Hormone Replacement

Therapy

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Indications
 Menopause
 With sx
 Surgical
 Premature ovarian failure

 Vasomotor instability
 Vaginal atrophy

 Reduce risk of osteoporosis

 Reduce risk of IHD?
Menopause
 ‘Last period’
 Scarcity of ova
 Resulting low oestrogen and high LH & FSH
 Perimenopausal symptoms (climacteric):
 Hot flushes
 Irregular menses
 Fat redistribution
 Hair thinning
 Atrophic vaginitis
 Trigonitis
Options
 Low dose oestrogen
 Natural
 Synthetic
 Unopposed oestrogens
 After hysterectomy only
 With cyclic progestagens
 1, 3 or 6 monthly bleeding
 With continuous progestagens
 But not within 1 year of menopause, 10% get
continuous spotting
 Tibolone
 Raloxifene (SERM) for osteoporosis prevention
Administration
 Oral
 But 1st pass metabolism
 Highest risk of VTE

 Transdermal patch/gel
 Implants
 Topical
 Vaginal
Risks
 Breast cancer
 Endometrial cancer
 Ovarian cancer
 VTE
 Stroke
 CHD
 Delay dementia but speeds decline if
current
 Additional cases Additional cases per
Background
per 1000 women 1000 women using
incidence per 1000
Age using oestrogen combined (oestrogen-
women in Europe
range only HRT progestogen) HRT
Risk not using HRT
(year (estimated) (estimated)
s)
For 5 For 10
Over 5 Over 10 For 5 For 10
years years
years years years use years use
use use
Breast 50–59 10 20 2 6 6 24
cancer 60–69 15 30 3 9 9 36
Endomet 50–59 2 4 4 32
rial
cancer 60–69 3 6 6 48

Ovarian 50–59 2 4 <1 1 <1 1

cancer 60–69 3 6 <1 2 <1 2
Venous 50–59 5 2 7
thrombo
embolis 60–69 8 2 10
m
50–59 4 1 1
Stroke
60–69 9 3 3
Coronar
y heart 70–79 29–44 15
disease
Contraindications
 Absolute
 Undiagnosed vaginal bleeding
 Severe liver disease
 Pregnancy
 CHD
 Venous thrombosis
 Endometrial cancer
 Relative
 Migraines
 PMH of breast cancer
 Uterine fibroids
 Ductal htperplasia
 Active gallbladder disease
Side Effects
 Headache
 Stomach cramps or bloating
 Diarrhoea
 Appetite and weight change
 Sex drive changes
 Nervousness
 Acne
 Fluid retention
 Breast tenderness, enlargement or
discharge
 Sudden difficulty wearing contact lenses!!