53 YEAR OLD WOMAN WANTING Fatima Jamshaid

TO START HORMONE
REPLACEMENT THERAPY (GY 5.3) 521513
 OBJECTIVES
 What is Hormone replacement therapy?
 Hormones involved
 Menopause and perimenopause
 Signs and symptoms
 Evaluation
 Diagnosis
 Indications and contraindications
 Benefits and risks of therapy
 Types of therapy
 Duration and monitoring
 Adverse Effects
WHAT IS HORMONE
REPLACEMENT THERAPY
(HRT)?
• Treatment used to relieve symptoms of perimenopause and
menopause

• Involves replacement of female hormones which decline with

age (estrogen and progesterone)

• Decrease in the levels of estrogen is responsible for causing most

of the symptoms of menopause
HORMONES INVOLVED
MENOPAUSE
• Natural menopause is defined as the permanent cessation of
menstrual periods,
• determined retrospectively after a woman has experienced 12 months of
amenorrhea
• without any other obvious pathological or physiological cause.

• Menopause is a gradual process.

PERIMENOPAUSE
• The transitional period before menopause, during which
menopausal symptoms begin to appear, is known as
perimenopause.

• Perimenopause is characterized by
• irregular menstrual cycles
• endocrine changes
• symptoms such as hot flashes.
SIGNS AND SYMPTOMS
Immediate (0-5 years) Intermediate Long term
▹ Vasomotor symptoms (e.g. hot (3-10 years) (>10 years)
flushes, night sweats)
▹ Psychological symptoms (e.g. ▹ Vaginal dryness, soreness ▹ Osteoporosis
labile mood, anxiety)
▹ Dyspareunia ▹ CVD
▹ Loss of concentration, poor
▹ Urgency of urine ▹ Dementia
memory
▹ Recurrent urinary tract
▹ Joint aches and pains
infections
▹ Dry and itchy skin
▹ Urogenital prolapse
▹ Hair changes
▹ Decreased sexual desire
EVALUATION
The evaluation for women of all ages should start with
• an assessment of the woman's menstrual cycle history (ideally with a menstrual
calendar)
• a detailed history of any menopausal symptoms (hot flashes, sleep disturbances,
depression, vaginal dryness)
• All women with symptoms should have a pelvic exam to evaluate for vaginal
atrophy.
• Medication history especially use of any herbal medication or OCPs
• Any significant past medical or surgical history including hysterectomy/endometrial
ablation
DIAGNOSIS
Women > 45 years
▹ Irregular menstrual cycles with
menopausal symptoms enough to
make dx of menopausal transition
▹ The possibility of pregnancy must
always be ruled out
▹ For asymptomatic women with
irregular periods, a serum FSH >15
to 25 international units/L would be
reassuring that this is simply the
menopausal transition and nothing
else
▹ Normal FSH does not rule out the
possibility of menopause because it
is variable
Women 40 – 45 years
▹ same as that for women over
45 years,
▹ except that other causes of
menstrual cycle dysfunction
must first be ruled out
▹ This would include lab
testing to exclude the
following:
▸ Pregnancy
▸ Hyperprolactinemia
▸ Hyperthyroidism
Women <40 years
▹ Evaluate for other causes
▹ Should not be dx as
menopausal
Women on OCPs
▹ Stop the pill
▹ FSH levels after 2-4 weeks
▹ FSH >25 positive
Women s/p hysterectomy or
endometrial ablation
▹ Measure serum FSH >25
INDICATIONS OF HRT
• To relieve vasomotor symptoms
• Vulvovaginal atrophy or genitourinary symptoms of menopause
• To improve urogenital symptoms
• To improve joint pains/ stiffness
• To improve mood lability/ depression
• Improve libido
• Prevention and treatment of osteoporosis
CONTRAINDICATIONS OF HRT
• History of breast cancer
• CHD
• Previous thromboembolic event
• Previous stroke
• Active liver disease
• Unexplained vaginal bleeding
• High-risk endometrial cancer
• High-risk transient ischemic attack
• Women with hypertriglyceridemia
• Active gallbladder disease
• Thrombophilias such as factor V Leiden.
BENEFITS AND RISKS
INVESTIGATIONS
BASELINE
• CBC
• LFTs
• Lipid profile

SPECIFIC
• Pelvic ultrasound scan +biopsy
• Thrombophilia screen
• Mammography/MRI
• Cervical screening
ESTROGREN THERAPY (PILLS)
Oral medication is the most common form of ERT. Examples are conjugated
Estrogens (Premarin), estradiol (Estrace), and Estratab.
PROS CONS
▹ reduce or resolve ▹ Increase in the risk of
strokes, blood clots, and
troublesome symptom other problems.
s of menopause. ▹ When combined with the
▹ lower the risk hormone progestin, the
of osteoporosis. risks of breast
CA and MI may rise as
well.
▹ Side effects include painful
and
swollen breasts, vaginal
discharge, headache,
and nausea.
ESTROGEN THERAPY
(TRANSDERMAL PATCHES)
PROS CONS
▹ More convenient to ▹ Milder side effects like
painful and swollen breasts,
use vaginal
▹ better tolerated for ▹ discharge, headache, and
liver disease, nausea. The patch itself
might irritate the skin
▹ decreases risk of clot where you apply it.
formation. ▹
Estrogen patches should
not be exposed to high heat
or direct sunlight.
ERT (TOPICAL CREAMS,
GELS, AND SPRAYS)
PROS CONS
Because estrogen creams can rub or wash off
are absorbed through the before it's been fully
skin and go directly into
absorbed.
the bloodstream, they're
safer than oral estrogen
for people who have liver
and cholesterol problems.
ERT ( VAGINAL SUPPOSITORIES, RINGS, AND
CREAMS)
These types of estrogen treatments can be applied directly to the vaginal area.
In general, these treatments are for women who are troubled specifically
by vaginal dryness, itchiness, and burning or pain during intercourse.
PROS CONS
▹ they can relieve ▹ only help with vaginal
vaginal symptoms symptoms of
without exposing the surgical menopause due
entire body to high to low dose.
doses of estrogen. ▹ They won't help with
▹ Theoretically, this other symptoms like hot
could reduce the more flashes.
serious risks of
estrogen.
COMBINATION THERAPY
• It combines doses of estrogen and progestin, the synthetic form of progesterone.
It’s meant for women who still have their uterus. Taking estrogen
with progesterone lowers the risk of developing endometrial cancer.
• Oral progestins – Taken in pill form, progestin medications
include medroxyprogesterone acetate (Provera) and the synthetic progestin pills
(norethindrone, norgestrel).
• Many experts now treat the majority of their menopausal patients with natural
progesterone rather than synthetic progestins.
• Intrauterine progestin – The low-dose intrauterine devices (IUD) levonorgestrel
are sold under the brand names: Liletta, Kyleena, Mirena and Skyla).
DURATION AND MONITORING
• For women who choose estrogen or combined EPT, short-term use is suggested,
generally not more than five years or not beyond age 60 years.
• However, hot flashes persist for an average of 7.4 years, and many women continue to
have symptoms for more than 10 years. Some women with persistent symptoms choose
longer-term therapy
• For women who experience recurrent, bothersome hot flashes after stopping estrogen,
we initially suggest non-hormonal options before considering resuming estrogen. For
those who do not get adequate relief with non-hormonal therapies, we consider extended
use of hormone therapy.
• Outline mammograms and breast exams are recommended in women taking MHT,
even when used short-term. The risk of breast cancer with combined EPT does not
increase until the fourth year. 
ADVERSE EFFECTS
ESTROGEN PROGESTERONE
RELATED RELATED

• Fluid retention
▹ Fluid retention • Breast tenderness
▹ Nausea • Headaches
▹ Headaches • Acne
▹ Breast enlargement • Mood swings
▹ Leg cramps • Depression
• Irritability
▹ Dyspepsia
• Bloating
• Increased appetite
REFERENCES
•https://www.medicinenet.com/menopause/article.htm
•https://www.uptodate.com/contents/treatment-of-menopausal-symptoms-with
-hormone-therapy
•https://www.uptodate.com/contents/clinical-manifestations-and-diagnosis-of-
menopause#H93667232
•https://www.uptodate.com/contents/menopausal-hormone-therapy-benefits-
and-risks
•https://www.glowm.com/section_view/heading/TheGynecologicHistoryandE
xamination/item/3
•https://www.webmd.com/menopause/guide/menopause-hormone-therapy#2
•https://www.webmd.com/menopause/guide/which-type-of-estrogen-hormone
THAN
K