This document provides a step-by-step guide to menopausal hormone therapy. It discusses assessing candidates for therapy, treatment options including different hormones and administration routes, starting treatment, and follow up and stopping treatment. It addresses indications, contraindications, and recommendations for using hormone therapy in symptomatic menopausal women with risk factors like age, obesity, diabetes, or smoking. The guide emphasizes using the lowest effective dose for the shortest time needed to manage menopausal symptoms.
Menopausal hormone therapy (MHT) also called postmenopausal hormone therapy and hormone replacement therapy. Here is presentation on Menopausal hormone therapy by Dr. Laxmi Shrikhande
Menopausal hormone therapy (MHT) also called postmenopausal hormone therapy and hormone replacement therapy. Here is presentation on Menopausal hormone therapy by Dr. Laxmi Shrikhande
Uterine Fibroids: Symptoms, Causes, Risk Factors & Treatment uterine fibroids aren't associated with an increased risk of uterine cancer and almost never develop into cancer
PANEL DISCUSSION ON PRACTICAL APPROACH TO ENDOMETRIOSISWith FOCUS ON DINOGESTLifecare Centre
PANEL DISCUSSION ON PRACTICAL APPROACH TO ENDOMETRIOSISWith FOCUS ON DINOGEST
UMA RAI
RAJ BOKARIA
JYOTI AGARWAL
JYOTI BHASKER
RENU CHAWLA
DIPTI NABH
VANDANA GUPTA
Discover the 5 essential steps for menopause hormone therapy, including benefits, risks, and how to make informed decisions for a smoother transition through menopause.
Uterine Fibroids: Symptoms, Causes, Risk Factors & Treatment uterine fibroids aren't associated with an increased risk of uterine cancer and almost never develop into cancer
PANEL DISCUSSION ON PRACTICAL APPROACH TO ENDOMETRIOSISWith FOCUS ON DINOGESTLifecare Centre
PANEL DISCUSSION ON PRACTICAL APPROACH TO ENDOMETRIOSISWith FOCUS ON DINOGEST
UMA RAI
RAJ BOKARIA
JYOTI AGARWAL
JYOTI BHASKER
RENU CHAWLA
DIPTI NABH
VANDANA GUPTA
Discover the 5 essential steps for menopause hormone therapy, including benefits, risks, and how to make informed decisions for a smoother transition through menopause.
Explore the intricacies of ovulation induction in intrauterine insemination (IUI) with Dr Laxmi Shrikhande's informative slide share presentation. From understanding the hormonal mechanisms to the latest techniques, this presentation offers insights into optimizing fertility through IUI. Whether you're a clinician seeking to enhance patient outcomes or an individual navigating fertility treatments, this resource provides valuable knowledge for your journey towards conception.
A benign tumor of muscular and fibrous tissues, typically developing in the wall of the uterus.
Prevalence varies among studies and countries (4.5-68.6%)
Nearly 20-30% Indian women in reproductive age group have fibroid uterus
At any given time, nearly 15-25 million Indian women have fibroid uterus
Understand fibroids in a better way
A slight description on contraception, its types along with a brief explanation on Oral Contraceptives. Types of oral contraceptives, it's types, mechanism of action, contraindications, dosing, advantages, disadvantages, risk, benefit amd recent research trends.
Learn about the connection between Polycystic Ovary Syndrome (PCOS) and Metabolic Syndrome. Discover symptoms, associated risks, and effective management strategies to improve your health and well-being.
Late onset menopause, or delayed menopause, refers to the cessation of menstrual periods and reproductive function occurring at an older age than the average onset of menopause, which is typically around 51 years old. When menopause occurs after the age of 55, it is considered late onset. This phenomenon is relatively rare, affecting a small percentage of women, and is influenced by various factors including genetics, lifestyle, and environmental factors.
A urinary tract infection (UTI) during pregnancy occurs when bacteria enter the urinary tract, leading to an infection. This condition is relatively common during pregnancy due to hormonal changes that can affect the urinary system, as well as the physical changes that occur as the uterus expands and puts pressure on the bladder. UTIs in pregnancy require prompt attention and treatment to prevent complications for both the mother and the baby
Discover the essential steps and expert advice for optimal pre-conception care. Learn how to enhance your fertility, ensure a healthy pregnancy, and lay the foundation for your baby's lifelong well-being
Discover the keys to maintaining optimal health and vitality during midlife with our comprehensive guide to nutrition. Learn about the dietary choices and habits that support physical well-being, cognitive function, and emotional balance as you navigate through this transformative stage of life. From nutrient-rich foods to mindful eating practices, empower yourself to thrive at midlife and beyond.
In this informative presentation, we delve into the complexities of fever during pregnancy. Pregnancy brings about various concerns, and fever can be particularly worrisome. Join us as we discuss the causes, potential risks, and necessary steps to take if you experience fever while pregnant. Our expert provides valuable insights and practical tips to ensure the safety and well-being of both mother and baby. Don't let uncertainty overwhelm you; empower yourself with knowledge about fever in pregnancy and learn what steps to take next. Watch now to gain the guidance you need for a healthy pregnancy journey.
Unlock the secrets to vibrant health and vitality during midlife with our comprehensive guide on nutrition tailored specifically for women. Discover expert advice, science-backed strategies, and practical tips to support hormonal balance, bone health, metabolism, and overall well-being. Whether you're navigating menopause or simply aiming to thrive in your prime years, this SlideShare presentation is your roadmap to achieving optimal nutrition and vitality in midlife
Welcome to "Gestational Diabetes Mellitus (GDM): What Every Obstetrician Should Know"
Overview of the presentation's objectives and key topics to be covered
IVF Pregnancy -Is it different? A presentation by Dr Laxmi Shrikhande the leading IVF specialist in India
IVF (In Vitro Fertilization) pregnancy can be both similar to and different from natural conception in several ways. In IVF, fertilization of the egg occurs outside the body in a laboratory setting, typically involving the extraction of eggs from the ovaries and combining them with sperm in a petri dish. Once fertilization is successful, the resulting embryos are transferred to the uterus for implantation
Non-Specific Musculoskeletal Pain presented by Dr.Laxmi Shrikhande Consultant –Shrikhande Hospital & Research Centre Pvt Ltd
Nagpur. The leading hospital in Nagpur
This presentation covers the
1)Pain
2)Characteristics
3) Causes
4) Symptoms
You can get the awareness that you were looking for Non Specific Musculoskeletal Pain details
Non-Specific Musculoskeletal Pain presented by Dr.Laxmi Shrikhande Consultant –Shrikhande Hospital & Research Centre Pvt Ltd
Nagpur. The leading hospital in Nagpur
This presentation covers the
1)Pain
2)Characteristics
3) Causes
4) Symptoms
Contraception where have we been and where are we going is a presentation made by Dr.Laxmi Shrikhande who is a Fertility Specialist, Laparoscopic Surgeon & no scar Hysterectomy Specialist and a leading Gynaecologist from Nagpur
Identifying women with GDM is important because appropriate therapy can decrease maternal and fetal morbidity .
Can prevent two generations from developing diabetes in the future.
Anti-Müllerian Hormone (AMH) is critical for physiologic involution of the Mullerian ducts during sexual differentiation in the male foetus.
In women,AMH is a product of the small antral follicles in the ovaries and serves to function as an autocrine and paracrine regulator of follicular maturation
Healthy Choices are the key!
Healthy diet including raw foods & avoiding processed food or high fat diet is the best way to eliminate toxins from your body. Toxins damage your egg follicles.
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
Anti ulcer drugs and their Advance pharmacology ||
Anti-ulcer drugs are medications used to prevent and treat ulcers in the stomach and upper part of the small intestine (duodenal ulcers). These ulcers are often caused by an imbalance between stomach acid and the mucosal lining, which protects the stomach lining.
||Scope: Overview of various classes of anti-ulcer drugs, their mechanisms of action, indications, side effects, and clinical considerations.
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
EATING DISORDERS (Psychiatry-7)by dr Shivam sharma.pptxShivam Sharma
For any queries ,contact shvmshrm@outlook.com
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## Introduction to Eating Disorders
Welcome to this comprehensive presentation on Eating Disorders, a critical and often misunderstood area of mental health. This presentation is designed to provide in-depth knowledge and insights into the various aspects of eating disorders, making it valuable for both postgraduate medical aspirants preparing for the INI-CET and the general public seeking to understand these complex conditions.
### Objectives:
1. **Understanding Eating Disorders**: Gain a clear understanding of what eating disorders are, their types, and their distinguishing characteristics.
2. **Etiology and Risk Factors**: Explore the underlying causes and risk factors that contribute to the development of eating disorders.
3. **Clinical Features and Diagnosis**: Learn about the clinical features, diagnostic criteria, and the importance of early detection.
4. **Management and Treatment**: Review the current approaches to managing and treating eating disorders, including medical, psychological, and nutritional interventions.
5. **Prevention and Awareness**: Discuss strategies for prevention, early intervention, and increasing awareness about eating disorders.
This presentation aims to bridge the gap between academic knowledge and practical understanding, providing you with the tools to recognize, diagnose, and effectively manage eating disorders. Whether you are preparing for a medical exam or seeking to educate yourself or others about these serious conditions, this presentation will equip you with essential information and practical insights.
Let's begin our journey into understanding eating disorders and the significant impact they have on individuals and society.
---
For any queries ,contact shvmshrm@outlook.com
EATING DISORDERS (Psychiatry-7)by dr Shivam sharma.pptx
Step by Step Guide to Menopause Hormone Therapy by Dr. laxmi Shrikhande
1. A Step by Step Guide to
Menopausal Hormone Therapy
Dr. Laxmi Shrikhande
Consultant - Shrikhande Hospital, Nagpur
https://facebook.com/laxmi.shrikhande | https://.linkedin.com/in/dr-laxmi-agrawal-shrikhande
2. Dr. Laxmi Shrikhande - MD; FICOG; FICMU;FICMCH
• Medical Director-Shrikhande Fertility Clinic, Nagpur
• Chairperson Designate Indian College of OB/GY ICOG
• National Corresponding Editor-The Journal of
Obstetrics &Gynecology of India
• Senior Vice President FOGSI 2012
• Patron & President -Vidarbha Chapter ISOPARB
• Received Nagpur Ratan Award at the hands of Union
Minister Shri Nitinji Gadkari
• Received Bharat excellence Award for women’s health
• Received Mehroo Dara Hansotia award for Best
Committee of FOGSI
• National Governing Council member ICOG 2012-2017
• National Governing Council Member ISAR 2014-2019
• National Governing Council Member IAGE for 3 terms
• Chairperson-HIV/AIDS Committee, FOGSI (2007-09)
• President Nagpur OB/GY Society 2005-06
• Immediate Past President Menopause Society, Nagpur
• Associate member of RCOG & ESHRE
• Member of European Society of Human Reproduction
• Visited 96 FOGSI Societies as invited faculty
• Delivered 11 orations and 450 guest lectures
• Publications-Twenty National & eleven International
• Presented Papers in FIGO, AICOG, SAFOG, AICC-RCOG
conferences
• Conducted adolescent health programme for more
than 15,000 adolescent girls
• Conducted health awareness programme for more
than 10,000 women
3. U turn in Menopausal Hormone Therapy
Widespread use of hormone therapy in the 1980s and
1990s came to an abrupt halt in the early 2000s after
initial findings of the Women’s Health Initiative trial
were published and the study was terminated
Over the next several years, extensive re-analysis and
assessment of the WHI data cast doubt about the
validity of the original conclusions
N Engl J Med 2016; 374(9): 803–806
4. U turn in Menopausal Hormone Therapy
● In 2016, to atone for the turmoil caused by the
inappropriately communicated findings of the WHI
trials, two WHI investigators published a request for
forgiveness
N Engl J Med 2016; 374(9): 803–806
5. U turn in Menopausal Hormone Therapy
There is general agreement among guideline groups that HT
has a favorable risk–benefit ratio in women who initiate
treatment between 50 and 59 years of age or within 10 years
of menopause onset
In this population, HT is highly effective for relief of
vasomotor and urogenital symptoms, and can prevent bone
loss and fracture
Symptom relief provides additional benefits such as
improved sexual function and overall quality of life (QoL)
Climacteric 2016; 19(2): 109–150
Menopause 2017; 24(7): 728–753
Minerva Ginecol 2018; 70(1): 27–34.
6. Menopausal Hormone Therapy
The timing hypothesis
Timing of initiation of hormone therapy affects the
relation with coronary risk
Estrogen may provide coronary benefit in early
menopause but harm if started later
Absolute risks of hormone therapy are lower in early
than late menopause
Hormone therapy is appropriate for vasomotor
symptom relief in early menopause
Hormone therapy is not recommended for chronic
disease prevention
Metabolism. 2016 May ; 65(5): 794–803
7. A Step by Step Guide to MHT = HRT
Steps
Step 1 - Assess if MHT is right for the patient
Step 2 – Hormonal therapy options
Step 3 – Starting MHT treatment
Step 4 – Follow-up
Step 5 – Stopping treatment
9. MHT indications
Vasomotor symptoms
− Hormone therapy has been shown in double-
blind RCTs to relieve hot flashes and is
approved as first-line therapy for relief of
menopause symptoms in appropriate
candidates
Prevention of bone loss
− Hormone therapy has been shown in double-
blind RCTs to prevent bone loss, and in the
WHI, to reduce fractures in postmenopausal
women
9
The Journal of The North American Menopause Society 2017
10. MHT indications
10
The Journal of The North American Menopause Society 2017
Premature hypoestrogenism
HT is approved for women with hypogonadism, POI,
or premature surgical menopause without
contraindications, with health benefits for
menopause symptoms, prevention of bone loss,
cognition and mood issues, and in observational
studies, heart disease
Genitourinary symptoms
Hormone therapy has been shown in RCTs to
effectively treat symptoms of vulvovaginal atrophy
11. MHT contraindications
(as specified by regulatory authorities)
Current, past or suspected breast cancer,
Known or suspected estrogen-dependent malignant tumors (e.g. endometrial
cancer),
Undiagnosed genital bleeding,
Untreated endometrial hyperplasia,
Previous idiopathic or current venous thromboembolism (deep venous
thrombosis, pulmonary embolism),
Active or recent arterial thromboembolic disease (e.g. angina, myocardial
infarction),
Untreated hypertension,
Active liver disease,
Known hypersensitivity to the active substances or to any of the excipients,
Porphyria cutanea tarda (an absolute contraindication).
The Journal of The North American Menopause Society 2017
12. Main risk factors for HT use
Older age (>60 years)
Obesity (BMI > 30 kg/m2),
Insulin resistance
Increase cardiovascular risk (dyslipidaemia,
hypertension, diabetes mellitus, smoking)
Personal or family history of venous
thromboembolism (VTE)
The presence of risk factors does not necessarily preclude use of HT
Women’s Health 2019
13. Recommendations for use of hormone
therapy in symptomatic menopausal
women with risk factors*
*Note: Based on international guidelines, clinical literature and expert opinion (clinical experience and
expertise) of the authors
Minerva Ginecol 2018; 70(1): 27–34
Diabetes Res 2015; 2015: 916585
Endocr Pract 2017; 23(7): 869–880
14. Age >60 years or more than 10 years since onset of
menopause
For current users of HT it can be continued at an appropriate dose (lowest
effective dose) for an appropriate time if no new contraindications emerge
For new users in whom HT is indicated, and in the absence of major
contraindications, treatment with transdermal oestradiol (either 25 mcg patch
or gel, 1 puff per day) and vaginal progesterone (either 100 mg in the evening
continuously or 200 mg in the evening for 14 days a month) is preferred. If
other risk factors are present, vaginal treatment with oestradiol or oestriol is
preferred
15. Obesity (BMI > 30 mg/m2)
As elevated oestrone production from adipose tissue increases the risk of
proliferative endometrial lesions, protecting the endometrium with
progesterone or progestogens (e.g. levonorgestrel or dienogest intrauterine
system) is a priority.
The woman’s willingness to make lifestyle improvements should be
empowered.
J Steroid Biochem Mol Biol 2007; 106(1–5): 81–96
16. Insulin resistance
Menopausal HT should be recommended to
women with type 2 diabetes, or a family history
of diabetes, as it reduces progression
Diabetes Res 2015; 2015: 916585
Climacteric 2014; 17(5): 540–556
17. Hypertension
Menopausal HT can improve recent-onset
hypertension, with enhanced response to
antihypertensive drugs
the option to start transdermal HT should
be discussed with a cardiologist
18. Smoking
Women who smoke should be counselled to
quit while also increasing daily aerobic exercise
in order to improve endothelial function, reduce
hypertension and, if relevant, reduce the risk of
weight gain
For women who choose not to quit, vaginal HT
is preferred. In selected cases, systemic HT
may be considered, but only if the woman is
fully aware of the higher independent
cardiovascular risk due to smoking
22. Basics of MHT
● Estrogen replacement therapy: for
women without a uterus
● Estrogen–progestogen therapy: For
women with intact uterus
23. Oestrogen
● Oestrogen is the primary active component of HT and is the recognized ‘gold
standard’ for treating menopausal symptoms, especially vasomotor
symptoms
● Systemic oestrogens used for MHT in India are conjugated equine estrogens
(CEEs) and oestradiol valerate
24. Estradiol valerate: Most Trusted form of Estrogen
● Natural estrogen
● Safer than its synthetic counterpart
● Micronized form: Increased dissolution and bioavailability
● Esterified preventing extensive first pass metabolism in liver and GIT
● Convenient oral administration
● Is safe even for long-term use (adherence is good even after 7 yrs. of
therapy)*
*Peter HM. Long term adherence to continuous combined HRT. Seven-year update on the Heikkinen
study. Menopause international. 2003;9:8-9
25. Parameters Estradiol Valerate Conjugated Estrogens (CE) Comments
Source Natural Pregnant mare’s urine
product
Estrogenic activity Estradiol valerate
contains the most active
estrogen i.e 17-
estradiol.
CE contains 52 –61% of
estrone that is 1/3 of Estradiol
activity.
CE also contains unknown
ingredients.
Ten hormones present in CE are chemically
different from female hormones.
Unknown ingredients may cause any
possible adverse effect.
Mammographic
density
No significant effect1 Significant increase in
mammographic density 2
Increase in mammographic density may be
a concern as it is a predictor of cancerous
growth in the breasts.
Blood Pressure
(BP)
No effect on renin-
aldosterone system.
Stimulates the liver
production angiotensinogen,
therofore increases BP
CE by stimulating renin-angiotensin
system is associated with the risk of
hypertension.
Coagulation Factor No effect on factor VII factor VII CE ( by factor VII) may cause abnormal
increase in clotting of blood.
Medscape Womens Health. 2002 Jul-Aug;7(4):1; Ginecol Obstet Mex. 2000 Nov;68:442-7.
E2V vs Conjugated Equine Estrogens
26. Parameters Estradiol valerate Conjugated estrogen (CE) Comments
Vasomotor
symptoms
Hot flushes, severe throbs, and
breast tenderness is lower 3
Presence of vasomotor
symptoms are higher with CE
EV could be an option that is
better accepted by
postmenopausal women. It is the
drug approved by US FDA for such
condition.
Lipid profile and
cardioprotective
effect
Offers favorable lipid profile4 Lesser favorable lipid profile. EV has better bioavailability and
therefore, is a better option in
dealing with concerns of
postmenopausal cardiovascular
protection
Endothelial function EV improves endothelial
function and reduces plasma
levels of endothelin-15
Vasoprotective effect not
reported
EV has fast effects on endothelial
function thus acutely
vasoprotective
Plasma
homocysteine level
EV has no effect on plasma
homocysteine level6
Effect on homocysteine level
not reported
Homocysteine is a risk factor for
CHD. EV reduces the risk of CHD
3Maturitas. 1997 Jul;27(3):275-84.
4Maturitas. 2001 Dec 14;40(3):239-45; 5Acta Obstet Gynecol Scand. 2006;85(11):1304-6.
E2V vs Conjugated Equine Estrogens
27. Vaginal Estrogen: Treatment of GSM*
Estrogen Preparation (FDA Approved)
Vaginal creams: 17-beta estradiol, conjugated estrogens
Vaginal ring: 17-beta estradiol, estradiol acetate
Vaginal tablet inserts: Estradiol hemihydrate
CLEVELAND CLINIC JOURNAL OF MEDICINE 2018
*Genitourinary Syndrome of Menopause
28. Vaginal Estrogen: Treatment of GSM*
Local Estrogen & Endometrial Impact
● Endometrial surveillance with either transvaginal ultrasonography or
endometrial sampling is not required, even with long-term use, but it should
be considered with higher doses or more frequent applications
● Progestogen therapy is not recommended with low-dose vaginal ET, but
appropriate evaluation of the endometrium should be performed if vaginal
bleeding occurs, given the limitations of safety data
CLEVELAND CLINIC JOURNAL OF MEDICINE 2018
*Genitourinary Syndrome of Menopause
29. Rationale of Progestogen in MHT
● Since chronic unopposed exposure of the endometrium to oestrogen
increases the risk of endometrial hyperplasia and cancer, progestogens are a
part of systemic HT in menopausal women with an intact uterus
30. Selecting the ‘Best’ Progestogen
● Although selecting the ‘best’ progestogen for use in an individual patient
requires further clarification, there is evidence to suggest that micronized
progesterone have better risk profiles than medroxyprogesterone acetate
(MPA), and is associated with a lower risk of breast cancer compared with
other progestogens
Maturitas 2014; 77(4): 311–317
31. An international expert panel’s recommendations on MHT containing micronized
progesterone are as follows
○ Oral micronized progesterone provides endometrial protection if applied
sequentially for 12–14 days/month at 200mg/day for up to 5 years
○ Vaginal micronized progesterone may provide endometrial protection if applied
sequentially for at least 10 days/month at 4% (45 mg/day) or every other day at
100mg/day for up to 3–5 years (off-label use)
○ Transdermal micronized progesterone does not provide endometrial protection
31
CLIMACTERIC, 2016
Selecting the ‘Best’ Progestogen
33. Dose and route of administration
Most appropriate dose of HT depends on the woman’s
phase of life, age and general health status
Useful approach may be to start HT at a low dose, then
titrate upwards to the lowest effective dose that is
consistent with the woman’s treatment goals
Women’s Health 2019
35. Starting MHT
International guidelines recommend that HT be
started as soon as menopausal signs or symptoms
appear which, in most women, is between 45 and
55 years of age
Women with primary ovarian insufficiency require
earlier and continued use of HT (at least until the
normal age of menopause) to protect against
associated postmenopausal chronic diseases
Women’s Health 2019;15:1-8
36. Starting MHT
Evaluating risk factors for MHT in candidate patients
Questions to ask
Age
Menstruation status
Menopausal symptoms
Past and current medical history
Family history
Lifestyle factors (e.g. smoking, alcohol use, exercise)
Concurrent medications
Women’s Health 2019;15:1-8
37. Evaluating risk factors for MHT in candidate patients
Examinations/investigations to perform:
Body weight
Waist circumference
Blood pressure
Blood tests if indicated by responses to questioning
Imaging (e.g. ultrasound, bone density) if indicated by
responses to questioning
Mammography if not performed within previous year
Bone densitometry (dual-energy x-ray absorptiometry) if
patient at risk for osteoporosis
Women’s Health 2019;15:1-8
Starting MHT
38. A Practical Approach
Uterus intact Post hysterectomy
First line
management
A. Oral E
B. Transdermal E patch or gel
A. Oral E plus oral P
B. Combined transdermal (E+P) patch
Jane and Davis; A practitioner’s Toolkit for the Menopause; Jean Hailes for Women’s Health | jeanhailes.org.au
39. Cyclical/sequential HT
Cyclical or sequential HT involves daily administration of oestrogen, with the
addition of progestogen for 10– 14 days a month (monthly bleeds) or for 10–
14 days every 13 weeks (bleeds every 3 months)
Any irregular bleeding and/ or spotting that occurs in addition to regular
progestogen withdrawal bleeds can be managed by increasing the oestrogen
dose as this stabilizes the endometrium
Climacteric 2016; 19(4): 316–328
40. Continuous HT
this regimen eliminates withdrawal bleeding and promotes amenorrhea
Should be used only in women who are at least 2 years past their last
menstrual period as it can cause irregular bleeding in perimenopausal women
due to the unpredictable residual production of oestradiol by remaining
primordial ovarian follicles
Climacteric 2016; 19(4): 316–328
42. Follow-up of patients prescribed MHT
Schedule a follow-up appointment after
initiation of a MHT regimen in one month, to
assess treatment effect
Adverse effects of MHT include bloating,
breast tenderness, increased blood pressure,
headaches, fluid retention and urinary
incontinence
www.bpac.org.nz
43. Follow-up of patients prescribed MHT
What to do if there is persistent vasomotor
symptoms?
Increase MHT doses or trial another
formulation
www.bpac.org.nz
44. Follow-up of patients prescribed MHT
What to do if there is breast tenderness ?
Reduce the dose of oestrogen or switch to
another progestogen
www.bpac.org.nz
45. Follow-up of patients prescribed MHT
What to do if there is unscheduled bleeding within the
first three months ?
Consider continuing treatment unless there is a high
suspicion of endometrial cancer as bleeding may settle
with time
Other options include:
o Switching to cyclical progestogen for patients taking
continuous progestogen
o Increasing the dose of progestogen
o Switching from oral progestogen to a levonorgestrel
IUD
www.bpac.org.nz
46. Follow-up of patients prescribed MHT
What to do if there is unscheduled bleeding
after the first three to six months of MHT?
Organise further investigations for
endometrial cancer
If no endometrial pathology is detected,
consider increasing oestrogen dose
www.bpac.org.nz
48. Stopping HT
Current users of HT can remain on treatment
indefinitely (lifelong if indicated), or at least until
such time as the patient asks to stop
Regular monitoring of HT is advised, with
adjustments made to type, dosage and/ or route of
administration according to a patient’s changing
circumstances and treatment goals
Women’s Health 2019;15:1-8
49. Conclusion
● MHT is a dominant therapeutic modality in climacteric medicine
● The skill lies in the ability to choose the optimal MHT preparation for the
given patient
● Follow the steps when it is decided to start MHT by both patient and doctor.
● The key is individualization, minimum possible dose, and early start of therapy
50. “No matter how good you get
you can always get better
and that's the exciting part”.
~ Tiger Woods ~