Hormone Replacement Therapy Christel Wekon-Kemeni

Disclosures None.

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

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

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

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”

Case Presentation!

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.

What’s going on with this poor lady?

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

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

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

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 10-14 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

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

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

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

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

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

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

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!

References "Hormone Replacement Therapy." The Free Dictionary. Farlex, n.d. Web. "Hormone Replacement Therapy (menopause)." Wikipedia. Wikimedia Foundation, 16 Aug. 2017. Web. "Hormone Therapy." Https://www.acog.org. N.p., n.d. Web. "Menopausal Hormone Replacement Therapy." Practice Essentials, Overview, Symptoms and Effects of Menopause. N.p., 06 Jan. 2017. Web. "Menopause." Menopause Key Highlights - Epocrates Online. N.p., n.d. Web.