Hormone replacement therapy

From Ganfyd

Following the menopause the reduction in regular cycles of oestrogen release can cause troublesome symptoms for some women. As older women are at increased risk of complications such as coronary events and osteoporosis than their younger counterparts, HRT has been proposed to treat a number of "illnesses" of older women.

The key points are:

1. That women with a uterus given exogenous oestrogen will always need a progestagen to prevent endometrial hyperplasia.
2. Within 2 years of the menopause there is a still a risk of fertility and HRT is not effective as contraception in this circumstance.

Use

• Menopausal women whose lives are inconvenienced by vasomotor instability or vaginal atrophy
• Reducing risk of osteoporosis. Especially in those with early natural or surgical menopause (<45) who are at the greatest risk and those with multiple risk factors.
• Has been considered as reducing risk of ischaemic heart disease

Proposed benefits

(need to check evidence base)

• Amelioration / reversal of menopausal effect
• Reduced osteoporosis
• Reduction in stroke
• Reduction in myocardial infarction
• Reduced risk of Alzheimer's Disease

Options

• Unopposed oestrogens - after hysterectomy
• Cyclic progestagens - bleeding every 1, 3 or 6 months
• Continuous progestagens - but not within one year of menopause, 10% get continuous spotting

Administration

• Oral - but large 1st pass effect on liver
• Transdermal patch
• Transdermal gel
• Implants
• Topical / Vaginal

Alternatives

• Raloxifen
  • Selective oestrogen receptor modifier, no effect on endometrium, prevents osteoporosis

Contra-indications

• Acute thromboembolism
• Undiagnosed vaginal bleeding
• Endometrial cancer or breast cancer
• Acute liver disease
• Breast feeding

Cautions

• Migraine
• History of breast nodules/fibrocystic disease
• Pre-existing uterine fibroids
• Endometriosis
• Risk factors for thromboembolic disease
• Porphyria

Side-effects

• Increased risk of:
  • Breast cancer - there has been a worldwide fall in age specific breast cancer incidence in those over 50 years after this risk was recognised in 2001^[1]
  • Endometrial cancer
  • Venous thromboembolism / Pulmonary Embolism
• Nausea and vomiting
• Abdominal cramps and bloating
• Weight changes
• Breast enlargement and tenderness
• Premenstrual-like syndrome
• Sodium and fluid retention
• Changes in liver function
• Changes in libido
• Depression
• Headache, migraine and dizziness.

References