Hormonal Replacement Therapy

Complete guidance on Hormonal replacement therapy for post menopause symptoms and oncologic hormonal therapy

1. HRT (Hormonal Replacement Therapy) KRVS Chaitanya

2. Introduction Hormone therapy  or  hormonal therapy  is the use of hormones in medical treatment. Treatment with  hormone antagonists  may also be referred to as  hormonal therapy  or  antihormone therapy . The most general classes of hormone therapy are  oncologic hormone therapy ,  hormone replacement therapy  (for menopause),  androgen replacement therapy  (ART),  oral contraceptive pills  and  transgender hormone therapy

3. Types: Hormone replacement therapy  (HRT), also known as menopausal hormone therapy (MHT), is for women suffering from  menopausal   symptoms . It is based on the idea that the treatment may prevent discomfort caused by diminished circulating oestrogen and progesterone hormones  It involves the use of one or more of a group of medications designed to artificially boost hormone levels. The main types of hormones involved are  estrogen ,  progesterone , or  progestins , and sometimes,  testosterone . It is often referred to as "treatment" rather than therapy.

4. Hormone replacement therapy for people with hypogonadism and intersex conditions  (e.g., Klinefelter syndrome, Turner syndrome)

5. Androgen replacement therapy  (ART) in males with low levels of testosterone due to disease or aging. It is a hormone treatment often prescribed to counter the effects of male hypogonadism or who for men who have lost their testicular function to disease, cancer, or other causes. [3]   It is sometimes used for late-onset hypogonadism (so-called " andropause ” The Food and Drug Administration (FDA) stated in 2015 that neither the benefits nor the safety of testosterone have been established in older men with low testosterone levels.

6. Transgender hormone therapy  for transgender people introduces sex steroids associated with the gender that the patient identifies with (notably testosterone for transgender men and estrogen for transgender women). types:  feminizing hormone therapy  and  masculinizing hormone therapy . Feminizing hormone therapy in sex reassignment therapy for transgender women Masculinizing hormone therapy in sex reassignment therapy for transgender men

7. Hormonal therapy for cancer Androgen deprivation therapy for men with  prostate cancer Estrogen deprivation therapy for women with  estrogen receptor -positive  breast cancer High-dose estrogen therapy for women with estrogen receptor-positive breast cancer

8. Chemical castration of men or sex offenders with paraphilias or hyper sexuality Growth hormone therapy for growth hormone deficiency Thyroid hormone replacement in hypothyroidism Antithyroid therapy in hyperthyroidism

9. Glucocorticoid  and/or  mineralocorticoid  replacement in conditions such as  Addison's disease Antiglucocorticoid  therapy in  Cushing's syndrome Insulin  therapy in Type 1 Diabetes Oral contraceptive pills  for various purposes including birth control

10. Side effects Common : Headache Upset stomach ,  stomach cramps  or  bloating Diarrhea Appetite  and weight changes Changes in  sex drive  or performance Nervousness Brown or black patches on the skin Acne Swelling of hands, feet, or lower legs due to  fluid retention Changes in  menstrual flow Breast tenderness, enlargement, or discharge Sudden difficulty wearing  contact lenses

11. Uncommon Double vision Severe  abdominal pain Yellowing of skin or eyes Severe depression Unusual bleeding Loss of appetite Skin rash Lassitude Fever Dark- colored urine Light colored stool Chorea

12. Absolute contraindications Undiagnosed vaginal bleeding Severe  liver disease Pregnancy Severe  coronary artery disease Aggressive  breast ,  uterine  or  ovarian cancer

13. Relative contraindications Migraine  headaches History of breast cancer History of ovarian cancer Venous thrombosis History of  uterine fibroids Atypical ductal  hyperplasia  of the  breast Active  gallbladder  disease ( cholangitis ,  cholecystitis ) Well-differentiated and early  endometrial cancer  - once treatment for the malignancy is complete, is no longer an absolute contraindication

14. Hormone replacement therapy (HRT ), also known as  menopausal hormone therapy  or  postmenopausal hormone therapy , is a form of  hormone therapy  used to treat  symptoms  associated with female  menopause . T hese symptoms can include  hot flashes ,  vaginal atrophy , accelerated  skin  aging,  vaginal dryness , decreased  muscle mass ,  sexual dysfunction , and  bone loss . They are in large part related to the diminished levels of  sex hormones  that occur during menopause

15. The main  hormonal medications  used in HRT for menopausal symptomsare  estrogens   and  progestogens and manufactured medication   used in menopausal hormone therapy.  Though both can have symptomatic benefits, progestogen is specifically added to estrogen regimens when the  uterus is still present . Unopposed estrogen therapy promotes  endometrial thickening  and can increase the risk of  cancer , while progestogen reduces this risk.

16. The long-term effects of HRT on most organ systems vary by age and time since the last  physiological   exposure to hormones, and there can be large differences in individual regimens, factors which have made analyzing effects difficult. HRT reduces all-cause mortality and risks of coronary disease, osteoporosis, and dementia . D ecreased risks of hip and vertebral fractures and an increased risk of venous thromboembolism when taken orally.

17. The current indications for use from the  United States Food and Drug Administration  (FDA) include short-term treatment of  menopausal symptoms , such as  vasomotor   hot flashes  or  vaginal atrophy , and prevention of  osteoporosis

18. Medical uses Approved uses of HRT in the United States include short-term treatment of menopausal symptoms such as hot flashes and vaginal atrophy, and prevention of osteoporosis . The  American College of Obstetrics and Gynecology  (ACOG) approves of HRT for symptomatic relief of menopausal symptoms,   and advocates its use beyond the age of 65 in appropriate scenarios.

19. Women receiving this treatment are usually  post- ,  peri- or  surgically menopausal . Menopause is the permanent cessation of  menstruation  resulting from loss of ovarian follicular activity . Menopause into early and late transition periods known as ' perimenopause ' and ' postmenopause '. Premature menopause can occur if the ovaries are  surgically removed , as can be done to treat  ovarian  or  uterine cancer .

20. Menopausal symptoms Hot flashes  - vasomotor symptoms Vulvovaginal atrophy  - atrophic vaginitis and  dryness Dyspareunia  - painful sexual intercourse due to vaginal atrophy and lack of  lubrication Bone loss  - decreased  bone mineral density Decreased sexual desire Defeminization  - diminished  feminine fat distribution  and accelerated  skin aging Sleep disturbances  and  joint pain The most common of these are  loss of sexual drive  and  vaginal dryness

21. Heart disease The risks of  coronary heart disease  with HRT vary depending on age and time since menopause. HRT with estrogen and progesterone also improves  cholesterol levels . With menopause,  HDL  decreases, while  LDL ,  triglycerides  and  lipoprotein a  increase, patterns that reverse with estrogen. Beyond this, HRT improves  heart contraction ,  coronary  blood flow,  sugar   metabolism , and decreases  platelet  aggregation and  plaque formation .

22. Blood clot s Effects of hormone replacement therapy on  venous blood clot  formation and potential for  pulmonary embolism  may vary with different estrogen and progestogen therapies, and with different doses or method of use. Comparisons between routes of administration suggest that when estrogens are applied to the skin or vagina, there is a lower risk of blood clots whereas when used orally, the risk of blood clots and pulmonary embolism is increased .

23. Stroke Multiple studies suggest that the possibility of HRT related stroke is absent if therapy is started within five years of menopause,  and that the association is absent or even preventive when given by non-oral routes. When oral synthetic estrogen or combined estrogen-progestogen treatment is delayed until 5 years from menopause have suggested an association with  hemorrhagic  and  ischemic stroke .

24. Endometrial cancer In postmenopausal women, continuous combined estrogen plus progestin decreases endometrial cancer incidence. The duration of progestogen therapy should be at least 14 days per cycle to prevent endometrial disease. Endometrial cancer has been grouped into two forms in the context of hormone replacement. Type 1 is the most common, can be associated with estrogen therapy, and is usually low grade. Type 2 is not related to estrogen stimulation and usually higher grade and poorer in prognosis. [39 ]   The  endometrial hyperplasia  that leads to  endometrial cancer  with estrogen therapy can be prevented by concomitant administration of  progestogen . Paradoxically, progestogens do promote the growth of  uterine fibroids .

25. Breast cancer HRT has been more strongly associated with risk of breast cancer in women with lower  body mass indices  (BMIs ). No breast cancer association has been found with BMIs of over 25.  Evaluating the response of breast tissue density to HRT using mammography appears to help assessing the degree of breast cancer risk associated with therap y. women with dense or mixed-dense breast tissue have a higher risk of developing breast cancer than those with low density tissue

26. Ovarian cancer HRT is associated with an increased risk of  ovarian cancer , with women using HRT .   This risk is decreased when progestogen therapy is given concomitantly, as opposed to estrogen alone . Regarding the specific  subtype , there may be a higher risk of  serous cancer , but no association with  clear cell ,  endometrioid , or  mucinous ovarian cancer . Hormonal therapy in ovarian cancer survivors after surgical removal of the ovaries is generally thought to improval survival rates

27. Sexual function HRT can help with the lack of sexual desire and sexual dysfunction that can occur with menopause . Several hormonal changes take place during this period, including a decrease in estrogen and an increase in  follicle-stimulating hormone . Decreases in  sex hormone-binding globulin  (SHBG) and  inhibin  (A and B) also occur . Testosterone is present declining gradually with age ; is less variation during the menopausal transition relative .

28. Muscle and bone There is a large decrease in  hip fracture  risk during treatment .   It also helps  collagen  formation, which in turn improves  intervertebral disc  and bone strength. Lower testosterone is associated with lower bone density and higher free testosterone is associated with lower hip fracture rates in older women. Testosterone therapy, which can be used for decreased sexual function, can also increase bone mineral density and muscle mass.

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