HEALTH-SYSTEM EDITION
CLINICAL TWISTERS

HRT with hip replacement?

A 65-year-woman, H.R., has been admitted to your hospital for hip replacement surgery. In reviewing her admitting history and setting her up on the in-house protocol for deep vein thrombosis (DVT) prevention, you notice that she is taking conjugated estrogens .625 mg—and probably has been taking it for at least 10 years. According to her medical history, she had a hysterectomy years ago (although no actual date is given). What do you recommend? Why?

I would recommend that conjugated estrogens be discontinued one month prior to surgery. I'd suggest to both the surgeon and the patient that she reschedule the total hip replacement surgery in one month if at all possible—with the conjugated estrogens therapy discontinued. The increased risk of deep vein thrombosis is exacerbated by estrogen replacement therapy, and in this type of surgery, the risk of DVT is high. When she is later admitted for total hip replacement surgery, then institute the in-house protocol for DVT prevention.

I would also highly recommend that the use of conjugated estrogens be discussed with her primary care physician due to the findings of The Women's Health Initiative.

Andrea Wilkerson, D.Ph.
O.R. Pharmacist
Saint Francis Hospital
Memphis

Since H.R. is in the hospital, this is a good time to discuss hormone replacement therapy (HRT) with her and the medical team. They need to understand that, based on recent clinical trials, H.R. does not need to be on conjugated estrogens. The perceived cardiovascular benefits have not been demonstrated in clinical trials, and there is actually increased risk for adverse effects, including increased risk of breast cancer, myocardial infarction, pulmonary emboli, DVT, and stroke.

The American Heart Association/American College of Cardiology guidelines for prevention of heart disease in women now state that HRT is a Class III recommendation—i.e., it may be harmful. If H.R. is at risk for cardiovascular disease, then therapy to decrease the risk of cardiovascular disease should be considered, including lipid-lowering therapy, antihypertensive therapy, diet, and exercise.

HRT may decrease the risk of hip fracture, but there are other medications on the market now to prevent/treat osteoporosis. By now, H.R. should be past the symptoms of her surgically induced menopause, and the conjugated estrogens therapy should be discontinued. However, it is very important to inform the patient and the medical team that conjugated estrogens therapy should not be discontinued abruptly. It should be tapered over four to six months so that symptoms do not recur. If symptoms do continue when conjugated estrogens is discontinued, then topical estrogen products should be considered until further studies evaluate these agents.

The current dose of conjugated estrogens may be decreased while the patient is in the hospital. She should be placed on DVT prophylaxis while in the hospital and extended prophylaxis may be considered because the HRT places H.R. at an increased risk of DVT.

Sandra L. Chase, B.S., Pharm.D., FMPA
Clinical Pharmacy Specialist
Spectrum Health
Grand Rapids, Mich.

 

Kathy Hitchens. HRT with hip replacement? Drug Topics Jun. 21, 2004;148:HSE9.