This document discusses menopause and its management. Key points include: - Menopause is defined as the permanent cessation of menstruation due to loss of ovarian function, with an average age of onset in India of 43.5-48.5 years. - Common symptoms include vasomotor symptoms like hot flashes, genital symptoms like dryness and infections, and increased risk of osteoporosis and cardiovascular disease due to loss of estrogen. - Management includes lifestyle modifications and hormone replacement therapy with estrogens, progestogens, SERMs or tibolone to treat symptoms and prevent long-term risks. Extended treatment requires evaluation of risks/benefits.

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MENOPAUSE
‫٭‬ Permanent cessation of menstruation
due to loss of ovarian follicular function
‫٭‬ Lack of ovarian hormones
‫٭‬ Diagnosed retrospectively after 12
months of amenorrhoea
‫٭‬ Average age of menopause in India
ranges from 43.5 to 48.5 yrs
‫٭‬ One third of life in menopausal state

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PROBLEM IN INDIA
‫٭‬ Life expectancy - 61 yrs
‫٭‬ Women in menopausal age (50-59 yrs)
- 36 millions
‫٭‬ Regional variation
– by age 40
• In Kerala - 8.2% menopausal
• In AP - 37.6% menopausal
– by age 50
• In Kerala - 53% menopausal
• In AP - 83% menopausal

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REACTION TO MENOPAUSE
‫٭‬ A welcome change -
– No bleeding and no risk of pregnancy
– Relatively clean state and hence can attend
religious and social functions
– Less psychological symptoms - joint family support
– Low-fat, high calorie diet
– Diet rich in soya products, milk products
– Adequate exercise
Ignorance is a bliss

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DEFINITIONS
‫٭‬ Premenopause - Two yrs before cessation
of periods
‫٭‬ Perimenopause - 5 yrs before and 1 yr
after menopause
‫٭‬ Postmenopause - dates from final
menstrual period
‫٭‬ Induced menopause - chemotherapy,
radiotherapy or surgery
‫٭‬ Climacteric - 2 yrs before and 5 yrs after
menopause

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VASOMOTOR SYMPTOMS
‫٭‬ Experienced by 50-75% women
‫٭‬ Only 25% suffer physical distress
‫٭‬ Hot flushes & night sweats
‫٭‬ Sudden, transient sensation ranging
from warmth to intense heat that
spreads over the body, particularly on
chest, face, and head. Accompanied by
flushing and perspiration, followed by a
chill
‫٭‬ Lasts for 3-6 mins
‫٭‬ Disturbed sleep-irritability-depression

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ENDOCRINOLOGY OF
VASOMOTOR SYMPTOMS
‫٭‬ Estrogen influences thermoregulatory,
neural and vascular function
‫٭‬ No association with LH surge, episodic
GnRH release.
‫٭‬ Sudden decrease in estrogen levels
‫٭‬ More marked in surgical menopause

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Anatomical Changes
‫٭‬ Atrophy of genital organs
– ovary,
– fallopian tubes,
– Uterus,
– Cervix,
– vagina,
– labia

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GENITAL SYMPTOMS
‫٭‬ Dryness of vagina
‫٭‬ Vaginal irritation
‫٭‬ Vaginal discharge
‫٭‬ Recurrent infections
‫٭‬ Vulvovaginal pruritis
‫٭‬ Dyspareunia
‫٭‬ Post-coital bleeding
‫٭‬ Genital prolapse

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URINARY SYMPTOMS
(Urethral Syndrome)
‫٭‬ Frequency
‫٭‬ Urgency
‫٭‬ Nocturia
‫٭‬ SUI
‫٭‬ Urge incontinence
‫٭‬ Recurrent UTI

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PSYCHOLOGICAL SYMPTOMS
‫٭‬ Sustained change of mood
‫٭‬ Inability to enjoy oneself
‫٭‬ Presence of depressive thought process
‫٭‬ Sexual dysfunction
‫٭‬ Increased irritability
‫٭‬ Reduced memory

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BONE AND OSTEOPOROSIS
‫٭‬ Postmenopausal osteoporosis - low
bone mass & micro architectural
deterioration of bone tissue due to
increased bone resorption - increased
fracture risk
‫٭‬ Indians have poor skeletal health
‫٭‬ High prevalence of osteoporosis

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EVALUATION FOR
POSTMENOPAUSAL OSTEOPOROSIS
‫٭‬ All women over 65 yrs of age
‫٭‬ Younger postmenopausal patients with
high risk factors
– Prior fracture
– Tobacco use
– Weight loss
– Low body weight
– Patients on long term glucocorticoid therapy
– Suspicion of osteoporosis on plain X-Ray

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Pathophysiology
‫٭‬ Balance between osteoblastic and
osteoclastic activity
‫٭‬ Accelerated bone loss after menopause
due to lack of estrogen

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Bone Formation & Bone resorption
Normal Osteoporosis
- BAD CELLS - GOOD CELLS

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EVALUATION FOR
POSTMENOPAUSAL OSTEOPOROSIS
‫٭‬ DEXA Scan for Bone Mineral Density
– Dual energy X-Ray absorptiometry of the hip and
spine
‫٭‬ For every 1-SD decrease in age-
adjusted BMD, the RR of fracture
increases by 2 fold
‫٭‬ Consider pharmacotherapy for patients
with low BMD

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LONG TERM GENITAL EFECTS
‫٭‬ Genital atrophy
‫٭‬ Senile vulvovaginitis
‫٭‬ UV prolapse
‫٭‬ Dyspareunia
‫٭‬ Recurrent infections

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EFFECT ON
CARDIOVASCULAR SYSTEM
‫٭‬ Cardioprotective role of estrogens
‫٭‬ Estrogen favourably affects lipid profile
‫٭‬ It lowers LDL and raises HDL
‫٭‬ Estrogen deficiency may lead to
atherosclerosis,IHD,MI

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EFFECT ON
CARDIOVASCULAR SYSTEM
‫٭‬ Epidemiological and Observational
studies have shown 35.5% reduction of
cardiovascular events in
postmenopausal women on traditional
HRT

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MISCELLANEOUS LONG
TERM EFFECTS
‫٭‬ Age related Lens opacities
‫٭‬ Menopausal gingivostomatitis
‫٭‬ The reduction of collagen causes
thinning of skin and wrinkling
‫٭‬ The incidence of thinning of skin and
wrinkling reduces by 30% in women on
traditional HRT
‫٭‬ Alzheimer disease

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WHY TREAT ?
‫٭‬ MEDICALIZATION OF NORMAL
PHYSIOLOGICAL PROCESS
– CHANGE OF LIFESTYLE
– DIETARY CHANGES
– EXERCISE
– REASSURANCE
– MEDITATION
‫٭‬ TREATMENT IMPROVES QUALITY OF
LIFE

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THE IDEAL HRT
‫٭‬ TREATS MENOPAUSAL SYMPTOMS
‫٭‬ BENEFICIAL EFFECT ON
CARDIOVASCULAR SYSTEM
‫٭‬ LOW INCIDENCE OF BREAST
TENDERNESS, NO INCREASE OF CA
BREAST
‫٭‬ NO ENDOMETRIAL PROLIFERATION
‫٭‬ TREATS VAGINAL ATROPHY
‫٭‬ PREVENTS MENOPAUSAL BONE LOSS

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PRE TREATMENT EVALUATION
‫٭‬ Routine Physical Examination
– Height
– Weight
– BP
– Breast Examination
– Pelvic Examination

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PRE TREATMENT EVALUATION
‫٭‬ Routine Screening Examination
– Mammography
– TVS
– Lipid Profile
– LFT
– Pap Smear

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Management of Menopause
‫٭‬ Counseling-Pregnancy and cancer
phobia
‫٭‬ Thorough clinical examination
‫٭‬ Contraceptive advice
‫٭‬ Diet
‫٭‬ Exercises

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Hormone Replacement therapy
‫٭‬ Estrogen
‫٭‬ Progesterone
‫٭‬ Androgens

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ESTROGENS
‫٭‬ Premarin, Conjugated estrogens 0.625
mg tab
‫٭‬ Premarin cream (conjugated estrogen)
‫٭‬ Evalon cream (Estriol succinate) 1 mg/g
‫٭‬ Progynova (Estradiol Valerate)
1 mg, 2 mg tab
‫٭‬ Estraderm skin patch, self adhesive
transdermal. 0.75, 1.5, 3 mg
‫٭‬ E 2 gel (estradiol 0.06% w/w)
‫٭‬ Sandrena gel (estradiol 1 mg / satchet)

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PROGESTERONES
‫٭‬ Deviry (medroxy progesterone acetate)
2.5 mg, 10 mg tab
‫٭‬ Regesterone ( Norethindrone acetate)
1 mg, 5 mg tab
‫٭‬ Microgest, Puregest (Micronised natural
progesterone) 100 mg, 200 mg, 400 mg
tab

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TRADITIONAL HRT
‫٭‬ Absence of uterus - continuos estrogen
replacement therapy (ERT)
‫٭‬ In presence of uterus (EPRT)
– addition of progesterones for 12-14 days each
month
• Cyclic (estrogen D 1-25, progesterone D 12-25)
• continuos (estrogen continuos, progesterone
D 12-25)

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CONTRA-INDICATIONS
‫٭‬ Active endometrial and gynaecological
hormone dependant cancers
‫٭‬ Active breast cancer and estrogen progestogen
receptor positive cancers
‫٭‬ Known or suspected pregnancy
‫٭‬ Undiagnosed, abnormal vaginal bleeding
‫٭‬ Severe active liver disease with
impaired/abnormal liver function
‫٭‬ Acute vascular thrombosis
‫٭‬ Estrogen dependent venous thrombosis
‫٭‬ Inherent increased risk of thromboembolism

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CONTRA-INDICATIONS
‫٭‬ Migraine headaches,
‫٭‬ Superficial thrombophlebitis
‫٭‬ Strong family history of breast cancer
‫٭‬ Uterine fibroids
‫٭‬ Endometriosis
‫٭‬ Gallbladder disease

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SIDE EFFECTS - ESTROGENS
‫٭‬ Leg pain
‫٭‬ Breast tenderness
‫٭‬ Headache
‫٭‬ Bloating
‫٭‬ Nausea
‫٭‬ Dyspepsia
‫٭‬ Vaginal discharge

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SIDE EFFECTS
PROGESTOGENS - PHYSICAL
‫٭‬ Acne
‫٭‬ Bloating
‫٭‬ Backache
‫٭‬ Breast tenderness
‫٭‬ Headache
‫٭‬ Dizziness
‫٭‬ Greasy skin
‫٭‬ Fatigue
‫٭‬ Weight gain

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SIDE EFFECTS
PROGESTOGENS - PSYCHOLOGICAL
‫٭‬ Anxiety
‫٭‬ Confusion
‫٭‬ Depression
‫٭‬ Forgetfulness
‫٭‬ Irritability
‫٭‬ Panic attacks
‫٭‬ Poor concentration
‫٭‬ Restlessness
‫٭‬ Poor sleep

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ANDROGENS
‫٭‬ Tab Testosterone undecanoate 40
mg/day
‫٭‬ Oral Micronised Testosterone 2.5
mg/day
‫٭‬ Gels, creams, transdermal matrix
patches

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ANDROGENS- INDICATIONS
‫٭‬ Premenopausally oophorectomized
women, who continue to suffer from
decreased libido or reduced energy
levels despite full dose ERT
‫٭‬ Women who have not experienced relief
of vasomotor symptoms despite
maximally tolerated estrogen dose
‫٭‬ Natural menopause with unsatisfactory
sexual function, especially loss of libido

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ANDROGENS
‫٭‬ Maximum duration 6-9 mths
‫٭‬ No long term studies
‫٭‬ Tibolone can be an alternative

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Other Drugs
‫٭‬ SERMS
– RALOXIFENE
– ORMILOXIFENE
‫٭‬ 19 nortestosterone derivative
– TIBOLONE
‫٭‬ PHYTO-ESTROGENS
– ISOFLAVONES
– LIGNANS

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Other Drugs
‫٭‬ Biphosphonates
‫٭‬ Herbs
‫٭‬ Micronutrients and antioxidants

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RALOXIFENE
‫٭‬ Dose - 60 mg/day
‫٭‬ Does not improve the vasomotor
symptoms of menopause, as well as the
symptoms of urogenital atrophy
‫٭‬ Important in Osteoporosis prevention
– Approved by USFDA for prevention and treatment
of osteoporosis in menopausal women
– MORE trial (Multiple Outcomes of Raloxifene)
– Increases bone mineral density
– Reduced incidence of fracture

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RALOXIFENE
‫٭‬ Effect on CVS
– Favourable effect on lipid profile
– Reduction in cardiovascular risk
‫٭‬ Effect on Endometrium
– No stimulatory effect
– Does not increase risk of endometrial hyperplasia

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RALOXIFENE
‫٭‬ Effect on breast
– Does not increase frequency of breast pain and
tenderness
– Reduces incidence of ER-positive breast tumours
– Long term effects on breast not known
Side Effects-Hot Flushes
Contraindications-Venous thrombosis,hepatic
dysfunction

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TIBOLONE
‫٭‬ Dose - 2.5 mg/day
‫٭‬ Estrogenic, progestogenic and
androgenic activity
‫٭‬ Tissue specific pharmacologic effects
‫٭‬ Metabolites
– Δ-4 tibolone
– 3α-OH tibolone
– 3β-OH tibolone

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TIBOLONE - clinical use
‫٭‬ Treatment of menopausal symptoms,
both vasomotor and psychological
‫٭‬ Beneficial effect on vaginal epithelium
‫٭‬ Reversal of atrophic vaginitis, reduction
of vaginal dryness
‫٭‬ Improvement of libido
‫٭‬ Reduction of dyspareunia

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TIBOLONE - clinical use
‫٭‬ Effect on Bone
– Exerts estrogenic effects on bone
– Effective in prevention and treatment of
osteoporosis
– Increases bone mass
– Prevents bone loss
– Reduces the incidence of fractures
‫٭‬ Effect on breast
– anti-estrogenic
– ? increase incidence of cancer breast
– No long term trials

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TIBOLONE - clinical use
‫٭‬ Effect on Endometrium
– No endometrial hyperplasia
– No effect on endometriosis
– Does not increase fibroid size
‫٭‬ No adverse effect on liver and renal
function
‫٭‬ No adverse effect on coagulation

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TIBOLONE - SIDE EFFECTS
‫٭‬ Vaginal bleeding
‫٭‬ Breast pain
‫٭‬ Headache
‫٭‬ Weight gain
‫٭‬ Edema
‫٭‬ Rash
‫٭‬ Depression

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PHYTOESTROGENS
‫٭‬ Isoflavones - Soya
– Dietary source
• Soy
• Lentils
• Beans
• Legumes
‫٭‬ Lignans - Flaxseed
– Dietary source
• Cereals
• Fruits
• Plant cell wall
• Flaxseed oil

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PHYTOESTROGENS
‫٭‬ Coumestans - Red Clover
– Dietary source
• Bean sprouts
• Sunflower seeds
• Red clover
‫٭‬ Weak estrogens. ER binding less than
1% of estradiol
‫٭‬ 300 plants possess estrogenic activity

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PHYTOESTROGENS
‫٭‬ Use of phytoestrogens associated with a
lower incidence of breast, endometrial,
and colorectal cancer
‫٭‬ Inhibitory effect on human cancer cell
line
‫٭‬ Decrease the intensity and frequency of
vasomotor symptoms
‫٭‬ Placebo controlled trial suggest that
daily intake of 60 gm/day soy protein is
useful in alleviating vasomotor
symptoms

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PHYTOESTROGENS
‫٭‬ Does not alter the psychological
symptoms of menopause
‫٭‬ Does not reduce symptoms of vaginal
atrophy
‫٭‬ Clinical trials have shown that the
incidence of cardiovascular disease is
reduced
‫٭‬ Favourable effect on lipid profile

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PHYTOESTROGENS
‫٭‬ Prevention of osteoporosis is
controversial. Data lacking
‫٭‬ Dose - 40 mg isoflavone daily
‫٭‬ Side effects:-
– acidity
– abdominal cramping
– constipation
– allergic reaction

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HERBS
‫٭‬ Turmeric
‫٭‬ Cumin (jeera)
‫٭‬ Saunf
‫٭‬ Methi
‫٭‬ Cardamom
‫٭‬ Cinnamon
‫٭‬ Saffron
‫٭‬ Ginger
‫٭‬ Ginseng

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BISPHOPHONATES
‫٭‬ Antiresorptive drugs
– Suppress bone resorption
– improve bone mass
– reduce fracture risk
‫٭‬ Alendronate
– For prevention 5 mg/day or 35 mg/week
– For treatment 10 mg/day or 70 mg/week
– Double blind randomised, placebo controlled trials
have shown efficacy in increasing bone mass and
reducing fracture incidence

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BISPHOPHONATES
‫٭‬ The effect lasts for 2 years after
stopping the drug
‫٭‬ Can be used safely for 7 years
‫٭‬ Can be combined with HRT
‫٭‬ Given along with calcium and Vit D

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CALCITONIN
‫٭‬ Not enough evidence
‫٭‬ Trials have shown some increase in
bone density
‫٭‬ Available as inj 100 U s/c per day or
Nasal spray 200 U/day

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MICRONUTRIENTS &
ANTIOXIDANTS
‫٭‬ Micronutrients & antioxidants have
definite beneficial effect on oxidative
stress of menopausal women
‫٭‬ Existing evidence supports increased
requirement for Vitamins E, A, C and
selenium. Recent evidence for increase
requirement of B1 and B6 is also
accumulating

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MICRONUTRIENTS &
ANTIOXIDANTS
‫٭‬ A balanced diet with 5–9 servings of
fruits & vegetables can provide all the
micronutrients & antioxidants

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‫٭‬ Menopause is ……….
not a pause,
…..It’s beginning of new
Life…………

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To be
continued

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“ You do not heal old age
You protect it;
You promote it;
You extend it.”
Sir James Ross

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Heart and Estrogen/Progestin
Replacement Study (HERS I)
(JAMA 1998)
 Secondary prevention of coronary heart
disease
 Included only women with a prior
history of CVD
 Average age - 67 years
 Duration of the follow-up was 4.1 years
among 2763 women
 Randomized to 0.625 mg of CEE plus 2.5
mg of MPA, to placebo
 Evaluate effects of HRT on fatal &
nonfatal CAD

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Mean Change in LDL, HDL and Triglyceride
Levels by One Year
HERS
JAMA 1998: 280: 605-613
% change from baseline
to year one
15
10
5
0
oestrogen-progestin
placebo
LDL-C HDL-C Triglycerides
-5
-10
-15
-20

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Incidence of Non Fatal MI and CHD Death
HERS
JAMA 1998: 280: 605-613
Incidence (%)
15
10
5
0
0 1 2 3 4 5
Follow-up (years)
oestrogen-progestin
placebo

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Despite improving the lipid
profile in women with CHD,
HRT did not improve their
survival

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HERS II RESULTS
(2002)
‫٭‬ The HERS II study reconfirms the absence of
secondary cardioprotection. However it
demonstrates no overall increased cardiac risk
with long term use.
‫٭‬ Extension of HERS I study
‫٭‬ Follow up of 6.8 yrs

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HRT & CA BREAST
‫٭‬ Meta-analysis published in Lancet 1997
‫٭‬ 52,705 patients of breast cancer and
108,411 women without breast cancer
were evaluated retrospectively
‫٭‬ Ever users for > 5 yrs had a relative risk
of 1.35 and risk increased with increasing
duration of use
Collaborative Group on Hormonal Factors in Breast Cancer. Lancet; 1997; 350: 1047

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What was the “ WHI (The
Women’s Health Initiative
Study)” all about?
JAMA, July 17, 2002 -- Vol 288, No. 3

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Objective
• Assess the major health benefits and risks of the most commonly used
combined hormone
Design
• First randomized placebo controlled primary prevention trial with oral
estrogen- progestin
Patient Population
• 16,608 post- menopausal women with intact uterus aged from 50 -79
Interventions
• 0. 625mg Premarin & 2.5mg Provera (PremPro)
Main Outcomes
– Coronary heart disease (nonfatal myocardial infarction and CHD death)
– Invasive breast cancer
Planned Duration
• 8. 5 years, however, stopped at 5.2 years on 31 Mar 2002
JAMA, July 17, 2002 -- Vol 288, No

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WHI TRIAL

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• Monitored outcomes
– Coronary Heart Disease (CHD)
– Invasive Breast Cancer
– Stroke
– Pulmonary Embolism (PE)
– Endometrial Cancer
– Colorectal Cancer
– Hip Fracture
– Death due to other causes
Risk ratio
calculated for
each condition
WHI TRIAL

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KAPLAN MEIER ESTIMATES

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CHD EVENTS
‫٭‬ Relative risk - 1.29
‫٭‬ Additional cases per 10,000 women/yr-7
‫٭‬ Higher in the first year
‫٭‬ With another peak at year 5
‫٭‬ Beneficial effect seen in year 6

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STROKE
‫٭‬ Relative risk - 1.41
‫٭‬ Additional cases per 10,000 women/yr-8
‫٭‬ Risk appeared during the 2nd year and persisted
through to 5th year
‫٭‬ Beneficial effect seen in the 6th year

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BREAST CANCER
‫٭‬ Relative risk -
‫٭‬ Additional cases per 10,000 women/yr-8
‫٭‬ Significant risk after first 4 years.
‫٭‬ Highest in the 5th year .
‫٭‬ Risk seemed to decline in the 6th year.
‫٭‬ Higher in women with prior use of hormones
‫٭‬ No increase in in-situ form of breast cancer
‫٭‬ Probably hastened detection of small existing
cancers

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PULMONARY EMBOLISM
‫٭‬ Relative risk - 2.11
‫٭‬ Additional cases per 10,000 women/yr-8
‫٭‬ Greatest in first 2 years
‫٭‬ With a second peak at year 5
‫٭‬ Beneficial effect seen in year 6.

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COLORECTAL CANCER
‫٭‬ Relative risk - 0.63
‫٭‬ Less cases per 10,000 women/yr - 6
‫٭‬ Beneficial effect seen in year 6.

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HIP FRACTURES
‫٭‬ Relative risk - 0.66
‫٭‬ Less cases per 10,000 women/yr - 5

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ALL CAUSE MORTALITY
NOT INCREASED

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WHY DID THE TRIAL STOP ?
ESTROGEN - PROGESTIN ARM
crossed global index of 19/10,000
RISKS
CHD > 7
STROKES > 8
BREAST CANCER > 8
PE > 8
BENEFITS
COLORECTAL CA < 6
HIP FRACTURES < 5
RISK - BENEFIT ANALYSIS
~ 19 additional risks per 10,000 patient years

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ESTROGEN ONLY ARM
DID NOT REACH A RISK -
BENEFIT LEVEL OF CONCERN
HENCE CONTINUING
STUDY CONCLUDES ON 31 MAR 2005

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LIMITATIONS OF WHI TRIAL
‫٭‬ The trial tested only one drug regimen and in
one fixed dose only
‫٭‬ The findings should not be extrapolated to
other forms of therapy like tibolone, SERMs,
phytoestrogens etc
‫٭‬ The trial did not differentiate between the
effects of estrogen and the MPA
‫٭‬ The results of this trial do not necessarily
apply to other routes of administration

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LIMITATIONS OF WHI TRIAL
‫٭‬ The long term effects have not really been
assessed because of stopping the trial early
‫٭‬ Some of the women participating in the trial
had either been past or current HRT users
with a family history of breast cancer
‫٭‬ The mean age of women in this trial was 63.3
years. This is an older age group than the
one which usually seeks HRT for symptom
relief

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HRT & CA OVARY
‫٭‬ Short term Estrogen-Progestin only
replacement therapy does not increase risk of
ovarian cancer in women.
‫٭‬ Women on Estrogen –only (unopposed
estrogen) therapy, particularly for 10 years or
more were at significant risk of ovarian
cancer.
Menopausal Hormone Replacement Therapy and Risk of Ovarian Cancer.
JAMA, July 17, 2002 –Vol288, No3, 334-431

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ASYMPTOMATIC
MENOPAUSAL WOMEN
NO TREATMENT

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SYMPTOMATIC MENOPAUSAL
WOMEN
‫٭‬ VASOMOTOR SYMPTOMS - TREAT
‫٭‬ ONLY PSYCHOLOGICAL SYMPTOMS
- DO NOT TREAT
– CHANGE OF LIFE STYLE
– DIETARY CHANGES
– EXERCISE
– MEDITATION

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SYMPTOMATIC MENOPAUSAL
WOMEN
‫٭‬ HYSTERECTOMIZED PATIENT
– ONLY ESTROGEN (ERT) 0.625 mg PREMARIN
DAILY
‫٭‬ INTACT UTERUS
– COMBINED ESTROGEN-PROGESTERONE
REPLACEMENT THERAPY
– 0.625 mg PREMARIN + 2.5 mg DEVIRY DAILY
– 0.625 mg PREMARIN DAILY + 10 mg DEVIRY FOR
12 DAYS IN A MONTH

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HOW LONG ?
‫٭‬ ERT - Results awaited (Mar 2005)
– More than 10 yrs - RR of Ca Ovary 2.0
‫٭‬ EPRT
– 2 Years
– Definitely not more than 4 years
– Taper off over 4 weeks ( every alternate day)
– Stop during winter months
– The increase in cardiac events in the first year in
the WHI trial could well be because the trial was
dealing with a mean age group of women who
were 63.3 years of age. Hence this data need not
necessarily apply to women in their 50s.

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HOW LONG ?
‫٭‬ EPRT
– In the WHI trial the risk of pulmonary embolism is
greatest in the first 2 years and the risk of stroke
appears in the 2nd year. The women considering
HRT would need to be counseled regarding these
issues
– If symptoms persist after withdrawal, consider:
• Change of life style
• Tibolone
• Phytoestrogens
• Herbal treatment

93. spsk
DO NOT START ERT/EPRT IN
THE SIXTH DECADE OF LIFE
ONWARDS

94. spsk
DO NOT GIVE HRT FOR
‫٭‬ PRIMARY OR SECONDARY
CARDIOPREVENTION
‫٭‬ OSTEOPREVENTION
‫٭‬ TREATMENT OF OSTEOPOROSIS

95. spsk
PATIENT HESITANT FOR
ERT/EPRT
‫٭‬ TIBOLONE
– Effective in alleviating symptoms
– Androgenic effects
– No need for adding progestogens
– Vaginal bleeding, depression
– Costly
– Long term randomised studies lacking

96. spsk
PATIENT HESITANT FOR
ERT/EPRT
‫٭‬ PHYTOESTROGENS
– Till further evidence is available, the use of
extracted phytoestrogen preparations cannot be
propagated. However consumption of natural
whole food with high content of phytoestrogens is
a good alternative until more scientific data is
available
– Do not alleviate psychological symptoms
– Do not improve urogenital symptoms

97. spsk
POSTMEONOPAUSAL
OSTEOPOROSIS
‫٭‬ PHARMACOTHERAPY FOR:-
– TREATMENT OF OSTEOPOROSIS
– PREVENTION OF OSTEOPOROSIS
• BMD WITH T-SCORE < 2.0
• BMD WITH T-SCORE < 1.0 WITH RISK
FACTORS OF OSTEOPOROSIS

98. spsk
POSTMEONOPAUSAL
OSTEOPOROSIS
‫٭‬ TAB ALENDRONATE
– For prevention - 5 mg/day or 35 mg/week
– For treatment - 10 mg/day or 70 mg/week
– For 7-9 years
‫٭‬ TAB RALOXIFENE
– Dose 60 mg/day
– Suitable in patients interested in breast cancer risk
reduction
– Does not alleviate menopausal symptoms

99. spsk
POSTMEONOPAUSAL
OSTEOPOROSIS
‫٭‬ TIBOLONE
– Dose 2.5 mg/day
– If patient has associated menopausal symptoms
‫٭‬ ALL PATIENTS WITH LOW BMD GIVE:-
– TAB CALCIUM 1200 mg - 1500 mg DAILY
– TAB VIT D 400 IU - 800 IU DAILY

100. spsk
ONGOING IMPORTANT
TRIALS
‫٭‬ WHI - ESTROGEN ONLY ARM
‫٭‬ WISDOM - Women International Study
of Long Duration Estrogen after
Menopause
‫٭‬ RUTH - Raloxifene use for the Heart
‫٭‬ MORE - Multiple outcomes of Raloxifene
evaluation