Morris Notelovitz MD PhD

Abstract | CV

Abstract

HORMONE REPLACEMENT THERAPY OR HORMONE THERAPY

Morris Notelovitz MD PhD
MB BCh FRCOG FACOG
Consultant Adult Women’s Health & Medicine
Boca Raton Fl Washington DC

The pre-WHI (Women’s Health Initiative) Study standard practice of Hormone Replacement Therapy (HRT) was predicated on a number of assumptions:

1. All menopausal women are hormone depleted.
2. All menopausal women are biologically similar – irrespective of their post-menopausal age or culture/ethnicity
3. All HRT is the same – irrespective of the type of estrogen/progestin and ? route of HRT.
4. A “standard” dose of HRT is equally effective for the treatment of menopausal symptoms, and the prevention/treatment of osteoporosis, cardiovascular disease and cognition. The implication of the term “HRT” was that of physiologic replacement of estrogen and progesterone (progestins) in post-menopausal women in order to replicate hormone levels that are normal for younger pre-menopausal women. In short, that the “menopause” is an endocrinopathy that has to be treated.

Post-WHI, the new ‘concensus” is that HRT is only appropriate for the treatment of menopausal symptoms (limited to 5 years) and once again, that all hormones are equal viz-a-viz their safety and efficacy in management of the climacteric and menopausal syndrome. This presentation will briefly review the following biological facts and indicate why the term “Hormone Therapy” HT is preferable.

1. Sex-steroid synthesis and function is related to conditions other than that associated with menopausal hot flushes.
2. That the “menopause” is an individual life event and necessitates variable therapies in relation to a woman’s biologic and chronologic age.
3. That menopausal women are hormone ”deficient” but not “depleted” and that the bioavailability of their sex steroids is governed by both modifiable and non-modifiable factors, that influence the clinical presentation of the menopause for that individual and her response to HT. Examples include:
   1. Vasomotor Symptoms: Prevalence; failure to respond to “adequate” HT; pharmacologic adjustment to enhance efficacy. 
   2. Cardiovascular Disease (CVD): Differentiating between primary prevention, secondary intervention and post-event treatment; timing of HT and its improvement or worsening of CVD; defining the “window of therapeutic opportunity” for HT.
   3. Breast Cancer: In situ synthesis of estrogen by breast tissue; influence on breast cancer; principle of breast cancer chemoprevention and the role of HT.
4. All estrogens are not equal. The biologic action of estrogen is influenced by:
   1. The type of estrogen
   2. The route of HT
   3. Concomittant progesterone/progestin therapy
5. Present day technology, utilizing selective testing does allow for true individualized HT.
6. Based on the pharmacokinetics and pharmacodynamics of available hormone therapies it is possible to replicate (replace) the hormonal milieu of both post-menopausal women (using non-oral estrogen) or to replenish pre-treatment hormonal levels in “‘naturally” menopausal women (via oral 17b estradiol). In either event, the therapy is “pharmacologic”. Hence, in this author’s opinion, the term HRT is a misnomer. Terminology is of lesser importance providing the following guiding principles are adopted.
   1. There has to be a valid indication(s) for HT.
   2. Use the lowest dose of HT appropriate to the woman’s total need(s).
   3. Monitor HT and adjust according to response.
   4. Recognize that although the treatment is targeted to a specific indication, the effect of HT is systemic.
   5. The only feature common to all menopausal women is cessation of menstruation. Biologically every woman is as unique as her own thumbprint. 

CV

Morris Notelovitz M.D. Ph.D. is a graduate of the University of Witwatersrand, Johannesburg R.S.A., where he received his medical degree (MB, BCh) in 1958. This was followed by a Doctorate in Medicine (M.D) from his alma mater in 1968 and a Ph.D. in Medicine from the University of Stellenbosch (1977). He was made a member of the Royal College of Obstetricians and Gynaecologists in 1964 and was elected a Fellow of the College in 1978. He is also a Fellow of the American College of Obstetricians and Gynecologists (1978).

Dr Notelovitz was actively involved in both the academic and private practice of obstetrics and gynecology and held senior faculty appointments at the University of Natal (1968-1974) and the University of Florida (1975-1895).

He has had a special interest in the menopause and midlife issues since 1969. Based on early experience gained in two traditional menopause clinics (Addington Hospital 1969; University of Florida 1976), Dr Notelovitz established the first multidisciplinary research center addressing gynecologic and non-gynecologic climacteric and menopausal issues, The Center for Climacteric Studies at the University of Florida (1980-1985). Research and clinical experience at this institute, resulted in the formulation of a broader concept of adult women’s medicine for the care of peri and postmenopausal women and led to the establishment of the Women’s Medical and Diagnostic Center, Inc.

Dr Notelovitz is the Founder and President Emeritus of the Women’s Medical and Diagnostic Center, Inc. Based in one facility, this center provided comprehensive multidisciplinary integrated health-care for adult women as well as providing for their participation in clinical research. Dr Notelovitz has been the principal investigator in 76 clinical investigations and has been awarded two National Institute of Health grants. Continuing research interests include: newer hormonal and other therapies to enhance postmenopausal health; exercise for adult women, design of women’s healthcare facilities and the development of clinical protocols and paradigms for the practice of adult women’s medicine.

Published work includes over 180 peer reviewed articles, 40 abstracts and 39 chapters contributed to various medical texts. He is the principal author of four major books for the lay public.

Dr Notelovitz is a past Chairman of the International Menopause Society and has served on the board of the North American Menopause Society. He has been recently appointed by the Council of Affiliated Menopause Societies (a subcommittee of the International Menopause Society together with a consortium of 20 National Menopause Societies) to develop a global strategy for the optimal care of menopausal women worldwide. Dr Notelovitz currently consults on adult women’s health issues with health care companies and universities. He lectures and teaches nationally and internationally on hormone replacement therapy and related subjects to physicians, other health care providers and consumers.