Presented By

Piyali Bhatta
Msc Nursing 1st year
Roll No -2188017
DEFINITION

Hormone replacement therapy (HRT) is a treatment used to

relieve symptoms of the menopause. It replaces female
hormone(estrogen)that is at a lower level as you approach the
menopause.
NEEDS OF HRT:

Symptomatic women who suffer from oestrogen deficiency.

High risk cases of menopausal complications such as
cardiovascular disease, osteoporosis, stroke, Alzheimer's
disease and colonic cancer
Premature menopause(spontaneous/post surgery)
Gonadal dysgenesis (therapeutic)
Women demanding HRT as prophylaxsis.
DRUGS USED IN HRT:

 ESTROGEN
 PROGESTERONE
 TIBOLONE
 RALOXIFENE
 BISPHOSPHONATES
 SOYA
 ANDROGENS
CATRGORIES

The short term use for relief of symptoms caused by lowered estrogen.
The long term therapy use for long term of period, can extends for a period of five to ten years or even be lifelong
BENIFITS

Most effective treatment at reducing vasomotor systems.

 Improvement in quality of life
 HRT may also improve sleep, muscle aches and pains and quality of life in symptomatic women.
 Improvement in quality of life: HRT may also improve sleep, muscle aches and pains and quality of life in symptomatic women.
 Short-term HRT may improve mood and also depressive symptoms.
 Improvement of urogenital symptoms: Various studies have shown that HRT significantly improves vaginal dryness and sexual function.
 Improving the symptoms related to vaginal atrophy
 Relieve the symptoms of urinary frequency, as it has a proliferative effect on the bladder and urethral epithelium.
 Topical oestrogen is very effective improving urinary symptoms in in menopausal women.
 Reduction in osteoporosis risk: HRT is effective in preserving bone mineral density.
 Taking HRT leads to a reduction in osteoporosis in the spine and hip.
 HRT is the first- line treatment for the prevention and management of osteoporosis in women with menopausal symptoms who are under the age of 50 years
INDICATIONS

 Relief of menopausal symptoms.

 Prevention of osteoporosis.
 To maintain the quality menopausal years. Of Life in
 Special group of women to whom HRT should be prescribed:
 Premature ovarian failure
 Gonadal dysgenesis.
 Surgical or radiation menopause.
 AVAILABLE
PREPARATIONS
FOR
HORMONE REPLACEMENT THERAPY
THE PRINCIPLE HORMONE USED IN HRT IS ESTROGEN.

 This is ideal for a woman who had her uterus removed ( hysterectomy) already. But in woman with an intact
uterus only estrogen therapy leads to endometrial hyperplasia and even endometrial carcinoma. Addition of
progestins for last 12-14 days each month can prevent this problem.
 Commonly used estrogens conjugated estrogen( 0.625-1.25 mg/ day) or micronized estradiol ( 1-2 mg/ day).
 Progestins used are medroxyprogesterone acctate (2.5- 5 mg/day), micronized progesterone ( 100 300 mg/day)
or dydrogesterone (5-10 mg/day)
 Considering the risks, hormone therapy I should be used with the lowest effective dose and for a short period of
time.
 Low dose oral conjugated estrogen 0.3 mg daily is effective and has got minimal side effects.
 Dose interval may be modified as daily for initial 2-3 months then it may be changed to every other day for
another 2-3 months and then every third day for the next 2-3 months.
 It may be stopped thereafter if symptoms are controlled
 Oral estrogen regime:- Estrogen Conjugated equine estrogen 0.3 mg or 0.625 mg is given daily for women who
had hysterectomy.
 Estrogen and cyclic progestin - For a women with intact uterus estrogen is given continuously for 25 days and
progestin is added for last 12-14 days.
  
 Continuous estrogen and progestin therapy- Continued combined therapy can prevent endometrial hyperplasia.
There may be irregular bleeding with this.
 Subdermal implants:- Implants are inserted subcutaneously over the anterior abdominal wall using local
anesthesia.
 17 beta 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. Implants maintain physiological Estradiol (E2) to Estrone
(E1) ratio.
 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 estradiol (90 120 pg/mL) can be maintained.
 Transdermal patch:- It contains 3.2 mg of 17 betaestradiol, releasing about 50 ug of estradiol in 24 hours.
 Physiological level of E2 to E1 is maintained. 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.
 It also reduce urinary frequency, urgency and recurrent infection. Women with symptoms of urogenital atrophy
and urinary symptoms and who do not like to have systemic HRT, are suitable for such treatment.
 Progestins: In patient with history of breast carcinoma, or endometrial carcinoma, progestins may be effective in
suppressing hot flushes and it prevents osteoporosis. Medroxyprogesterone acetate 2.5 - 5 mg/day can be used.
 (LNG-IUS Levonorgestrel intrauterine system) :- With daily release of 10 microgram of levonorgestrel per 24
hours, it protects the endometrium from hyperplasia and cancer.
  
 Tibolone - Tibolone is a steroid ( 19 nortestosterone derivative) having weekly estrogenic, progestogenic and
androgenic properties.
 • It prevents osteoporosis, atrophic changes of vagina and hot flushes. It increases libido. Endometrium is
atrophic. A dose of 2.5 mg per day is given.
ACTION OF ESTROGEN

 The action of estrogen is medicated through receptors. The two distinct types of receptors, ER alpha and ER beta
are similar but functionally different as they are expressed differently in the various parts of the body.
 Estrogen Receptor alpha is predominant in the breast, uterus and vagina and is mainly involved in reproductive
events.
 When estrogen or any other compound bind with these receptors, it causes a conformational change that then
predicts the response in the various end organs.
 Depending on the predominant receptor found in the end organ, differing responses may then be obtained.
 The principal aim of HRT is to restore healthy levels of estrogen so as to reduce the effects of estrogen
deprivation.
 HRT can be started at the menopausal or post menopausal phase.
ACTION OF ESTROGEN

 To starting HRT, a full examination which includes a detailed history, general examination, blood pressure
reading, breast examination, Pap smear and a gynecological examination is important.
 Screening mammograms should encouraged in women over the age of fifty.
 Bone mineral density testing should be carried out in women with a high risk osteoporosis. Every woman should
be counseled in detail regarding HRT.
 Her individual benefits and risks towards HRT should be evaluated.
 . Estrogen Receptors beta is more general and is found in the ovary, brain, cardiovascular system and skin.
HRT RISK AND POSSIBLE SIDE EFFECTS
ENDOMETRIAL CANCER

 When estrogen is given alone to a women with intact uterus, it causes endometrial proliferation, hyperplasia and
carcinoma.
 It is therefore advised that a progestrogen should be added to HRT to counter balance such risks.
 Research shows that who have their uterus and use estrogen alone are at risk of endometrial cancer
BREAST CANCER :

 Combined estrogen and progestin replacement therapy, increases the risk of breast cancer slightly.
 Adverse effects of hormone therapy are related to the dose and duration of therapy.
 Recent research by women's health initiative (WHI) indicates that hormone therapy and especially estrogen
progestin therapy, increases the risk of breast cancer although the increase in
VENOUS THROMBOEMBOLIC ( VTE) DISEASE:-

 Has been found to be increased with the use of combined oral estrogen and progestin.
 Transdermal estrogen use does not have the same risk compared to oral estrogen.
 Research by Heart and Estrogen Replacement Study and WHI shown that there is a 2 to 3 fold increase in VTE
events with HRT use.
 Slightly increased risk of blood clots, associated primarily with oral estrogens such as Premarin.
  
 Hormones used in HRT can have associated side effects like fluid retention, bloating, breast tenderness or
swelling, headaches, indigestion, depression, acne, backache.
CORONARY HEART DISEASES (CHD) :

 Combined HRT therapy shows a relative hazard of CHD. Hypertension has not been observed to be a risk of HRT. 
 Research by Women's Health Initiative ( WHI) trial demonstrated that there was a small increase in the incidence
of coronary heart disease in the first year after starting HRT ( women in this trial were taking conjugated equine
oestrogens with or without medroxyprogesterone acetate).
LIPID METABOLISM :-

 An increased incidence of gallbladder disease has been observed following HRT due to rise in cholesterol.
Research by WHI shown that HRT increase the cholesterol level.
DEMENTIA, INCREASED ALZHEIMER:

 Disease are Research by WHI memory study showed that in women above the age of 65 years, have greater
chance of developing Alzheimer and Dementia with HRT.
 Slightly increased risk of blood clots, associated primarily with oral estrogens such as Premarin.
 Hormones used in HRT can have associated side effects like fluid retention, bloating, breast tenderness or
swelling, headaches, indigestion, depression, acne, backache
CONTRAINDICATION

 Known or suspected pregnancy or breast cancer.

 Undiagnosed genital tract bleeding.
 Presence estrogen dependent neoplasm in the body.
 Neoplasia is a medical term describing an abnormal group of rapidly dividing cells.
 An estrogen dependant neoplasia is a type of breast tumor that is dependent on estrogen for growth.
 History of venous thromboembolism.
 Active liver disease. Gallbladder disease.
ROLE OF CALCIUM

 Adequate calcium intake has been shown to prevent bone loss and reduce fracture risk in peri and post
menopausal women.
 Though not as effective as other antiresorption agents, doses between 1000 and 1500 mgs of calcium per day
have been shown to be effective.
 Vitamin D (400-600 IU/day) to aid calcium absorption, is supplemented in women who are unable to get enough
sunlight or those who are institutionalized.
THE PRESENT RECOMMENDATION TOWARDS HRT USE ARE:

 An individual risk profile is essential for every women contemplating any regimen of HRT. Women should be
informed of the risk.
 The primary indication of HRT is the treatment of menopausal symptoms ( vasomotor and urogenital).
 Women with an intact uterus should be given progestin for more than 10 days while women without a uterus
should only have estrogen.
OTHER ESTROGEN- PROGESTIN COMBINATIONS AND A TRANSDERMAL
THERAPY

 Other estrogen- progestin combinations and a transdermal therapy should be considered.

 In practice, HRT is the drug of choice for women with vasomotor symptoms and is advised to be given short term.
 Short term previously considered at 5 years, however with the increased risk of breast cancer after 4 years in the
WHI study, short term seems now more in the region of 3 to 4 years.
 Women already on HRT for long term should evaluate their individual risks and benefits and consider alternative
therapy.
 For women planning to discontinue HRT, there is no definitive guide to this process.
CONTRAINDICATION

 Known or suspected pregnancy or breast cancer

 .Undiagnosed genital tract bleeding.
 Presence estrogen dependent neoplasm inthe body.
 Neoplasia is a medical term describing an abnormal group of rapidly dividing cells.
 An estrogen dependant neoplasia is a type of breast tumor that is dependent on estrogen for growth.
 History of venous thromboembolism
 .Active liver disease.
 Gallbladder disease.
NURSES ROLE IN HRT

 Prior to administration:
 Obtain a complete history including personal or familial history of breast cancer, gallbladder disease, diabetes
 mellitus, liver or kidney disease. Obtain a drug history to determine possible drug interactions and allergies.
 Assess cardiovascular status including hypertension, history of MI, cerebrovascular accident, thromboembolic
disease.
DURING HRT:

 Monitor for thromboembolic disease. (Estrogen increase risk for thromboembolism).

 Monitor for abnormal uterine bleeding. (If undiagnosed tumor is present, these drugs can increase its size and
cause uterine bleeding.
 Monitor breast health. (Estrogen promote the growth of certain breast cancer).
 Monitor for vision changes. (These drugs may worsen myopia or astigmatism and cause intolerance of contact
lenses).
 Encourage client not to smoke. ( Smoking increases risk of cardiovascular disease)
 Encourage client to avoid caffeine. ( Estrogens and caffeine may lead to increased CNS stimulation).
DURING HRT:

 Evaluate the effectiveness of drug therapy by confirming that client expected outcomes have been met.
 The client verbalizes relief of unpleasant symptoms of menopause.
 understanding of the drug's actions by accurately describing drug side effects and precautions.
 The client accurately states signs and symptoms to be reported to the healthcare provider.
 Evaluate the effectiveness of drug therapy by confirming that client expected outcomes have been met.
 The client verbalizes relief of unpleasant symptoms of menopause.
 The client demonstrates an understanding of the drug's actions by accurately describing drug side effects and
precautions.
 The client accurately states signs and symptoms to be reported to the healthcare provider.
LITERATURE OF REVIEW

 Effects of hormone replacement therapy on glucose and lipid metabolism in peri- and postmenopausal women
with a history of menstrual disorders
 Saisai Li et al. BMC Endocr Disord. 2021
 Previous studies have indicated that women with a history of menstrual disorders have an increased risk of metabolic and cardiovascular
diseases. This has been attributed to the high proportion of polycystic ovary syndrome (PCOS) among this group. The favorable effects
of hormone replacement therapy (HRT) on serum lipid profiles and glucose homeostasis in postmenopausal women is widely accepted.
Whether HRT can also show positive effects on metabolic homeostasis in menopausal women with prior menstrual disorders (a putative
PCOS phenotype) has not been reported yet. The aim of the study was to compare the effects of HRT on glucose and lipid metabolism
in peri- and postmenopausal women with prior menstrual disorders and controls who did not have prior menstrual disorders.
 Results: HRT significantly decreased fasting insulin and homeostasis model assessment of insulin resistance in perimenopausal users,
and fasting plasma glucose levels in postmenopausal users with prior menstrual disorders, compared with baseline. Furthermore, HRT
decreased low-density lipoprotein cholesterol, total cholesterol, fasting insulin, fasting plasma glucose and homeostasis model
assessment of insulin resistance in both peri- and postmenopausal controls, compared with baseline. Nevertheless, no significant
differences were observed in any of the glucose or lipid metabolism indicators at baseline and follow-up, as well as changes from
baseline levels between menopausal women with and without prior menstrual disorders.
CONCLUSION

Hormone replacement therapy (HRT) is a treatment to relieve symptoms of the menopause. It

replaces hormones that are at a lower level as you approach the menopause. Hormone replacement
therapy (HRT), also known as menopausal hormone therapy or postmenopausal hormone therapy, is
a form of hormone therapy used to treat symptoms associated with female menopause.[1][2] These
symptoms can include hot flashes, vaginal atrophy, accelerated skin aging, vaginal dryness,
decreased muscle mass, sexual dysfunction, and bone loss. They are in large part related to the
diminished levels of sex hormones that occur during menopause.
BIBLIOGRAPHY

 "Hormone Replacement Therapy." The Free Dictionary. Farlex, n.d. Web.

 "Hormone Replacement Therapy (menopause)." Wikipedia. Wikimedia Foundation, 16 Aug. 2017. Web.
 "Hormone Therapy." Https://www.acog.org. N.p., n.d.
 Web.
 "Menopausal Hormone Replacement Therapy." Practice Essentials, Overview, Symptoms and Effects of
Menopause. N.p., 06 Jan. 2017. Web.
 "Menopause." Menopause Key Highlights - Epocrates Online. N.p., n.d. .