Comment on estrogen and the skin

Abstract

To the Editor: Thank you to Hall and Phillips1Hall G. Phillips T.J. Estrogen and skin: the effects of estrogen, menopause, and hormone replacement therapy on the skin.J Am Acad Dermatol. 2005; 53: 555-568Abstract Full Text Full Text PDF PubMed Scopus (216) Google Scholar for tackling a timely and relevant topic. We dermatologists need to be conversant in hormonal physiology not only to explain to our menopausal patients why their skin is aging so rapidly, but also to understand hormone-based treatments as they evolve. To facilitate communication within the wider medical community, the Journal may wish to conform to the terminology endorsed for industry by the Food and Drug Administration soon after the Prempro arm of the Women's Health Initiative was abruptly terminated. “The draft guidance no longer uses the phrase “hormone replacement” because neither estrogen alone nor estrogen/progestin treatments for symptoms of menopause should be considered replacement hormones.” Preferred terms are hormone therapy (HT) and estrogen therapy (ET).2FDA Docket No. 03D-0007. Draft guidance for industry on estrogen and estrogen/progestin drug products to treat vasomotor symptoms and vulvar and vaginal atrophy symptoms–Recommendations for clinical evaluation; availability. Margaret M. Dotzel, Assistance Commissioner for Policy, Health and Human Services. January 23, 2003.Google Scholar The North American Menopause Society recommends using HT as a general term encompassing the more specific terms ET for estrogen therapy and EPT for estrogen/progestin therapy.3Menopause practice: a clinician's guide. The North American Menopause Society, Cleveland (OH)2004Google Scholar As our knowledge becomes more sophisticated, other subtleties in terminology emerge. Historically, various synthetic or equine estradiol analogs (estrogens) were considered functionally identical to estradiol and to each other and the terms were often used interchangeably. Both the Food and Drug Administration and North American Menopause Society still state that until reliable evidence proves otherwise, we must assume that the risks and benefits of all estrogens are the same.2FDA Docket No. 03D-0007. Draft guidance for industry on estrogen and estrogen/progestin drug products to treat vasomotor symptoms and vulvar and vaginal atrophy symptoms–Recommendations for clinical evaluation; availability. Margaret M. Dotzel, Assistance Commissioner for Policy, Health and Human Services. January 23, 2003.Google Scholar, 3Menopause practice: a clinician's guide. The North American Menopause Society, Cleveland (OH)2004Google Scholar However, accumulating evidence makes it clear that conjugated equine estrogens (Premarin) and synthetic analogs (ethinyl estradiol, esterified estrogens) differ from the predominant human hormone, estradiol, and from each other.4Smith N.L. Heckbert S.R. Lemaitre R.N. Reiner A.P. Lumley T. Weiss N.S. et al.Esterified estrogens and conjugated equine estrogens and the risk of venous thrombosis.JAMA. 2004; 292: 1581-1587Crossref PubMed Scopus (150) Google Scholar, 5Leng X.H. Zhang W. Nieswandt B. Bray P.F. Effects of estrogen replacement therapies on mouse platelet function and glycoprotein VI levels.Circ Res. 2005; 97: 415-417Crossref PubMed Scopus (23) Google Scholar Effects vary in different tissues, presumably because of the variable receptor affinity for slightly different molecules. Hall and Phillips attempted valiantly to differentiate among the estrogens, employing the different terms used in the various references they reviewed. Unfortunately, research in this area has progressed with great confusion of terms, measurements, baselines, doses, delivery systems, and regimens. We should not be surprised to find conflicting results and conclusions. When we review the literature of female hormone science, our challenge is not only to identify estrogen's effects, but to understand how the effects differ with the different estrogen analogs.