HRT - Current Status Dr.Hemantha Perera MS FRCOG Consultant Obstetrician & Gynecologist

1. HRT - Current Status Dr.Hemantha Perera MS FRCOG Consultant Obstetrician & Gynecologist Sri Jayawardenapura General Hospital President- Menopause Society of Sri Lanka

2. HRT Menopause Estrogen deficiency Estrogen replacement

3. Conventional HRT • ET • EPT SERMS -agonistic and antagonistic effects Tibolone Phytoestrogens Testosterone

4. Estrogen • Oral - Conjugated equine estrogen - 17β estradiol

5. Hormone replacement therapy(HRT) (HT) • Estrogen plus progestin for a woman who has an intact uterus or • Estrogen alone for a woman who has had a hysterectomy

6. Main Indication • For symptom relief in peri and postmenopausal women.

8. Indications (ctd.) • Treatment with hormones may be helpful where the physical, mental, and emotional effects of perimenopause are strong enough that they significantly disrupt the everyday life of the woman experiencing them.

9. Indications (ctd.) • Women with a premature menopause should normally be offered HT until the average age of the menopause (52 years)

10. Estrogen may be administered in several ways: • Oral Pills • Intramuscular injections • Transdermal patches or gels • Subcutaneous pellets • Vaginal creams / rings • Nasal spray

11. Transdermal oestrogen delivery Oestrogen only ( with oral progestogen) Oestrogen & Progestogen (sequential or combined)

15. Women whose uterus is present should be offered appropriate progestogen therapy as oestrogen alone will increase the risk of endometrial cancer .

16. Progesterone • 19 nor testesterone derivatives – Norgestrel • 17 alpha OH progesterone derivatives MPA Levonorgestrel • Dydrogesterone • Drospirenone - activities similar to spironolactone

17. Progestogen also may be administered in several ways: • Oral Pills • Intramuscular injections • Transdermal patches, gels • intrauterine systems (Mirena). • Vaginal creams

18. Mirena (LNG IUS) 52 mg Levonorgestrel 20mcg/day 5 years (7 years bio-availability)

19. Each delivery method has its own advantages and disadvantages.

20. Recent Research • Several major studies have questioned the health benefits and risks of hormone replacement therapy, including the risk of developing breast cancer, heart attacks, strokes, and blood clots.

21. Women’s Health Initiative (WHI) • The WHI was launched in 1991 and consisted of a set of clinical trials and an observational study, which together involved 161,808 generally healthy postmenopausal women.

22. Million Women Study (MWS) • involving more than one million UK women aged 50 and over •  Between 1996 and 2001

23. The results from WHI and MWS are not necessarily relevant to younger postmenopausal women taking appropriate doses of different regimens .

24. The oestrogen alone arm of WHI found a reduced risk of breast cancer and coronary heart disease in women less than 60 years of age.

25. Recent data support the initiation of HRT around the time of menopause • to treat menopause-related symptoms • to treat or reduce the risk of certain disorders, such as osteoporosis or fractures in selected postmenopausal women • or both.

26. The benefit-risk ratio for menopausal HRT • is favorable for women who initiate HRT close to menopause • but decreases in older women and with time since menopause in previously untreated women.

27. The benefit-risk ratio for menopausal HRT • Treatment for up to five years does not add significantly to lifetime risk of breast cancer, but significantly decreases bone loss and risk of osteoporotic fractures.

28. The benefit-risk ratio for menopausal HRT The merits of long term use need to be assessed for each individual at regular intervals, such as annually .

29. The benefit-risk ratio for menopausal HRT Some women may be susceptible to early thrombotic risk, but when appropriate HRT is given after individual clinical evaluation, the benefits will far outweigh any potential risks and the treatment should be recommended

30. Vaginal Estrogens • Vaginal ET should be continued for women as long as distressful symptoms remain. • Progestogen is generally not indicated when low-dose estrogen is administered locally for vaginal atrophy. • Data are insufficient to recommend annual endometrial surveillance in asymptomatic women using vaginal ET.

31. Soy and midlife women • Larger studies are needed in younger postmenopausal women, and more research is needed to understand the modes of use of soy isoflavone supplements in women. • Greater standardization and documentation of clinical trial data of soy are needed.

32. Soy and midlife women • More clinical studies are needed that compare outcomes among women whose intestinal bacteria have the ability to convert daidzein to equal (equal producers) with those that lack that ability (equal nonproducers) in order to determine if equal producers derive greater benefits from soy supplementation.

33. Soy and midlife women • The interrelations of other dietary components on soy isoflavones consumed as a part of diet or by supplement on equal production also require further study • as do potential interactions with prescription and over-the counter medications.

34. Soy and midlife women • The choice of therapy should be guided by clinical experience and patient preference.

35. Compliance • Many women who try HRT discontinue it because they are bothered by side effects.

36. Most common side effects of HRT • Breast swelling and tenderness, heavy menstrual bleeding, menstrual cramps. • Premenstrual symptoms such as depression and/or irritability during progestogen therapy.

37. Inability to tolerate menstrual bleeding. • Migraine headaches, nausea, and vomiting . • Increased blood pressure, fluid retention, bloating, weight gain, aching legs.

38. Depression, irritability, mood changes, loss of sex drive. • Development of large varicose veins or worsening of existing varicose veins. • Chloasma (dark and/or blotchy brown facial pigmentation).

39. Current guidelines of Menopause Society of Sri Lanka include: • The main indication for HRT use in postmenopausal women remains the relief of menopausal symptoms . • Evaluation of individual risk factors must be done before prescription of a HRT. Risks should be weighed against expected benefit from symptom relief and improved quality of life.

40. Informed decision by the client is mandatory. • Women taking HRT should have a low risk for stroke, heart disease, blood clots, or breast cancer. • HRT may be started in women who have recently entered menopause. • HRT should not be used in women who have started menopause many years ago.

41. HRT should currently not be prescribed solely for primary or secondary prevention of CHD and dementia.

42. However in 50–59-year-old women a “window of opportunity” for a benefit in cardiovascular disease displays a high plausibility.

43. Treatment significantly decreases bone loss and risk of osteoporotic fractures.

44. The results from recent papers have thus far given no reason to make any change in current clinical practice for the use of HRT

45. Menopause Society of Sri Lanka web: http://www.menosocsl.org email : menosoc.srilanka@gmail.com