Hormone Replacement Therapy

REVIEWING THE LITERATURE News and Views From the Literature Hormone Replacement Therapy Androgen Replacement Therapy and Prostate Cancer: Is Androgen Replacement Safe in High-Risk Patients? Reviewed by Randall B. Meacham, MD Division of Urology, University of Colorado School of Medicine, Denver, CO [Rev Urol. 2004;6(2):93-94] © 2004 MedReviews, LLC s our population grows older, ever-greater attention is being focused on therapies aimed at forestalling negative effects of the aging process. Prominent in this regard is androgen replacement in the aging man. Numerous publications have documented the potential benefit of testosterone supplementation among hypogonadal A men. Conditions such as decreased bone density, loss of muscle mass and strength, increased adipose tissue, loss of sexual function, and mood disorders may, to some extent, be ameliorated through androgen replacement therapy. Equal attention, however, has been focused on the potential for deleterious effects to arise from androgen supplementation. Perhaps the most concerning is the suggestion that androgen replacement may contribute to the development or progression of prostate malignancy. Although few empiric data exist to support this concept, the fact that prostate cancer is a hormone-responsive malignancy has understandably led to concern that administration of exogenous androgen might have a trophic effect on undetected carcinoma. The level of concern is even greater when considering androgen replacement among men who are considered to be at particular risk for prostate cancer. One such population is men with prostatic intraepithelial neoplasia (PIN), as the presence of this condition is an ominous risk factor for prostate cancer. To assess the potential for androgen replacement therapy in hypogonadal men to exacerbate undiagnosed prostate cancer, Rhoden and Morgentaler followed 20 such men in whom PIN had been diagnosed before starting replacement therapy and compared them with 55 patients who had negative prostate biopsy results. VOL. 6 NO. 2 2004 REVIEWS IN UROLOGY 93 Hormone Replacement Therapy continued Testosterone Replacement Therapy in Hypogonadal Men at High Risk for Prostate Cancer: Results of 1 Year of Treatment in Men With Prostatic Intraepithelial Neoplasia Rhoden EL, Morgentaler A. increased risk as it pertains to prostate malignancy. Because this study examines a population at high risk for prostate cancer, its results are of particular interest. These data are one more piece of the clinical puzzle of androgen replacement therapy in the aging man. J Urol. 2003;170:2348-2351. The practice of Rhoden and Morgentaler is to perform prostate needle biopsy in all patients who are prescribed androgen replacement therapy, thus providing a unique opportunity to identify patients who have abnormal prostate histology and follow them during replacement therapy. In this report, the investigators compare the results of serum prostate-specific antigen (PSA) evaluation and rectal examination at baseline and 1 year after initiation of androgen replacement among patients with (n = 20) and without (n = 50) PIN. The authors noted no significant differences between the 2 groups in regard to mean baseline PSA or serum testosterone levels. For purposes of this study, a serum total testosterone level of less than 300 ng/dL was considered to be subnormal. During the course of therapy, patients who Incontinence Estrogen for Overactive Bladder and Patient Perception of Incontinence Reviewed by Christopher Chermansky, MD, Michael B. Chancellor, MD University of Pittsburgh School of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA [Rev Urol. 2004;6(2):94-95] PIN does not appear to be a contraindication for the use of androgen replacement therapy among hypogonadal men. were noted to have a rise in PSA of greater than 1.0 ng/dL or who manifested an alteration in rectal examination results underwent repeat prostate needle biopsy. Using these parameters, 4 men in the group without PIN underwent biopsy (all of which were negative). Two patients in the group with PIN qualified for biopsy based on increasing PSA level; one of these men refused the procedure. An additional patient in the PIN group was noted to have an abnormal rectal examination result and was found to have prostate cancer on biopsy. It was also noted that the increase in serum PSA level at 1 year versus baseline was not significantly different between patients without PIN and those with PIN (0.25 ng/dL and 0.35 ng/dL, respectively). Although the authors acknowledge that this study includes a relatively small cohort of patients and is limited by the duration of follow-up, they conclude that PIN does not appear to be a contraindication for the use of androgen replacement therapy among hypogonadal men. Certainly, additional investigation is needed to more fully assess whether androgen replacement therapy poses 94 VOL. 6 NO. 2 2004 REVIEWS IN UROLOGY © 2004 MedReviews, LLC A Double-Blind Placebo-Controlled Trial on the Effects of 25 mg Estradiol Implants on the Urge Syndrome in Postmenopausal Women Rufford J, Hextall A, Cardozo L, Khullar V. Int Urogynecol J Pelvic Floor Dysfunct. 2003;14:78-83. ver the past 12 months, estrogen has been battered in the medical and public press because of the controversy that an increased risk of cancer may outweigh any beneficial clinical effect. Nevertheless, estrogen remains a commonly prescribed therapy for both stress and urge incontinence. Is the use of estrogen in this setting justified? The aim of this prospective, double-blind, randomized, placebo-controlled trial was to determine the effect of systemic estrogen on the “urge syndrome” in postmenopausal women. The study was conducted in the urogynecology unit at King’s College Hospital in London, UK. Forty postmenopausal women with the urge syndrome were randomly allocated to receive a 25-mg 17ß-estradiol implant or a placebo implant. Serum estradiol levels and endometrial thickness were measured before and after treatment at 1, 3, and 6 months. Outcome measures included videocystourethrography, frequency volume chart, visual analogue score of symptoms, and the King's Health Care O