Harmone replacement therapy

1. Hormone Replacement Therapy Hormone Replacement Therapy
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Why Hormone Replacement Therapy?
With a marked increase in longevity, women now
spend 1/3 rd of their lives in the post-menopausal
period. It is estimated that 1/3 rd of total female
population are in menopause. Therefore they would
have to cope with the post menopausal syndrome and
face the consequences .HRT relieves the well known
symptoms of post menopausal syndrome .Again
women are now asking for a quality life after
menopause. So HRT is a hot topic in this era as it is
no more for symptomatic management for PMS, but
for the total management from prophylactic to curative
.

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Since estrogen deficiency is a major cause
of the long-term complications of the
menopause, estrogen replacement is the
rational treatment to address the cause of
the problems after menopause .But as there
are limitations of estrogen therapy as HRT,
some other drugs are also used besides
estrogen
What is hormone replacement therapy?

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Oral: -
Conjugated equine estrogen (CEE): 0.625 mg (Estrone
Sulphate + equilin sulphate +17 d dihydro equilin)
Estradiol valerate (1, 2, 4 mg).
Estrial succinate (1, 2 mg).
Transdermal (estradiol): -
Patches: 25 micro gm, 50 micro gm / 24 hour twice
weekly.
Gel : 75 micro gm / 24 hours daily.
Sub cutaneous implant (estradiol): -
25 / 50 / 100 mg. 6 monthly.
Vaginal: cream.
1)
Estrogens-
DRUGS USED IN HRT

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DRUGS USED IN HRT
Oral route –.
Norgestrol: 150 mg /day.
Micronised progesterone: 200 mg /day.
Dydrogesterone: 20 mg / day.
Medroxy progesterone acetate: 10mg/day.
Norethisterone acetate : 0.7 – 2.5 mg/ day.
Hormone releasing intra uterine system –.
Levonorgestrel: 20 mcg / day.
Progestasert: 65mcg / day.
Vaginal - natural progesterone gel / pessary.
Transdermal - sequential / continuous patch.
2) Progestins:

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DRUGS USED IN HRT
Synthetic steroid, tissue specific HRT
2 hydroxy metabolites are estrogenic
D 4 isomer binds to progesterone & androgen
receptors
Addition of progesterone not required
3) Tibolone-
4) Androgen -
•Oral Tablets
•Implants-Pellets of 100 mg testosterone

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DRUGS USED IN HRT
Regimens
 Estrogen alone: in post hysterectomy cases
 E + P
Cyclic sequential: E on day 1-25; P on day 14 –25 (for
climacteric patients with intact uterus )
Continuous sequential: E daily; P for 12 days at 16
days interval (for post menopausal patients with intact
uterus)
Continuous combined: E + P taken daily
 Progesterone alone: cyclic / continuous
 Estrogen + Progesterone + Androgen

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Vasomotor symptoms:
Hot flushes & night sweats resulting from hyperactivity of
mid brain-hypothalamic-pituitary axis & characteristic of
climacteric are relieved by HRT
Sleep disturbances:
Early morning awakening and inability to get back to
sleep is a frequent complaint in postmenopausal
women. Estrogen receptors are present in Reticular
Activation System, preoptic area, and hypothalamus.
Estrogen replacement improves sleep by acting at
these sites.
Benefits of HRT

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Mood & psychological changes:
Estrogen replacement appears to have a direct mental
tonic effect on the cognitive functions even in the
absence of vasomotor symptoms .It over comes anxiety,
over sensitivity, tearfulness, irritability, aggression.
However if progesterone is also given, it may reduce the
beneficial effects of estrogen on libido & mood.
Benefits of HRT

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Benefits of HRT
Atrophy of genital tract
leading to vaginal dryness & postmenopausal bleeding
from atrophic vaginitis / atrophic endometrium respond
to estrogen therapy.
Dyspareunea
due to vaginal dryness is not a problem in
menopause, but it is a problem during climacteric.
Loss of libido
also responds to estrogen replacement. Some also
get benefit from testosterone.

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Benefits of HRT
Urinary symptoms:
Incontinence –Urethral abnormality, Detrussor
instability, Overflow Incontinence
Frequency, Urgency, Dysuria
Difficulty in voiding
Estrogen may produce considerable improvement in
these symptoms by increasing
Epithelial thickness, vascularity, closing pressure of urethra
Adrenergic receptor in bladder urethral muscle
Collagen content of connective tissue

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Benefits of HRT
Bone & skeleton:
Post menopausal women, due to increased bone
resorption, exceeding the rate of new bone formation.
Loose 30% of their total bone mass. It leads to
osteoporosis, and fracture may occur with minimal /
trivial trauma.
Estrogens cause stimulation of C cells of thyroid
resulting in increased level of calcitonin, which causes
inhibition of osteoclastic bone resorption.
 Progesterone has synergistic action, as it binds
competitively with glucocorticoid receptors in bone, thus
inhibiting the resorbing effect of cortisone.

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Benefits of HRT
Cardiovascular system :
In menopause as there is increased level of plasma
total cholesterol & LDL and decreased level of HDL,
leading to atherosclerosis, there is increase in
cardiovascular diseases.
Estrogen causes decreases the incidence & mortality
of I.H.D., due to its beneficial effect on the lipid
metabolism.
Skin, hair, body fat :
In postmenopausal women there is decrease in
content of collagen in skin .So the skin becomes
wrinkled. Estrogen increases the collagen content .It
also prevents varicose ulceration.

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Benefits of HRT
Neuroprotection:
It reduces the risk of Alzheimer’s disease by reducing
b amyloid protein & cholinergic dysfunction in brain.
It enhances the proliferation of neuronal cell
population within the hippocampus.
It regulates the synaptic neurotransmission &
increases nerve growth factor. Thus it enhances
neuroplasticity, memory, and cognition.
It delays the onset of Parkinson’s disease by its
action on dopaminergic system in midbrain.

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Benefits of HRT
Other effects:
Estrogen prevents tooth loss & periodontal disease.
There is substantial decrease in the risk of fatal
colon cancer.
There is reduction in age related macular
degeneration,cataract and severe nuclear sclerosis.
In diabetic women there is improvement in glycemic
control.
Less risk of Osteoarthritis:.
Alleviates the worsening symptoms of multiple
sclerosis.

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Specific actions of TIBOLONE
Tibolone comes closest to being the ideal product
for long term HRT because of the specific actions.
Brain: - enhances mood, libido.
Heart: -beneficial effects on CVS.
Breast: -lower incidence of breast tenderness and no
effect on mammography.
Endometrium: -no proliferation.
Urogenital symptoms:- improved.
Bone: -prevents bone loss.
It induces amenorrhoea.
Thus it is a menstruation free HRT, which is most
welcome to most women, with an intact uterus.

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RISKS OF HRT
Continuous use of estrogen can cause
endometrial hyperplasia, leading to endometrial
carcinoma.
Addition of progesterone reduces this risk as it
inhibits DNA synthesis,
reduces the no. of estrogen receptors,
stimulates the enzyme 17alpha dehydrogenase, which
converts E2 to E1.
Tibolone does not stimulate the endometrium as
it exhibits progestogenic & androgenic activities
in endometrial tissue.
Endometrial risk:

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RISKS OF HRT
There is increased incidence of breast carcinoma
with long-term use of estrogen.
Progestogen has no protective effect .
So annual breast examination including
mammography is necessary.
Tibolone & its metabolites are very potent inhibitors
of stimulants of breast tumors.
Breast neoplasia:

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RISKS OF HRT
Unopposed estrogen therapy may cause
endometroid tumor. So patients need annual
pelvic examination.
Ovarian neoplasia
Venous thromboembolic disease
There is little risk of venous thromboembolism
with conventional HRT.

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Advantages.
Easy to take & cheap.
Good control due to short ½ life.
Disadvantages.
High dose required.
Wide variation in absorption & metabolism during its first pass
through intestine, liver.
High incidence of minor side effects.
 E2: E1 remains same.
Increase in free cholesterol pool in hepatic cells.
Increases serum triglycerides, worsens glucose tolerance & insulin
resistance
Advantages & Disadvantages of each preparation: -
ESTROGEN: ORAL -

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Advantages.
Stable compound due to ethinyl group,
Minimal dose required 10 –20 microgram.
Disadvantages.
Passes unchanged to liver, greater metabolic effects on
liver results in increased risk of venous & arterial
thrombosis,
Suppression of F.S.H. & Urinary calcium excretion.
Relatively increased incidence of breast carcinoma.
 Stimulates: hepatic production of renin substrate &
angiotensinogen with risk of hypertension,
vasoconstriction, platelet aggregation
Advantages & Disadvantages of each preparation: -
ESTROGEN: ORAL - ETHINYL ESTRADIOL

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Very potent, not subject to enzymatic metabolism,
low plasma clearance.
Stored in fat & released slowly. But in higher doses
(1.25 mg /day) this may cause increased plasma
level of renin substrate like EE.
Advantages & Disadvantages of each preparation: -
ESTROGEN: ORAL - CEE.

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Short acting as it has only short retention time in the
nuclei of endometrial cells .No endometrial
proliferation.
 Cyclic progesterone administration is not required.
Postmenopausal withdrawal bleeding do not occur.
Particularly effective in the treatment of urogenital
symptoms.
Advantages & Disadvantages of each preparation: -
ESTROGEN: ORAL - Estriol

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Low dose, pure estradiol.
Avoids intestine & liver metabolism.
Physiological E2: E1.
Reduces serum triglyceride & insulin resistance.
No adverse effect on biliary cholesterol saturation
index & biliary salt composition.
But more expensive, not well tolerated in warm
climates, skin reaction may occur.
Variable absorption.
Advantages & Disadvantages of each preparation: -
ESTROGEN: TRANSDERMAL

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Pure estradiol, 6 monthly insertion, high level of
estradiol in blood.
Avoids first pass effects, physiological E2: E1 ratio,
better response in severe osteoporosis.
But needs surgical procedure, unable to control
absorption, risk of supraphysiological blood levels,
difficult to remove pellet, prolonged release of
estradiol.
Advantages & Disadvantages of each preparation: -
ESTROGEN: IMPLANTS

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 Given with / without combination of systemic
therapy to the older women having urogenital
symptoms. Natural estrogen preparation avoids
significant systemic absorption.
Advantages & Disadvantages of each preparation: -
ESTROGEN: VAGINAL CREAM

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SPECIAL SITUATIONS
Hypertension:- non oral estrogens are of choice
Thromboembolism:- Transdermal route is
preferable
Gallbladder disease: - non-oral route
Side effects: change to non-oral
Poor response: may be due to inadequate
absorption from intestine / transdermally: - Implant
is beneficial
Lactose intolerance: - lactose present in oral
preparation, so non-oral route is of choice
Choice Of Preparation

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INDICATIONS FOR STARTING HRT
1)Women having climacteric symptoms
2)All asymptomatic high-risk women having
Premature menopause (surgical / spontaneous)
Established osteoporosis on x-ray /B.M.D.
Measurements
Family history of osteoporosis
Thin, small sedentary women
Poor diet, excess alcohol
Corticosteroid & other medications
High urinary calcium / creatinine
Low plasma estradiol
3)Asymptomatic women with / without risk factors
having no contraindications but who request
HRT

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Contraindications of conventional HRT
Known / suspected breast cancer
Estrogen dependent neoplasia
Undiagnosed abnormal genital bleeding
Active thrombophlebitis
Abnormal liver function tests
Malignant melanoma
Known / suspected pregnancy

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SPECIFIC INDICATIONS OF TIBOLONE
Breast cancer risk
Breast cancer treated
Family history
Low parity / nulliparity
Racial factor
Endometrial cancer risk
Past H/O endometriosis / fibroid
Patients with NIDDM
Patients with hypertriglyceridemia & H/O
thromboembolic phenomena

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Adverse effects of Progestins & their
management
Bleeding problems: heavy / prolonged bleeding on
sequential therapy – Select more androgenic type
progestogen (LNG & Norethisterone).
Physical side effects: edema, weight gain, bloating,
migraine - Spironolactone 25 mg O.D. In the last week.
Acne, greasy skin - progestogen having no androgenic
effect.
Head ache - adding a mild diuretic / androgen.
Psychological: fatigue, depression, irritability, anxiety, and
forgetfulness - switch from oral to non oral treatment.
Women having CVS disease / DM: natural progesterone /
less androgenic derivative of progesterone is ideal.