disease, and irritable bowel syndrome (IBS) poses several risks and benefits.

• Cardiovascular Risks: According to 3, estrogen-replacement therapy does not reduce the risk of death or the recurrence of stroke in postmenopausal women with cerebrovascular disease. In fact, it may increase the risk of fatal stroke.
• Osteoporosis Benefits: Studies such as 4 and 5 suggest that estrogen replacement therapy can improve bone density and reduce the risk of osteoporotic fractures in postmenopausal women.
• Alzheimer's Disease: Research including 6 implies that estrogen replacement therapy may lower the risk for dementia due to Alzheimer's disease, although the issue remains unsettled and requires further investigation.
• Other Risks: As noted in 5, unopposed estrogen increases the risk of endometrial cancer, and long-term use may increase the risk of breast cancer.
• Half-life of Estradiol: The study 7 found that the half-life of estradiol after removal of a transdermal estradiol patch is approximately 2.7 hours, which may be relevant when considering the timing and dosage of the patch.

Considerations for the Patient

Given the patient's complex medical history, it is essential to weigh the potential benefits of estradiol patch therapy against the risks. The decision to use this therapy should be made after careful consideration of the patient's individual circumstances and consultation with a healthcare provider. Factors such as the severity of osteoporosis, the risk of further cardiovascular events, and the progression of Alzheimer's disease should be taken into account. Additionally, the patient's history of IBS may need to be considered when deciding on the form of estrogen replacement therapy.