finer
door af Mera
pause
Learning objectives
What is HRT
Methods of giving HRT
Contraindications absolute and
relative
What is raloxifine and tibolon
Hormone replacement therapy is
medication that contains female
hormone to replace the estrogen that
the body stops making during
menopause. Hormone therapy is most
often used to treat common
menopausal symptoms, including hot
flashes and vaginal discomfort.
Hormone therapy has also been proved to prevent
bone loss and reduce fracture in=
postmenopausal
=
-
women.
However, there are risks associated with using
-
hormone therapy. These risks depend
-
= on the type
of hormone therapy, the dose, how long the
medication is taken and individual
-
= health risks.
For best results, hormone therapy should be
-
tailored to each person and reevaluated every so
-
-
often to be sure the benefits still outweigh the
-
risks.
What are the basic types of hormone therapy?
Hormone replacement therapy primarily focuses on
replacing the estrogen that the body no longer makes
after menopause. There are two main types of estrogen
- -
therapy:
-
y Systemic hormone therapy. Systemic estrogen — which
-
comes in pill, skin patch, typically contains a higher
dose of estrogen that is absorbed throughout the body.
It can be used to treat any of the common symptoms of
F
F
menopause.
y
Low-dose vaginal products. Low-dose vaginal
preparations of estrogen — which come in cream,
tablet or ring form — minimize the amount of
estrogen absorbed by the body. Because of this, low-
dose vaginal preparations are usually only used to treat
the vaginal and urinary symptoms of menopause.
Estrogen
, a steroid hormone, is derived from the androgenic precursors
androstendione and testosterone by means of aromatization. In
order of potency, naturally occurring estrogens are 17 (beta)-
estradiol (E2), estrone (E1), and estriol (E3). The synthesis and
actions of these estrogens are complex.
1.Estradiol is primarily produced by theca and granulosa cells of
the ovary, and it is the predominant form of estrogen found in
premenopausal women.
2.Estrone is formed from estradiol in a reversible reaction. This is
the predominant form of circulating estrogen after menopause.
Estrone is also a product of the peripheral conversion of
androstendione secreted by the adrenal cortex.
3.Estriol is the peripheral metabolite of both estradiol and
estrone; it is not secreted by the ovary
There is controversy between using HRT
in menopausal women that is natural
and physiological and requires no
interventions and that it is true hormonal
state and thus should be treated with
replacement therapy
HRT should be given when oestrogen
deficiency symptoms affect or
interfere with her personal life
How to prescribe HRT
History
Complete , oestrogen deficiency
symptoms
Family history of cardiovascular disease
,angina, MI and stroke Alzheimer
disease and neurological disease
Personal history of gastrointestinal
diseases, liver diseases, interfere with
normal pharmacodynamics of
oestrogen
Gynecological history, fibroid,
endometriosis, benign or malignant
breast disease
Examination BP, breast , pelvis, tumor,
fibroid, endometriosis, ovarian tumour
Mode of treatment
1- Oral : commonly used three weeks
of oral c.p., oral oestrogen, oestradiol
valerate 1 or 2 mg , conjugated equine
oestrogen 0.625 or 1.25 mg , oestrone
1.25 mg
2- Transdermal oestrogen matrix
patch: pass directly to systemic
circulation across the epidermis thus
bypass, hepatic first pass which
occur in oral route and this maintain
E2 oestradiole ratio 2/1 highly
physiological.
And reduce impact on various
metabolic parameters such as
haemostatic and coagulation system so
it can be used in women with personal
and family history of venous
thrombosis or non liver abnormalities
3- Subcutaneous implantation , in
patient undergone hysterectomy
,under local anesthesia application
of pellet in subcutaneous tissue in
lower abdomen available at 25, 50 ,
and 100 microgram strength
and reveal each
time by checking
plasma level of E2
should not be
above 1000 pmole
per litre before
reimplantation
Oestrogen also cause hyperplasia so
use progesterone 12 days per month
For secretory transformation of
endometrium and shedding , either
norethisterone or norgestrol or
medroxyprogesterone acetate or
micronized progesterone
progesteron either given cyclic in 28
days or continously to prevent
withdrawal bleeding called ( no
bleed ) tretment in patient really
menopause if any bleeding occurs
the patient should be investigated
Progesterone secreting IUCD
(levonorgestrel) used if the women
not tolerate other types of
progesterone
Progesterone is not necessary in
patients with hysterectomy
4- local oestrogen cream, pessary or
vaginal tablets and ring to treat
genitourinary symptoms in lower
genital tract, bladder, urethra, no
systemic effect, it is given daily for 2
weeks, then reduce to once or twice
weekly for 12 weeks
5-trasnasal 150 microgram oestradiol
Duration of treatment
5 years if started in women after 50
years but some take treatment until 60
years , longer duration is needed in
women with premature menopause
Contraception should be used for 1 year
after menopause either condom or
progesterone secreting IUCD
Contraindications
Absolute : present or suspected
pregnancy, suspicious of breast
carcinoma, suspicious of endometrial
carcinoma , acute liver disease,
uncontrolled hypertension , VTE
Relative : uterine fibroid, past history of
benign breast disease, chronic stable
liver disease, migraine, abnormal
uterine bleeding
Management of patient receiving HRT
Side effect: Alarming her symptoms
specially 1st 3 months breast tenderness,
nipple sensitivity, increased appetite,
weight gain, calf cramps, and vasomotor
symptoms reaches baseline in 3 months,
if no symptoms, patient revealed after 6
months and then annually
Each visit : breast examination, BP, if
normal no need , if any heavy
bleeding or recurrent drops, vaginal
US fibroid, polyp , hysteroscopy and
biopsy.
Also HRT can be used to prevent
Alzheimer disease , oestrogen
increases cerebral blood flow
Risk of HRT
1- breast cancer more than 5 years
2- endometrial cancer
3- ovarian cancer more than 10 years use of
HRT.
4- venous thromboembolism during 1st
year of treatment , increased risk in women
who are obese and smoker
5- coronary heart disease and stroke
specially in smokers and if women more
than 60 years if HRT not start
immediately after menopause, it should
not be initiate in women over 60 years
selective oestrogen receptor -
modulator acts selectively
(Raloxifene)
Used for the prevention and treatment of
osteoporosis not act on breast and uterus
and it can be used in women over 60
years has high risk of osteoporosis
Tibolone ((Livial)
Livial, is used in the treatment of menopausal
symptoms like hot flashes and vaginal atrophy,
postmenopausal osteoporosis, Tibolone possesses a
complex pharmacology and has weak estrogenic,
progestogenic, and androgenic activity
Other drug used for osteoporosis
Bisphosphonates are usually the first choice for
osteoporosis treatment. These include: Alendronate
(Fosamax), a weekly pills. its used for elderly patient
when HRT is contraindicated
Parathyroid hormone is reserved
Testesterone
In menopause there is decrease in sex
hormone binding globulin so there is small
rise in free testosterone
But in women who undergo a surgical or
chemo radiation induced menopause there
may be deficiency of testosterone and this
cause decrease libido , it can be given in
conjunction with estrogen
Other management :
Diet , exercise , stop smoking, herbals, other
non hormonal treatment,
1.Selective serotonin reuptake inhibitors(
fluoxetine)
2. Alpha adrenergic agonist ( clonidine) ,
beta blockers
3.( propranolol ),
4Gabapentin all theses drugs are given for
hot flashes
Other complementary treatments (
acupuncture ) may improve vasomotor
symptoms
