1. ((Hormone replacement therapy))
((Menopause))
And
((Hormone replacement therapy))

2. Objective:-
Climacteric and menopause is one phase
in woman”s life
It is associated with health changes and
diseases
Hormone replacement therapy needed to
improve quality of life and prevent medical
complications which follow menopause

3. Menopause is the last menstrual period the average age is 51 years.
Climacteric is transition from fertility to infertility from 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.

4. Causes of menopause
A)Premature ovarian failure
Menopause occuring before 45 years,low oestrogen,high FSH&L
May be associated with autoimmune pathology.
B) Surgical menopause
Menopause after oophorectomy,after hysterectomy menopause occurs about 3 years earlier the natural menopause.

5. C) After chemotherapy or radiotherapy as breast cancer or lymphoma.
Diagnosis of menopause
History(age,disease,surgery,treatment)
Clinical examination
Investigations
Low oestrogen(E pg/ml)
High FSH&LH >10IU/L
Total cholesterol increase
HDL cholesterol decrease
LDL cholesterol increase

7. D.Diagnosis:- 1.Early changes:- PMS 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.

8. 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.

9. 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
Principles
Depend on the presence and severity of
symptons.
Patient decision.
Careful counselling before treatment.

11. Examination:- 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.

12. Contraindications of HRT Absolute:-
Present or suspected pregnancy
Suspicion of breast cancer
Suspicion of endometrial cancer
Active liver disease
Uncontrolled hypertension
Cofirmed VTE
Relative:-
Presence of fibroid
Past history of benign breast disease
Uconfirmed VTE
Chronic liver disease
Migraine

13. Preparations of HRT
Natural oestrogens(from plants or animal)
Oestradiol valerate 1-2mg
Congugated equine oestrogens
Oestrone 1.25mg
Progestogens
Medroxyprogesterone acetate 10mg
Dydrogesterone 10mg
Norethisterone 1mg
Norgesterel mg

15. 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 days)
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 symptoms)

16. Tibolone:- Raloxifene SERM:- 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
receptors
May worsen vasomotor symptons

17. 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)