Hormone Replacement Therapy in Premature Ovarian Failure

HRT in POF Vs Natural Menopause

►True example of replacement therapy Vs extension therapy

►Started at time of diagnosis AND continued till natural age of menopause

► No long-term ill effects (WHI study) as estrogen years are not increased

►Full dose long-term Vs low dose short-term►5-10% will resume spontaneous ovulation &

menstruation

Tailor HRT According to Type of POF

Type I POF - Prepubertal

Individualize the Treatment

14 years Turner’s mosaic

Counseling of the girl & parents COC pillsOccasionally can conceive

Types of HRT Regimens

Estrogen Preparations- Indian MarketMarket name Molecule Strength Prep Dose

Evalon Estriol succinate 1.0mg Tab 8-16mg/day

Premarin CEE 0.625mg Tab 0.625mg/day

Progynova Esradiol valerate 1.0mg/2mg Tab 2mg/day

Estraderm patchOr Susten 50

Estradiol 25/50/100 цg patch 1 every 4 days 50 цg

E 2 GelOr Sandrena gel

Estradiol 1.5mg/2.5g1mg/gm

Dermal gel Once a day

Estaspray Estradiol 0.375mg Dermal spray 1-3 accutations/day

Premarine gel CEE 0.625mg/gm Daily x 2weeksVaginal gel then twice a weekEvalon gel Estriol 1mg/gm

E 2 Gel Estradiol 0.025mg/gm

Transdermal Estrogens

Estragel 1.5mg/2.5g OD

EstaSpray 0.375mg BD

Currently there appears to be no clear advantage of the transdermal over the oral route

Oral estrogens• Blood levels

• Lipoproteins LDL ↓ HDL ↑ Lpa ↓Prevent oxidation yes TGL ↑• CRP ↑ • SHBG, TBHG ↑• Coagulation factors ↑

Transdermal

more stable, square dose curve

↓ or same same ↓ or same yes same No effect No effect less effect

Progesterone preparations-Indian MarketDrug Route Sequential (10-14 days) continuous

MPA Oral 5mg daily 2.5mg daily

Norethisterone Oral 1mg daily 0.3 mg daily

Norethindrone Oral 2.5mg daily 0.5mg daily

Dydrogesterone Oral 10mg daily 5mg daily

Drospirenone Oral - 2mg daily

Natural progesterone Oral 300mg daily 200mg daily

Natural progesterone Vaginal 200mg daily 100mg daily

Natural progesterone Vaginal gel 45mg daily 45mg daily

LNG-IUS Intra-uterine _ 20mcg daily

Various options Tiboloneo Steroido Metabolites are activeo Mildly estrogenic

progestogenic androgenico Amenorrhoeao Good for VMS, libido, boneso No change in breast densityo Endometrial bleeding -5%

• 0.625 mg premarin + MPA 5mg 12 days

• Estragel/estaSpray + LNG IUS or MPA

• Angeliq 1 OD

Type III POF - Iatrogenic

• Sudden & precipitous fall of estrogens – severe symptoms VMS, risk of CHD, osteoporosis, suicidal depression

• Lack of androgens – lack of energy & libido

• Need to start ET early while in the hospital & full dose or may be higher dose

HRT in Surgical Menopause

HRT in Cancer Survivors

Stem Cell Transplant - POF

HRT - POF

Premature ovarian failure Not your failure