An update on menopause and its treatments. Personal experience with subcutaneous estradiol implants in the UK.

Menopause is a reproductive milestone in a woman life. Although individual experience of this delicate transition phase varies widely, estrogen deprivation can cause physical symptoms that may be debilitating, including hot flushes and night sweats, urogenital atrophy, sexual dysfunction, mood changes, bone loss and metabolic changes that predispose to cardiovascular disease and diabetes. Among the available management options, that include lifestyle modifications as well as hormonal and non-hormonal pharmacological interventions, estrogen administration through various formulations remains the most effective therapeutic choice. Estradiol subcutaneous implants have been effectively used for the relief of climacteric symptoms for many years and represent an attractive option due to recognized benefits comparing with other routes of administration: avoidance of first pass effect and consequent lower metabolic impact, more stable serum estradiol levels and optimal compliance to therapy are some examples. In this clinical audit, serum estradiol levels were evaluated in 127 patients on estabilished estradiol implant therapy, who attended a dedicated menopause clinic in the UK (Chelsea nd Westminster Hospital, London) between 2012 and 2014. Prior to this time frame, licenced estradiol implants were used at a standard dose of 50 mg given every 6 months, with trough serum estradiol levels in the target range of 200-600 pmol/l. Following their withdrawal from the market, pharmacologically identical unlicenced estradiol implants have been used at the same standard dose and time range, although there is no literature or guidelines on their best use. Data collected from this population showed a mean serum estradiol level peak at 18-24 months after implantation, suggesting a prominent accumulation effect associated with the use of unlicenced estradiol pellets; a fall in serum estradiol levels in the second semester of 2014 is consistent with the observed trend of reducing implant dose to 25 mg. Current local guidelines should be appriopriately revised and 25 mg estradiol subcutaneous implants every 6-7 months should be used as a standard dose in all age groups, with alterations based on clinical need and individualized at the lowest effective dose, as suggested by HRT consensus guidelines.