Is HRT for the Post Menopausal Women

8/11/2019 Is HRT for the Post Menopausal Women

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Is HRT for the post menopausal

women.Dr. Eugene DSilva

DGO,MD,DNB,FRCS,FRCOG,FICSTRINITY HEALTHCARE

MIRAMAR GOA


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Is HRT for the post menopausalwomen.

Life expectancy has increased to 80 - 85 years Age at Menopause not changed much ,with average

age being 51 years across countries and Races* More and more women will spend a third of their

lives in menopause Expectations of life , health , social and sexual values

have changed.Every body wants to be Forever Young !

Journal of Clinical and Diagnostic Research.2012 May (Suppl-2), Vol-6(4): 597- 601


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MENOPAUSE: The permanent cessation ofmenses following loss of Ovarian Activity.

(12 months of amenorrhea after last period )

Menopause occurs when the total remainingfollicle in the ovary falls to below the criticalthreshold of 1000 follicles


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ENDOCRINE CHANGES INHIBIN B : very low to undetectable

AMH : Very low to undetectable FSH : 10 to 20 fold Increase LH : 5 to 10 fold Increase

DECREASE IN TOTAL ESTROGEN


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CIRCULATING HORMONES INMENOPAUSE

Premenopause Postmenopause

Estradiol 40 to 400 pg/ml 10 to 20 pg/ml

Estrone 30 to 200 pg/ml 30 to 70 pg/ml

Testosterone 20 to 80 ng/ml 15 to 70 ng/ml

Androstenedione 60 to 300 ng/ml 30 to 150 ng/ml


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SYMPTOMS OF MENOPAUSE Vasomotor symptoms : Hot flushes , cold sweats

Irritability,Mood disorders and Depression Dermatological : Dry skin, itching Urogenital Atrophy Vaginaldryness/discomfort/SUI Sexual Dysfunction : Low libido, dysparunia,

anorgasmia


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If the treatment for other hormonal deficiencyis replacement therapy than the treatment of

menopausal symptoms resulting fromESTROGEN deficiency should be ESTROGEN

replacement therapy!


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TYPE OF SEX HORMONE REPLACEMENT THERAPY

ESTROGEN Replacement therapy (ERT)

ESTROGEN AND PROGESTIN Replacement therapy( HRT)Sequential HRT

Combined HRT


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ROUTE OF ADMINSTERATION Enteral : Pill Transdermal: Patch/cream /gels Intra Vaginal : Creams/ gels/ Tablets/ Rings Subcutaenous : Depot Injections / PelletsEnteral adminsteration results in first pass metabolism leading to higher estrone to estradiol ratios (3:1). Significant impact on HDL and triglycerides and SHBG Increased coaguability of blood.


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WHY USE ERT/HRT? Effective relief of vasomotor symptoms

Dramatic improvement in depression andmood disorders Marked improvement in urogenital symptoms

Improvement in sexual function Inhibits ageing of skin and maintains

connective tissue integrity


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LONG TERM BENEFITS OF HRT.

Osteoporosis: estrogen inhibits osteoclastic activity

Cardiovascular disease: estrogen keeps HDL levels high

Cognitive disorders and Alzheimers diseaseEstrogen protects against neuronal cytotoxicity due to

oxidationIt also reduces serum concentrations of amyloid PIt increases synapses and neuronal growth


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OsteoporosisBoth ERT and HRT even in low doses have aneffect in preserving bone density and reducing

the risk of fractures of hips and spine.

Even the WHI study demonstrated a 25%reduction in the risk of fractures


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Cardiovascular Disease and HRT

HRT/ERT reduces the risk of cardiovascular events such asmyocardial infarction and cardiac failure are by 35% to 50%.(whenstarted within 3 years of menopause and taken for 5 to 10 years) --------------Danish Osteoporosis prevention Study 2012----- -----Nurses Health Study----------Clarksons Monkey Study

Sub Analysis of the WHI confirms this finding (39%) inthe age group of 54-59 years


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Alzheimer's and Dementia

HRT/ERT improves cognitive brain function andreduces the risk of all cause dementia ifstarted within the perimenopausal transition

and early menopause.


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Cancer and HRT. HRT /ERT reduces the risk of Colorectal

cancers and may also reduce the risk of LungCancers.

Although it seems to increase the risk of Ovariancancer this increase is not statistically significant andreturns to normal on discontinuing treatment


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RESULTS OF WHIEvents per 10000 forplacebo per year

Events per 10000per HRT per year

Excess events

CVD 30 37 7

Stroke 21 29 8

Breast cancer 30 38 8

VTE 16 34 18

Colorectal cancer 16 10 -6

Hip fractures 15 10 -5

JAMA 2002;288:321-33


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SHORT COMING OF WHI. Study done using conjugated Equine

estrogens(Premarin) and Medroxy progesteroneacetate.

Women with symptoms of menopause excluded Average age of study population 63 years Only 567 women between the age of 54-59 Most serious Cardiovasular and strokecomplications seen in women started on HRT 20

years after the menopause.


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Despite these shortcomings WHI confirmed25% Reduction of risks in Osteoporosis related

fractures of hips and spine.

35% Reduction of risks of CVD in women started onHRT within 5 years of Menopause and continuedfor 10 years.*

16% Reduction in risks of Colorectal cancers.

No difference in the number of strokes in womenstarting ERT between 3 to 5 years of MenopauseAND continued for 7 years

Rossouw et al, JAMA 2007; 297: 1465-77


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VTE : Risk highest in the first 2 years of use andrestricted to women with other co-morbiditiessuch as Obesity , previous DVT, and underlying

thrombophilic conditions such as Protein C ,Protein S deficiency and Factor V Leiden.

All the above conditions are infrequent , can be

screened for before starting HRT and should betreated as contraindications.HRT cannot be blamed for poor patient selection.


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*Breast Cancer:Relative increase in risk is 26% after 5 years of use.Actual increase is about 4 / 1000 after 5 years of use ,

that too only in the Estrogen + progestin group Unmasking of existing pathology Slow growing tumors of extremely good prognosis. No difference in the estrogen only group, after 7

years of use.

Anderson et al, Womens Health Initiative randomized controlled trial. JAMA.2004;291(14):1701 12.


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Is HRT for the post menopausal women.

So what does the Evidence say? HRT Effectively treats menopausal symptoms with dramatic

improvement in quality of life HRT reduces the incidence of osteoporosis and risk of fractures. HRT reduces risk of Colorectal cancer HRT started early within 3 years of the menopause and continued

for at least 7 years offers primary prevention against CVD and allcause dementia.

In the appropriately selected patient HRT does not significantlyincrease the incidence of VTE or strokes especially if used in the

smallest therapeutic dose and by the transdermal route. The risk of breast cancer has to be weighed against the benefits inthe symptomatic postmenopausal woman and it should be thepatient that makes the decision after having all the information


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HRT most certainly is for the postmenopausalwomen!


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THANK YOU

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Is HRT for the Post Menopausal Women