I am going to talk about 3 hormone issues now…each of which could be its own talk so I will try to get in some meaningful comments about each of these issues
I wanted to start talking about the Premenstrual syndrome by showing this graph in order to illustrate the complexity involved in a normal menstrual cycle. The normal menstrual cycle is driven by hormones from both the pituitary gland and from the ovaries. These hormones coordinate both the uterine lining and the follicle growth from the ovary. What is key is that there are a lot of fluctuations in hormones that go during the course of a menstrual cycle and it is those fluctuations that are thought to be at the heart of why some susceptible women experience pre-menstrual symptoms. So it will be important to keep that in mind when we talk about the potential treatments.
So in this slide I will talk about the signs and symptoms of PMS and also distinguish PMS from a more severe form called premenstrual dysphoric disorder. The prevalence of PMS symptoms is high, about 75% of women report such symptoms. A smaller amount about 20-30% report signficant, repetitive symtpoms and a much smaller group about 2-6% can be classified as having the dysphoric disorder.
Generally speaking there are relatively few reproductive age women that are not eligible for hormonal contraception. I will first start by talking about the patch, pill and ring. Each of these vary only in their mode of delivery but essentially they each contain both estrogen and progesterone given together. Patches deliver the hormones through the skin, pills are obviously taken by mouth and with the ring the hormones are delivered through the vaginal wall. All three have similar efficacy and similar adverse side effects. Injections of depoprovera are a good alternative when estrogen is contraindicated as are IUDs. There are also pills that only contain progesterone. Generally speaking progesterone only methods have more side effects of break through bleeding.
BTB definitely a common problem but worse with initiating pills or changing the brand and worse with progesterone only pillsBreast tendernessDepression and mood changes – little evidence for this and as I have said we use them to treat these issues that are associated with mensesLibido – no clear relationship between type of progesterone or androgen levels and sexual function in womenWeight- all studies conclude that BC are weight neurtral with the exception of depoproveraNausea from the progesteroneHeadaches – can improve themBlood clots – any time you increase estrogen levels, it can increase the risk of blood clots but putting the risk in perspective, the risk associated with endogeneous levels of estrogen production in pregnancy in and post partum is much much higher
Hormone replacement therapy refers to using estrogen and progesterone to relieve bothersome symptoms related to menopause. Estrogen relieves the symptoms and progesterone is given to prevent uterine cancer when giving estrogen. Women who have had a hysterectomy do not need progesterone.Estrogen comes in many forms and can be taken by mouth or absorbed through the skin with creams, patches and gels or given through the vagina. The WHI was initially designed to see if taking HRT would prevent heart attacks and after it first came out it seemed that in fact it increased the risk. But when we looked closer at the data, it became more clear that the risk of heart attacks in women depended on the age they started the hormones and it became clear that women who start less from their menopause or were age 50-59 when they started did not run into any additional problems.
One of the most important lessons is that the risks associated with HRT depend on your age when you start them. In fact there is no increased risk of heart attacks related to HRT in women who became menopausal less than 10 years before starting hormones or who were 50-59 years old when they started the hormones.
Menopause symptoms vary from woman to woman; some women report significant, disabling symptoms while other women go through the menopausal transition with no symptomsThis slide lists common complaints reported by women transitioning through menopause
There is almost universal agreement in the medical community that estrogen therapy (ET) and estrogen plus progestin therapy (HT) have been shown to be effective in treating and preventing vasomotor symptoms (VMS), vulvovaginal atrophy, and certain urinary symptoms, as well as in preventing osteoporotic fractures of the hip and spine. This efficacy has biologic plausibility and has been demonstrated in both observational and randomized clinical trials (RCT).ReferencesGreendale GA, Reboussin BA, Hogan P, et al. Symptom relief and side effects of postmenopausal hormones: results from the Postmenopausal Estrogen/Progestin Interventions Trial. Obstet Gynecol. 1998;92:982-988. Notelovitz M, Cassel D, Hille D, et al. Efficacy of continuous sequential transdermalestradiol and norethindrone acetate in relieving vasomotor symptoms associated with menopause. Am J Obstet Gynecol. 2000;182:7-12. Raz R, Stamm WE.A controlled trial of intravaginalestriol in postmenopausal women with recurrent urinary tract infections. N Engl J Med. 1993;329:753-756. Writing Group for the PEPI Trial. Effects of hormone therapy on bone mineral density: results from The Postmenopausal Estrogen/Progestin Interventions Trial. JAMA. 1996;276:1389-1396.
Women's Health: Your Changing Hormones - Dr. Glueck
Your Changing Hormones: PMS, birth control and hormone replacement therapy<br />Jennifer Glueck, MD<br />Assistant Professor of Clinical Medicine<br />Division of Endocrinology, Diabetes and Metabolism<br />
What is HRT?<br />Term used to describe the use of estrogen and progesterone to relieve bothersome symptoms of menopause<br />Estrogen is the hormone that relieves the symptoms and progesterone has to be given to women with a uterus to protect the uterus<br />Estrogen can be delivered by mouth, skin (patches, sprays, creams) or through the vagina<br />
Perspective on Risks of HRT<br />The Women’s Health Initiative was a large study that was conducted to find out if using HRT prevented heart attacks<br />Initially caused fear of HRT because it looked like there was an increased risk with HRT<br />A closer look revealed some important lessons<br />Overall, in most women suffering from menopausal symptoms, the benefits outweigh the risks<br />
Lessons from the WHI: Appropriate Candidates for HT<br />
Indications for Menopausal Hormone Therapy (FDA approved)<br />In randomized trials and observational studies, estrogen therapy (ET) and estrogen plus progestin therapy (HT) have been shown to be effective in:<br />• Treating and preventing<br /><ul><li> Vasomotor symptoms (VMS)