Veozah vs. Lo Loestrin for Hormone Replacement Therapy
17β-estradiol (Veozah) is preferred over ethinyl estradiol (Lo Loestrin) for hormone replacement therapy due to its more physiological profile and better safety outcomes for cardiovascular and thrombotic risk. 1
Comparison of Estrogen Components
17β-estradiol (Veozah)
- Natural estrogen identical to what is produced by the ovaries
- Preferred for HRT according to clinical guidelines 1
- More favorable impact on:
- Cardiovascular system
- Blood pressure
- Lipid profile
- Hemostatic factors
- Bone mineral density
Ethinyl estradiol (Lo Loestrin)
- Synthetic estrogen primarily used in combined oral contraceptives
- More potent than natural estradiol (20μg EE ≈ 2mg 17β-estradiol) 1
- Associated with:
- Higher risk of venous thromboembolism
- Greater impact on hepatic protein synthesis
- Less favorable effects on blood pressure
- Negative impact on insulin tolerance 1
Clinical Considerations for Selection
Cardiovascular Risk
- Transdermal 17β-estradiol has significantly lower VTE risk (OR 0.9) compared to oral estrogen preparations (OR 4.2) 1
- 17β-estradiol reduces LDL levels and increases HDL levels more favorably than ethinyl estradiol 1
- Blood pressure levels are statistically lower with 17β-estradiol-based HRT compared to ethinyl estradiol formulations 1
Bone Health
- 17β-estradiol has been demonstrated to be more effective in achieving peak bone mineral density and reducing bone resorption markers compared to ethinyl estradiol-based contraceptives 1
- This is particularly important for women with premature ovarian insufficiency who need optimal bone protection 1
Route of Administration
- Transdermal administration of 17β-estradiol is particularly recommended as it:
- Avoids hepatic first-pass effect
- Minimizes impact on hemostatic factors
- Provides more stable hormone levels
- Is specifically recommended for women with hypertension 1
Progestogen Component Considerations
When a progestogen is needed (for women with intact uterus):
- Micronized natural progesterone has advantages including:
- Minimal impact on cardiovascular risk factors
- Neutral or beneficial effect on blood pressure
- Better safety profile for thrombotic risk 1
- Oral cyclical combined treatment provides the strongest evidence for endometrial protection 1
Algorithm for Selection
First choice: 17β-estradiol (Veozah) administered transdermally
- Particularly important for women with cardiovascular risk factors
- Optimal for bone health protection
- Preferred for women with hypertension
Consider Lo Loestrin only if:
- Contraception is required alongside HRT
- Patient has strong preference for oral administration
- Patient has poor tolerance to transdermal delivery systems
Dosing considerations:
- For 17β-estradiol: 50-100μg transdermal daily or 1-2mg oral daily
- Add progestogen if uterus is intact (micronized progesterone 100-200mg daily for 12-14 days per month) 1
Important Caveats
- HRT with early initiation is strongly recommended for cardiovascular disease risk reduction 1
- HRT should be continued at least until the average age of natural menopause 1
- Annual clinical review is recommended for women on HRT, with particular attention to compliance 1
- Women with POI should be informed that HRT has not been found to increase breast cancer risk before the age of natural menopause 1
In summary, 17β-estradiol (Veozah) offers significant advantages over ethinyl estradiol (Lo Loestrin) for hormone replacement therapy, particularly regarding cardiovascular safety, bone health, and physiological hormone replacement.