Hormone replacement therapy

Abstract

This is one of a series of occasional articles on therapeutics for common or serious conditions, covering new drugs and old drugs with important new indications or concerns. The series advisers are Robin Ferner, honorary professor of clinical pharmacology, University of Birmingham and Birmingham City Hospital, and Philip Routledge, professor of clinical pharmacology, Cardiff University. To suggest a topic for this series, please email us at practice@bmj.com.A 51 year old woman presents to her general practitioner with troublesome hot flushes and night sweats for the past eight months. She is sexually active and her last period was about 5 months ago. She has taken a number of over-the-counter preparations, but none have been effective. She is anxious about having hot flushes at work and exhausted from sleep disturbance. She wants advice about managing her symptoms. What is hormone replacement therapy?Menopause is a normal physiological event in women, occurring at a median age of 51 years. Hormone replacement therapy (HRT) contains oestrogen for relieving menopausal symptoms; for women who still have their uterus it is combined with a progestogen for endometrial protection. The oestrogen (oestradiol, oestradiol 17β, oestrone, or conjugated equine oestrogen) can be oral, intravaginal, or transdermal. The progestogen can be oral, transdermal, or delivered via an intrauterine device (Mirena, Bayer Schering). In HRT regimens the oestrogen is taken daily, with progestogen added either sequentially (cyclic regimen) or daily (continuous combined regimen) if it is needed. 1 Tibolone is an oral synthetic steroid preparation with oestrogenic, androgenic, and progestogenic actions that can also be used as HRT. Testosterone can be added to HRT, but the role of supplemental testosterone will not be covered in this case.The key indication for HRT or tibolone is the presence of troublesome vasomotor symptoms (hot flushes and night sweats, with or without awakening). Vasomotor symptoms are normal and affect about 80% of women during the menopause transition and are severe in about 20% of these women. The duration of these symptoms varies, with a median of four years, but may continue for as many as 12 years in about 10% of women. 2 HRT may be indicated when menopausal symptoms are adversely affecting quality of life. How well does HRT work?HRT is currently the most effective treatment for troublesome vasomotor symptoms. A systematic review showed a significant mean reduction in the frequency of hot flushes by around 18 a week and in the severity of hot flushes by 87% compared with placebo. 3 Large randomised controlled trials have confirmed that HRT also significantly reduces fracture risk, improves vaginal dryness and sexual function, and may also improve sleep, muscle aches and pains, and quality of life in symptomatic women. 4 5 The figure⇓ provides the estimated absolute benefits from HRT use in postmenopausal women aged 50-59 years or <10 years after menopause, based on background risk in American women, 6 using data from t...

A clinical guide to the management of genitourinary symptoms in breast cancer survivors on endocrine therapy

“…Concerns about the use of HT increasing risk of breast cancer recurrence mean that it is generally contraindicated after breast cancer [Von Schoultz and Rutqvist, 2005;Hickey et al 2010Hickey et al , 2012. Nonetheless, QoL concerns, magnitude of symptoms and endocrine therapy compliance may justify the use of HT in selected cases [Hickey et al 2010[Hickey et al , 2012.…”

“…However, a single RCT suggested that HT in breast cancer survivors may increase breast cancer recurrence or new breast cancers by 2-3-fold [Holmberg and Anderson, 2004]. Alternative nonhormonal options should always be considered first option in these patients, but if symptoms persist and QoL is seriously impaired, then individual women with a low risk of tumor recurrence may wish to explore the option of HT [Loibl et al 2011;Pfeiler et al 2011;Hickey et al 2010;Hickey et al 2012]. In these selected cases, management of symptoms should take both women's needs and the recommendations of their oncologists into consideration [ACOG Committee on Practice Bulletins-Gynecology, 2012].…”

Unscheduled bleeding on HRT - do we always need to investigate for endometrial pathology?

“…3 The progestogen phase of HRT should coincide with the luteal phase of the cycle, which is the last 12-14 days of the cycle. Although natural cycle lengths may vary considerably, the luteal phase is consistent.…”

Potential therapeutic effect of amniotic stem cell transplantation on ovarian function and folliculogenesis in rats with induced ovarian failure

“…It is considered that hormone replacement therapy is an appropriate treatment for some women with menopausal symptoms. However, because of its risks including thromboembolic disease (venous thromboembolism and pulmonary embolism), stroke, cardiovascular disease, breast and endometrial cancer, and gallbladder disease [5], they should take the lowest dose for the shortest period of time. Infertility remains a significant issue for most women undergoing POI.…”