HORMONE REPLACEMENT

:THERAPY (HRT)
DR.FATIN
 HRT should be offered when the presence of symptoms
or effects of oestrogen deficiency interfere with the life,
maritual or occupational welfare.
 The woman herself has the final say in whether or not she
will initiate and continue with such therapy.
:Before initiating HRT the followings should be done
HISTORY AND CONSULTATION:
1-A full history with concentration on oestrogen deficiency symptoms and
their impact on the personal ,domestic and occupational efficiency of
woman's life.
: A family history of-2
Cardiovascular disease particularly angina pectoris,-
.myocardial infarction and stroke
Skeletal disease particularly osteoporosis manifested in-
relatives through height loss and low-trauma fracture to
.wrist, hip and other sites
Presence of Alzheimer's disease or other neurodegenerative-
.disease in the family
History of any gastrointestinal or liver disease that might-3
interfere with the normal pharmacodynamics of oestrogen
.therapy
4-Gynaecological history:
Previous medical and surgical interventions particularly the presence of
conditions affected by plasma oestrogen as endometriosis or leiomyomata.

A history of benign or malignant breast disease should be sought and a

review of histological report on any breast biopsy material to see whether or
not cellular atypia was present as this may affect future management.
The patient's mammographic record should be ascertained and she should
be encouraged to participate in breast screening programs from age 50 to
64.
Any heavy or persistently irregular bleeding should be further investigated
by pelvic ultrasound, proceeding if required to hysteroscopy and
endometrial biopsy.
EXAMINATION:
Breast examination if indicated from the history. Patients should be advised
to be aware of any breast changes or masses through self-examination if
necessary.
Pelvic examination should be done when indicated ( not routinely ) and a
record is made of any uterine enlargement , the presence of fibroids, any
signs suggestive of past or present endometriosis, and any adnexal mass.
Blood pressure should be checked.
 
Preparation of the patient for those symptoms that mark the re-introduction
of oestrogen and progestogens into the ciculation. The patient needs to be
told that these start-up symptoms are likely to be temporary and to remit
by 3 months. These symptoms include:
 Breast tenderness
 Nipple sensitivity
 Appetite rise
 Weight gain
 Calf cramps
First critical review will be at 3 months after starting HRT where enquiry
should be made about the resolution of menopausal symptoms and of
start-up effects.

The incidence of vasomotor symptoms reaches baseline at 3 months and

hence a critical review prior to this time may falsely indicate that
treatment is failing. If no unwanted effects are encountered the patient
may be reviewed 6 months later and then annually.
In the annual review :
Breast: the patient’s participation in breast screening programmes if
available should be ascertained and if the patient is breast aware and
performing self-examination regularly and participating in the
mammographic programme then a full clinical breast examination is
probably not necessary.
If there is any doubt about her breast awareness and if she complains of
breast pain or swelling a breast examination should be performed.
There is evidence that long term use of oestrogen and progestogen is
associated with a small but measurable increase in the risk of breast
cancer.
Blood pressure:
This should be checked at least annually.
 Pelvic examination:
If the patient is amenorrheoic on a continuous oestrogen/ progestogen or
tibolone treatment,or if she is bleeding on time and with normal flow
on a cyclic regimen then routine pelvic examination is probably not
needed because it is unlikely to disclose an abnormality.

If unscheduled bleeding occurs, especially if it is prolonged or recurrent

this needs a specialist consultation with a view to hysteroscopy and
endometrial biopsy if indicated. Ultrasound evaluation of the pelvis
preferentially transvaginally may help diagnosing a leiomyomata or
endometrial polyps.
OPTIONS FOR THE TREATMENT OF VASOMOTOR
SYMPTOMS:
1.Lifestyle changes
.Reducting body temperature.
.maintaining a healthy weight
.Smoking cessation
.Paced respiration
 .Non prescription medications.2
.Isoflavone supplements: Phyoestrogens containing
isoflavones are found to lower the incidence of vasomotor
symptoms, osteoporosis and cardiovarscular disease.it
reduces the risk of endometrial cancer.
.Soy products: is also found effective to reduce vasomotor
symptoms.Soy protein acts as SERMS.
.Black cohosh
.Vitamin E.
3.Non hormonal prescription medications:
.Clonidine: an α adrenergic agonist may behelpful where
estrogen is contraindicated(hypertension).
.Selective serotonin and norepinephrine reup take inhibitors:
Paroxetine, a selective serotonin reuptake inhibitors, is
effective to reduce hot flushes(both the frequency and
severity)
.Gapapentin: is an analog of gamma-aminobutyric acid.it is
effective to control hot flushes.
4.Hormonal therapy:
.estrogon therapy:oral,transdermal,subcutaneous
routes .
.combination estrogen and progestin therapy.
.progestin therapy.
.Tibilone a synthetic hormone preparation.
 
 :Treatment of atrophic vaginitis

:ESTROGEN REPLACEMENT. 1
Estrogen replacement restores normal pH levels and thickens and
revascularizes the epithelium. Estrogen therapy may alleviate existing
symptoms or even prevent development of urogenital symptoms if
initiated at the time of menopause. Routes of administration include
oral, transdermal and intravaginal. Dose frequency may be continuous,
or cyclic. The amount of estrogen and the duration of time required to
eliminate symptoms depend greatly on the degree of vaginal atrophy
and vary among patients.
Systemic administration of estrogen has been shown to
have a therapeutic effect on symptoms of atrophic vaginitis.
Standard dosages of systemic estrogen, however, may not
eliminate the symptoms of atrophic vaginitis in 10 to 25
percent of patients. Systemic estrogen in higher dosages may
be necessary to alleviate symptoms. Some women require
coadministration of a vaginal estrogen product that is applied
. locally
Up to 24 months of therapy may be necessary to totally
eradicate dryness; however, some patients do not fully
respond even to this treatment regimen. Other treatment
options include transvaginal delivery of estrogen in the form
.of creams, pessaries or a hormone-releasing ring (Estring)
 :MOISTURIZERS AND LUBRICANTS.2

Moisturizers and lubricants may be used in conjunction

with estrogen replacement therapy or as alternative
treatments.Some patients choose not to take hormone
replacement, or they may have medical contraindications
or experience hormonal side effects. Patients who wish to
avoid using estrogen should not use moisturizers that
contain ginseng because they may have estrogenic
properties. Moisturizers help maintain natural secretions
and coital comfort.
 :Sexual Activity
Sexual activity is a healthful prescription for
postmenopausal women who have a substantially
estrogenized vaginal epithelium. It has been shown to
encourage vaginal elasticity and pliability, and the
lubricative response to sexual stimulation. Women who
participate in sexual activity report fewer symptoms of
atrophic vaginitis and, on vaginal examination, have less
evidence of stenosis and shrinkage in comparison with
sexually inactive women.
What treatments are available for bladder control
:problems
Treatment depends on the kind of bladder control problem
you have. We may recommend some of the following
:lifestyle changes
 
 Limiting caffeine.1
Avoiding bladder irritants such as alcohol, carbonated. 2
.beverages, and spicy foods
Strengthening pelvic muscles with Kegel exercises. These. 3
exercises strengthen the pelvic floor muscles. To do Kegel
exercises, squeeze and hold the pelvic muscles and then
. .relax them
Training the bladder to hold more urine.4
If these simple treatments do not work, there are other
options, including
Medication such as tolterodine (Detrol®), oxybutynin. 1
.(Ditropan®) etc
Biofeedback, which is a method of learning to voluntarily. 2
control certain body functions with the help of a special
.machine
.Electrical stimulation of pelvic muscles.3
A device inserted in the vagina to hold up the bladder.4
. (pessary)
A device inserted directly into the urethra to block leakage.5
Surgery to lift a sagging bladder into a better position.6
Estrogen therapy is not FDA-approved for the treatment of
incontinence, but local vaginal estrogen may reduce
recurrent urinary tract infections and is recommended by
national guidelines to treat minor bladder symptoms in
post-menopausal women.
How will you assess her risk for having osteoporosis?
1-History (risk factors).
2. Diagnosis:computed tomography CT and the dual-energy X-ray
absorptiometry are reliable methods to assess the bone mineral
density.
Assessment of osteoporosis by DXA is recommended for
1-.all women aged 65 and older, regardless of risk factors.
2-.for younger postmenopausal women with 1 or more risk factors, other
than being white and menopausal.
Biochemical parameters to detect bone loss are measurement of.-3
.urinary calcium/ creatinine and hydroxyproline/creatinine ratios
Options for osteoporosis prevention and treatment:

1-Non hormonal treatment:

a.Lifestyle modification includes:
.Physical activity. Exercise-weight bearing exercises, walking, jogging
.Supplementary calcium –daily intake of 1-1.5 g. can reduce osteoporosis.
.Vitamin D –supplementation of vitamin D3 (1500-2000 IU/day) along
with calcium can reduce osteoporosis and fractures.Exposure to
sunlight enhances synthesis of cholecalciferol vitamin D3 in the skin .
.Cessation of smoking and alcohol ,reducing medications that causes bone
loss(corticosteroids) ,reduced high coffee intake.
.Evaluation of bone density(hip) should be done periodically.
b-Thiazides reduce urinary calcium excretion. It increase
bone density specially when combined with oestrogen.

c-Phytoestrogen containing isoflavones are found to lower the

incidence of vasomotor, osteoporosis and cardiovascular
disease .it reduce the risk of breast and endometrial cancer.

d-Biphosphonates: are pyrophosphate analogues which

interfere with osteoclastic resorption e.g. Alendronate used to
prevent and treat osteoporosis and hip and spine fractures.
e-SERM: seletive oestrogen receptor modulator, raloxifene.
2-hormonal treatment:
-oestradiol 2mg or equivalent needed to increase rather than
maintain bone mass.
-combined oestrogen –progestogen .
-tibilone.
 
Risks of hormone therapy:
1.In addition to an increased risk of heart attack, stroke,
2.breast cancer.
3.and Alzheimer disease.
4.VTEs are increased approximately two to threefold with HT use.
Women taking HT should be advised to stop therapy several days before elective
surgery.
5.There also is a twofold risk of gallbladder disease with HT use.
Common side effects include:
breast tenderness,exacerbation of migraine headaches, and vaginal bleeding.
 
CONTRINDICATIONS TO HRT:
ABSOLUTE
*Present or suspected pregnancy
*Suspicion of breast cancer
*Suspicion of endometrial cancer
*Uncontrolled hypertension
*Confirmed venous thromboembolism VTE
*Acute active liver disease or gallbladder disease.
 
2-RELATIVE
*Presence of uterine fibromyomata
*Past history of benign breast disease
*Unconfirmed VTE
*Migraine
*Heart disease.
*Chronic stable liver disease.
*History of liver or gallbladder disease,endometrial cancer
 Fibroid are responsive to oestrogen, and involute after the menopause.
HRT may continue to stimulate these benign gynaecological tumours
causing some to increase in size.This can cause an increase in
menstrual blood loss, but in practice this does not usually represent a
problem as treatment can easily be discontinued.However in patients
with a good indication who wish to continue therapy,fibroid resection,
embolization, myomectomy or hysterectomy are all options available.
*Patients who have suffered with endometriosis and become
menopausal ,are usually cured of their sympyoms .some may wish to
consider HRT and recurrence rates of 4% on HRT can be
expected.Recurrence of symptoms is alleviated by stopping HRT.
NEW DEVELOPMENTS:
 
Selective oestrogen receptor modulators ( SERMs ): These agents are specific
i.e they do not engage the oestrogen receptors in all tissues but do so selectively
with the central object of retaining the protective oestrogenic actions on the
skeleton while avoiding the two key adverse effects of conventional HRT
namely breast cancer and vaginal bleeding.
The first SERM is Raloxifene which is now licensed in USA and European
Union for the prevention and treatment of bone loss. Raloxifene does not
reduce and indeed may exacerbate the vasomotor symptoms of menopause and
its use will be restricted initially to patients at risk of developing osteoporosis,
such as those with premature menopause, steroid therapy and positive family
history.
Thank You