HRT-what you need to know! why opt for it? who should take it? contraindications. estrogen therapy, progestins, tibolone. *Associations with osteoporosis, breast cancer, endometrial cancer

1. HORMONE REPLACEMENT
THERAPY

2. • Initially, Every menopausal woman
was advised to go on HRT as soon as
menopause sets in.
• Now, 70-80% of women remain
healthy & need only good nutrition &
healthy lifestyle.
• Few women need prophylactic &
therapeutic HRT.

4. Who needs HRT?
THERAPEUTIC
• Symptomatic women who
suffer from estrogen
deficiency.
• Gonadal dysgenesis in
adolescents.
PROPHYLATIC
• High risk cases of menopausal
complications like
cardiovascular disease,
osteoporosis, stroke,
Alzheimer's disease & colonic
cancer.
• Premature menopause or
following surgery,
chemotherapy or
radiotherapy.

5. • Symptomatic women (vasomotor symptoms, urinary
symptoms, sexual disharmony with dyspareunia): HRT for 3-6
months.
• After 6 months, woman gets adjusted and settles down with
menopausal phase of life.

6. INDICATIONS
• Short term-
– Hot flushes, vasomotor symptoms
– Dyspareunia, libido
– Urethral symptoms
• Long term-
– osteoporosis
– Cardiovascular
– Alzheimer’s disease

7. CONTRAINDICATIONS
• Breast cancer, uterine cancer or family history of cancer
• Previous history of thromboembolic disorder.
• Liver & gall bladder disease.
• Lipid profile dysfunction.
• Uterine fibroids

8. OSTEOPOROSIS & HRT
• Prevents bone loss  reduces risk of fractures to 25-50%
• Prescribed when osteopenia is observed while study of bone
density mass.
• For osteoporosis early in menopause: natural oestrogen, progestogen,
tibolone & raloxifene.
• For osteoporosis late in menopause: bisphosphonates.
• Oestrogen protects against osteoporosis by 50% in all skeletal bones.

9. PROPHYLAXIS OF OSTEOPOROSIS
• Oestrogen hormone therapy ERT (hysterectomised)
• HRT
• Tibolene
• Raloxifene
• Soya
• Bisphosphonates
• Calcitonin
• Diet

10. CARDIO-PROTECTIVE EFFECT OF HRT
• Oestrogen deficiency: ↑ risk of atherosclerosis, ischemic
heart diseases & angina.
• HRT: ↑ HDL, ↓LDL, cholesterol & TG.

11. ESTROGEN THERAPY
• Oral
• Transdermal
• Vaginal cream
• Vaginal ring
• Implants

12. ORAL THERAPY
• Short term therapy (lowest dose) for hot flushes, night sweats,
palpitations & disturbed sleep.
• Preparations of oestrogen:
– Oral Premarin(E1 natural equine-conjugated oestrogen)
0.625mg OD upto 1.25mg
– Ethinyl oestradiol 0.01mg
– Micronized oestrogen 1-2mg
– Evalon 1-2mg

13. ORAL THERAPY
• Long term therapy:
– In delaying osteoporosis & reducing cardiovascular diseases.
– Beyond 8-10 years is not beneficial.
ADVANTAGES DISADVANTAGES
Cheap & easy to take High doses are required(oestrone in
intestine & liver  10% reaches systemic
circulation)
Good for lipid profile & cardiovascular
protection
Daily intake
High incidence of side effects.
Increase chances of HTN,
thromboembolism

14. TRANSDERMAL PATCH
• Estraderm patch: 3-4 mg oestradiol & releases 50 mcg each
day.
• Applied away from breasts on arms, legs & thighs.
• Patch needs to be changed twice.

15. TRANSDERMAL ESTROGEN
Advantages
• Low-dose estradiols
• Avoids first pass effect &
liver metabolism
• Reduces TG
• No thromboembolic or
hypertension risk
Disadvantages
• Costly
• Not tolerated in warm
climates
• Variable absorption
• Skin reaction with alcohol
based patches

16. • VAGINAL CREAM:
– Dyspareunia, urethral syndrome & senile vaginitis.
– Oestriol base cream ½ g is applied everyday -10-12 days for 3-6
months.
• VAGINAL RING:
– Estring releases 5-10mcg oestrogen for 90 days.
• IMPLANT:
– Containing 25-50mg oestradiol is effective for 6 months each.
– Maintains E2 level at 50-60pg/ml.
– Suitable in hysterectomised patients.

17. PROGESTINS
• Used to avoid the risk of endometrial hyperplasia & cancer of non-
hystrectomised patients.
• Given 12 days in each cycle reduces risk to less than 2%.
• Enzyme: 17β-hydroxydehydrogenase  inactivates E2 controls mitotic
activity in endometrial cells.
• Drugs :
– Duphaston/medroxyprogesterone 10mg
– Primolut-N 2.5mg OD for 10-12 days each month (prevent
endometrial hyperplasia)

18. PROGESTINS
• Side effects:
– Bloated feel
– wt. gain
– Depression
– Adversely alter lipid profile
– poor compliance
• Mirena IUCD (levonorgestrel) for 5 years.
• Drospirenone: no androgenic & adverse lipid effect.
– 3mg combined 30mcg estradiol is been tried.
• Testosterone implant & combined tablet with oestrogen- to improve
libido

19. OTHER DRUG
• Tibolone: synthetic derivative of 19-nortestoterone
– Weak oestrogenic, progestrogenic & androgenic action.
– Elevates mood, relieves vasomotor symptoms, improves sex drive &
reduces bone resorption
– Cardioprotective  decreases TG
– S/E: wt. gain, edema, tenderness in breast, vaginal bleed, greasy skin.

20. HRT & BREAST CANCER
• Risk does not increase upto 3yrs of HRT & 5yrs of oestrogen alone
replacement therapy.
• Can cause recurrence of breast cancer.
• Increases density of breast tissue & impede screening programme
of mammogram subsequently.
• Breast cancer following HRT – low grade with good prognosis

21. HRT & ENDOMETRIAL CARCINOMA
• ERT can cause well differentiated carcinoma.
• Minimum of 12 days of progesterone added to ERT reduces
risk to 2%
• Combined HRT – better protection
• Tibolene – safe drug which does not cause endometerial
hyperplasia.

22. MONITORING BEFORE & DURING HRT
Baseline parameters and their subsequent check-ups necessary:
• Physical examination including pelvic examination
• Blood pressure recording
• Breast examination & mammography
• Cervical cytology
• Pelvic ultrasonography: to measure endometrial thickness
• Endometrial biopsy, hysteroscopy- any irregular bleeding
• Serum estradiol levels (100pg/ml)

23. THANK YOU