((Hormone replacement therapy)) ((Menopause)) And ((Hormone replacement therapy))

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

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 pathology. 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

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.

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

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.

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

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 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 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)

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

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)