Not all estrogens are created equal. Nor are all women the same.
So why does the 60-year-old estrogen therapy drug Premarin continue to be one of the top-selling drugs in America when other options have joined the market?
Although results of recent studies have questioned the safety of Premarin in women with cardiovascular disease and other medical conditions, some doctors say insurance companies continue to favor this drug and exclude coverage on some of the newer drugs that they say may be better tolerated by patients on hormone therapies.
"All HRT is not the same HRT. There are differences," said Dr. Anthony Gentile, an obstetrician/gynecologist at Magee-Womens Hospital.
He said he's tried to prescribe the most appropriate therapies based on his patients' lipid profiles and medical histories, but then has seen those requests rejected by managed care plans.
HealthAmerica, for example, marks Premarin as its preferred estrogen therapy on its formulary, which is the list of drugs approved for coverage.
Kendall Marcocci, spokeswoman for the Harrisburg-based HMO, said the drug is marked "preferred" because it is the most widely prescribed and most studied. "Often, but not always, they are the most cost-effective," she said. But doctors can still choose from any of 16 HRT drugs listed.
Premarin has long been hailed by some doctors as the ticket to youthful aging since early studies showed it kept bones strong, cardiovascular systems supple and minds sharp. But newer studies on Premarin have shown no reduction of heart disease in women who already have heart problems and also an increase in blood clots. Some studies also suggest an increased risk of breast cancer.
New drugs derived from the estrogens of plants, such as soy and yam, can mimic the effects of the body's estrogen without some of the unpleasant side effects of bloating, weight gain, migraines or spotting that can come with synthetic estrogens. Creams, gels and skin patches may be more easily tolerated by some women, as well as some of the newer combination drugs such as FemHRT, Activella and Ortho-Prefest.
Dr. Sarah Berga, director of the Division of Reproductive Endocrinology and Infertility at the University of Pittsburgh School of Medicine, isn't ready to discredit Premarin because she believes the drug plays an important role in menopausal therapies. But she agreed that providing more choices to women was necessary.
"I really think all of these products have their role. I use them all," she said. "I frequently get very frustrated. I take a very long time getting to know a patient, the patient history. I give her a sample in the office, she tries it. She goes to renew the script and they say, 'No, you can't have it.' That's incredible."
Highmark, the region's largest insurance carrier, has a panel of doctors and pharmacists that review drugs every three months for its three formularies. Subcommittees of specialists such as endocrinologists and ob-gyns provide recommendations, said Pat Kerrish, Highmark vice president of medical and pharmacy affairs.
At least two-thirds of its members have access to an open or a three-tiered formulary that makes all the HRT drugs available, albeit some with a higher co-payment.
Two of the newer HRT drugs, Ortho-Prefest and Activella, are excluded from the closed formulary, but have been reviewed by the committee and deemed not to be any better than what already is on the list, said Bob Wanovich, manager of clinical services. Physicians can request exceptions, however.
They questioned whether some drug makers were pressuring doctors to seek their products as the manufacturers try to get a foothold in the market.
Premarin costs roughly 37 cents per day, vs. about 72 or 73 cents per day for estrogen/progesterone combinations such as Prempro and the newer drugs.
Dr. Eugene Scioscia Jr., chairman of obstetrics and gynecology at Allegheny General Hospital, said data isn't available to show that one HRT drug works better than another.
But having a wide choice is important. He used birth control pills as an analogy. All prevent pregnancies, but women prefer some brands over others.
"If one combination hormone replacement therapy isn't well tolerated, it's within the patient's interest to have other options, rather that having them discontinue therapy altogether."
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