Menopausal hormone therapy (MHT) also called postmenopausal hormone therapy and hormone replacement therapy. Here is presentation on Menopausal hormone therapy by Dr. Laxmi Shrikhande
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step by step guide to menopause hormone therapy (MHT)
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. 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
5. 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
7. 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
8. 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
10. Basics of MHT
● Estrogen replacement therapy: for
women without a uterus
● Estrogen–progestogen therapy: For
women with intact uterus
11. 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
12. 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
14. 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
15. 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
17. 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
19. 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
20. 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