Hormone replacement therapy Presented by: dr. menna shawkat Prepared by: Dr. Mohamed mortada Lecturer of Geriatrics and Gerontology Ain Shams University

Hormone supplementation with estrogen, progesterone, testosterone, growth hormone and thyroid hormone has the potential to improve quality of life and to prevent, or reverse, the many symptoms and conditions associated with aging, including fatigue, depression, weight gain, frailty, osteoporosis, loss of libido, and heart disease.

Much hesitation surrounds the possible long-term side effects of hormone therapies, including the potential increased risk of cancers. Users of HRT were found to be at increased risk of breast cancer, and the risk increased with increasing length of use.

Short periods of hormone replacement therapy (HRT) are often used to treat vasomotor symptoms around the time of the menopause, but long-term adherence to therapy is low. However, there is accumulating evidence to support the initiation or re-initiation of HRT as a later intervention for a variety of progressive conditions associated with menopause and aging.

If the risk-benefit ratio is in favor of HRT, various strategies can be used to improve acceptance and minimize side effects, with the goal of improving the quality, if not the quantity, of life.

In recent years, standard teaching suggested that HRT should be continued throughout the menopausal years to confer maximal relief of vasomotor symptoms, optimal effects on bone, lipids, and the urogenital tract, and the possibility of protection from cardiovascular disease, cerebrovascular disease, colon cancer, and neurodegenerative disorders such as Alzheimer’s disease.

Concerns about a possible increase in breast cancer risk appear to be the largest hurdle to initiating HRT, while withdrawal or breakthrough bleeding is the main reason for discontinuing therapy.

The case for intermittent or late-onset HRT In such a model, HRT might be used for 1 to 5 years in the perimenopausal interval to control vasomotor symptoms and irregular bleeding. A second discussion about the use of HRT (and other therapies), particularly for bone protection and relief of urogenital symptoms, may then be initiated in later life, depending on individual symptoms, health status, and risk factors.

Indications for late-onset HRT Vasomotor symptoms Vasomotor symptoms are usually most troublesome in the perimenopause and early menopausal years, but generally improve spontaneously over a period of 2 to 5 years. Some women have residual bothersome symptoms that persist for years or decades. Level I evidence from randomized placebo-controlled trials indicates rapid and effective relief of vasomotor symptoms with either oral or transdermal estrogen. If estrogen is not appropriate or not tolerated, relief may be obtained with progestins alone.

Genitourinary and sexual symptoms In contrast to vasomotor symptoms that appear early and tend to dissipate with time, urogenital symptoms tend to develop progressively in the years or decades following menopause Urogenital complaints may affect 30% to 50% of menopausal women and may be a source of considerable daily discomfort Vaginal dryness during sexual arousal is often the first symptom and may precede physical findings.

There is level I evidence to support the use of estrogen for vaginal atrophic symptoms and as prophylaxis for recurrent urinary tract infections. Interestingly, systemic HRT may not provide complete relief of vaginal symptoms, necessitating augmentation or replacement with local vaginal estrogen therapy. Low doses of vaginal estrogen can be used to treat urogenital symptoms, even in women with contraindications or intolerance to systemic estrogen therapy. Vaginal estrogen is absorbed systemically.

Musculoskeletal protection In order to significant skeletal benefits from HRT, therapy must be administered for at least 5 to 10 years. However, long-term adherence to HRT is relatively low, and bone loss resumes after discontinuation of HRT. Catch-up bone loss is believed to occur, so that 10 or more years after stopping estrogen, bone mass appears similar in treated women and untreated controls.

Cardioprotection Postmenopausal estrogen therapy is associated with endothelial vasodilation and beneficial changes in the lipid profile. Numerous case-control and cohort studies have demonstrated a 40% to 50% reduction in the risk of coronary heart disease (CHD) among postmenopausal HRT users. The protection dissipates following cessation of therapy, suggesting that it is mediated by a direct vascular action.

Neurocognitive protection Use of HRT for the prevention or treatment of disorders such as Alzheimer’s disease. Estrogen appears to have a neuroprotective role, likely mediated by its antioxidant properties and its ability to enhance cerebral blood flow, improve cerebral glucose metabolism, and reduce ß-amyloid deposition. It follows that loss of these protective effects after the menopause may contribute to the neurocognitive deterioration that occurs with normal aging.

Initiating HRT in older women As there is no urgency to reach full therapeutic doses of HRT, side effects can be minimized by Starting with half the anticipated dose, Administered daily or on alternate days. Subsequent dose increases can occur gradually over the ensuing weeks until symptoms are alleviated (if applicable), Undesirable side effects occur, or the desired dose is reached. In women with a uterus, it may be prudent to delay addition of the progestin for some weeks in order to differentiate side effects attributable to the estrogen and progestin components.

If the risk-benefit ratio favors HRT, various strategies can be used to improve acceptance and minimize side effects: Instituting therapy slowly. Considering lower doses. Evaluating systemic versus local therapy.

Side effects of HRT CAD (coronary artery diseases) CVS DVT Pulmonary embolism

Contraindications of HRT Liver disease Undiagnosed vaginal bleeding History of DVT or hypercoagulable state History of certain cancers

Thank you