Lori C. Brown, PharmD

PHARMACY RESIDENCIES ARE designed to further prepare pharmacists for advanced professional practice. Not only does residency completion afford pharmacists a competitive advantage in the marketplace, but residency programs train pharmacists in a variety of patient care settings and

provide opportunities to interact and network with many different types of health care practitioners. Residency training also increases professional confidence and competence and gives residents exposure to innovative practice styles and settings.

The American Society of Health-System Pharmacists (ASHP) serves as the accrediting body for pharmacy residencies in the <?xml:namespace prefix = st1 />

. ASHP believes that postgraduate residencies are the best source of highly qualified pharmacy manpower, and therefore has developed stringent accreditation standards to ensure quality residency training. The accreditation process is rigorous, including application, site survey, preliminary accreditation, survey report and follow-up, accreditation, and ongoing quality improvement measures. 

Residents must participate in formal evaluation processes to ensure that their activities are meeting the goals and objectives of their particular residencies. Additionally, residents design, implement, and evaluate a project during the course of the residency year, which usually requires approval by an Institutional Review Board. Findings from this research are often presented at regional and even national meetings, and can parlay into publications for the resident. 

So who should complete a residency? Students should consider their long-term career goals and weigh the costs of completing a residency against the benefits it could afford. In a competitive pharmacy marketplace, residency training is mandatory for certain types of positions, but it can certainly be hard to swallow the year of hard work for much lower pay, especially after at least 6 long years as a student. Pharmacists who have been in practice for years are certainly eligible to complete residency training as well, and often do so after realizing it is necessary to accomplish their career goals.

While academic success is certainly an important qualification for completing a residency, residency programs consider multiple other factors, including communication skills, pharmacy practice  experience, participation in extracurricular or volunteer activities, and a sense of commitment

to the pharmacy profession. The interview process is weighted heavily with most residency programs, as are letters of recommendation from clerkship preceptors, employers, and/or professors.

Residency programs are available in a variety of practice settings, including hospitals, community  pharmacies, home care and long-term care facilities, ambulatory care settings, managed care facilities, and others. The pharmacist?s career objectives should be considered in determining the type of  residency to pursue. Two types of pharmacy residencies are accredited by ASHP?postgraduate year 1 (PGY1) and postgraduate year 2 (PGY2). Generally, the PGY1 experience allows the resident to focus on gaining a solid foundation in delivery of patient care, including optimizing drug therapies, fostering relationships and collaboration with other health care disciplines, and more.

Upon completion of a PGY1 residency, pharmacists are eligible for PGY2 opportunities in a variety of practice settings, including ambulatory care, cardiology, critical care, drug information, geriatrics, infectious diseases, and many others. 

For more information on pharmacy residencies, refer to the ASHP residency directory on the ASHP Web site, available at: 

http://www.ashp.org/s_ashp/residency_index.asp?CID=1212&DID=1254

Articles

Dr. Brown is manager of clinical services at Kerr Drug Inc Clinical Services.

UNDERSTANDING A PHARMACY RESIDENCY PROGRAM

	    We all get a cold from time to time, and we wonder how to get rid of it. The bad news: there is no cure . . . yet. The good news: you can prevent colds. If you do get a cold, however, you can treat the symptoms. The common cold is caused by 1 of more than 200 known viruses, so antibiotics are 

 effective treatments. Symptoms appear gradually and include congestion, sneezing, sore throat, and sometimes a cough.

	    Once you start feeling bad, it is important to determine whether your symptoms are caused by the common cold or the flu. If you become sick quickly, have joint pain or aches, or have a high fever, chances are you have the flu, which is caused by the 

 virus. (See the Table for more information on the differences between a cold and the flu.) The best way to prevent the flu is to get a yearly flu shot. Like the common cold, there is no cure for the flu, and antibiotics are 

 helpful in treating the flu either. Some over-the-counter (nonprescription) products and remedies, however, can help you feel better and make dealing with the flu or a common cold a little bit easier.

	    Because there is no known cure for the common cold, prevention is key to keeping colds away. Most of the time, you acquire a cold virus by touching your eyes, nose, or mouth with an object that has the cold virus on it. Therefore, to help avoid catching a cold:

			Wash your hands thoroughly and frequently with warm, soapy water

			Sneeze into a tissue, rather than into your hands, then discard the tissue

			Don?t touch your face?your hands may have come in contact with the cold virus!

	    Whether or not you take medicine for your symptoms, a cold will probably last about a week. Be sure to drink plenty of fluids to help with congestion, and get plenty of rest?up to 12 hours a night. Be considerate of others?you are contagious for the first 3 days that you have cold symptoms.

	    Dozens of cold medicines are available over the counter. Some of these products contain multiple active ingredients, and others contain only 1 active ingredient. By choosing single-ingredient preparations, you can be sure to treat only the symptoms that you have. Combination products may be more convenient, but you can easily overmedicate yourself. You may feel the side effects of these unnecessary extra ingredients. Always check with your pharmacist if you have questions about over-the-counter medicines.

What Are the Ingredients in Cold Medicines? 

 (guaifenesin) loosen up the congestion in your chest, which helps you cough up the mucus. Guaifenesin comes in short-acting and extended-release formulas. Short-acting guaifenesin products are available as a syrup or pill (Robitussin). Short-acting products generally are taken every 4 hours. Mucinex is the only extended- release guaifenesin product available. It is an over-the-counter medicine and is in the form of a tablet. Do not crush, chew, or break the tablet. Expectorants are most effective when taken with plenty of water. (Note: All single-ingredient, extended-release guaifenesin tablets sold as prescription products will not be available for retail dispensing as of December 1, 2003.)

 are used to treat nasal stuffiness and drainage. Decongestants work by temporarily shrinking blood vessels in the lining of your nose, which results in easier breathing. They also help dry up postnasal drip, so they may help a sore throat. Decongestants can be taken by mouth or as a nasal spray or drops. Pseudoephedrine (Sudafed, Cenafed, Decofed, Dorcol, Efidac 24, Pedia- Care, Sinutab) is a single-ingredient oral decongestant that works well but has the potential to cause rapid heartbeat. Oral decongestants should be avoided in children younger than 6 months. If you have heart disease, high blood pressure, an enlarged prostate, glaucoma, diabetes, or an overactive thyroid, check with your doctor or pharmacist before taking a decongestant by mouth. Other decongestants are available over the counter as nasal sprays (Afrin, Dristan, Neo-Synephrine [4 hour], Vicks, Otrivin). They are less likely to cause side effects when used correctly, so always read the package insert.

 keep you from coughing. They are best suited for a dry, hacking cough, particularly when it keeps you awake at night. Dextromethorphan is found as a single ingredient in liquid and capsule forms (eg, Delsym, Hold DM, Robitussin Pediatric, Robitussin Cough Calmers, St. Joseph Cough Suppressant, Sucrets Cough Control). Cough suppressants may hold mucus in your lungs and make breathing more difficult for some people. So, if you are elderly or frail, or if you have chronic respiratory problems, ask your physician or pharmacist for advice before taking a cough suppressant.

 may help if you have a mild fever or sore throat. Acetaminophen (Tylenol) is the safest choice for most people, but it should not be used if you have liver damage or disease. Ibuprofen (Advil, Motrin) and naproxen sodium (Aleve) are nonsteroidal anti-inflammatory drugs (NSAIDs) that are effective in treating pain and swelling. NSAIDs should be taken with food. You should consult your pharmacist or physician before using NSAIDs if you have heart disease, including hypertension, or if you have a history of ulcers or stomach/intestinal bleeding. Sore throats also can be relieved by gargling with salt water (1/2 teaspoonful of salt dissolved in 8 ounces of warm water) or by sucking on lozenges or sour candy.

 usually are not effective for the common cold. They can thicken mucus, which makes it more difficult to break up and get rid of. Antihistamines are preferred for treating allergy symptoms, such as sneezing, itchy or watery eyes, and runny nose.

	    Usually, it is not necessary to see the doctor for a common cold. You 

			You have a cold that lasts for more than 10 days

			You are short of breath or you experience wheezing

			You have severe pain in your face or forehead

			You have an earache or your ear is draining

			You have a sore throat for more than 5 days

	Mucinex is the first and only single-ingredient, extended-release guaifenesin product to have a new drug application approved by the Food and Drug Administration. The patented, bilayer 600-mg guaifenesin tablet provides an immediate release of 100 mg of guaifenesin for rapid onset of action and 500 mg of extended-release guaifenesin for the only approved 12-hour delivery. It helps loosen mucus and thin bronchial secretions to rid the bronchial passageways of bothersome mucus and make coughs more productive.

	    Additionally, Mucinex has been approved as an 

 product and is available to patients without a prescription. Mucinex is dosed as 1 or 2 tablets every 12 hours. It is sold in bottles of 20 tablets (5-10 days of therapy) or 40 tablets (10-20 days of therapy). With the approval of Mucinex, all single ingredient, extended-release guaifenesin tablets sold as prescription products will not be available for retail dispensing as of December 1, 2003.

The Common Cold: Advice for the Patient

    We all get a cold from time to time, and we wonder how to get rid of it. The bad news: there is no cure . . . yet. The good news: you can prevent colds. If you do get a cold, however, you can treat the symptoms. The common cold is caused by 1 of more than 200 known viruses, so antibiotics are 

 effective treatments. Symptoms appear gradually and include congestion, sneezing, sore throat, and sometimes a cough. 

    Once you start feeling bad, it is important to determine whether your symptoms are caused by the common cold or the flu. If you become sick quickly, have joint pain or aches, or have a high fever, chances are you have the flu, which is caused by the 

 helpful in treating the flu either. Some over-the-counter (nonprescription) products and remedies, however, can help you feel better and make dealing with the flu or a common cold a little bit easier. 

    Because there is no known cure for the common cold, prevention is key to keeping colds away. Most of the time, you acquire a cold virus by touching your eyes, nose, or mouth with an object that has the cold virus on it. Therefore, to help avoid catching a cold: 

Wash your hands thoroughly and frequently with warm, soapy water 

Sneeze into a tissue, rather than into your hands, then discard the tissue 

Don?t touch your face?your hands may have come in contact with the cold virus! 

    Whether or not you take medicine for your symptoms, a cold will probably last about a week. Be sure to drink plenty of fluids to help with congestion, and get plenty of rest?up to 12 hours a night. Be considerate of others?you are contagious for the first 3 days that you have cold symptoms. 

    Dozens of cold medicines are available over the counter. Some of these products contain multiple active ingredients, and others contain only 1 active ingredient. By choosing single-ingredient preparations, you can be sure to treat only the symptoms that you have. Combination products may be more convenient, but you can easily overmedicate yourself. You may feel the side effects of these unnecessary extra ingredients. Always check with your pharmacist if you have questions about over-the-counter medicines. 

 loosen up the congestion in your chest, which helps you cough up the mucus. Guaifenesin comes in short-acting and extended-release formulas. Short-acting guaifenesin products are available as a syrup or pill (Robitussin). Short-acting products generally are taken every 4 hours. Mucinex is the only extended- release guaifenesin product available. It is an over-the-counter medicine and is in the form of a tablet. Do not crush, chew, or break the tablet. Expectorants are most effective when taken with plenty of water. (

: All single-ingredient, extended-release guaifenesin tablets sold as prescription products will not be available for retail dispensing as of December 1, 2003.) 

 are used to treat nasal stuffiness and drainage. Decongestants work by temporarily shrinking blood vessels in the lining of your nose, which results in easier breathing. They also help dry up postnasal drip, so they may help a sore throat. Decongestants can be taken by mouth or as a nasal spray or drops. Pseudoephedrine (Sudafed, Cenafed, Decofed, Dorcol, Efidac 24, Pedia-Care, Sinutab) is a single-ingredient oral decongestant that works well but has the potential to cause rapid heartbeat. Oral decongestants should be avoided in children younger than 6 months. If you have heart disease, high blood pressure, an enlarged prostate, glaucoma, diabetes, or an overactive thyroid, check with your doctor or pharmacist before taking a decongestant by mouth. Other decongestants are available over the counter as nasal sprays (Afrin, Dristan, Neo-Synephrine [4 hour], Vicks, Otrivin). They are less likely to cause side effects when used correctly, so always read the package insert. 

 keep you from coughing. They are best suited for a dry, hacking cough, particularly when it keeps you awake at night. Dextromethorphan is found as a single ingredient in liquid and capsule forms (eg, Delsym, Hold DM, Robitussin Pediatric, Robitussin Cough Calmers, St. Joseph Cough Suppressant, Sucrets Cough Control). Cough suppressants may hold mucus in your lungs and make breathing more difficult for some people. So, if you are elderly or frail, or if you have chronic respiratory problems, ask your physician or pharmacist for advice before taking a cough suppressant. 

may help if you have a mild fever or sore throat. Acetaminophen (Tylenol) is the safest choice for most people, but it should not be used if you have liver damage or disease. Ibuprofen (Advil, Motrin) and naproxen sodium (Aleve) are nonsteroidal anti-inflammatory drugs (NSAIDs) that are effective in treating pain and swelling. NSAIDs should be taken with food. You should consult your pharmacist or physician before using NSAIDs if you have heart disease, including hypertension, or if you have a history of ulcers or stomach/intestinal bleeding. Sore throats also can be relieved by gargling with salt water (1/2 teaspoonful of salt dissolved in 8 ounces of warm water) or by sucking on lozenges or sour candy. 

 usually are not effective for the common cold. They can thicken mucus, which makes it more difficult to break up and get rid of. Antihistamines are preferred for treating allergy symptoms, such as sneezing, itchy or watery eyes, and runny nose. 

    Usually, it is not necessary to see the doctor for a common cold. You 

You have a cold that lasts for more than 10 days 

You are short of breath or you experience wheezing 

You have severe pain in your face or forehead 

You have an earache or your ear is draining 

You have a sore throat for more than 5 days 

    Mucinex is the first and only single-ingredient, extended-release guaifenesin product to have a new drug application approved by the Food and Drug Administration. The patented, bilayer 600-mg guaifenesin tablet provides an immediate release of 100 mg of guaifenesin for rapid onset of action and 500 mg of extended-release guaifenesin for the only approved 12-hour delivery. It helps loosen mucus and thin bronchial secretions to rid the bronchial passageways of bothersome mucus and make coughs more productive. 

 product and is available to patients without a prescription. 

 is dosed as 1 or 2 tablets every 12 hours. It is sold in bottles of 20 tablets (5-10 days of therapy) or 40 tablets (10-20 days of therapy). With the approval of 

 tablets sold as prescription products will not be available for retail dispensing as of December 1, 2003.

    Blood pressure is the force against which the heart must pump in order to perfuse the body with blood. Systolic and diastolic pressures are measured. Systolic pressure is the pressure in the blood vessels when the heart contracts and pumps blood. Diastolic pressure is the pressure in the vascular system when the heart is filling. Hypertension is defined as systolic blood pressure >140 mm Hg or diastolic blood pressure >90 mm Hg. 

    Hypertension affects about 1 in 4 adult Americans.

 The disease usually occurs in people over the age of 35. Its highest prevalence is in middle-aged and elderly people, in African Americans, and in people who are overweight.

 This common but dangerous disease directly increases the risk of myocardial infarction (MI), congestive heart failure (CHF), stroke, renal failure, atherosclerosis, and dementia. 

    Although high blood pressure usually does not have symptoms or make people feel bad, it is important to educate patients on the complications and effects of uncontrolled hypertension. Hypertension leads to an overworked heart and blood vessels, which tire over time, and serious complications may arise. When hypertension is well managed, however, cardiovascular morbidity and mortality decline, and the risk of stroke, coronary artery disease, and congestive heart failure decreases. Unfortunately, US data show that only 54% of hypertensive patients are treated, and only 28% are treated adequately.

    The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) provides the following classes of hypertension. 

: defined as systolic blood pressure of 120 to 139 mm Hg or diastolic blood pressure of 80 to 89 mm Hg. Prehypertensive patients should be educated about and encouraged to adopt healthy lifestyle changes in order to minimize their cardiovascular disease risk. 

: defined as systolic blood pressure of 140 to 159 mm Hg or diastolic blood pressure of 90 to 99 mm Hg 

: defined as systolic blood pressure >160 mm Hg or diastolic blood pressure >100 mm Hg (Table 1)

    The goal of hypertensive therapy, whether drug or nondrug, is to prevent cardiovascular disease and death. Each patient?s therapy should be based on his or her untreated blood pressure level and the presence of cardiovascular risk. Nondrug therapy (lifestyle modification) is indicated for all patients with hypertension. Nondrug therapy can be used alone for 6 months for patients who have risk factors and up to 12 months for patients without risk factors. If lifestyle modifications fail to bring blood pressure to goal levels, drug therapy can be added. Drug therapy is indicated as the first line of therapy, however, if a patient has diabetes or cardiovascular, renal, cardiac, cerebrovascular, or retinal disease. 

    Weight reduction, sodium restriction, smoking cessation, and increased physical activity are some of the lifestyle modifications that can help patients achieve their blood pressure goals and reduce cardiovascular disease risk. For example, sodium causes fluid retention, which can exacerbate hypertension. Restricting the daily intake of sodium to <2 g has been shown to reduce both systolic and diastolic blood pressures.4 It is important to educate patients with hypertension about the significant effect a healthy lifestyle can have (Table 2).

 Because hypertension is most often not accompanied by symptoms, patients should monitor their blood pressure regularly. Monitoring devices include manual-inflation cuffs with sphygmomanometer or digital display and automatic-inflation cuffs with digital display with or without memory. Patients should be encouraged to keep a log of their blood pressure readings, since blood pressure does have variations throughout the day. 

. Diuretics are effective antihypertensive agents because they decrease plasma volume, thereby reducing the pressure against which the heart has to pump. Additionally, they have been shown to reduce morbidity and mortality associated with hypertension. 

 The JNC 7 guidelines recommend diuretics as first-line therapy for hypertension. 

 There are 4 general classes of diuretics: loop, thiazide (or thiazidelike), potassium-sparing, and osmotic. Loop diuretics, such as furosemide, increase sodium excretion, resulting in high urine output, and they are most commonly used for edema. Thiazide and thiazide-like diuretics, such as hydrochlorothiazide, cause increased sodium and chloride excretion and are used most often to treat hypertension. Potassium-sparing diuretics, such as triamterene, are the least potent of all diuretics and often are used in conjunction with other classes of diuretics to minimize potassium loss. Osmotic diuretics are the least commonly used of all diuretics and are not used to treat hypertension. 

. Like diuretics, betablockers reduce morbidity and mortality associated with hypertension.

 Betablockers reduce the workload of the heart by acting on the sympathetic nervous system. Beta-receptor activation results in increased heart rate and increased force of the heartbeat. Betablockers inhibit this reaction, thereby easing cardiac stress by slowing down the heart rate and decreasing the heart muscle?s contractile force. For these reasons, beta-blockers are used to reduce blood pressure in patients who have had an MI or who have CHF. 

    The 2 types of beta-receptors are beta-1 and beta-2 receptors. Beta-1 receptors are found primarily in the heart, and beta-2 receptors are found in the lungs and blood vessels. Beta-1 selective beta-blockers are preferred over nonselective agents for the treatment of hypertension and other cardiac conditions. Nonselective betablockers antagonize both beta-1 and beta-2 receptors and therefore produce noncardiac effects, such as bronchoconstriction and vasoconstriction. Nonselective agents should be avoided in patients with respiratory disease such as asthma or chronic obstructive pulmonary disease. Beta-blocker therapy should be initiated at low doses and titrated upward slowly, so as to minimize the risk of slowing the heart rate down too quickly. 

    Angiotensin-Converting Enzyme (ACE) Inhibitors. 

ACE inhibitors inhibit the breakdown of bradykinin, thereby inhibiting the conversion of angiotensin I to angiotensin II. Angiotensin II is a vasoconstrictor that raises blood pressure, so ACE inhibitors work by vasodilation, without causing reflex tachycardia. ACE inhibitors are the preferred antihypertensive therapy for patients with diabetes because they protect the kidneys from the disease?s harmful effects. The most common side effect of ACE inhibitor therapy is a dry cough, which is a result of bradykinin degradation. ACE inhibitors also can increase serum potassium. A rare but very serious side effect of ACE inhibitors is angioedema, which is characterized by swollen lips and tongue. 

    Angiotensin II Receptor Blockers (ARBs).

 These drugs block the effects of angiotensin II without affecting bradykinin, and therefore they often are used in patients who cannot tolerate ACE inhibitor therapy due to cough. Like ACE inhibitors, ARBs have been shown to protect renal function in patients with type 2 diabetes and nephropathy. ARBs, however, generally are more expensive than ACE inhibitors.

. These agents prevent the flow of calcium into the heart muscle cells and blood vessels, resulting in reduced work for the heart and vasodilation. Calcium-channel blockers are the preferred antihypertensive therapy for patients with coronary artery disease (angina) or arrhythmias. Edema and constipation are the 2 most common potential side effects with calciumchannel blocker therapy. 

. These blockers are often used in patients who have hypertension and benign prostatic hyperplasia (BPH) because these medications reduce blood pressure and relieve BPH symptoms. They are, however, associated with more drowsiness and lethargy than other antihypertensive classes. 

Putting It All Together: JNC 7 Guidelines 

    The JNC 7 Clinical Guidelines were released May 14, 2003. According to these guidelines, most patients should receive a low-dose thiazide diuretic as first-line therapy for hypertension. Usually, more than 1 therapy is needed to bring the patient to his or her goal blood pressure. Second and even third or fourth agents from other classes can be added, depending on patient-specific factors (ethnicity, comorbidities, cost considerations, etc).

    Antihypertensive medications are effective in helping patients achieve their blood pressure goals. Because hypertension is most often a symptomless disease, antihypertensive therapy has the potential to make patients feel worse than the condition being treated did. Many patients with hypertension discontinue their medications due to a lack of understanding about the disease and its complications, a lack of symptoms, the cost of therapy, or the complexity of the medication regimen.

 Pharmacists and other health care providers should counsel patients about the great importance of adhering to antihypertensive regimens, including nondrug and drug therapies. 

    For a list of references, send a stamped, self-addressed envelope to: References Department, Attn. D. Ryan, Pharmacy Times, 241 Forsgate Drive, Jamesburg, NJ 08831; or send an e-mail request to: 

Review and Update on Treatments for Hypertension

Menopause is a normal part of aging for women. It is the time in a woman?s life when the ovaries no longer produce eggs and menstruation stops. During this ?change of life,? the amount of estrogen circulating in the body sharply declines, thus presenting a variety of symptoms and new health concerns. Menopausal symptoms include hot flashes, vaginal dryness, sleeplessness (perhaps due to hot flashes), and mood changes. Estrogen replacement alleviates these symptoms for many women.

Hormone replacement therapy (HRT) consists of estrogen alone (for women who have had a hysterectomy) or estrogen plus a progestin for women who have an intact uterus. HRT provides symptom relief in the majority of women who use it, and it has been associated with other positive effects, such as preventing bone loss and reducing the risk of colorectal cancer. As with any medication, however, there are also risks associated with HRT use, including a moderate increase in risk for breast cancer and blood clots.

Until recently, HRT has been used not only to treat menopausal symptoms, but also to prevent cardiovascular disease, osteoporosis, and colorectal cancer.  Recent research, however, has indicated that estrogen-plus-progestin HRT should not be used for primary or secondary prevention of cardiovascular events.  It is still indicated for symptoms associated with menopause and for prevention of osteoporosis in those women whose potential benfit outweighs potential risk.  Therefore, it is important for health care providers and women together to evaluate the risks and benefits of using HRT and to understand when it is a good therapeutic choice for each individual woman.

The latest study of HRT found hormone therapy doubled the risk of Alzheimer?s disease and other forms of dementia in women who began the treatment at age 65 and older.(1)The findings are based on a 4-year trial involving 4532 women at 39 medical centers, part of the Women?s Health Initiative (WHI). Half of the participants took placebos, and half took Prempro (Wyeth Pharmaceuticals), a combination of estrogen and progestin. The results showed 40 cases of dementia in the hormone group, compared with 21 in the placebo group. For women 65 and older on hormone therapy, there would be 23 cases of dementia per 10,000 women annually, according to the study. Because the women in the study were 65 and older, it is not known if the findings apply to younger postmenopausal women or if the results apply to women who take other hormone combinations or estrogen alone.

Sally A. Shumaker, PhD, lead investigator of the study and researcher at Wake Forest University Health Sciences in Winston-Salem, NC, stressed the fact that women 65 and older taking Prempro or other hormone combinations should discuss the reason they are taking the drugs with their physicians and if they should quit. Researchers now advise that only women with severe menopausal symptoms such as hot flashes and night sweats take HRT and for the shortest time possible.

WHI was a large study involving about 160,000 healthy, postmenopausal women. The study was designed to clarify the role of HRT in the treatment of menopause. Specifically, the WHI study assessed the long-term effects of HRT on heart attack, stroke, blood clots, bone fractures, breast cancer, and colorectal cancer.(2)The most important facts about the WHI study are as follows:

Premarin (0.625 mg of conjugated estrogens) was used for the estrogen-only group in the study. Prempro (0.625 mg of conjugated estrogens and 2.5 mg of medroxyprogester-one) was used for the estrogen-plus-progestin group. Therefore, results from this trial cannot be directly related to the use of other combination forms of HRT.

Women enrolled in the WHI study who are taking Premarin (estrogen only) are still being evaluated.

There were more cases of breast cancer, heart attacks, strokes, and blood clots in women taking estrogen plus progestin than in women taking sugar pills. 

There were fewer cases of hip fractures, other fractures, and colorectal cancer in women taking estrogen plus progestin than in women taking sugar pills. 

There were no differences between the 2 groups in the number of women who had endometrial cancer or the number who died.

If a woman has questions about whether HRT is appropriate for her, the pharmacist should counsel her to address these concerns with her physician. It is absolutely essential that a patient and her doctor work together to determine whether or not she should stop or start HRT. Every woman is unique, and her specific situation is different from that of her friends. The doctor should evaluate the woman?s risk for heart disease, osteoporosis, and certain cancers. For most women, relieving menopausal symptoms by taking HRT for short periods is safe and appropriate. It also is important for women to adjust their lifestyle to make menopause as easy a transition as possible. They should be advised to quit smoking, increase their physical activity, eat healthy foods, and minimize stress in order to decrease menopausal symptoms. Adopting healthy habits also allows women to lower their risk for certain diseases that are more likely to occur after menopause.

If a woman and her doctor decide that it is appropriate for her to stop HRT, the dosage should be tapered before discontinuation so that she does not have rebound symptoms. Once she has stopped HRT, the patient and her doctor should discuss the symptoms she may have and discuss other ways to treat those symptoms.

Lifestyle changes are the first step to minimizing hot flashes. Dressing in layers of clothing that can be removed, sleeping in a cool room, and avoiding hot and spicy foods are some of the ways to avoid hot flashes. If, however, a woman does start to experience a hot flash, she should be advised to breathe slowly and deeply to lessen the effect. Cold, caffeine-free beverages also may help. For vaginal dryness, lubricants and moisturizers can provide relief and are available without a prescription.

Soy and isoflavones contain plant-derived estrogens, or ?phytoestrogens,? which have estrogen-like activity. Phy-toestrogens have been shown to relieve hot flashes in some women, and soy may improve bone density. Because phytoestrogens act at the same receptor as estrogen, however, they may confer the same risks as do prescription estrogen therapies. Whole soy foods?such as soybeans, soy flour, soy milk, tofu, and tempeh? are the preferred sources for isoflavones. 

Nutritional supplements and herbal therapies for menopause may be useful in some women, but their safety and efficacy are not guaranteed or monitored by the FDA. A woman should talk to her physician before taking any nutritional supplement or herbal therapy. 

A woman?s bone density may decrease significantly without estrogen in the years just after menopause. Calcium is important for the maintenance of bone density. According to the National Osteoporosis Foundation, most women consume less than half of the recommended daily allowance of elemental calcium, which is 1200 mg daily for women over age 50. If a woman?s diet is not rich in dairy products or other sources of calcium, she may be advised to take a calcium supplement. Because the body can absorb only about 500 mg of calcium at a time, calcium should be ingested throughout the day, not all at once. 

Vitamin D also plays an important role in bone health by helping the body absorb calcium. The body produces vitamin D when skin is exposed to natural sunlight, and it is also available through diet. Adequate calcium and vitamin D intake, along with regular weight-bearing exercise, can help maintain existing bone density. Menopause is an appropriate time for a bone density test to be performed. Prescription medications can be used to prevent or treat osteoporosis as well.

The number-1 killer of women is heart disease. A woman should talk to her physician about having her cholesterol and blood pressure checked, as well as whether she is a good candidate for daily low-dose aspirin therapy to prevent blood clots. She should eat healthy foods, increase soluble fiber, and decrease saturated fat. Regular exercise and avoiding tobacco use reduce the risk for heart disease.

For a list of references, send a stamped, self-addressed envelope to: References Department, Attn. D. Ryan, Pharmacy Times, 241 Forsgate Drive, Jamesburg, NJ 08831; or send an e-mail request to: 