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Menopause and hormone replacement therapy


((Hormone replacement therapy))
 Climacteric and menopause is one phase
 in woman”s life
 It is associated with health changes and
 Hormone replacement therapy needed to
  improve quality of life and prevent medical
  complications which follow menopause
 Menopause is the last menstrual period
  the average age is 51 years.
 Climacteric is transition from fertility to
  infertility from 45-55 years.
 Women live 40% of her life in menopause.
 The first endocrine change in menopause
  is fall in inhibin(glycoprotein) from ovaries
  which inhibit the release of FSH and LH
  from pituitary,so FSH and LH rise.
Causes of menopause
A)Premature ovarian failure
 Menopause occuring before 45 years,low
  oestrogen,high FSH&L
 May be associated with autoimmune
B) Surgical menopause
 Menopause after oophorectomy,after
  hysterectomy menopause occurs about 3
  years earlier the natural menopause.
C) After chemotherapy or radiotherapy as
  breast cancer or lymphoma.
Diagnosis of menopause
 History(age,disease,surgery,treatment)
 Clinical examination
 Investigations
  Low oestrogen(E2 10-50pg/ml)
  High FSH&LH >10IU/L
 Total cholesterol increase
  HDL cholesterol decrease
  LDL cholesterol increase
 Depression
 Thyroid disease
 Phaeochromocytoma,carcinoid syndrome.

Clinical features
1.Early changes:-
     Vsomotor symptoms(disturbance in the
    thermoregulator in the hypothalamus) occur in
    70% of women.
    Frequency – few to several times per day.
  Duration –weeks to years.
  Hot flushes followed by sweating.
 Psychological symptoms
  Insomnia,poor concentration,irritability,
  anxiety and lethergy.
 2. Intermediate changes(2-4 years,collagen )
    Wrinkled skin,small breasts.
    Genital tract,thin and dry vagina,acidity
    reduced       infection,dysparunia and
    genital prolapse.
    Urinary symptoms,frequency,dysuria,urgency,
     and stress incontnence.
3.Late changes(>10 years)
  Bones,osteoporosis(colle’s fracture,fracture
  of neck femur and vertebral crush fracture)
  CVS,stroke and heart attacks.
Treatment:Hormone Replacement Therapy
 Depend on the presence and severity of
 Patient decision.
 Careful counselling before treatment.
 BP,breast examination(mammogram)
 Pelvic examination,look for oestrogen
  sensitive tumours(fibroid,endometriosis,
  endometrial carcinoma)
Benefits of HRT
 Cure early symptons of menopause.
 Prevent fractures in about 50%.
 Reduce heart attacks in about 40%.
 Reduce bladder dysfunction.
 May prevent against bowel carcinoma and
  Alzheimer’ disease.
Contraindications of HRT
   Present or suspected pregnancy
   Suspicion of breast cancer
   Suspicion of endometrial cancer
   Active liver disease
   Uncontrolled hypertension
   Cofirmed VTE
   Presence of fibroid
   Past history of benign breast disease
   Uconfirmed VTE
   Chronic liver disease
   Migraine
Preparations of HRT
Natural oestrogens(from plants or animal)
 Oestradiol valerate 1-2mg
 Congugated equine oestrogens
 Oestrone 1.25mg
 Medroxyprogesterone acetate 10mg
 Dydrogesterone 10mg
 Norethisterone 1mg
 Norgesterel        0.15mg
Post-hysterectomy : use only oestrogens
Add progestogens at least for 12 days of
 28 days for non-hysterectomized patient.
 Combined oral oes. And prog. (pills 28
 Combined oes. And prog. In patch(weekly)
 Oestrogen patch
 Oestrogen gel rubbed into the skin daily
 Inplant s\c for one year
 Vaginal(cream,pessary,tablet for local
 Synthetic steroid
 Has oestrogenic,progestogenic and
  androgenic effect
 Used 1year after menopause 2.5mg daily
Raloxifene SERM:-
 Selective oestrogen receptor modulator
 Prevent osteoporosis
 Does not stimulate breast and endometrial
 May worsen vasomotor symptons
Side effcts of HRT(first 12 weeks)
 Breast tenderness and nipple sensitivity
 Appetite rise and weight gain
 Calf cramps
Patient must reviewed 6 months then
  annually(BP,breast,pelvic examination)

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