Hormone Replacement Therapy

  HRT has been a revelation in the management of menopause in middle-aged women.
– The basic principle is to replace the oestrogen that falls during menopause to alleviate symptoms.
– It controls menopausal symptoms and protects against osteoporosis.
– Also, may reduce the risk of colorectal cancer, type 2 diabetes and CHD/Alzheimer’s (if started early)
– When prescribing HRT, the 2 most important things to consider is whether the patient has a uterus (hysterectomy) and whether they are peri-or-post menopausal:

Side Effects:
– Fluid retention
– Nausea, dyspepsia, bloating
– Breast tenderness
 – Headaches

Risks of HRT:
– Cancer –> Increased risk of breast cancer + endometrial cancer (reduced by adding progestogen)
– Thrombosis –> Increased risk of DVT/PE (lesser risk with transdermal HRT)
– Cardiovascular –> Increased risk of CHD/stroke seen with combined HRT started in women >60yrs)

Contraindications:
i) Current or past breast cancer 
ii) Undiagnosed vaginal bleeding
iii) Any oestrogen sensitive cancer
iv) Untreated endometrial hyperplasia

When taking HRT, you can take oestrogen only, or combined oestrogen with progesterone:

  • Oestrogen Only HRT – Oestradiol

This form of hormone replacement therapy provides a direct replacement for the fall in oestrogen levels
– But, it can only be used in patients without a uterus, or a progesterone coil in situ due to the raised risk of endometrial cancer. It is available in several different forms:

– Oraltablet
–These are tablets which are absorbed by the gut and enter the systemic circulation
– Carry a higher risk of DVT/PE than transdermal methods
– Means in certain types of people e.g. high BMI, VTE sufferer, they should not be used

– Oestrogen only patch
A patch which releases oestrogen and is more effective than tablets.
– Unlike the tablets, this does not increase the risk of VTE or stroke.

Indications for transdermal use:
– BMI>30
– Previous/family history of VTE
– Variable BP control
– Migraine
– Poor symptom control with oral
– Gallbladder disease
– On medicines which alter liver enzymes
– GI disorder affecting absorption

– Vaginal Gel
–This is a gel which can be applied over the vagina, used to prevent vaginal atrophy
– It is the safest as no systemic absorption and so can be used in women with a uterus
– Used in women with vaginal symptoms and no systemic menopausal symptoms

  • Combined HRT – Oestradiol + Progestogen (Norethisterone/levonorgestrel)

This form of HRT involves both oestrogen for replacement + progesterone for protective purposes
– Needed in women who have a uterus, as progesterone provides protection against endometrial cancer
– It is given via combination tablets, combination patches or separate oestrogen + progesterone tablets.
– It can be given sequentially/cyclically or continuously:

i) Sequential
This is used for peri-menopausal women (those whose last period < 1 year ago)
– In this type of therapy, women will still have a bleed every month or every 3 months:

–> Monthly HRT –> take oestrogen every day + progestogen alongside it for the last 14 days of your menstrual cycle

–> 3-monthly HRT –> you take oestrogen every day, and take progestogen alongside it for around 14 days every 3 months

ii) Continuous
– This is used for post-menopausal women (those whose last period > 1 year ago)
– It involves taking combined HRT (oestrogen and progestogen) every day without a break

 

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