Hormone Replacement

Therapy
Not all women require HRT
70-85% of women remain healthy
need only good nutrition and
healthy life style.
 Recomendation
women who have symptoms of
menopause
the need for prevention of
osteoporosis
 Indication
1. Women having climacteric symptoms
Vasomotor symptoms
Urinary symptoms
Sexual dysharmony
Established osteoporosis on x-ray /B.M.D.
Measurements
2. All asymptomatic high-risk women having
Premature menopause (surgical /
spontaneous)
Family history of osteoporosis
Thin, small sedentary women
Poor diet, excess alcohol
CVD, Alzhemeirs disease, colonic cancer
Corticosteroid & other medications
High urinary calcium / creatinine
Low plasma estradiol
 Contraindication
Breast cancer, uterine cancer or
family history of cancer.
Previous history of thromboembolic
episode.
Liver & gall bladder disease.
 HRT is not Osteoporosis
Treatment
Should not be prescribed as specific
agents for osteoporosis as there are
prescriptive drugs available without
the controversies of long term use of
hormone therapy
 HT, when indicated should be given
at the lowest dose needed to control
symptoms and should be
administered for the shortest
duration possible.
 Prescribing Hormone
therapy
Each women should be counseled
regarding
Benefit for short term and long term
Risks & contraindication of HT
HT regime/type
Follow up
Healthy life style
Alternative therapy
Usage of Hormone Therapy
Indication Contraindication

Symptom: Unexplained vaginal

Vasomotor, uro-genital bleeding
atrophy, sexual Thromboembolic
dysfunction disease
Short term relief of Coronary arterial
perimenopausal disease
bleeding Liver Disease
Prevention of Breast or uterus
osteoporosis cancer
 HRT
Consists of estrogen & progestogen
May be delivered by various routes
Oral, vaginal, transdermal, implant &
parenteral
Vaginal cream/gel is useful for local
vaginal dryness and symptoms of
urgency for women who are
contraindicated to systemic HT but
require estrogen for local symptoms
 Transdermal route is suitable for
women with risk factors for venous
thromboembolism, liver disease or
gastrointestinal problems.
 Treatment with oestrogen alone
greatly increases the risk of
endometrial hyperplasia and cancer
adding a progestogen will diminish
this risk
 Side Effects of Hormone
Therapy
Side effects vary with the womens age,
environment, nutritional, lifestyles,
genetic & medical history.
Other side effects are related to
Routes of administration, dose & duration of
treatment
Many women experience side effects in
the first few months of taking HT
If problem persist after 3 months of therapy, a
change in medications should be considered.
Side Effect of HT
Minor
Progesterone effect Major
Depression
Feeling irritable
Bloating
Breast cancer in long
Breast discomfort

term use
Reduced libido, weight
gain Thromboembolism
Estrogen effect Cardiovascular effect
Nausea, dizziness, Stroke
headache
Breast
tenderness/fullness
Irregular bleeding
 DRUGS USED IN HRT
Oestrogen
Progesterone
Other drugs:
Tibolone
Raloxifene
Soya
Bisphosphonates
 PREMATURE MENOPAUSE
Def: ovarian failure occurring 2 SD in year
before the mean menopausal age in the
population.
Clinically: sec. amenorrhea for at least 3
months with raised FSH/LH & low E2 level in
a women under 40 year of age.
Inc. 1% -be. 30yr-1:1000

-at 35yr-1:250
-be.40yr-1%
 AETIOLOGY
1.Genetic disorder
chr. abnormalities (10-20%) X sex chr.
AD sex linked inheritance.
Ovarian dysgenesis-30%
2.Autoimmune disease(30-60%)
Mumps, thyroid dys.,hypo parathyroidism, &
Addisons dis.
Ovarian biopsy infiltration of follicle with plasma
cells& lymphocytes.
CD8 & CD4 autoimmune d.
Antiovarian Ab are present.
3.Tuberculosis
4.Smoking
5.Radiaton & chemotherapy
Reversible
Radiation up to 400 to 500 rads. restores
normal ovarian fun. in 50% cases.
Alkalytic agents.
6.Hystrectomy
Kinking & blockage of ovarian vessels
Tubectomy
7.Prolonged GnRH therapy.
8.enz.defect-17-hydroxylase & galactosemia
have adverse effect on oocytes pri.
Amenorrhea.
9.Resistant ovary
Terminology is used less frequently these
days.
Follicles fail to respond to gonadotropin
stimulation.
10.Induction of multiple ovulation in infertility.
PATHOPHYSIOLOGY
Lack of receptors is explained as the
cause of non response of follicle.
 C/F
Hot flushes
Sweating
Insomnia
Headache
Psychological
Cancer phobia
Pseudocyesis
Irritability
Depression
Lack of conc.
 INVESTIGATION
FSH level: 40mIU/ml or more.
E2 level: 20pg/ml or less
Thyroid fun., Ca level, chr. study,& thyroid Ab.
Blood sugar.
X-ray pituitary fossa for the tumour.
BMD study is not always necessary, it is an
invasive procedure.
Ovarian biopsy.
Ultrasound.
Prolactin level.
 COMPLICATIONS
The risks of osteoporosis &
cardiovascular diseases increase in
premature menopause.
 MANAGEMENT
1.Cause of premature menopause
should be ascertained & the cause
treated.
2.Ovulation induction or oocyte
donation in IVF programme has
caused pregnancies to occur in some
cases.
3.Progestogen challenge test will
indicate if menstruation can be
induced, provided endometrium is
4.Corticosteroid therapy is effective in
autoimmune disease if Ab to sex
hormone are present in the blood.
Plasmapheresis has also been attempted.
5.A women with hypo-oestrogenism may
require HRT or other drugs to prevent
osteoporosis . oestrogen implant with
progestogen or Mirena IUCD offers long-
term HRT.
 LATE MENOPAUSE
Def: cond. in which menstruation
cond. beyond 52 year.
Late menopause occurs in women
with fibroids and is seen in women
who develop endometrial cancer.
Often it is constitutional. Beyond 52
yr , endometrial biopsy is required to
rule out endometrial pathology.
 POSTMENOPAUSAL BLEEDING
Normally-1 yr POA after 40 yr.
however, VB anytime after 6 MOA in
menopausal age postmenopausal
bleeding & investigated.
without amenorrhea / irre. Bleeding , if
the women over the age of 52 yr cont.
to menstruate, she needs investigation
to rule out endometrial hyperplasia &
mali. Of genital tract.
 AETIOLOGY
1.vulva-trauma , vulvitis ,benign &
malignant lesions.
2.vagina-foreign body such as ring
pessary for prolapse, senile vaginitis ,
vaginal tumour (benign as well as
malignant) postradition vaginitis.
3.cervix-cervical erosion, cervicitis,
polyp, decubitus ulcer in prolapse
&cervical malignancy.
4.uterus-senile endometritis,
tubercular endometritis, endometrial
hyperplasia(10%) , polyp,
endometrial carcinoma& sarcoma , &
mixed mesodermal tumour.
5.Dysfunctional uterine bleeding,
metropathia haemorrhagica, uterine
polypi & endometrial hyperplasia.
6.Fallopian tube malignancy .
 7. ovary- benign ovarian tumour such as
benner tumour, granulosa & theca cell
tumour, & malignant ovarian tumour.
8. Hypertension & blood dyscrasia.
9. Urinary tract- urethral caruncle,
papilloma &CA of bladder. May be mistaken
for genital tract bleeding.
10.bowel- bleeding from haemorrhoid , anal
fissures, & rectal cancer may be
misleading.
11.imp. Reason indiscriminate. Prolonged
use of oestrogen unopposed by
progestogens, & HRT when applied
clinically. Tamoxifen causes endometrial
hyperplasia & cancer.
30-50% -PMB malignancy of genital tract
-most common endometrial cancer ,
cervical cancer& ovarian tumour.
Common benign conditions are endometrial
hyperplasia and polypi.
 C/F
HISTORY
*age menarche & menopause
*taking oestrogen & tamoxifen
*prolapse details
*abdominal pain &foul smelling
discharge- malignant tumours
*urinary& rectal symptoms .
 EXAMINATION
*BP
*GE- obesity& diabetes
*abdominal pain
*speculum & bimanual examination
 INVESTIGATION
Aim: Excluding malignancy
1.Blood count & smear- blood dyscrasia.
2.Blood sugar level.
3.Cervical cytology-cervical lesion.
4.Endometrial study.
5.Sonosalpingography endometrial polyp.
6.ultrasound- endometrial thickness >4mm
indicates the need of endometrial biopsy.
 Several methods
Dilatation & curettage (D&C)
fractional curettage comprising
separate scrap of endometrium
&endocervix not only allows the
exact site of malignancy if present,
but also detect the extent of the
tumour & staging.
Uterine cavity aspiration &
endometrial sampling.
 Vibra aspirator, Gravlees jet
washer , Isaacs aspirator & Pipelle
aspiration end. Sample.
7.Hystroscopy inspection& selective
biopsy.
8.CT & MRI .
9.Diagnostic laparoscopy .
10.Cytoscopy & proctoscopy.
 MANAGEMENT
1. Treat the cause.
2. When no cause is found, & if there has
been only one bout of bleeding, the pt
should be kept under observation.
. Abt 80% of cases do not bleed again.
. If cond. to bleed- laparotomy.
. An undiagnosed small tumour may be
discovered & dealt appropriately. AH with
bilateral oophorectomy
histopathological study.