Hormone replacement therapy ( HRT ) in menopause is the medical treatment of postmenopausal, perimenopausal, and surgical menopausal women. The goal is to reduce the discomfort caused by decreased circulating estrogen and progesterone in menopause. The combination of HRT is often recommended because it reduces the amount of endometrial hyperplasia and cancer associated with estrogen therapy that is not preferred. The major hormones involved are estrogens such as estradiol and progesterone or progestin. Some therapies include the use of androgens such as testosterone or dehydroepiandrosterone (DHEA) as well.
The 2002 Women's Health Initiative from the National Institutes of Health found different results for all causes of death with HRT, found it to be lower when HRT started earlier, between the ages of 50-59, but higher when it started after age 60. In more patients old, there is an increased incidence of breast cancer, heart attack and stroke, although the incidence of colorectal cancer and fractures is reduced. Some of the findings of WHI are again found in larger national studies conducted in the UK, known as The Million Women Study. As a result of these findings, the number of women taking HRT decreased dramatically. The Women's Health Initiative recommends that women with non-surgical menopause take the most appropriate HRT dose for the shortest possible time to minimize associated risks.
Current indications for use from the US Food and Drug Administration include short-term treatment of menopausal symptoms, such as vasomotor hot flash or urogenital atrophy, and prevention of osteoporosis. In 2012 and 2017, the United States Prevention Task Force concluded that the harmful effects of combined estrogen and progestin are likely to exceed the benefits of chronic disease prevention in most women. The consensus opinion published by The Endocrine Society states that when taken during perimenopause, or early years of menopause, hormonal therapy carries much less risk than previously published, and reduces all-cause mortality in most patient scenarios. The American Association of Clinical Endocrinology also released a position statement in 2009 that approved HRT in a suitable clinical scenario.
Video Hormone replacement therapy (menopause)
Health effects
There are a number of cross-sectional studies and large-scale cohorts of HRT effects, the largest in the United States, Britain and China. Demographically, most of the data available is in postmenopausal American women with pre-existing conditions, and with an average age above 60 years.
The American American Menopause Society (NAMS) 2016 annual meeting mentioned that HRT may have more benefits than risk when it comes to women under the age of 60.
In 2002, the Women's Health Initiative (WHI) was published. The study looked at the effects of hormone replacement therapy in postmenopausal women. Both age groups had a slightly higher incidence of breast cancer, and both heart attacks and strokes increased in older patients, although not in the younger participants. In fact, the use of HRT in the United States has actually dropped significantly since 2002. Progesterone is a major anabolic hormone for breast tissue, and therefore breast cancer is not elevated in patients who only undergo estrogen therapy after hysterectomy. Treatment with unopposed estrogen (endogenous estrogen supplementation without progestogen) is contraindicated if the uterus is still present, due to the proliferative effect on the endometrium. The WHI also found a decrease in the incidence of colorectal cancer when estrogen and progesterone are used together, and most importantly, reduced incidence of fractures. Ultimately, this study found different results for all causes of death with HRT, found it to be lower when HRT started during the age of 50-59, but was higher when it started after age 60. Several findings from the WHI have been reconfirmed in a national study bigger done. in the United Kingdom, known as The Million Women Study. The scope of WHI findings led to a decrease in the number of postmenopausal women in HRT. The study authors recommend that women with non-surgical menopause take the most appropriate HRTHRT dose, and for the shortest possible time, to minimize the risk.
Data published by the WHI recommend estrogen supplements increase the risk of venous embolism and breast cancer but protect against osteoporosis and colorectal cancer, while the impact on cardiovascular disease is mixed. These results were later confirmed in trials from the UK, but not in more recent studies from France and China. Genetic polymorphism appears to be related to inter-individual variability in the metabolic response to HRT in postmenopausal women.
However, this recommendation does not persist with further data analysis. The next finding released by WHI shows that all causes of death do not differ dramatically between groups receiving conjugated horse estrogens (CEEs), those receiving estrogen and progesterone, and those not on HRT at all. In particular, the relative risk for all causes of death was 1.04 (confidence interval 0.88-1.22) in a CEEs-alone trial and 1.00 (CI, 0.83-1.19) in progesterone plus estrogen experiments. Furthermore, in the data collection analysis of both trials, postmenopausal HRT was associated with a significant reduction in mortality (RR, 0.70, CI, 0.51-0.96) among women aged 50-59. This will represent five fewer deaths per 1,000 women per 5 years. therapy.
However, neither the WHI nor the Millions of Women Studies did not distinguish the results for the different types of progestogen used. Medroxyprogesterone acetate (MPA) - the type most commonly used in the United States - is the only one examined by WHI, which in its analysis and conclusions extrapolates the benefits versus MPA risk for all synthetic progesterone. This conclusion has been challenged by some researchers as unfair and misleading, resulting in unreasonable and unnecessary avoidance by many HRT women. In fact, primate studies suggest that the side effects of MPA may be much worse than other progestogen effects, and some human studies suggest that MPA may be responsible for excluding the benefits of estrogen-protecting hearts found for HRT users who only contain estrogen. Critics including Bethea note that there are now research papers that show much better results in brain, breast, and cardiovascular parameters with estradiol plus progesterone instead of MPA and conclude that further research is needed to find out more precisely what differences in effects when other progestin is used versus natural progesterone in HRT, so women need not be desperate to look for HRT.
A robust Bayesian meta-analysis of 19 randomized clinical trials reported data similar to RR mortality of 0.73 (CI, 0.52-0.96) in women younger than age 60. However, HRT had minimal effects among them aged between 60 and 69 years (RR, 1.05, CI, 0.87-1.26) and were associated with a significant increase in their mortality limit between 70 and 79 years (RR, 1.14, CI, 0 , 94 -1.37; P for trend & lt; 0.06). Similarly, in the HER-test, with participants having an average age of 66.7 years, HRT did not reduce total mortality (RR, 1.08, CI, 0.84 to 1.38). A 2003 meta-analysis of 30 randomized trials of HRT in relation to mortality showed that it was associated with nearly 40% reduction in mortality in trials in which participants had an average age of less than 60 years or were in 10 years of onset of menopause but not related to mortality in other trials. Findings in the younger age group were similar to those in Observational Nurses Health Study (RR for mortality, 0.63, CI, 0.56Ã, ± 0.70).
The beneficial potential of HRT is reinforced in the opinion of consensus experts published by The Endocrine Society, which states that when taken during perimenopause or early years of menopause, hormonal therapy carries significantly less risk than previously published and reduces all-cause mortality in most patient scenario.. The American Association of Clinical Endocrinology released a position statement in 2009 that approved HRT in a suitable clinical scenario.
A mixture of progestin and exclusive CEEs is the usual form of HRT prescribed. As the most common and longest-prescribed type of estrogen used in HRT, most research on HRT involves CEEs. Recently developed forms of drug delivery include suppositories, subdermal implants, skin patches and gels. They have more local effects, lower doses, fewer side effects, and produce constant serum hormone levels than cyclic.
Management of sexual dysfunction
The goal of HRT is to reduce the discomfort caused by estradiol and progesterone in circulation that decreases at the time of menopause. In those with early menopause or induced surgery, a combination of HRT is often recommended, as it can prolong life and may reduce a woman's chances of developing endometrial cancer associated with estrogen therapy without opponents, and by reducing the incidence of dementia. The major hormones involved are estradiol and progesterone. Some of the latest therapies include the use of androgens as well.
Data from various studies have consistently found that HRT leads to improvement in postmenopausal sexual dysfunction. Sexuality is an important aspect of quality of life for most menopausal women; therefore, any feature of the menopausal transition that can negatively affect female sexuality has the ability to significantly alter the quality of life. The most common of female sexual dysfunctions associated with menopause include lack of desire and low libido, both of which can be explained by changes in hormonal physiology.
Improvements in sexual pain, vaginal lubrication and orgasm were found to be statistically different from those using HRT. Estrogen has a positive effect of mood, sexual function, final target organ, and cognitive function.
Venous and arterial coagulation
Comparison of orally administered pills and transdermal patches shows that when estrogen is taken orally, the risk of thrombophlebitis and pulmonary embolism is increased, an effect that is not apparent with topical administration. Transdermal and transvaginal administration are not subject to first passing metabolism, and so the lack of anabolic effects that oral therapy has on the liver synthesis of clotting factor of vitamin K depends. This effect refers only to patches for HRT, which contain estradiol, rather than those used in oral contraceptive therapy, containing ethinylestradiol. The latter is associated with an increased incidence of venous clots. The WHI also showed an increased incidence of arterial disease, stroke, in patients who started HRT after age 65, although this effect was not significant in those who started therapy during their fifth decade.
Cardiovascular effects
The impact of HRT on cardiovascular morbidity is the subject of much controversy in the medical literature. The risk of reduced cardiovascular disease associated with HRT, reported in observational studies, has not been confirmed in randomized clinical trials. The increased risk of cardiovascular disease in the WHI is not statistically significant, and is only found in the oldest women, and those who start HRT late after the menopause begins. The increased risk of coronary heart disease in the treatment arm of the study varies with age and year since the onset of menopause. Women aged 50 to 59 who use HRT show a tendency toward a lower risk of coronary heart disease, as do women within five years of the onset of menopause.
A Cochrane review showed that in women who started HRT less than 10 years after menopause had lower mortality and lower rates of coronary heart disease compared with placebo or no treatment, without strong evidence of the effect on stroke risk. Early therapy over 10 years after menopause has little effect on death and coronary heart disease, but has an increased risk of stroke. Overall, however, taking an increased risk of venous thromboembolism into account, came to the conclusion that HRT has little benefit for the prevention of primary or secondary cardiovascular disease.
Adverse cardiovascular outcomes may be applicable only to oral doses with progestin and horse estrogens in oral system therapy, whereas topical estradiol and estriol may not result in the same risk, since the absence of anabolic effects of vitamin K-dependent clotting factors.
At the molecular level, HRT at the time of menopause has an effect on the lipid profile. In particular, HDL decreases, while LDL, triglycerides and lipoproteins increase. Additional estrogens enhance the lipid profile by reversing each of these effects. Beyond this, increased cardiac contractility, coronary artery blood flow, carbohydrate metabolism, and decreased platelet aggregation and plaque formation. At the molecular level, HRT can improve transport of reverse cholesterol (RCT) through the induction of ABC cholesterol transporter.
Endometrial effects
While estrogen-progesterone combination supplementation has been associated with an increased incidence of endometrial cancer, the specific subtype is usually stage I, or in situ , and has very low morbidity and mortality, and studies in American women have shown tumors not to has a tendency for growth to the myometrium or soft tissues of the parametrium. When viewed in the context of all causes of death, women who take estrogen and develop endometrial cancer have higher survival rates than women who did not take hormonal therapy at all, which is caused by the effect of preventing HRT on hip fractures.
The unbalanced estrogen hormone can also cause endometrial hyperplasia, a precursor to endometrial cancer. The extensive use of high doses of estrogen for birth control in 1970 is thought to have resulted in a significant increase in the incidence of this type of cancer.
The musculoskeletal effect
HRT is effective to reverse the effects of aging on muscles.
Neurological effects
According to a 2007 presentation at the American Academy of Neurology meeting, HRT taken immediately after menopause can help protect against dementia, but it increases the risk of mental decline in women who do not take HRT until they are older. The risk of dementia is 1% in women who initiate preliminary HRT, and 1.7% in non-women (ie women who do not take HRT appear to have an average - 70% higher risk of dementia than women who start HRT around the time the start of menopause). This suggests that there may be a "critical period" during which time taking HRT may have benefits, but if HRT starts after that period, it will not have such benefits and can cause harm. This is consistent with research that HRT improves the executive process and attention on postmenopausal women. This is also supported by research on monkeys given ovariectomy to mimic the effects of menopause and then estrogen therapy. This suggests that treated replacement compared to untreated monkeys has long-term prefrontal cortex executive abilities in the Wisconsin Card Sorting Test.
Effects of breast tissue
The relative risk (RR) of breast cancer varies from 1.24 in the WHI study to 1.66 in Million Women Study, with different results according to the interval between menopause and HRT and HRT methods. Initial results of the WHI in 2004 found an insignificant trend in estrogen-own clinical trials of reduced risk of breast cancer and the 2006 update concluded that the use of estrogen-only HRT for 7 years did not increase the risk of breast cancer in postmenopausal women who had undergone hysterectomy. The results of WHI's own estrogen-testing show that the progestin used in WHI estrogen-plus-progestin trials increases the risk for upper estrogen-related breast cancer alone. HRT has been stronger associated with breast cancer risk in women with a low or normal body mass index (BMI) of less than 25, but no association has been observed in women with high body mass index.
A recent randomized controlled trial suggests that the increased risk of breast cancer is only applied to women using progesterone analogues, but not to those who use bio-identical progesterone alone, or for women who undergo hysterectomy who take estrogen without resistance.
Some reports have not found a relationship of progesterone therapy and breast cancer. The absence of effects in this study has been suggested to be due to selective prescription for overweight women, or to very low progesterone serum levels after oral administration leads to a strong tumor inactivation rate.
For women who have previously had breast cancer, it is recommended to first consider non-hormonal options for menopausal effects, such as bisphosphonates or selective estrogen receptor modulators (SERMs) for steoporosis, cholesterol-lowering agents and aspirin for local cardiovascular and estrogen vaginal diseases. symptoms. Observational studies of systemic HRT after breast cancer are generally reassuring. If HRT is needed after breast cancer, only estrogen therapy or estrogen therapy with intrauterine devices with progestogens is safer than joint systemic therapy.
Hip fractures
Estrogen prevents osteoclast activity, and increases bone mineral density. Hip fractures are a major cause of morbidity and mortality in older women, and usually do not occur in osteoporosis settings. Estrogen is the only medical therapy that has been shown to prevent hip fracture in non-osteoporotic women, with higher efficacy than bisphosphonates or calcium and vitamin D supplements.
Ovarian cancer
A 2015 meta-analysis found that HRT was associated with an increased risk of ovarian cancer. The authors concluded that if the relationship is causal, women using HRT have about one additional case of ovarian cancer per 1,000 users.
Epigenetic aging effects
HRT appears to slow the rate of biological/epigenetic aging of buccal cells but not blood cells. In contrast, the loss of unpredictable hormones resulting from menopause accelerates the rate of biological aging of blood according to an aging molecular biomarker known as the epigenetic clock.
Maps Hormone replacement therapy (menopause)
Premature_stoppage_of_Women.27s_Health_Initiative "> Premature Termination of Women's Health Initiative
Clinical medical practice is changed based on two parallel WHI studies on HRT. Previous studies were smaller, and many of the women who electively took hormonal therapy. The WHI study was the first major, double-blind, placebo-controlled, controlled trial of HRT in healthy women.
One part of the parallel study followed more than 16,000 women for an average of 5.2 years, half of whom took a placebo, while the other half used a combination of progestin medroxyprogesterone acetate (Provera) and CEEs (Premarin). The combination of hormones is referred to as Prempro.
WHI's estrogen-plus-progestin trial was discontinued prematurely in 2002 because preliminary results show the combined risk of CEE and progestin outweigh its benefits. The first report on the WHI estrogen-plus-progestin study was discontinued in July 2002.
The study reported statistically significant increases in rates of breast cancer, coronary heart disease, stroke and pulmonary embolism. The study also found a statistically significant decrease in hip fracture and colorectal cancer rates. "A year after the study was discontinued in 2002, a published article showed that estrogen plus progestin also increased the risk of dementia." The conclusion of this study is that the combination of HRT presents a risk that exceeds measurable benefits. The results were almost universally reported as the risks and problems associated with HRT in general, rather than with Prempro, a combination of the specific ownership of CEE and the progestin studied.
After the clotting increase found at the first WHI outcome reported in 2002, the number of preset Prempro recipes was reduced by almost half. After the WHI results, most HRT users opt out of them, which is rapidly followed by a sharp decline in breast cancer rates. Decreased rates of breast cancer continue in the following years. A number of unknown women began to take an alternative to Prempro, like a bioidentic hormone, although scientists have confirmed that the hormone does not differ significantly from Prempro.
Other parts of the parallel study show women who are post-hysterectomized so that the consequences do not need to take progestin when using estrogen. They were given placebo or CEEs only. This group did not show the risks shown in the study of combination hormones, and the only estrogen study was not discontinued in 2002. However, in February 2004 it was also, discontinued. While there was a 23% decrease in incidence of breast cancer in study participants containing only estrogen, the risk of stroke and pulmonary embolism was slightly increased, especially in patients who started HRT over age 60.
Limitations and criticisms of Women's Health Initiatives
WHI trials are limited by low adherence, high attrition, inadequate power to detect risk for multiple outcomes, and evaluation of multiple regimens. Multiple validity is limited to the results of the study because of its effect on the patient's exclusion criteria. Patients who experience menopausal transition symptoms are excluded from the study, which means that younger women who have recently experienced menopause are not significantly represented. As a result, while the average age of menopause is 51 years, the average study participant was 62 years old. Demographically, most are Caucasian, and tend to be slightly overweight and ex-smokers.
Bioidentic hormone therapy
Bacterial hormone therapy (BHT) is the use of hormones that are chemically identical to the hormones produced in a woman's body. Proponents also claim that BHT can offer advantages beyond the typical of traditional HRT.
Some BHT formulations are approved by the United States Food and Drug Administration (FDA). Others are provided in conjunction with the practice of preparing pharmaceutical compounds and testing saliva to determine, and adjust, female hormone levels. The latter two practices are not widely accepted in clinical medicine. Compounding has not shown any benefit and presents risks with uncertain doses, potential and possible contamination. In addition, the saliva test is a limited utility due to natural fluctuations in hormone levels, and a lack of consensus for the ideal dose in humans.
The FDA has stated that BHT is not supported by medical evidence, and its administration is considered wrong and misleading by the agency. The FDA has expressed concern that unfounded claims such as misleading women and health care professionals. Traditional therapy has been studied to measure these risks and benefits, and is produced by manufacturers with stringent standards of purity and potency.
All testosterone specified in the UK is bio-identical and its use is supported by the NHS. Marketing authorizations exist for male testosterone products. The NICE Guide 1.4.8 states: 'consider testosterone supplementation for menopausal women with low sexual desire if HRT alone is not effective'. Footnotes add: 'at the time of publication (November 2015), testosterone has no UK marketing authorization for this indication to women. Bio-identical progesterone is used in IVF treatment and for pregnant women at risk of preterm delivery.
Compounding in the UK is a regulated activity. MHRA arranges the compounding done under the Specialized Manufacturing license and GPhC arranges the compounding done at the pharmacy.
HRT and sexuality
Menopause is the permanent cessation of menstruation due to loss of ovarian follicle activity. Menopause can be divided into early and late transition periods, also known as perimenopause and postmenopausal. Each stage is characterized by changes in the hormonal pattern, which can induce menopausal symptoms. It is possible to induce menopause prematurely by surgically removing the ovaries or ovaries (oophorectomy). This is often done as a consequence of ovarian failure, such as ovarian or uterine cancer. The most common side effects of menopausal transition are: lack of sexual desire or libido, lack of sexual arousal, and vaginal dryness. Modification of female physiology can lead to changes in sexual response, the development of sexual dysfunction, and changes in the level of sexual desire.
It is commonly felt that once a woman approaches the end of their reproductive years and enters the menopause that this is the same as the end of her sexual life. However, especially since women currently live one-third or more of their lives in a postmenopausal state, maintaining, if not improving, the quality of their lives, in which their sexuality can be a major determinant, is important. A recent study of sexual activity among women aged 40-69 revealed that 75% of women are sexually active at this age; this shows that sexual health and menopausal women's satisfaction are aspects of sexual health and quality of life worthy of care by health care professionals.
The main complaint among postmenopausal women is decreased libido, and many may seek medical consultation for this. Some hormonal changes occur during the menopause period, including decreased estrogen levels and an increase in follicle stimulating hormone. For most women, most changes occur during the perimenopausal and postmenopausal stages. The decline of other hormones such as sex hormone binding globulins (SHBG) and inhibin (A and B) also occurs in the postmenopausal period. Testosterone, a hormone most often associated with men, is also present in women. It peaks at age 30, but decreases with age, so there is little variation throughout lifetime and during the menopausal transition. However, in surgically induced menopause, rather than estrogen and testosterone levels slowly decline over time, they decrease very sharply, producing more severe symptoms.
In menopausal women, sexual function can affect several dimensions of a woman's life, including her physical, psychological, and mental health. During early menopause, sexuality can be an important issue in determining whether a person begins to experience a change in the sexual response cycle. Age-related events and menopause can affect the integrity of a woman's biological system involved in the sexual response cycle, which includes the hormonal environment, the neuro-muscular substrate, and the vascular supply. Therefore, it may be appropriate to use HRT, especially in women with low or decreased quality of life due to sexual difficulties.
The current study that has examined the effects of menopause on self-reported female sexual satisfaction shows that 50.3% of women experience multiple sexual disorders in one of five domains, and 33.7% have interference in two domains. Among these are desire, orgasm, lubrication, and arousal. With regard to stimuli, they found a significant negative relationship between age and passion, because when women of their age were more likely to report lower passion scores. In the domain of desire and orgasm, 38% of women reported disruption in their desires, and 17% reported impairment in their orgasmic abilities; of 17%, 14% were premenopausal, 15.2% were postmenopausal and took the form of HRT, and 22% were postmenopausal rather than on HRT form. Eight percent of women report lubricating disorders during sexual activity; 14.3% in the premenopausal group, 30% in the postmenopausal group who did not use HRT, and 11.7% among postmenopausal women taking HRT. Finally, 21% of women reported pain as a disorder in their sexual satisfaction - premenopausal group of 14.3%, postmenopausal women taking HRT of 13.3% and the group with the highest rate, similar to other outcomes, were postmenopausal women. not using HRT of 34%. The study concluded that there was a significant reduction in sexual function associated with menopause in the domain of pain and lubrication.
Maintenance and improvement of quality of life during the menopause period is the core of HRT-based estrogens and progestin. HRT therapy and estrogen replacement therapy (ERT) have been shown to increase sexual desire in a significant percentage of women; however, as with all pharmacological treatments, not all women are responsive, especially those with pre-existing sexual difficulties. ERT restores vaginal cells, pH levels, and blood flow to the vagina, all of which are related to the occurrence of menopause. Dyspareunia (due to dry vagina) appears to be the most responsive component of menopausal women sexuality for ERT. It has also been shown to have a positive effect on the urinary tract and atrophy and can initially increase libido or sexual sensitivity. Other improvements in areas such as sexual desire, passion, fantasy, and frequency of coitus and orgasm have also been noted. However, the effectiveness of ERT has been shown to decrease in some women after prolonged use. Numerous studies have found that the combined effects of estrogen/androgen replacement therapy can improve the female motivation aspect of sexual behavior above and beyond what can be achieved only with estrogen therapy alone. The finding on a relatively new form of HRT called tibolone - a synthetic steroid with estrogenic, androgenic, and progestogenic properties - indicates that it has the ability to improve mood, libido, and somatic symptoms of women undergoing menopause to a greater extent than ERT.. In various placebo-controlled studies, improvements in vasomotor symptoms, emotional reactions, sleep disturbances, somatic symptoms, and sexual desire have been observed. However, while it has been available in Europe for almost two decades, it has not been approved for use in North America at this time.
Effects on sexuality on transgender individuals
Hormone therapy is an integral component in the medical care of transgender people, as hormones can lead to a reduction in the dichotomy between the individual body and their gender identity. Managing long-term hormonal regimens has not been studied and is difficult to estimate because studies on long-term use of hormonal therapy have not been recorded. However, it is possible to speculate the outcome of this therapy in transgender people based on knowledge of the current effects of gonadal hormonal function on men and women on cisgender.
Firstly, if one wishes to reduce testosterone in the gender transition to men, it is likely that sexual desire and passion will be inhibited; Alternatively, if high-dose estrogens have a negative impact on sexual desire, which has been found in several studies with cisgender women, it is hypothesized that combining androgens with high estrogen levels will improve this outcome. Unfortunately, until now there has been no randomized clinical trial examining the relationship between type and dose of transgender hormone therapy, so the relationship between them remains unclear. Usually, the estrogen given for male-to-female gender transition is 2 to 3 times higher than the recommended dose for HRT in postmenopausal women. Pharmacokinetic studies show that increasing this dose may lead to a higher increase in plasma estradiol levels; However, long-term side effects have not been investigated and the safety of these routes is unclear.
As with any pharmacological or hormonal therapy, there are potential side effects, which in the case of transgender hormone therapy include changes in sexual function. It has the ability to significantly affect sexual function, either directly or indirectly through various side effects, such as cerebrovascular disorders, obesity, and mood fluctuations. In addition, several studies have found the onset of diabetes following feminizing hormone therapy, which impairs sexual response. Regardless of the route chosen by an individual and his doctor, it is important to consider both the medical risks of hormonal therapy and the psychological needs of the patient.
Contraindications
Absolute contraindication
- Undiagnosed vaginal bleeding
- Severe heart disease
- Pregnancy
- Coronary artery disease (CAD)
- Endometrial cancer differentiation and a good start (once treatment for malignancy is complete, no longer an absolute contraindication). Progestin alone can relieve symptoms if the patient can not tolerate estrogen.
- Latest DVT or stroke
Relative contraindication
- Migraine headaches
- Personal history of breast cancer
- Personal history of ovarian cancer
- Venous thrombosis
- The history of uterine fibroids
- Atypical ductal hyperplasia of the breast
- Active gallbladder disease (cholangitis, cholecystitis)
Adverse effects
History
Extraction of CEEs from pregnant horse urine led to marketing in 1943 one of the earliest forms of HRT, Premarin. From then until 1975, estrogen was administered without additional progesterone or progestin. A study by Kaiser Permanente by Dr. Harry Ziel points out that in the absence of progesterone, patients are at an increased risk of endometrial cancer with unopposed estrogen therapy. After this, progestin is added to women who do not receive surgical hysterectomy, to reduce the incidence of endometrial hyperplasia and cancer. This was followed by the Women's Health Initiative (WHI) in 2002. However, the WHI arm who received Estrogen and Progesterone combined therapy was closed prematurely by the Data Monitoring Committee (DMC) due to perceived health risks, even though the trial was suspended for only a full year after data shows the increased risk of being real. In 2004, the WHI arm in which post-hysterectomy patients were treated with estrogen alone was also covered by DMC.
Administration and formulation
HRT is available in various forms. Usually give a low dose of one or more estrogens, and often also provide progesterone or chemical analog, called progestin. Testosterone can also be included. Some HRT treatments like Livial contain Tibolone, anabolic steroids, which have estrogen, progestogen, and testosterone properties. Such treatment is usually not recommended for women who have perimenopause or at least 12 months after the last menstrual period.
In women who have undergone hysterectomy, usually given estrogen without any progesterone, a therapy called "estrogen therapy without the opponent". HRT can be delivered to the body through patches, tablets, creams, troch, IUD, vaginal ring, gel or, less frequently, by injection. For example, estrogens administered orally include those given by intravaginal tablets, creams and rings, and can have more effects on atrophic vaginitis with less systemic effect than estrogen given in other ways.
Doses often vary cyclically to more closely mimic the ovarian hormone cycle, with estrogen being taken daily and progesterone or progestin taken for about two weeks every month or two; a method called "cyclic HRT" or "combined aggregate HRT" (abbreviated SCHRT). An alternative method, a constant dose with both hormones taken daily, is called "continuous combined HRT" or ccHRT, and is a newer innovation. Sometimes androgens, commonly testosterone, are added to treat reduced libido. It can also treat reduced energy and help reduce osteoporosis after menopause.
HRT is often given as short-term relief (often one or two years, usually less than five) of menopausal symptoms (hot flushes, irregular menstruation, fat redistribution, etc.). Younger women with premature ovarian failure or surgical menopause can use HRT for years, until the age of natural menopause.
The estradiol formulations include: oral tablet, usually given in the amount of 1 to 2 milligrams of estradiol per day, with trade names including Progynon .
In addition, there are many estradiol formulations combined with one of the various progestin, such as norethisterone (in Activelle, Novofem and Cliovelle), levonorgestrel, medroxyprogesterone acetate (in indivina ), dienogest or drospirenone.
See also
References
External links
- Hormone Education Council
- The North American Menopause Society
- FDA Articles on Menopause and Hormones
Source of the article : Wikipedia
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