This document discusses hormone replacement therapy for premature ovarian failure. It notes that HRT for POF is true replacement therapy rather than extension therapy. It should be started at diagnosis and continued until natural menopause to avoid long-term ill effects. The document outlines different types of POF and tailoring HRT to each type. It provides details on estrogen and progesterone preparations available in India and various HRT regimens and options for POF.

1. Hormone Replacement Therapy
in Premature Ovarian Failure

2. HRT in POF Vs Natural Menopause
►True example of replacement therapy Vs
extension therapy
►Started at time of diagnosis AND continued till
natural age of menopause
► No long-term ill effects (WHI study) as
estrogen years are not increased
►Full dose long-term Vs low dose short-term
►5-10% will resume spontaneous ovulation &
menstruation

3. Tailor HRT According to Type of POF

4. Type I POF - Prepubertal

5. Individualize the Treatment

7. 14 years Turner’s mosaic

8.  Counseling of the girl & parents
 COC pills
Occasionally can conceive

10. Types of HRT Regimens

11. Estrogen Preparations- Indian Market
Market name Molecule Strength Prep Dose
Evalon Estriol succinate 1.0mg Tab 8-16mg/day
Premarin CEE 0.625mg Tab 0.625mg/day
Progynova Esradiol valerate 1.0mg/2mg Tab 2mg/day
Estraderm patch
Or Susten 50
Estradiol 25/50/100 цg patch 1 every 4 days
50 цg
E 2 Gel
Or Sandrena gel
Estradiol 1.5mg/2.5g
1mg/gm
Dermal gel Once a day
Estaspray Estradiol 0.375mg Dermal spray 1-3 accutations/day
Premarine gel CEE 0.625mg/gm
Daily x 2weeks
Vaginal gel then twice a weekEvalon gel Estriol 1mg/gm
E 2 Gel Estradiol 0.025mg/gm

12. Transdermal Estrogens
Estragel
1.5mg/2.5g OD
EstaSpray 0.375mg BD

13. Currently there appears to be no clear advantage of the
transdermal over the oral route
Oral estrogens
• Blood levels
• Lipoproteins
LDL ↓
HDL ↑
Lpa ↓
Prevent oxidation yes
TGL ↑
• CRP ↑
• SHBG, TBHG ↑
• Coagulation factors ↑
Transdermal
more stable, square dose curve
↓ or same
same
↓ or same
yes
same
No effect
No effect
less effect

14. Progesterone preparations-Indian Market
Drug Route Sequential (10-14 days) continuous
MPA Oral 5mg daily 2.5mg daily
Norethisterone Oral 1mg daily 0.3 mg daily
Norethindrone Oral 2.5mg daily 0.5mg daily
Dydrogesterone Oral 10mg daily 5mg daily
Drospirenone Oral - 2mg daily
Natural progesterone Oral 300mg daily 200mg daily
Natural progesterone Vaginal 200mg daily 100mg daily
Natural progesterone Vaginal gel 45mg daily 45mg daily
LNG-IUS Intra-uterine _ 20mcg daily

15. Various options
Tibolone
o
Steroid
o
Metabolites are active
o
Mildly estrogenic
progestogenic
androgenic
o
Amenorrhoea
o
Good for VMS, libido, bones
o
No change in breast density
o
Endometrial bleeding -5%
• 0.625 mg premarin +
MPA 5mg 12 days
• Estragel/estaSpray
+ LNG IUS or MPA
• Angeliq 1 OD

16. Type III POF - Iatrogenic
• Sudden & precipitous fall of estrogens –
severe symptoms VMS, risk of CHD,
osteoporosis, suicidal depression
• Lack of androgens – lack of energy & libido
• Need to start ET early while in the hospital &
full dose or may be higher dose

17. HRT in Surgical Menopause

18. HRT in Cancer Survivors

19. Stem Cell Transplant - POF

20. HRT - POF

21. Premature ovarian failure
Not your failure