Hormone replacement therapy in Post menopausal women

HRT-what you need to know! why opt for it? who should take it? contraindications. estrogen therapy, progestins, tibolone.
*Associations with osteoporosis, breast cancer, endometrial cancer

1. HORMONE REPLACEMENT THERAPY

2. Initially, Every menopausal woman was advised to go on HRT as soon as menopause sets in. Now, 70-80% of women remain healthy & need only good nutrition & healthy lifestyle. Few women need prophylactic & therapeutic HRT.

3. Who needs HRT? THERAPEUTIC Symptomatic women who suffer from estrogen deficiency. Gonadal dysgenesis in adolescents. PROPHYLATIC High risk cases of menopausal complications like cardiovascular disease, osteoporosis, stroke, Alzheimer's disease & colonic cancer. Premature menopause or following surgery, chemotherapy or radiotherapy.

4. Symptomatic women (vasomotor symptoms, urinary symptoms, sexual disharmony with dyspareunia): HRT for 3-6 months. After 6 months, woman gets adjusted and settles down with menopausal phase of life.

5. INDICATIONS Short term- Hot flushes, vasomotor symptoms Dyspareunia, libido Urethral symptoms Long term- osteoporosis Cardiovascular Alzheimer’s disease

6. CONTRAINDICATIONS Breast cancer, uterine cancer or family history of cancer Previous history of thromboembolic disorder. Liver & gall bladder disease. Lipid profile dysfunction. Uterine fibroids

7. OSTEOPOROSIS & HRT Prevents bone loss  reduces risk of fractures to 25-50% Prescribed when osteopenia is observed while study of bone density mass. For osteoporosis early in menopause: natural oestrogen, progestogen, tibolone & raloxifene. For osteoporosis late in menopause: bisphosphonates . Oe strogen protects against osteoporosis by 50% in all skeletal bones.

8. PROPHYLAXIS OF OSTEOPOROSIS Oestrogen hormone therapy ERT (hysterectomised) HRT Tibolene Raloxifene Soya Bisphosphonates Calcitonin Diet

9. CARDIO-PROTECTIVE EFFECT OF HRT Oestrogen deficiency: ↑ risk of atherosclerosis, ischemic heart diseases & angina. HRT: ↑ HDL, ↓LDL, cholesterol & TG.

10. ESTROGEN THERAPY Oral Transdermal Vaginal cream Vaginal ring Implants

11. ORAL THERAPY Short term therapy (lowest dose) for hot flushes, night sweats, palpitations & disturbed sleep. Preparations of oestrogen: Oral Premarin(E1 natural equine-conjugated oestrogen) 0.625mg OD upto 1.25mg Ethinyl oestradiol 0.01mg Micronized oestrogen 1-2mg Evalon 1-2mg

12. ORAL THERAPY Long term therapy: In delaying osteoporosis & reducing cardiovascular diseases. Beyond 8-10 years is not beneficial. ADVANTAGES DISADVANTAGES Cheap & easy to take High doses are required( oestrone in intestine & liver  10% reaches systemic circulation ) Good for lipid profile & cardiovascular protection Daily intake High incidence of side effects. Increase chances of HTN, thromboembolism

13. TRANSDERMAL PATCH Estraderm patch: 3-4 mg oestradiol & releases 50 mcg each day. Applied away from breasts on arms, legs & thighs. Patch needs to be changed twice.

14. TRANSDERMAL ESTROGEN Advantages Low-dose estradiols Avoids first pass effect & liver metabolism Reduces TG No thromboembolic or hypertension risk Disadvantages Costly Not tolerated in warm climates Variable absorption Skin reaction with alcohol based patches

15. VAGINAL CREAM: Dyspareunia, urethral syndrome & senile vaginitis. Oestriol base cream ½ g is applied everyday -10-12 days for 3-6 months. VAGINAL RING: Estring releases 5-10mcg oestrogen for 90 days. IMPLANT: Containing 25-50mg oestradiol is effective for 6 months each. Maintains E2 level at 50-60pg/ml. Suitable in hysterectomised patients.

16. PROGESTINS Used to avoid the risk of endometrial hyperplasia & cancer of non- hystrectomised patients. Given 12 days in each cycle reduces risk to less than 2%. Enzyme: 17 β - hydroxydehydrogenase  inactivates E2 controls mitotic activity in endometrial cells. Drugs : Duphaston /medroxyprogesterone 10mg Primolut -N 2.5mg OD for 10-12 days each month (prevent endometrial hyperplasia)

17. PROGESTINS Side effects: Bloated feel wt. gain Depression Adversely alter lipid profile poor compliance Mirena IUCD (levonorgestrel) for 5 years. Drospirenone: no androgenic & adverse lipid effect. 3mg combined 30mcg estradiol is been tried. Testosterone implant & combined tablet with oestrogen- to improve libido

18. OTHER DRUG Tibolone: synthetic derivative of 19-nortestoterone Weak oestrogenic, progestrogenic & androgenic action. Elevates mood, relieves vasomotor symptoms, improves sex drive & reduces bone resorption Cardioprotective  decreases TG S/E: wt. gain, edema , tenderness in breast, vaginal bleed, greasy skin.

19. HRT & BREAST CANCER Risk does not increase upto 3yrs of HRT & 5yrs of oestrogen alone replacement therapy. Can cause recurrence of breast cancer. Increases density of breast tissue & impede screening programme of mammogram subsequently. Breast cancer following HRT – low grade with good prognosis

20. HRT & ENDOMETRIAL CARCINOMA ERT can cause well differentiated carcinoma. Minimum of 12 days of progesterone added to ERT reduces risk to 2% Combined HRT – better protection Tibolene – safe drug which does not cause endometerial hyperplasia.

21. MONITORING BEFORE & DURING HRT Baseline parameters and their subsequent check-ups necessary: Physical examination including pelvic examination Blood pressure recording Breast examination & mammography Cervical cytology Pelvic ultrasonography: to measure endometrial thickness Endometrial biopsy, hysteroscopy- any irregular bleeding Serum estradiol levels (100pg/ml)

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