Hormonal therapy for menopause
Content
MENOPAUSE
Menopause is the transition period in a woman's life when her ovaries stop
producing eggs, her body produces less estrogen and progesterone and
menstruation becomes less frequent, eventually stopping altogether. Menopause is a
natural event that normally occurs between the ages of 45 and 55. Before
menstruation stops at menopause, a woman will go through premenopausal and
perimenopause. During premenopausal, menstrual periods begin to become
irregular. During perimenopause, a women’s menstrual period will become highly
irregular and she may experience various symptoms. Perimenopausal occurs a few
years before a woman reaches menopause. The symptoms of menopause are
caused by changes in estrogen and progesterone levels. The ovaries make less of
these hormones over time. The specific symptoms and how significant (mild,
moderate, or severe) they are varies from woman to woman. A gradual decrease of
estrogen generally allows your body to slowly adjust to the hormonal changes. Hot
flashes and sweats are at their worst for the first one to two years. During
menopause, changes also occur in the vagina and urinary tract. Vaginal tissue
becomes thinner, drier, and less elastic, which may cause discomfort or pain during
sexual intercourse. Urinary tract tissue also becomes less elastic, which may cause
a release of urine during laughter, coughing, sneezing, or exercise. Many
menopausal women also find that urinary tract infections occur more frequently
during this time. Other symptoms of menopause may include mood changes,
insomnia (or other sleep disturbances), depression, or anxiety. Hormone
replacement therapy (HRT) can relieve many of these symptoms. Hormone
replacement therapy is a medication which contains hormones that a woman’s body
stops producing after menopause.
1) Treatment
Hormone replacement therapy (HRT) for menopause patients involves the
administration of synthetic estrogen and progestogen to replace a woman’s depleting
hormone levels and thus alleviate menopausal symptoms. There are many forms of
hormonal therapy available in market. Hormone therapy usually prescribes as local
therapy or systemic therapy. Local therapy includes cream, pessaries or even rings.
Systemic therapy on the other hand includes oral drugs, transdermal patches, gels
and implants. The hormonal products available may contain estrogen alone, or
combined progestogen, selective estrogen receptor modulator (SERM), and
gonadomimetics such as tibolone. The estrogens most commonly prescribed are
conjugated estrogens that may be synthetic, micronized 17B estradiol, and ethinyl
estradiol. The progestin’s that are used commonly are medroxyprogesterone acetate
(MPA) and norethindrone acetate. There are various schedules of hormone therapy
which include taking estrogens daily, cyclic or sequential regimens where
progestogen added for 10-14 days every 4 weeks and lastly continuous combined
regimen where estrogen and progestogen are taken daily.
2) Clinical uses
Firstly, this hormone replacement therapy is used to relieve menopause symptoms
which can be further divided into vasomotor symptoms and urogenital symptoms.
The most common vasomotor symptoms namely hot flushes, night sweats,
headache, and palpitations. On the other hand, the urogenital symptoms include
vaginal dryness, superficial dyspareunia, reduced sex drive, and urinary frequency
and urgency. Both topical and systemic estrogens have been shown to improve
these urogenital symptoms. Achievement of these beneficial effects requires longterm therapy. Symptoms usually recur after the hormonal therapy is stopped. Other
than relieving symptoms, this therapy also can reduce risk of disorders that usually
affects elderly females such as osteoporosis, increased risk for cardiovascular
disease, depression and others. The risk for cardiovascular disease increases when
normal ovulatory function ceases and the oestrogen level fall, there is an accelerated
rise in plasma cholesterol and LDL concentration. However, there isn’t much change
in HDL concentration and very little changes in VLDL. Increase in cholesterol level
also becomes a part of other causes which are common for elderly women. These
include gaining weight, high blood pressure, diabetes and others. Hormone
replacement therapy can also be given as a preventive medication, especially for
those who experience early menopause. It is advisable for them to take hormone
therapy immediately from the menopause start period until natural menopause age.
3) Contraindications
A history of endometrial cancer
Porphyria
Severe active liver disease
Hypertriglyceridemia
Thromboembolic disorders
Undiagnosed vaginal bleeding
Endometriosis
A history of breast cancer
4) Evaluation
All candidates for hormonal therapy should be thoroughly evaluated with a detailed
history and complete physical examination for a proper diagnosis and identification
for any contraindications. Baseline laboratory and imaging studies should be
conducted before administering hormonal therapy. Among studies/ result needed are
hemography, urinalysis, fasting lipid profile, blood sugar levels, serum estradiol
level : in women who will be prescribed an implant and in those whose symptoms
persist despite use of an adequate dose of a patch or gel, ultrasonography : to
measure endometrial thickness and ovarian volume, electrocardiography and
mammography. Endometrial sampling is usually not required in routine practice.
However, the presence of abnormal bleeding before or during hormonal therapy
should prompt consideration to check endometrial thickness (cutoff, <4 mm)
5) Management
A low dose of hormone replacement therapy is usually recommended to begin with.
It is best to start with the lowest effective dose, to minimise side effects. Preserve
with hormonal replacement therapy and wait a few months to evaluate the
effectiveness of the treatment. There are many types of different preparation
available in market and the main three are discussed below.
(a) Estrogen-only hormone replacement therapy
It usually recommended for women who have had their womb removed during
hysterectomy. There is no need to take progestogen because there is no risk of
womb/uterus cancer or also called endometrial cancer. However, it is given for
symptomatic relief such as hot flushes, climacteric depression and sleep
disturbances. Estrogen alone is given 5 times per week. The treatment for this risk is
given for limited period only as there is high risk from breast cancer.
(b) Cyclical hormone replacement therapy
Cyclical hormone replacement therapy, also known as sequential hormone replacement
therapy is often recommended for women who have menopausal symptoms but still have
their periods. There are two types of cyclical hormone replacement therapy which are
monthly HRT and three-monthly HRT. Monthly HRT is a regimen where estrogen is taken
every day and progestogen at the end of the menstrual cycle for 12-14 days. This type of
HRT is usually recommended for women having regular periods. Three-monthly HRT is a
regimen where you take estrogen every day and progestogen for 12-14 days, every 13
weeks. This regimen is recommended for women experiencing irregular periods.
(c) Continuous combined hormone replacement therapy
Continuous combined HRT is usually recommended for women who are postmenopausal. A woman is usually said to be post-menopausal if she has not had a period
for a year. This continuous HRT involves taking estrogen and progestogen every day
without a break.
(d) Androgen replacement therapy
Interest is growing in the role of androgen replacement for postmenopausal patients.
Androgenic hormones are usually produced in the premenopausal ovaries and the adrenal
glands in a very small quantity. Androgens increase libido and protect bone mass, but also
decrease HDL cholesterol. Estrogen-androgen combinations provide relief of somatic
symptoms at a lower dose of estrogen. Adverse effects such as virilisation are few and can
be minimized with reduction of the dosage. Androgens are available in many different form
such as oral (methyltestosterone, fluoxymesterone) , injections (testosterone enanthate,
testosterone cypionate) and oral estrogen-androgen combinations . The oral tablet should
be either given separately or combined with estrogen in a fixed ratio due to the ability of
the hormones of being digested in liver. That is why a sublingual tablet is more preferable.
Due to the side effects of androgen such as facial hair growth, mood changes, and acne,
the dosage needs to be monitored very carefully.
Menopause is the transition period in a woman's life when her ovaries stop
producing eggs, her body produces less estrogen and progesterone and
menstruation becomes less frequent, eventually stopping altogether. Menopause is a
natural event that normally occurs between the ages of 45 and 55. Before
menstruation stops at menopause, a woman will go through premenopausal and
perimenopause. During premenopausal, menstrual periods begin to become
irregular. During perimenopause, a women’s menstrual period will become highly
irregular and she may experience various symptoms. Perimenopausal occurs a few
years before a woman reaches menopause. The symptoms of menopause are
caused by changes in estrogen and progesterone levels. The ovaries make less of
these hormones over time. The specific symptoms and how significant (mild,
moderate, or severe) they are varies from woman to woman. A gradual decrease of
estrogen generally allows your body to slowly adjust to the hormonal changes. Hot
flashes and sweats are at their worst for the first one to two years. During
menopause, changes also occur in the vagina and urinary tract. Vaginal tissue
becomes thinner, drier, and less elastic, which may cause discomfort or pain during
sexual intercourse. Urinary tract tissue also becomes less elastic, which may cause
a release of urine during laughter, coughing, sneezing, or exercise. Many
menopausal women also find that urinary tract infections occur more frequently
during this time. Other symptoms of menopause may include mood changes,
insomnia (or other sleep disturbances), depression, or anxiety. Hormone
replacement therapy (HRT) can relieve many of these symptoms. Hormone
replacement therapy is a medication which contains hormones that a woman’s body
stops producing after menopause.
1) Treatment
Hormone replacement therapy (HRT) for menopause patients involves the
administration of synthetic estrogen and progestogen to replace a woman’s depleting
hormone levels and thus alleviate menopausal symptoms. There are many forms of
hormonal therapy available in market. Hormone therapy usually prescribes as local
therapy or systemic therapy. Local therapy includes cream, pessaries or even rings.
Systemic therapy on the other hand includes oral drugs, transdermal patches, gels
and implants. The hormonal products available may contain estrogen alone, or
combined progestogen, selective estrogen receptor modulator (SERM), and
gonadomimetics such as tibolone. The estrogens most commonly prescribed are
conjugated estrogens that may be synthetic, micronized 17B estradiol, and ethinyl
estradiol. The progestin’s that are used commonly are medroxyprogesterone acetate
(MPA) and norethindrone acetate. There are various schedules of hormone therapy
which include taking estrogens daily, cyclic or sequential regimens where
progestogen added for 10-14 days every 4 weeks and lastly continuous combined
regimen where estrogen and progestogen are taken daily.
2) Clinical uses
Firstly, this hormone replacement therapy is used to relieve menopause symptoms
which can be further divided into vasomotor symptoms and urogenital symptoms.
The most common vasomotor symptoms namely hot flushes, night sweats,
headache, and palpitations. On the other hand, the urogenital symptoms include
vaginal dryness, superficial dyspareunia, reduced sex drive, and urinary frequency
and urgency. Both topical and systemic estrogens have been shown to improve
these urogenital symptoms. Achievement of these beneficial effects requires longterm therapy. Symptoms usually recur after the hormonal therapy is stopped. Other
than relieving symptoms, this therapy also can reduce risk of disorders that usually
affects elderly females such as osteoporosis, increased risk for cardiovascular
disease, depression and others. The risk for cardiovascular disease increases when
normal ovulatory function ceases and the oestrogen level fall, there is an accelerated
rise in plasma cholesterol and LDL concentration. However, there isn’t much change
in HDL concentration and very little changes in VLDL. Increase in cholesterol level
also becomes a part of other causes which are common for elderly women. These
include gaining weight, high blood pressure, diabetes and others. Hormone
replacement therapy can also be given as a preventive medication, especially for
those who experience early menopause. It is advisable for them to take hormone
therapy immediately from the menopause start period until natural menopause age.
3) Contraindications
A history of endometrial cancer
Porphyria
Severe active liver disease
Hypertriglyceridemia
Thromboembolic disorders
Undiagnosed vaginal bleeding
Endometriosis
A history of breast cancer
4) Evaluation
All candidates for hormonal therapy should be thoroughly evaluated with a detailed
history and complete physical examination for a proper diagnosis and identification
for any contraindications. Baseline laboratory and imaging studies should be
conducted before administering hormonal therapy. Among studies/ result needed are
hemography, urinalysis, fasting lipid profile, blood sugar levels, serum estradiol
level : in women who will be prescribed an implant and in those whose symptoms
persist despite use of an adequate dose of a patch or gel, ultrasonography : to
measure endometrial thickness and ovarian volume, electrocardiography and
mammography. Endometrial sampling is usually not required in routine practice.
However, the presence of abnormal bleeding before or during hormonal therapy
should prompt consideration to check endometrial thickness (cutoff, <4 mm)
5) Management
A low dose of hormone replacement therapy is usually recommended to begin with.
It is best to start with the lowest effective dose, to minimise side effects. Preserve
with hormonal replacement therapy and wait a few months to evaluate the
effectiveness of the treatment. There are many types of different preparation
available in market and the main three are discussed below.
(a) Estrogen-only hormone replacement therapy
It usually recommended for women who have had their womb removed during
hysterectomy. There is no need to take progestogen because there is no risk of
womb/uterus cancer or also called endometrial cancer. However, it is given for
symptomatic relief such as hot flushes, climacteric depression and sleep
disturbances. Estrogen alone is given 5 times per week. The treatment for this risk is
given for limited period only as there is high risk from breast cancer.
(b) Cyclical hormone replacement therapy
Cyclical hormone replacement therapy, also known as sequential hormone replacement
therapy is often recommended for women who have menopausal symptoms but still have
their periods. There are two types of cyclical hormone replacement therapy which are
monthly HRT and three-monthly HRT. Monthly HRT is a regimen where estrogen is taken
every day and progestogen at the end of the menstrual cycle for 12-14 days. This type of
HRT is usually recommended for women having regular periods. Three-monthly HRT is a
regimen where you take estrogen every day and progestogen for 12-14 days, every 13
weeks. This regimen is recommended for women experiencing irregular periods.
(c) Continuous combined hormone replacement therapy
Continuous combined HRT is usually recommended for women who are postmenopausal. A woman is usually said to be post-menopausal if she has not had a period
for a year. This continuous HRT involves taking estrogen and progestogen every day
without a break.
(d) Androgen replacement therapy
Interest is growing in the role of androgen replacement for postmenopausal patients.
Androgenic hormones are usually produced in the premenopausal ovaries and the adrenal
glands in a very small quantity. Androgens increase libido and protect bone mass, but also
decrease HDL cholesterol. Estrogen-androgen combinations provide relief of somatic
symptoms at a lower dose of estrogen. Adverse effects such as virilisation are few and can
be minimized with reduction of the dosage. Androgens are available in many different form
such as oral (methyltestosterone, fluoxymesterone) , injections (testosterone enanthate,
testosterone cypionate) and oral estrogen-androgen combinations . The oral tablet should
be either given separately or combined with estrogen in a fixed ratio due to the ability of
the hormones of being digested in liver. That is why a sublingual tablet is more preferable.
Due to the side effects of androgen such as facial hair growth, mood changes, and acne,
the dosage needs to be monitored very carefully.
