HRT

● Hormone replacement therapy is

medication that contains female hormones.
It will be taken to replace the estrogen that
the body stops making during menopause.
Hormone therapy is most often used to
treat common menopausal symptoms,
including hot flashes and vaginal
discomfort.
● Hormone therapy has also been proved to prevent bone
loss and reduce fracture in postmenopausal women.
● However, there are risks associated with using hormone
therapy. These risks depend on the type of hormone
therapy, the dose, how long the medication is taken and
individual health risks. For best results, hormone
therapy should be tailored to each person and re
evaluated every so often to be sure the benefits still
outweigh the risks.
What are the basic types of hormone therapy?
Hormone replacement therapy primarily focuses on
replacing the estrogen that the body no longer makes
after menopause. There are two main types of estrogen
therapy:
Systemic hormone therapy. Systemic estrogen — which
comes in pill, skin patch, typically contains a higher
dose of estrogen that is absorbed throughout the body.
It can be used to treat any of the common symptoms of
menopause.
Low-dose vaginal products. Low-dose vaginal
preparations of estrogen — which come in cream,
tablet or ring form — minimize the amount of
estrogen absorbed by the body. Because of this, low-
dose vaginal preparations are usually only used to
treat the vaginal and urinary symptoms of
menopause.
Estrogen
, a steroid hormone, is derived from the androgenic precursors
androstendione and testosterone by means of aromatization. In
order of potency, naturally occurring estrogens are 17 (beta)-
estradiol (E2), estrone (E1), and estriol (E3). The synthesis and
actions of these estrogens are complex.
1.Estradiol is primarily produced by theca and granulosa cells of
the ovary, and it is the predominant form of estrogen found in
premenopausal women.
2.Estrone is formed from estradiol in a reversible reaction. This is
the predominant form of circulating estrogen after menopause.
Estrone is also a product of the peripheral conversion of
androstendione secreted by the adrenal cortex.
3.Estriol is the peripheral metabolite of both estradiol and estrone;
it is not secreted by the ovary
There is controversy between using HRT
in menopausal women that is natural
and physiological and requires no
interventions and that it is true hormonal
state and thus should be treated with
replacement therapy
 How to prescribe HRT

●History
●Complete , oestrogen deficiency
symptoms
●Family history of cardiovascular
disease ,angina, MI and stroke
Alzheimer disease and neurological
disease
Mode of treatment
●1- Oral : commonly used three
weeks of oral c.p., oral oestrogen,
oestradiol valerate 1 or 2 mg ,
conjugated equine oestrogen 0.625
or 1.25 mg , oestrone 1.25 mg
●Oestrogen also cause hyperplasia so
use progesterone 12 days per month
●For secretory transformation of
endometrium and shedding , either
norethisterone or norgestrol or
medroxyprogesterone acetate or
micronized progesterone
●

●progesteron either given cyclic in 28 days

or continuously to prevent withdrawal
bleeding called ( no bleed ) treatment in
patient really menopause if any bleeding
occurs the patient should be investigated
●Progesterone secreting IUCD
(levonorgestrel) used if the women not
tolerate other types of progesterone
●Progesterone is not necessary in
patients with hysterectomy
●4- local oestrogen cream, pessary or
vaginal tablets and ring to treat
genitourinary symptoms in lower
genital tract, bladder, urethra, no
systemic effect, it is given daily for 2
weeks, then reduce to once or twice
weekly for 12 weeks
●5-trasnasal 150 microgram oestradiol
●Duration of treatment
●5 years if started in women after 50
years but some take treatment until
60 years , longer duration is needed
in women with premature
menopause
●Contraception should be used for 1
year after menopause either condom
or progesterone secreting IUCD
 Contraindications
●Absolute : present or suspected
pregnancy, suspicious of breast
carcinoma, suspicious of endometrial
carcinoma , acute liver disease,
uncontrolled hypertension , VTE
●Relative : uterine fibroid, past history of
benign breast disease, chronic stable liver
disease, migraine abnormal uterine
bleeding
●Management of patient receiving HRT

●Side effect: Alarming her symptoms

specially 1st 3 months breast tenderness,
nipple sensitivity, increased appetite,
weight gain, calf cramps, and vasomotor
symptoms reaches baseline in 3 months, if
no symptoms, patient revealed after 6
months and then annually
●2.Raloxifene is a selective estrogen receptor
modulator (SERM)it have a mixed agonist
and antagonist of the estrogen receptor (ER)
in different tissues. It has estrogenic activity
in some tissues, such as bone and liver, and
antiestrogenic activity in other tissues, such as
the breasts and uterus. Its used for the
prevention and treatment of osteoporosis not
act on breast and uterus and it can be used in
women over 60 years has very high risk of
osteoporosis
 Action of individual SERM
● BREAST Bone endomtrial T.
estrogen R estrogen R estrogen R
● Antagonist Agonist Agonist Antagonist
● all SERM all SERM Tamoxifen Raloxifen
Raloxifene is used for the
treatment and prevention of
osteoporosis in postmenopausal
women. It is used at a dosage of
60 mg/day for both the
prevention and treatment of
osteoporosis. In the case of
either osteoporosis prevention
or treatment, supplemental
calcium and vitamin D should
be added to the diet if daily
intake is inadequate.
 Common side effects of raloxifene
● include hot flashes
● vaginal dryness, and leg cramps (generally mild;
● (((( Raloxifene does not cause breast tenderness, endometrial
hyperplasia, menstrual bleeding, or endometrial cancer.))))
● Raloxifene is a teratogen; i.e., it can cause developmental
abnormalities such as birth defects.

● Raloxifene may infrequently cause serious blood clots to form in

the legs, lungs, or eyes. Other reactions experienced include leg
swelling/pain, trouble breathing, chest pain, and vision changes.
in 2007 warning of increased risk of death due to stroke for
postmenopausal women with documented coronary heart
disease or at increased risk for major coronary events, as well as
increased risk for deep vein thrombosis and pulmonary
embolism.
 Bisphosphonates
● Bisphosphonates are a class of drugs that prevent the loss of
bone density, used to treat osteoporosis and similar diseases.
They are the most commonly prescribed drugs used to treat
osteoporosis. Bisphosphonates are a group of medicines that
slow down or prevent bone loss, strengthening bones.
Bisphosphonates inhibit osteoclasts which are responsible for
breaking down and reabsorbing minerals such as calcium from
bone (the process is known as bone resorption).
Bisphosphonates allow osteoblasts (bone building cells) to
work more effectively, improving bone mass.
 ●Parathyroid hormone
●Testesterone

●In menopause there is decrease in sex

hormone binding globuline so there is
small rise in free testesterone
●But in women who undergo a surgical or
chemo radiation induced menopause there
may be deficiency of testosterone and this
cause decrease libido , it can be given in
conjunction with estrogen
 Tibolone (Livial)
● Livial, is used in the treatment of menopausal symptoms like
hot flashes and vaginal atrophy, postmenopausal
osteoporosis, Tibolone possesses a complex pharmacology
and has we2ak estrogenic, progestogenic, and androgenic
activity
● Tibolone reduces hot flashes, prevents bone loss, improves
vaginal atrophy and urogenital symptoms (e.g., vaginal
dryness, dyspareunia), and has positive effects on mood and
sexual function.The medication may have greater benefits on
libido than standard menopausal hormone therapy, which
may be related to its androgenic effects. It is associated with
low rates of vaginal bleeding and breast pain.
●Risk of HRT
●1- breast cancer more than 5 years
●2- endometrial cancer
●3- ovarian cancer more than 10 years
use of HRT.
●4- venous thromboembolism during
1st year of treatment , increased risk
in women who are obese and smoker
●5- coronary heart disease and stroke
specially in smokers and if women
more than 60 years if HRT not start
immediately after menopause, it
should not be initiate in women over
60 years
●Other management :
●Diet , exercise , stop smoking,
herbals, other non hormonal
treatment, selective serotonin
reuptake inhibitors( fluoxetine) in
patient who cannot receive HRT
●Alpha adrenergic agonist
( clonidine) , beta blockers
( propranolol )
●Other complementary treatments
( acupunctur ) may improve
vasomotor symptoms