((((Hormone replacement therapyHormone replacement therapy))))

((MenopauseMenopause))))

AndAnd

ObjectiveObjective-:-: Climacteric and menopause is one phaseClimacteric and menopause is one phase

in woman”s lifein woman”s life It is associated with health changes and It is associated with health changes and

diseasesdiseases Hormone replacement therapy needed to Hormone replacement therapy needed to

improve quality of life and prevent medicalimprove quality of life and prevent medical

complications which follow menopausecomplications which follow menopause

Menopause is the last menstrual period Menopause is the last menstrual period the average age is the average age is 5151 years. years.

Climacteric is transition from fertility to Climacteric is transition from fertility to infertility from infertility from 45-5545-55 years. years.

Women live Women live 40%40% of her life in menopause. of her life in menopause. The first endocrine change in menopause The first endocrine change in menopause

is fall in inhibinis fall in inhibin((glycoproteinglycoprotein(( from ovaries from ovaries which inhibit the release of FSH and LH which inhibit the release of FSH and LH from pituitary,so FSH and LH risefrom pituitary,so FSH and LH rise..

Causes of menopauseCauses of menopause

A(A(Premature ovarian failurePremature ovarian failure

Menopause occuring before Menopause occuring before 4545 years,low years,low oestrogen,high FSH&L oestrogen,high FSH&L

May be associated with autoimmune May be associated with autoimmune pathology.pathology.

B(B( Surgical menopause Surgical menopause

Menopause after oophorectomy,after Menopause after oophorectomy,after hysterectomy menopause occurs about hysterectomy menopause occurs about 33 years earlier the natural menopause.years earlier the natural menopause.

C(C( After chemotherapy or radiotherapy as After chemotherapy or radiotherapy as breast cancer or lymphoma.breast cancer or lymphoma.

Diagnosis of menopauseDiagnosis of menopause HistoryHistory((age,disease,surgery,treatmentage,disease,surgery,treatment(( Clinical examinationClinical examination InvestigationsInvestigations Low oestrogenLow oestrogen(E2 10-50pg/ml((E2 10-50pg/ml( High FSH&LH >10IU/LHigh FSH&LH >10IU/L Total cholesterol increaseTotal cholesterol increase HDL cholesterol decreaseHDL cholesterol decrease LDL cholesterol increase LDL cholesterol increase

D.Diagnosis:-D.Diagnosis:- PMSPMS DepressionDepression Thyroid diseaseThyroid disease Phaeochromocytoma,carcinoid syndrome.Phaeochromocytoma,carcinoid syndrome.

Clinical featuresClinical features

1.1.Early changes:-Early changes:- Vsomotor symptomsVsomotor symptoms((disturbance in the disturbance in the

thermoregulator in the hypothalamusthermoregulator in the hypothalamus(( occur in occur in 70%70% of women. of women.

Frequency – few to several times per day.Frequency – few to several times per day.

Duration –weeks to yearsDuration –weeks to years..

Hot flushes followed by sweating. Hot flushes followed by sweating. Psychological symptomsPsychological symptoms

Insomnia,poor concentration,irritability, Insomnia,poor concentration,irritability,

anxiety and lethergy.anxiety and lethergy.

2.2. Intermediate changes Intermediate changes(2-4(2-4 years,collagen years,collagen ( (

Wrinkled skin,small breasts.Wrinkled skin,small breasts.

Genital tract,thin and dry vagina,acidity Genital tract,thin and dry vagina,acidity

reduced infection,dysparunia and reduced infection,dysparunia and

genital prolapse. genital prolapse.

Urinary symptoms,frequency,dysuria,urgency, Urinary symptoms,frequency,dysuria,urgency,

and stress incontnence.and stress incontnence.

33..Late changesLate changes(>(>10 years10 years((

Bones,osteoporosisBones,osteoporosis((colle’s fracture,fracturecolle’s fracture,fracture

of neck femur and vertebral crush fractureof neck femur and vertebral crush fracture((

CVS,stroke and heart attacksCVS,stroke and heart attacks . .

Treatment:Hormone Replacement TherapyTreatment:Hormone Replacement Therapy

PrinciplesPrinciples Depend on the presence and severity of Depend on the presence and severity of

symptonssymptons.. Patient decision.Patient decision. Careful counselling before treatment. Careful counselling before treatment.

ExaminationExamination-:-: BP,breast examinationBP,breast examination((mammogrammammogram(( Pelvic examination,look for oestrogen Pelvic examination,look for oestrogen

sensitive tumourssensitive tumours((fibroid,endometriosis, fibroid,endometriosis,

endometrial carcinomaendometrial carcinoma((

Benefits of HRTBenefits of HRT Cure early symptons of menopause.Cure early symptons of menopause. Prevent fractures in about Prevent fractures in about 50%.50%. Reduce heart attacks in about Reduce heart attacks in about 40%.40%. Reduce bladder dysfunction.Reduce bladder dysfunction. May prevent against bowel carcinoma andMay prevent against bowel carcinoma and

Alzheimer’ disease.Alzheimer’ disease.

Contraindications of HRT Contraindications of HRT Absolute:-Absolute:-

Present or suspected pregnancyPresent or suspected pregnancy Suspicion of breast cancerSuspicion of breast cancer Suspicion of endometrial cancerSuspicion of endometrial cancer Active liver diseaseActive liver disease Uncontrolled hypertensionUncontrolled hypertension Cofirmed Cofirmed VTEVTE

Relative:-Relative:- Presence of fibroidPresence of fibroid Past history of benign breast diseasePast history of benign breast disease Uconfirmed Uconfirmed VTEVTE Chronic liver diseaseChronic liver disease Migraine Migraine

Preparations of HRTPreparations of HRT

Natural oestrogensNatural oestrogens((from plants or animalfrom plants or animal(( Oestradiol valerate Oestradiol valerate 1-2mg1-2mg Congugated equine oestrogens Congugated equine oestrogens Oestrone Oestrone 1.25mg1.25mg

ProgestogensProgestogens Medroxyprogesterone acetate Medroxyprogesterone acetate 10mg10mg Dydrogesterone Dydrogesterone 10mg10mg Norethisterone Norethisterone 1mg1mg Norgesterel Norgesterel 0.15mg 0.15mg

Post-hysterectomy Post-hysterectomy :: use only oestrogens use only oestrogens

Add progestogens at least for Add progestogens at least for 12 12 days ofdays of

2828 days for non-hysterectomized patient. days for non-hysterectomized patient. Combined oral oes. And prog. Combined oral oes. And prog. ((pills pills 28 28

daysdays(( Combined oes. And prog. In patchCombined oes. And prog. In patch((weeklyweekly(( Oestrogen patchOestrogen patch Oestrogen gel rubbed into the skin dailyOestrogen gel rubbed into the skin daily Inplant Inplant s\cs\c for one year for one year VaginalVaginal((cream,pessary,tablet for local cream,pessary,tablet for local

symptomssymptoms((

Tibolone:-Tibolone:- Synthetic steroidSynthetic steroid Has oestrogenic,progestogenic and Has oestrogenic,progestogenic and

androgenic effectandrogenic effect Used Used 11year after menopauseyear after menopause 2.5mg 2.5mg dailydaily

Raloxifene SERM:-Raloxifene SERM:- Selective oestrogen receptor modulatorSelective oestrogen receptor modulator Prevent osteoporosisPrevent osteoporosis Does not stimulate breast and endometrialDoes not stimulate breast and endometrial receptorsreceptors May worsen vasomotor symptons May worsen vasomotor symptons

Side effcts of HRTSide effcts of HRT((first first 12 12 weeksweeks(( Breast tenderness and nipple sensitivityBreast tenderness and nipple sensitivity Appetite rise and weight gainAppetite rise and weight gain Calf crampsCalf cramps

Patient must reviewed 6 months then Patient must reviewed 6 months then annuallyannually((BP,breast,pelvic examinationBP,breast,pelvic examination((