1. Hormone Replacement Therapy
Christel Wekon-Kemeni

2. Disclosures
None.

3. Learning Objectives
Define Hormone Replacement Therapy and explain why it is used
Understand the typical presentation of menopause
Provide a differential diagnosis and management plan for a patient needing HRT
Describe the different options of HRT
Outline the benefits and drawbacks/complications of HRT
Counsel a patient about being on HRT

4. What is HRT?
The use of exogenous female hormones to replace the declining levels of estrogen and progesterone witnessed in menopause
Purposes of HRT:
Preventive treatment against osteoporosis & heart disease
Relief of menopausal symptoms

5. Brief History of HRT
Estrogen was widely used to treat menopausal symptoms in the 1950s and 60s
Link between estrogen-only therapy and endometrial cancer in postmenopausal women found in mid-1970s
It was discovered that the risk of endometrial cancer was reduced with the addition of progesterone to estrogen therapy

6. Brief History cont.
Combination therapy was found to provide additional long-term protection against:
Osteoporosis
Heart disease
Alzheimer disease
In 2002, the Women’s Health Initiative study linked HRT to a “slightly increased risk of stroke, heart disease and breast cancer”

7. Case Presentation!

8. A 51-year old G1P1001 woman comes into your clinic with complaints of irregular menstrual cycles and hot flashes. She first noticed her cycles becoming irregular two years ago, with her LMP being exactly 12 months ago. She also has noticed a decreased desire for sex as of late and wakes up tired most mornings.

9. What’s going on with this poor lady?

10. Differential Diagnosis
Pregnancy
Polycystic ovary syndrome
Hyperthyroidism
Hypothyroidism
Anorexia
Depression
Medication effects
Carcinoid syndrome
Menopause

11. Typical Presentation of Menopause
Woman in her late 40s-early 50s with complaints of:
Hot flashes
Irregular menstrual cycles
Weight gain
Vaginal dryness
Mood swings
Heart palpitations
Sleep disturbances
Loss of sexual desire
Urinary frequency & urgency

12. Hormone Replacement Therapy!
So what can we do for her?
Recommend lifestyle changes
Hormone Replacement Therapy!
Lifestyle changes include:
Losing weight
Increase exercise
Avoidance of spicy foods, alcohol, caffeine, warm environments, stress
Drinking cold water
Using hand-held fans

13. HRT Options Estrogen-only hormone therapy
Oral combination estrogen/progestin therapy
Cyclic therapy
Continous therapy
Transdermal or topical estrogen
Bioidentical hormones
Estrogen +/- progestin in a custom compounded base
- Estrogen only: Lowest effective dose for shortest amount of time
Combo: Progestin for a minimum of days each month is recommended for endometrial protection
Cyclic – estrogen every day; progestin added for several days each month or several days every 3 or 4 months
Continous – estrogen and progestin every day

14. Benefits of HRT Relief of hot flashes and night sweats
Relief of vaginal dryness
Protection against bone loss in osteoporosis
Prevention of hip and spine fractures
Reduced risk of colon cancer

15. Drawbacks of HRT Increased risk for breast cancer*
Increased incidence of endometrial cancer
Increased risk of thromboembolism
Increased risk of cholelithiasis
Slight increased risk of heart attack**
*Breast cancer risk is associated with combination therapy. No significant association with estrogen-only HRT
**Combined HRT may protect against heart attacks for women younger than 60 years starting treatment within 10 years of menopause
- Progesterone relaxes Sphincter of oddi; relative deficiency of progesterone to estrogen causes decreased bile flow

16. Relative Contraindications to HRT
History of:
Breast cancer
Endometrial cancer
Hypertriglyceridemia
Thromboembolic disorders
Undiagnosed vaginal bleeding
Fibroids
Endometriosis

17. Preparation for HRT Pap smear and breast examination Urinalysis
Bone density test
Blood tests
RBC, blood sugar, cholesterol levels
Liver & thyroid function
Progesterone challenge test

18. Treatment Monitoring
Patients should see doctor at least twice a year for checkups
Annual surveillance to make sure that the patient is benefiting from treatment
Complete physical on a yearly basis
Coach patient to enact lifestyle changes
Breast exam twice a year; assess for any abnormal bleeding
Mammogram and pelvic exam yearly
Lifestyle changes:
Relaxation techniques
Losing weight
Increase exercise
Avoidance of spicy foods, alcohol, caffeine, warm environments, stress
Drinking cold water
Using hand-held fans

19. Summary Slide
HRT is used to provide relief to patients suffering from menopausal symptoms
Consider other potential diagnoses before diagnosing menopause
There are multiple types of HRT that can be prescribed to patients
Consider the contraindications of administering HRT
There are multiple benefits and drawbacks to HRT
Patients should be monitored while on HRT

20. Our patient decides to start combination HRT and will be assessed in six months. You tell her to contact you immediately if any vaginal bleeding occurs while on the therapy. She thanks you and is excited to start this treatment plan!

21. References
"Hormone Replacement Therapy." The Free Dictionary. Farlex, n.d. Web.
"Hormone Replacement Therapy (menopause)." Wikipedia. Wikimedia Foundation, 16 Aug Web.
"Hormone Therapy." N.p., n.d. Web.
"Menopausal Hormone Replacement Therapy." Practice Essentials, Overview, Symptoms and Effects of Menopause. N.p., 06 Jan Web.
"Menopause." Menopause Key Highlights - Epocrates Online. N.p., n.d. Web.