In terms of progesterone creams, a randomized controlled trial of 223 women with severe menopausal symptoms using progesterone cream found the progesterone arm to be no more effective than placebo (108). In another randomized controlled trial, transdermal progesterone was compared to placebo. One-quarter teaspoon of 20 mg of progesterone was used daily for 12 months. In addition, all patients took a multivitamin plus 1,200 mg of calcium. Outcomes evaluated included dual-energy x-ray absorptiometry (DEXA) results, serum thyroid-stimulating hormone, follicle-stimulating hormone, lipids, chemistry, and symptom diary. The group that received the progesterone cream reported 83% improvement in hot ﬂashes compared with 19% improvement in the placebo group. There was no difference in bone density (109).
Given the data currently available, progesterone or yam creams should not be considered adequate to protect the uterus in a woman taking systemic estrogen. Progesterone cream may be useful for symptom relief in women not taking systemic hormone therapy, and it may prove to have other benefits and risks.
Table 13.12 Unknown Aspects of Hormone Therapy
Risks and benefits of bioidentical hormone therapy (i.e., how the results of the Women’s Health Initiative translate to bioidentical hormones)
Role of medroxyprogesterone acetate in increasing certain risks
Long-term risks and benefits of estriol
Effects of different doses of hormones
Correlation of circulating hormone levels to different doses, and the correlation of different hormone levels to risks and benefits
Effect of lifelong hormonal exposure
Risks and benefits of hormone therapy when initiated at the age of menopause
It’s important to communicate to patients what is known regarding hormone therapy and what is not known. Some of the unknown aspects of hormone therapy are listed in Table 13.12.
Given the present state of the medical knowledge, the need to individualize treatment plans in menopausal women cannot be overemphasized. It is essential to clarify patient goals, and individual health risks, history of hormonal exposure (both length and time), family history, and personal preferences.
Studies showed that most surgical patients use some form of CAM. There are special considerations regarding CAM and the surgical patient. These issues primarily fall into two domains: 1.
Supplements that, when used perioperatively, may affect the patient’s course 2.
CAM approaches that may be of benefit to the surgical patient