Women who receive pellet hormonal therapy may be significantly more likely to have side effects such as mood swings, anxiety, breast tenderness, hair pattern change, acne, and weight gain, compared with women who receive hormonal treatments that have been approved by the Food and Drug Administration, a study indicates.
In addition, abnormal uterine bleeding may be significantly more common in women who receive pellets than it is in women who receive Food and Drug Administration–approved options, according to the retrospective study, which was published online in Menopause.
Women receiving pellets also were more likely to undergo hysterectomy while on hormonal therapy, and they had higher supraphysiological levels of estradiol and total testosterone during treatment, compared with women on conventional therapy, the study of 539 women shows.
The findings, which had been presented at the North American Menopause Society annual meeting, were highlighted during a lecture at the 2021 virtual meeting of the American College of Obstetricians and Gynecologists.
The data are “not very reassuring at all,” said Robert P. Kauffman, MD, a professor of obstetrics and gynecology at Texas Tech University, Amarillo, who was not involved in the study.
Kauffman commented on the research during a review of concerns surrounding non–FDA-approved hormone replacement therapies at the ACOG meeting. Concerns include variations in compounded products, a lack of randomized, controlled trial data supporting their use, and ethical dilemmas that may exist if clinicians have financial incentives to provide compounded bioidentical hormone therapy over FDA-approved treatments.
No peer-reviewed studies show that compounded hormone creams or pellets are safer, more efficacious, or less likely to cause adverse effects, compared with FDA-approved products, Kauffman said.
Data From Pennsylvania
For the retrospective study, Xuezhi (Daniel) Jiang, MD, PhD, and colleagues identified postmenopausal patients in the Reading Hospital Electronic Medical Record System, including 10,801 on FDA-approved hormonal therapy and 1,061 on pellet hormonal therapy. Their analysis focused on data from the medical records of 384 women on pellet hormonal therapy and 155 women on FDA-approved hormonal therapy. Jiang is affiliated with the department of obstetrics and gynecology at Reading (Pa.) Hospital and Sidney Kimmel Medical College, Philadelphia.
The researchers examined data from 2005 to 2017 for patients in the pellet therapy group, and from 1985 to 2017 for patients in the conventional therapy group.
Patients in the conventional therapy group received 24 brands of FDA-approved hormone products; 4.5% received testosterone or methyltestosterone in addition to estrogen. Patients in the pellet therapy group had pellets prescribed by clinicians at two private practices in the hospital system that use this treatment approach. Patients in the pellet group received Sottopelle and compounded estradiol and testosterone pellets made at a pharmacy in Tennessee. Almost all of the patients in the pellet group received testosterone and estradiol pellets.
Low libido was listed as a reason why women started treatment for 83.5% of the pellet group versus 4.5% of the conventional therapy group.
In all, 57.6% of patients on pellet therapy had side effects, versus 14.8% on FDA-approved therapy, the researchers found. Patients on pellet hormonal therapy reported higher incidence of mood swings (7% vs. 1.9%), anxiety (18.5% vs. 5.8%), breast tenderness (10.1% vs. 2.6%), hair pattern change (13.5% vs. 2.6%), acne (8.6% vs. 1.3%), and weight gain (34.4% vs 4.5%), relative to patients on FDA-approved options.
Among those with an intact uterus when starting therapy (246 of those on pellets and 133 of those on FDA-approved treatments), abnormal uterine bleeding occurred in 55.3% on pellets, compared with 15.2% on FDA-approved treatments (adjusted odds ratio, 7.9). Hysterectomy secondary to abnormal uterine bleeding occurred in 20.3% of the patients on pellets versus 6.3% on FDA-approved treatments (aOR, 3.2).
In many cases, records show that patients chose to have a hysterectomy so they could continue pellet therapy without worrying about abnormal uterine bleeding, Jiang said in an interview.
Kauffman has seen patients on pellet therapy, usually implanted by family physicians, develop postmenopausal bleeding because of high levels of estrogen. “Our experience has been too that, if you have pellets, you are more likely to get a hysterectomy for bleeding issues. And I think these are the safety issues that need to be looked at on a broader scope,” he said in an interview.
Although hysterectomy may stop the bleeding, other safety risks may remain with pellet therapy, noted Sharon Winer, MD, MPH, an obstetrician and gynecologist with a subspecialty in reproductive endocrinology and infertility who practices in Beverly Hills, Calif.
Pellets, which are about the size of a grain of rice, typically are implanted in the hip, lower abdomen, or buttock and release hormones over 3-6 months. The pellets are not retrievable. “The question becomes, what if she has a new breast cancer diagnosis or a diagnosis where estrogen is contraindicated? She has got that estrogen already in her system,” Winer said.
“The hysterectomy may solve the bleeding problem … but it doesn’t solve the safety problem overall,” said Winer, who also is a professor of obstetrics and gynecology and codirector of the reproductive endocrinology and infertility clinic at the University of Southern California, Los Angeles.
Elevated Levels
Average peak serum estradiol was significantly higher in the pellet treatment group than in the conventional therapy group (237.70 pg/mL vs. 93.45 pg/mL), as was average peak serum testosterone (192.84 ng/dL vs. 15.59 ng/dL), the researchers reported. Patients on FDA-approved treatments were less likely to have had their hormone levels measured. How concentrations of hormone levels correlate with side effects is unclear, Jiang said.
The study was limited by its single-institution, retrospective design, and some patient characteristics differed between the treatment groups, the authors noted.
Still, “clinicians ought to be mindful of fully counseling patients on side effects identified in the current study,” Jiang and coauthors concluded. Clinicians also need to discuss potential risks of breast cancer, endometrial cancer, and cardiovascular disease with patients.
Many primary care clinicians rely on outdated information from the Women’s Health Initiative, published in 2002 and 2004, in their understanding of postmenopausal hormonal therapy and its risks and benefits, Jiang said. And some patients consider custom-compounded hormone therapy to be safer and more natural, “which is totally misleading.”
Pellets and other custom-compounded medicine containing testosterone may make patients feel better and more energetic, Jiang acknowledged. “That’s a reason why patients … tend to stay on, even though they have side effects. The only issue is the safety.”
Additional questions remain. The researchers recently started to examine rates of breast cancer and abnormal breast pathology and mammogram results. “It’s a long journey,” he said.
Plenty of Approved Options
Custom-compounded medicines are not FDA approved and are not recommended by medical menopause societies, Jiang said. Meanwhile, plenty of approved hormone therapies, including bioidentical treatments, have safety data and are available.
A 2020 consensus study report from the National Academies of Sciences, Engineering, and Medicine that examined the use of compounded hormonal therapy and provides guidance for clinicians is a good start in addressing this major issue, he added.
A committee determined “there is insufficient evidence to support the overall clinical utility of [compounded bioidentical hormone therapies] as treatment for menopause and male hypogonadism symptoms.”
If an FDA-approved option is available, “I would always go with an FDA-approved product before I would go with a compounded product,” Winer said. A 2012 fungal meningitis outbreak linked to a compounding pharmacy highlighted risks associated with poor quality compounded drugs.
“I think at least now it is recognized that compounding is an issue that has got to be dealt with,” Winer said. “It is just that it is so widespread and it is sometimes under the radar … that I think it is really hard for the FDA to get a handle on it.”
Winer has seen patients on compounded treatments who are underdosed and patients who are overdosed. “I’ve also seen patients who do quite well with it, but I’m not happy continuing it because tomorrow there may be inconsistency in potency or quality resulting in a different clinical response,” she said.
Nevertheless, compounded pharmacies are needed, Winer said. If she wants to give natural progesterone that is FDA approved but happens to be made with peanut oil, she will have a compounding pharmacy make it with canola oil instead if a patient has a peanut allergy, for example. Other patients need dosages that are so low that they are not available as FDA-approved products.
In general, many practitioners need to be better informed about hormonal therapy, and patients need to understand that using compounded hormones is not like taking a vitamin, Winer said. “Compounded medications are drugs. And every drug has risks and benefits no matter where it comes from.”
Jiang and Kauffman had no relevant financial disclosures. Winer has done work with AbbVie (related to endometriosis), TherapeuticsMD (related to a menopause bioidentical hormonal pill and vaginal estrogen product), and Biogix (related to an antioxidant supplement for menopause symptoms).
This article originally appeared on MDedge.com, part of the Medscape Professional Network.
