Menopause detailed PowerPoint presentation

Menopause and the drugs used to manage this condition

1. MenopauseMenopause
Dr Bellington VwalikaDr Bellington Vwalika

2. 22
DefinitionDefinition
The cessation of menstruation for at least The cessation of menstruation for at least
12 months12 months
The climacteric is that period of a woman’s The climacteric is that period of a woman’s
life encompassing the cessation of life encompassing the cessation of
reproduction and is characterized by reproduction and is characterized by
variable endocrine, somatic and variable endocrine, somatic and
psychological changes culminating in the psychological changes culminating in the
menopausemenopause

3. 33
MenopauseMenopause
The average age of menopause is stable The average age of menopause is stable
world wide at 51 years with a range of 43-world wide at 51 years with a range of 43-
59 years59 years
The anatomic and physiologic alterations The anatomic and physiologic alterations
in the ovary that eventually result in in the ovary that eventually result in
diminished oestrogen production begin diminished oestrogen production begin
several years before permanent cessation several years before permanent cessation
of menstruation. of menstruation.

4. 44
MenopauseMenopause
The number of follicle is steadily depleted The number of follicle is steadily depleted
as a woman ages. The human female has as a woman ages. The human female has
about 6-7 million oogonia during the 20th about 6-7 million oogonia during the 20th
week of fetal age. At birth, this number is week of fetal age. At birth, this number is
reduced to 100,000. After menarche, as reduced to 100,000. After menarche, as
the woman ages, the number of primary the woman ages, the number of primary
follicles in the ovary gradually decreases, follicles in the ovary gradually decreases,
with markedly reduced numbers after age with markedly reduced numbers after age
40 40

5. 55
MenopauseMenopause
After menopause there are usually no After menopause there are usually no
follicles present in the ovariesfollicles present in the ovaries

6. 66
MenopauseMenopause
About 6 months to 1 year before the About 6 months to 1 year before the
menopause, as the number of follicles is menopause, as the number of follicles is
further depleted, the elevated FSH levels further depleted, the elevated FSH levels
fail to stimulate sufficient estradiol fail to stimulate sufficient estradiol
secretion and estradiol levels steadily secretion and estradiol levels steadily
decline, eventually leading to failure of decline, eventually leading to failure of
endometrial development and absence of endometrial development and absence of
uterine bleeding,clinically observed as uterine bleeding,clinically observed as
menopause menopause

7. 77
Reduced number
of primordial
follicles respond
to FSH/LH
stimulation
Fall in
circulating
oestrogen level
Five-fold increase in
circulating FSH/LH levels
Increased secretion
of FSH/LH releasing
factor in the
hypothalamus
Reduced of number
Graafian follicles
show mature
changes

8. 88
MenopauseMenopause
The decline in circulating oestrogen The decline in circulating oestrogen
around the time of the menopause can around the time of the menopause can
induce symptoms that affect the well being induce symptoms that affect the well being
and health of women; hot flushes, and health of women; hot flushes,
insomnia, declining bone mass, night insomnia, declining bone mass, night
sweats, mood disturbances and urogenital sweats, mood disturbances and urogenital
atrophyatrophy

9. 99
Genito-urinary systemGenito-urinary system
The vaginal and transitional epithelium of The vaginal and transitional epithelium of
the lower urinary tract are oestrogen the lower urinary tract are oestrogen
sensitivesensitive
After menopause urinary frequency, dysuria, After menopause urinary frequency, dysuria,
nocturia, urgency and incontinence may nocturia, urgency and incontinence may
occuroccur
vaginal dryness (senile or atrophic atrophic vaginal dryness (senile or atrophic atrophic
vaginitis) and painful intercourse are also vaginitis) and painful intercourse are also
commoncommon

10. 1010
Skeletal systemSkeletal system
Before menopause, the rate of bone loss Before menopause, the rate of bone loss
in women is 3-5 % per decade; after the in women is 3-5 % per decade; after the
menopause it is approximately 2 % per menopause it is approximately 2 % per
annum.annum.
Hence the risk of osteoporotic fractures in Hence the risk of osteoporotic fractures in
older womenolder women

11. 1111
Cardiovascular systemCardiovascular system
Oestrogens lower total cholesterol and LDL Oestrogens lower total cholesterol and LDL
cholesterol and raises HDL cholesterolcholesterol and raises HDL cholesterol
After menopause, the hypo-oestrogenic After menopause, the hypo-oestrogenic
state abolishes this beneficial effect, and the state abolishes this beneficial effect, and the
risk of cardiovascular disease increases risk of cardiovascular disease increases
substantiallysubstantially
After the age of 50, the incidence of MI is After the age of 50, the incidence of MI is
greater in women than in men and the ratio greater in women than in men and the ratio
is 2:1 by 65 years and 1:1 by 80 yearsis 2:1 by 65 years and 1:1 by 80 years

12. 1212
PsychePsyche
Some women are troubled by somatic Some women are troubled by somatic
manifestations of the climacteric, namely; manifestations of the climacteric, namely;
hot flushes, night sweats, insomnia hot flushes, night sweats, insomnia
depression, lability of mooddepression, lability of mood
These symptoms usually resolve within 3-These symptoms usually resolve within 3-
5 years5 years

13. 1313
Skin Skin
Most of the subepithelial portion of the skin Most of the subepithelial portion of the skin
is composed of collagenis composed of collagen
With postmenopausal oestrogen With postmenopausal oestrogen
deficiency the amount of collagen in the deficiency the amount of collagen in the
dermis progressively diminishes, the skin dermis progressively diminishes, the skin
become s thin and wrinkling occursbecome s thin and wrinkling occurs

14. 1414
Role of Hormone Replacement Role of Hormone Replacement
TherapyTherapy
(HRT) (HRT)

15. 1515
Why Hormone Replacement Why Hormone Replacement
Therapy?Therapy?
With a marked increase in longevity, women now spend With a marked increase in longevity, women now spend
1/3 rd of their lives in the post-menopausal period. It is 1/3 rd of their lives in the post-menopausal period. It is
estimated that 1/3 rd of total female population are in estimated that 1/3 rd of total female population are in
menopause. Therefore they would have to cope with menopause. Therefore they would have to cope with
the post menopausal syndrome and face the the post menopausal syndrome and face the
consequences .HRT relieves the well known symptoms consequences .HRT relieves the well known symptoms
of post menopausal syndrome .Again women are now of post menopausal syndrome .Again women are now
asking for a quality life after menopause. So HRT is a asking for a quality life after menopause. So HRT is a
hot topic in this era as it is no more for symptomatic hot topic in this era as it is no more for symptomatic
management for PMS, but for the total management management for PMS, but for the total management
from prophylactic to curative .from prophylactic to curative .

16. 1616
Since estrogen deficiency is a Since estrogen deficiency is a
major cause of the long-term major cause of the long-term
complications of the menopause, complications of the menopause,
estrogen replacement is the rational estrogen replacement is the rational
treatment to address the cause of treatment to address the cause of
the problems after menopause .But the problems after menopause .But
as there are limitations of estrogen as there are limitations of estrogen
therapy as HRT, some other drugs therapy as HRT, some other drugs
are also used besides estrogen are also used besides estrogen
What is hormone replacement therapy?

17. 1717
Oral: -Oral: -
–Conjugated equine estrogen (CEE): 0.625 mg Conjugated equine estrogen (CEE): 0.625 mg
(Estrone Sulphate + equilin sulphate +17 d dihydro equilin)(Estrone Sulphate + equilin sulphate +17 d dihydro equilin)
–Estradiol valerate (1, 2, 4 mg).Estradiol valerate (1, 2, 4 mg).
–Estrial succinate (1, 2 mg).Estrial succinate (1, 2 mg).
Transdermal (estradiol): -Transdermal (estradiol): -
–Patches: 25 micro gm, 50 micro gm / 24 hour twice Patches: 25 micro gm, 50 micro gm / 24 hour twice
weekly.weekly.
–Gel : 75 micro gm / 24 hours daily.Gel : 75 micro gm / 24 hours daily.
Sub cutaneous implant (estradiol): -Sub cutaneous implant (estradiol): -
–25 / 50 / 100 mg. 6 monthly. 25 / 50 / 100 mg. 6 monthly.
Vaginal: cream.Vaginal: cream.
1)
Estrogens-
DRUGS USED IN HRTDRUGS USED IN HRT

18. 1818
DRUGS USED IN HRTDRUGS USED IN HRT
Oral route –.Oral route –.
–Norgestrol: 150 mg /day.Norgestrol: 150 mg /day.
–Micronised progesterone: 200 mg /day.Micronised progesterone: 200 mg /day.
–Dydrogesterone: 20 mg / day.Dydrogesterone: 20 mg / day.
–Medroxy progesterone acetate: 10mg/day.Medroxy progesterone acetate: 10mg/day.
–Norethisterone acetate : 0.7 – 2.5 mg/ day.Norethisterone acetate : 0.7 – 2.5 mg/ day.
Hormone releasing intra uterine system –.Hormone releasing intra uterine system –.
–Levonorgestrel: 20 mcg / day.Levonorgestrel: 20 mcg / day.
–Progestasert: 65mcg / day.Progestasert: 65mcg / day.
Vaginal - naturalVaginal - natural progesterone gel / pessary.progesterone gel / pessary.
Transdermal -Transdermal - sequential / continuous patch.sequential / continuous patch.
2) Progestins:

19. 1919
DRUGS USED IN HRTDRUGS USED IN HRT
Synthetic steroid, tissue specific HRT Synthetic steroid, tissue specific HRT
2 hydroxy metabolites are estrogenic2 hydroxy metabolites are estrogenic
D 4 isomer binds to progesterone & androgen D 4 isomer binds to progesterone & androgen
receptorsreceptors
Addition of progesterone not requiredAddition of progesterone not required
3) Tibolone-

20. 2020
DRUGS USED IN HRTDRUGS USED IN HRT
Regimens
Estrogen alone: in post hysterectomy casesEstrogen alone: in post hysterectomy cases
E + PE + P
–Cyclic sequential: E on day 1-25; P on day 14 –25 (for Cyclic sequential: E on day 1-25; P on day 14 –25 (for
climacteric patients with intact uterus )climacteric patients with intact uterus )
–Continuous sequential: E daily; P for 12 days at 16 Continuous sequential: E daily; P for 12 days at 16
days interval (for post menopausal patients with intact days interval (for post menopausal patients with intact
uterus)uterus)
–Continuous combined: E + P taken daily Continuous combined: E + P taken daily
Estrogen + Progesterone + AndrogenEstrogen + Progesterone + Androgen

21. 2121
Vasomotor symptoms:Vasomotor symptoms:
–Hot flushes & night sweats resulting from Hot flushes & night sweats resulting from
hyperactivity of mid brain-hypothalamic-pituitary axis hyperactivity of mid brain-hypothalamic-pituitary axis
& characteristic of climacteric are relieved by HRT& characteristic of climacteric are relieved by HRT
Sleep disturbances:Sleep disturbances:
–Early morning awakening and inability to get back to Early morning awakening and inability to get back to
sleep is a frequent complaint in postmenopausal sleep is a frequent complaint in postmenopausal
women. Estrogen receptors are present in Reticular women. Estrogen receptors are present in Reticular
Activation System, preoptic area, and hypothalamus. Activation System, preoptic area, and hypothalamus.
Estrogen replacement improves sleep by acting at Estrogen replacement improves sleep by acting at
these sites.these sites.
Benefits of HRTBenefits of HRT

22. 2222
Mood & psychological changes:Mood & psychological changes:
–Estrogen replacement appears to have a direct Estrogen replacement appears to have a direct
mental tonic effect on the cognitive functions mental tonic effect on the cognitive functions
even in the absence of vasomotor symptoms .It even in the absence of vasomotor symptoms .It
over comes anxiety, over sensitivity, tearfulness, over comes anxiety, over sensitivity, tearfulness,
irritability, aggression. However if progesterone irritability, aggression. However if progesterone
is also given, it may reduce the beneficial effects is also given, it may reduce the beneficial effects
of estrogen on libido & mood.of estrogen on libido & mood.
Benefits of HRTBenefits of HRT

23. 2323
Benefits of HRTBenefits of HRT
Atrophy of genital tractAtrophy of genital tract
–leading to vaginal dryness & postmenopausal leading to vaginal dryness & postmenopausal
bleeding from atrophic vaginitis / atrophic bleeding from atrophic vaginitis / atrophic
endometrium respond to estrogen therapy. endometrium respond to estrogen therapy.
DyspareuneaDyspareunea
–due to vaginal dryness is not a problem in due to vaginal dryness is not a problem in
menopause, but it is a problem during menopause, but it is a problem during
climacteric. climacteric.
Loss of libidoLoss of libido
–also responds to estrogen replacement. Some also responds to estrogen replacement. Some
also get benefit from testosterone.also get benefit from testosterone.

24. 2424
Benefits of HRTBenefits of HRT
Urinary symptoms:Urinary symptoms:
–Incontinence –Urethral abnormality, Detrussor Incontinence –Urethral abnormality, Detrussor
instability, Overflow Incontinenceinstability, Overflow Incontinence
–Frequency, Urgency, DysuriaFrequency, Urgency, Dysuria
–Difficulty in voidingDifficulty in voiding
–Estrogen may produce considerable Estrogen may produce considerable
improvement in these symptoms by increasingimprovement in these symptoms by increasing
Epithelial thickness, vascularity, closing pressure of Epithelial thickness, vascularity, closing pressure of
urethra urethra
Adrenergic receptor in bladder urethral muscleAdrenergic receptor in bladder urethral muscle
Collagen content of connective tissueCollagen content of connective tissue

25. 2525
Benefits of HRTBenefits of HRT
Bone & skeleton: Bone & skeleton:
–Post menopausal women, due to increased bone Post menopausal women, due to increased bone
resorption, exceeding the rate of new bone resorption, exceeding the rate of new bone
formation. Loose 30% of their total bone mass. It formation. Loose 30% of their total bone mass. It
leads to osteoporosis, and fracture may occur with leads to osteoporosis, and fracture may occur with
minimal / trivial trauma. minimal / trivial trauma.
–Estrogens cause stimulation of C cells of thyroid Estrogens cause stimulation of C cells of thyroid
resulting in increased level of calcitonin, which resulting in increased level of calcitonin, which
causes inhibition of osteoclastic bone resorption.causes inhibition of osteoclastic bone resorption.
– Progesterone has synergistic action, as it binds Progesterone has synergistic action, as it binds
competitively with glucocorticoid receptors in bone, competitively with glucocorticoid receptors in bone,
thus inhibiting the resorbing effect of cortisone.thus inhibiting the resorbing effect of cortisone.

26. 2626
Benefits of HRTBenefits of HRT
Neuroprotection: Neuroprotection:
–It reduces the risk of Alzheimer’s disease by It reduces the risk of Alzheimer’s disease by
reducing reducing  amyloid protein & cholinergic amyloid protein & cholinergic
dysfunction in brain.dysfunction in brain.
–It enhances the proliferation of neuronal cell It enhances the proliferation of neuronal cell
population within the hippocampus.population within the hippocampus.
–It regulates the synaptic neurotransmission & It regulates the synaptic neurotransmission &
increases nerve growth factor. Thus it enhances increases nerve growth factor. Thus it enhances
neuroplasticity, memory, and cognition.neuroplasticity, memory, and cognition.
–It delays the onset of Parkinson’s disease by its It delays the onset of Parkinson’s disease by its
action on dopaminergic system in midbrain.action on dopaminergic system in midbrain.

27. 2727
Benefits of HRTBenefits of HRT
Other effects:Other effects:
–Estrogen prevents tooth loss & periodontal disease.Estrogen prevents tooth loss & periodontal disease.
–There is substantial decrease in the risk of fatal There is substantial decrease in the risk of fatal
colon cancer.colon cancer.
–There is reduction in age related macular There is reduction in age related macular
degeneration,cataract and severe nuclear sclerosis.degeneration,cataract and severe nuclear sclerosis.
–In diabetic women there is improvement in glycemic In diabetic women there is improvement in glycemic
control.control.
–Less risk of Osteoarthritis:.Less risk of Osteoarthritis:.
–Alleviates the worsening symptoms of multiple Alleviates the worsening symptoms of multiple
sclerosis.sclerosis.

28. 2828
Specific actions of TIBOLONESpecific actions of TIBOLONE
TiboloneTibolone comes closest to being the ideal product comes closest to being the ideal product
for long term HRT because of the specific actions.for long term HRT because of the specific actions.
–Brain: - enhances mood, libido.Brain: - enhances mood, libido.
–Heart: -beneficial effects on CVS.Heart: -beneficial effects on CVS.
–Breast: -lower incidence of breast tenderness and no Breast: -lower incidence of breast tenderness and no
effect on mammography.effect on mammography.
–Endometrium: -no proliferation.Endometrium: -no proliferation.
–Urogenital symptoms:- improved.Urogenital symptoms:- improved.
–Bone: -prevents bone loss.Bone: -prevents bone loss.
–It induces amenorrhoea.It induces amenorrhoea.

29. 2929
Thus it is a menstrual free HRT which is Thus it is a menstrual free HRT which is
welcome by most women with an intact welcome by most women with an intact
uterusuterus

30. 3030
Adverse effects of Progestins & Adverse effects of Progestins &
their managementtheir management
Bleeding problems: heavy / prolonged bleeding on Bleeding problems: heavy / prolonged bleeding on
sequential therapy – Select more androgenic type sequential therapy – Select more androgenic type
progestogen (LNG & Norethisterone).progestogen (LNG & Norethisterone).
Physical side effects: edema, weight gain, bloating, Physical side effects: edema, weight gain, bloating,
migraine - Spironolactone 25 mg O.D. In the last week.migraine - Spironolactone 25 mg O.D. In the last week.
Acne, greasy skin - progestogen having no androgenic Acne, greasy skin - progestogen having no androgenic
effect.effect.
Head ache - adding a mild diuretic / androgen.Head ache - adding a mild diuretic / androgen.
Psychological: fatigue, depression, irritability, anxiety, and Psychological: fatigue, depression, irritability, anxiety, and
forgetfulness - switch from oral to non oral treatment.forgetfulness - switch from oral to non oral treatment.
Women having CVS disease / DM: natural progesterone / Women having CVS disease / DM: natural progesterone /
less androgenic derivative of progesterone is ideal.less androgenic derivative of progesterone is ideal.

31. 3131
RISKS OF HRT RISKS OF HRT
Continuous use of estrogen can cause Continuous use of estrogen can cause
endometrial hyperplasia, leading to endometrial endometrial hyperplasia, leading to endometrial
carcinoma. carcinoma.
–Addition of progesterone reduces this risk as it Addition of progesterone reduces this risk as it
inhibits DNA synthesis, inhibits DNA synthesis,
reduces the no. of estrogen receptors, reduces the no. of estrogen receptors,
stimulates the enzyme 17alpha dehydrogenase, stimulates the enzyme 17alpha dehydrogenase,
which converts E2 to E1.which converts E2 to E1.
Tibolone does not stimulate the endometrium Tibolone does not stimulate the endometrium
as it exhibits progestogenic & androgenic as it exhibits progestogenic & androgenic
activities in endometrial tissue.activities in endometrial tissue.
Endometrial risk:

32. 3232
RISKS OF HRT RISKS OF HRT
There is increased incidence of breast There is increased incidence of breast
carcinoma with long-term use of estrogen. carcinoma with long-term use of estrogen.
–Progestogen has no protective effect .Progestogen has no protective effect .
–So annual breast examination including So annual breast examination including
mammography is necessary. mammography is necessary.
Tibolone & its metabolites are very potent Tibolone & its metabolites are very potent
inhibitors of stimulants of breast tumors.inhibitors of stimulants of breast tumors.
Breast neoplasia:

33. 3333
RISKS OF HRT RISKS OF HRT
Unopposed estrogen therapy may cause Unopposed estrogen therapy may cause
endometroid tumor. So patients need endometroid tumor. So patients need
annual pelvic examination.annual pelvic examination.
Ovarian neoplasia
Venous thromboembolic disease
There is little risk of venous thromboembolism
with conventional HRT.

34. 3434
Advantages.Advantages.
–Easy to take & cheap.Easy to take & cheap.
–Good control due to short ½ life.Good control due to short ½ life.
Disadvantages.Disadvantages.
–High dose required.High dose required.
–Wide variation in absorption & metabolism during its first pass Wide variation in absorption & metabolism during its first pass
through intestine, liver.through intestine, liver.
–High incidence of minor side effects.High incidence of minor side effects.
– E2: E1 remains same.E2: E1 remains same.
–Increase in free cholesterol pool in hepatic cells.Increase in free cholesterol pool in hepatic cells.
–Increases serum triglycerides, worsens glucose tolerance & Increases serum triglycerides, worsens glucose tolerance &
insulin resistanceinsulin resistance
Advantages & Disadvantages of each preparation: -
ESTROGEN: ORAL -

35. 3535
Advantages.Advantages.
–Stable compound due to ethinyl group,Stable compound due to ethinyl group,
–Minimal dose required 10 –20 microgram.Minimal dose required 10 –20 microgram.
Disadvantages.Disadvantages.
–Passes unchanged to liver, greater metabolic effects on Passes unchanged to liver, greater metabolic effects on
liver results in increased risk of venous & arterial liver results in increased risk of venous & arterial
thrombosis,thrombosis,
–Suppression of F.S.H. & Urinary calcium excretion.Suppression of F.S.H. & Urinary calcium excretion.
–Relatively increased incidence of breast carcinoma.Relatively increased incidence of breast carcinoma.
– Stimulates: hepatic production of renin substrate & Stimulates: hepatic production of renin substrate &
angiotensinogen with risk of hypertension, angiotensinogen with risk of hypertension,
vasoconstriction, platelet aggregationvasoconstriction, platelet aggregation
Advantages & Disadvantages of each preparation: -
ESTROGEN: ORAL - ETHINYL ESTRADIOL

36. 3636
Very potent, not subject to enzymatic Very potent, not subject to enzymatic
metabolism, low plasma clearance.metabolism, low plasma clearance.
Stored in fat & released slowly. But in higher Stored in fat & released slowly. But in higher
doses (1.25 mg /day) this may cause doses (1.25 mg /day) this may cause
increased plasma level of renin substrate increased plasma level of renin substrate
like EE.like EE.
Advantages & Disadvantages of each preparation: -
ESTROGEN: ORAL - CEE.

37. 3737
Short acting as it has only short retention time in the Short acting as it has only short retention time in the
nuclei of endometrial cells .No endometrial nuclei of endometrial cells .No endometrial
proliferation.proliferation.
Cyclic progesterone administration is not required.Cyclic progesterone administration is not required.
Postmenopausal withdrawal bleeding do not occur.Postmenopausal withdrawal bleeding do not occur.
Particularly effective in the treatment of urogenital Particularly effective in the treatment of urogenital
symptoms.symptoms.
Advantages & Disadvantages of each preparation: -
ESTROGEN: ORAL - Estriol

38. 3838
Low dose, pure estradiol.Low dose, pure estradiol.
Avoids intestine & liver metabolism.Avoids intestine & liver metabolism.
Physiological E2: E1.Physiological E2: E1.
Reduces serum triglyceride & insulin resistance.Reduces serum triglyceride & insulin resistance.
No adverse effect on biliary cholesterol saturation No adverse effect on biliary cholesterol saturation
index & biliary salt composition.index & biliary salt composition.
But more expensive, not well tolerated in warm But more expensive, not well tolerated in warm
climates, skin reaction may occur.climates, skin reaction may occur.
Variable absorption.Variable absorption.
Advantages & Disadvantages of each preparation: -
ESTROGEN: TRANSDERMAL

39. 3939
Pure estradiol, 6 monthly insertion, high level Pure estradiol, 6 monthly insertion, high level
of estradiol in blood.of estradiol in blood.
Avoids first pass effects, physiological E2: E1 Avoids first pass effects, physiological E2: E1
ratio, better response in severe osteoporosis.ratio, better response in severe osteoporosis.
But needs surgical procedure, unable to But needs surgical procedure, unable to
control absorption, risk of supraphysiological control absorption, risk of supraphysiological
blood levels, difficult to remove pellet, blood levels, difficult to remove pellet,
prolonged release of estradiol.prolonged release of estradiol.
Advantages & Disadvantages of each preparation: -
ESTROGEN: IMPLANTS

40. 4040
Given with / without combination of Given with / without combination of
systemic therapy to the older women having systemic therapy to the older women having
urogenital symptoms. Natural estrogen urogenital symptoms. Natural estrogen
preparation avoids significant systemic preparation avoids significant systemic
absorption.absorption.
Advantages & Disadvantages of each preparation: -
ESTROGEN: VAGINAL CREAM

41. 4141
SPECIAL SITUATIONSSPECIAL SITUATIONS
Hypertension:- non oral estrogens are of choice Hypertension:- non oral estrogens are of choice
Thromboembolism:- Transdermal route is Thromboembolism:- Transdermal route is
preferablepreferable
Gallbladder disease: - non-oral route Gallbladder disease: - non-oral route
Side effects: change to non-oral Side effects: change to non-oral
Poor response: may be due to inadequate Poor response: may be due to inadequate
absorption from intestine / transdermally: - Implant absorption from intestine / transdermally: - Implant
is beneficial is beneficial
Lactose intolerance: - lactose present in oral Lactose intolerance: - lactose present in oral
preparation, so non-oral route is of choicepreparation, so non-oral route is of choice
Choice Of Preparation

42. 4242
INDICATIONS FOR STARTING INDICATIONS FOR STARTING
HRTHRT
1)1)Women having climacteric symptomsWomen having climacteric symptoms
2)2)All asymptomatic high-risk women havingAll asymptomatic high-risk women having
–Premature menopause (surgical / spontaneous)Premature menopause (surgical / spontaneous)
–Established osteoporosis on x-ray /B.M.D. Established osteoporosis on x-ray /B.M.D.
MeasurementsMeasurements
–Family history of osteoporosisFamily history of osteoporosis
–Thin, small sedentary womenThin, small sedentary women
–Poor diet, excess alcoholPoor diet, excess alcohol
–Corticosteroid & other medicationsCorticosteroid & other medications
–High urinary calcium / creatinineHigh urinary calcium / creatinine
–Low plasma estradiolLow plasma estradiol
3)3)Asymptomatic women with / without risk factors Asymptomatic women with / without risk factors
having no contraindications but who request HRThaving no contraindications but who request HRT

43. 4343
Contraindications of Contraindications of
conventional HRTconventional HRT
Known / suspected breast cancerKnown / suspected breast cancer
Estrogen dependent neoplasiaEstrogen dependent neoplasia
Undiagnosed abnormal genital bleedingUndiagnosed abnormal genital bleeding
Active thrombophlebitisActive thrombophlebitis
Abnormal liver function testsAbnormal liver function tests
Malignant melanomaMalignant melanoma
Known / suspected pregnancyKnown / suspected pregnancy

44. 4444
SPECIFIC INDICATIONS OF SPECIFIC INDICATIONS OF
TIBOLONETIBOLONE
Breast cancer risk Breast cancer risk
–Breast cancer treated Breast cancer treated
–Family historyFamily history
–Low parity / nulliparityLow parity / nulliparity
–Racial factorRacial factor
Endometrial cancer risk Endometrial cancer risk
Past H/O endometriosis / fibroidPast H/O endometriosis / fibroid
Patients with NIDDMPatients with NIDDM
Patients with hypertriglyceridemia & H/O Patients with hypertriglyceridemia & H/O
thromboembolic phenomenathromboembolic phenomena