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Principles of HRT


INDICATIONS for HORMONE REPLACEMENT THERAPY (H.R.T.)

  • Relief of menopausal symptoms (short-term).
  • Prevention / treatment of osteoporosis (long-term).

CONTRAINDICATIONS for H.R.T.

  • Pregnancy
  • Undiagnosed abnormal vaginal bleeding
  • Active thromboembolic disorder or acute-phase myocardial infarction
  • Suspected or active breast or endometrial cancer
  • Active liver disease with abnormal liver function tests
  • Porphyria cutanea tarda

OTHER POSSIBLE BENEFITS

Reduction in risk of colonic cancer, macular degeneration and cataract formation, with improved dentition and skin healing. If commenced in the early menopausal years, possible reduction in cardiovascular disease and alzheimer type dementia-- these still controversial.

RISKS of H.R.T.

  • Small increased risk of breast cancer with long-term treatment (> 5 years).
  • Small increased risk of venous thrombo-embolism - most significant in patients with other risk factors.
  • Association between HRT and Cardiovascular disease.
    For many years, it was thought that HRT significantly reduced the risk of cardiovascular disease and stroke. Following recent studies such as the HERS and WHI studies, it appeared possible that certain types of HRT may confer an increased risk. It now seems that HRT commenced early in the menopause can provide benefit but if commenced later, when atherosclerosis is already present, there may be a small increased risk. Results from studies using different types and routes of HRT are awaited. HRT should not currently be taken for presumed cardiovascular benefit, and HRT should only be prescribed to women who have, or are at risk of cardiovascular disease if there are good indications, and after full discussion.

HORMONES INVOLVED

  1. Estrogen - should be given continuously.
  2. Progestogen - given in addition to estrogen in non-hysterectomised patients to reduce the risk of endometrial hyperplasia. Duration and frequency of the progestogen determines the presence and pattern of bleeding.

ROUTE of H.R.T.

  1. Oral - Usually first choice - cost-effective and acceptable.
  2. Non-oral - Transdermal--patch or gel,  - have different metabolic effects e.g. on lipid metabolism and clotting system.
  3. Significance of these effects is controversial. Non-oral therapies are thought to produce more physiological hormone levels than oral therapy, avoiding bolus first-pass effect on the liver, but generally more expensive.

INDICATIONS for NON-ORAL ROUTE

  • Patient preference.
  • Poor symptom control with oral treatment
  • Side effects e.g. nausea with oral treatment.
  • History of, or risk of venous thrombo-embolism (when HRT should only be considered after full discussion and appropriate investigation).
  • Variable hypertension (blood pressure should be controlled before starting HRT).
  • Hypertriglyceridaemia.
  • Current hepatic enzyme inducing agent, e.g. anticonvulsant therapy.
  • Bowel disorder which may affect absorption of oral therapy.
  • History of migraine (when steadier hormone levels may be beneficial).
  • Lactose sensitivity.
  • History of gallstones.

Wide range of types and routes of estrogen and progestogen allows flexibility and enables treatment to be individualised. Prices indicated generally represent 28 days treatment.

Page last updated: 24 November 2011

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