Trends in Menopausal Hormone Therapy Use of U.S. Office-based Physicians, 2001-2008

1. Trends in Menopausal Hormone Therapy Use of U.S. Office-based Physicians, 2001-2008 SA Tsai MD, MPH, ML Stefanick, PhD, RS Stafford, MD, PhD Stanford Prevention Research Center NHLBI Training Session March 3, 2010

2. Introduction • WHI Estrogen + Progestin (E+P) 2002 • Increased breast CA and CHD risk • MHT use declined • Practice recommendations changed • Not for use in CHD prevention • Use lowest effective dose • Use for shortest duration

3. Additional Evidence • WHI ET 2004: more balanced risk-benefit profile • Sub-analyses: possible CV benefit younger women and closer to menopause • Low dose: similar benefits, dose response • Transdermal: lower venous thrombosis risk • Vaginal: less systemic absorption

4. Objective • Evaluate whether MHT use was in line with recent evidence and current clinical recommendations • Examine if subgroups of women are using MHT in the expected ways

5. Methods • National Disease and Therapeutic Index™ (NDTI) database, 2001-2008 • Physician survey • Selected from AMA/ AOA’s compiled list • 1800 physicians quarterly • Two consecutive randomly assigned workdays • Record patient diagnoses and meds • Info projected to national estimates

6. Methods • Selected visits associated with MHT • Trends differentiated by: • Dose: • Standard (CEE 0.625mg or more) • Lower (CEE <0.625mg or estradiol 0.5 mg) • Route: • oral, transdermal, intramuscular, vaginal • Presence of progestin: ET or EPT • Patient age

7. U.S. MHT Trends by Routes of Administration WHI E+P June 2002 WHI E alone April 2004

8. Standard dose oral MHT use remains greater than Lower dose Prempro Low Premarin Low June 2003

9. Total MHT Use

10. Systemic MHT decreased most for oldest group Patient Visits in Thousands WHI E+P June 2002 WHI E alone April 2004 50-59 yo 60+ yo 59% <50 yo 66% 58% Year

11. Lower dose oral MHT increased in all age groups Premarin Low, Prempro Low Approved June 2003 142% 46% 60+ yrs 206% 50-59 yrs <50 yrs

12. Proportion of all oral MHT that is Lower dose increases over time

13. Vaginal MHT use by age group 9% 60+ yo 71% 50-59 yo 26% <50 yo

14. Conclusion • Continued slower MHT decline • Transformation of MHT - right direction • Lower dose - greater consideration • Transdermal may be underutilized • Greater recognition by patient age

15. Thank you!