hormonal replacement

1. Menopause & Hormonal
Replacement Therapy
Ms.T Haripriya
Clinical instructor
AACON

2. Introduction
Menopause starts gradually and is usually signaled by changes in
menstruation. The monthly flow may increase, decrease, become irregular,
and finally cease. Often, the interval between periods is longer; a lapse of
several months between periods is not uncommon.
Changes signaling menopause begin to occur as early as the late 30s,
when ovulation occurs less frequently, estrogen levels fluctuate, and FSH
levels rise in an attempt to stimulate estrogen production

3. Definition
1. Menopause is the permanent physiologic cessation of menses associated
with declining ovarian function; during this time, reproductive function
diminishes and ends. - Brunner & Suddarth
2. Menopause means permanent cessation of menstruation at the end of
reproductive life due to loss of ovarian follicular activity. It is the point of
time when last and final menstruation occurs. - D.C.Dutta

4. Stages of menopause
1. Perimenopause is the part cyclic irregular. perimenopause to the
period around menopause (40–55 years).
2. Post-menopause is the phase of life that comes after the menopause.
Age of Menopause: Age at which menopause occurs is genetically
predetermined. The age of menopause is not related to age of menarche
or age at last pregnancy. The age of menopause ranges between 45–55
years, average being 50 years.

5. MENSTRUATION PATTERN PRIOR TO MENOPAUSE
Any of the following patterns are observed:
i. Gradual decrease in both amount and duration. It may be spotting or
delayed and ultimately lead to cessation.
ii. Irregular with or without excessive bleeding. One should exclude genital
malignancy prior to declare it as the usual premenopausal pattern.

6. MENOPAUSAL SYMPTOMS
In majority, apart from cessation of menstruation, no more symptoms are
evident. In some women symptoms appear. The important symptoms and the
health concerns of menopause
Urogenital atrophy
Osteoporosis and fracture
Cardiovascular disease
Cerebrovascular disease
Psychological changes
Skin and Hair
Sexual dysfunction
Dementia and cognitive decline.

7. COMMON SYMPTOMS
Profuse sweating
Discomfort
Sleep disturbances
Subsequent fatigue
Embarrassment
Osteoporosis (decreased bone density)
Bone fractures
Vaginal secretions decrease
Dyspareunia (discomfort during intercourse)
Bacterial infections (atrophic vaginitis) & discharge, itching,
and vulvar burning
Some women report fatigue,
dizziness, forgetfulness, weight
gain, irritability, trouble sleeping,
and feelings of panic. Menopausal
complaints need to be evaluated
carefully as they may indicate
other disorders.

8. Diagnosis of menopause
 Complete history collection
 Physical examination
 Cessation of menstruation for consecutive 12 months during cyclic
 Appearance of menopausal symptoms ‘ ‘night sweats’.
 Vaginal cytology – showing least (Features of low estrogen).
 Serum FSH and LH:>40 ml U/mL
 Ultrasonographical examination

9. TREATMENT MANAGEMENT
Nonhormonal Treatment: Lifestyle modification includes: Physical
activity (weight bearing), reducing high coffee intake, smoking and excessive
alcohol. There should be adequate calcium intake (300 mL of milk),
reducing medications that causes bone loss (corticosteroids)
Nutritious diet: balanced with calcium and protein is helpful.
Supplementary calcium: daily intake of 1–1.5 g can reduce osteoporosis
and fracture
Exercise: weight bearing exercises, walking, jogging

10. Cont.
Vitamin D: supplementation of vitamin D3 (1500–2000 IU/day) along with
calcium can reduce osteoporosis and fractures. Exposure to sunlight enhances
synthesis of (vitamin D3) in the skin
Cessation of smoking and alcohol
Fluoride prevents osteoporosis and increases bone matrix. It is given at a
dose of 1 mg/kg for short-term only. Calcium supplementation should be
continued. Long-term therapy induces side effects (brittle bones).
Calcitonin inhibits bone resorption. Simultaneous therapy with calcium and
vitamin D should be given. It is given either by nasal spray (200 IU daily) or by
injection (SC) (50–100 IU daily). It is used when estrogen therapy is
contraindicated

11. Cont.
Selective estrogen receptor modulators (SERMs): It increase bone
mineral density, reduce serum LDL and to raise HDL2 level.
Thiazides: reduce urinary calcium excretion. It increases bone density
specially when combined with estrogen.
Paroxetine: a selective serotonin reuptake inhibitor, is effective to reduce hot
flushes (both the frequency and severity). Coolness body

12. Cont.
Phytoestrogens containing isoflavones are found to lower the incidence
of vasomotor symptoms, osteoporosis and cardiovascular disease. It
reduces the risk of breast and endometrial cancer.

13. Hormone Replacement Therapy (HRT)

14. Hormone Replacement Therapy (HRT)
The HRT is indicated in menopausal
women to overcome the short-term and
long-term consequences of estrogen
deficiency.

15. Indication of Hormone Replacement Therapy
i. Relief of menopausal symptoms.
ii. Prevention of osteoporosis.
iii. To maintain the quality of life in menopausal years.
Special group of women to whom HRT should be
prescribed:
 Premature ovarian failure
 Surgical or radiation menopause

16. Benefits Of Hormone Replacement Therapy (HRT)
Improvement of vasomotor symptoms (70– 80%)
Improvement urogenital atrophy
Increase in bone mineral density (2–5%)
Decreased risk in vertebral and hip fractures (25–50%)
Reduction in colorectal cancer (20%)
Possibly cardio-protection

17. Contraindications to HRT
Undiagnosed genital tract bleeding
or venous thromboembolism
Active liver disease
Gallbladder disease
Risks Of Hormone
Replacement Therapy
 Endometrial cancer
 Breast cancer
 Venous thromboembolic (VTE)
disease
 Coronary heart disease (CHD)
 Lipid metabolism
 Dementia, Alzheimer disease

18. Available Preparations For Hormone Replacement Therapy
The principal hormone used in HRT is estrogen. This is ideal for a woman
who had her uterus removed (hysterectomy) already. Addition of progestins
for last 12–14 days each month can prevent this problem. Commonly used
estrogens are conjugated estrogen (0.625–1.25 mg/day) or micronized
estradiol (1–2 mg/day). Progestins used are medroxyprogesterone acetate
(2.5–5 mg/day), micronized progesterone (100–300 mg/day) or
Dydrogestrone (5–10 mg/day).

19. Cont.
Oral estrogen regimen: Estrogen—conjugated equine estrogen 0.3 mg or 0.625
mg is given daily for woman who had hysterectomy.
Estrogen and cyclic progestin: For a woman with intact uterus estrogen is given
continuously for 25 days and progestin is added for last 12–14 days.
Continuous estrogen and progestin therapy:
Subdermal implants: Implants are inserted subcutaneously over the anterior
abdominal wall using local anesthesia. 17 β estradiol implants 25 mg, 50 mg or 100
mg are available and can be kept for 6 months. This method is suitable in patients
after hysterectomy.
Percutaneous estrogen gel: 1 g applicator of gel, delivering 1 mg of estradiol
daily, is to be applied onto the skin over the anterior abdominal wall or thighs.
Effective blood level of oestradiol (90–120 /mL) can be maintained.

20. Cont.
Transdermal patch: It contains 3.2 mg of 17 β estradiol, releasing about 50
µg of estradiol in 24 hours. It should be applied below the waist line and
changed twice a week. Skin reaction, irritation and itching have been
noted with their use.
Vaginal cream: Conjugated equine vaginal estrogen cream 1.25 mg daily is
very effective specially when associated with atrophic vaginitis.
Progestins: In patients with history of breast carcinoma, or endometrial
carcinoma, progestins may be used. It may be effective in suppressing hot
flushes and it prevents osteoporosis. Medroxyprogesterone acetate 2.5–
5 mg/day can be used.

21. Monitoring prior to and during HRT
A base level parameter of the following and their subsequent
check up (at least annually) are mandatory.
Physical examination including pelvic examination.
Blood pressure recording.
Breast examination
Mammography
Cervical cytology
Pelvic ultrasonography
Endometrial thickness (normal <5 mm).
Any irregular bleeding should be investigated thoroughly
(endometrial biopsy, hysteroscopy).

22. Cont.
Duration of HRT: Use Generally, use of HRT for a short period of 3–5
years have been advised. Reduction of dosage should be done as soon as
possible. Menopausal women should maintain optimum nutrition, ideal
body weight and perform regular exercise.

23. Abnormal Menopause
1. Premature Menopause: If the menopause occurs at or below the age of
40, it is said to be premature.
2. Delayed Menopause: If the menopause fails to occur even beyond 55
years, it is called delayed menopause.
3. Artificial Menopause: Permanent cessation of ovarian function done by
artificial means, e.g. surgical removal of ovaries or by radiation is called
artificial menopause.
4. Surgical Menopause: Menstruating women who have bilateral
oophorectomy, experience menopausal symptoms. It is sometimes more
troublesome than natural menopause

24. Cont.
5. Radiation Menopause: The ovarian function may be suppressed by
external gamma radiation in women below the age of 40.The menstruation
may resume after 2 years and even conception is possible.