Decreased vitamin 0 5. A 48 years old female suffering from severe menorrhagia (DUB) underwent hysterectomy. She wishes to take hormone replacement therapy. Physical examination and breast are normal but X - ray shows osteoporosis. The treatment of choice is
Ans. is c i.e Estrogen Hormone Replacement Therapy for a oo.st - menopausal female can be in the form of Estrogen Alone Progesterone Tibolone Selective Androgens Estrogen Oestrogen Receptor Estrogens Modulator 1. Estrogen Alone : MC estrogen used : Conjugated equine oestrogen Advantages It decreases hot flushesdeg Prevents osteoporosisdeg Useful in senile vaginitisdeg Useful in dyspareunia and urethral syndromedeg Disadvantage : Besides the risk of Coronary hea diseasedeg. (as discussed earlier) it can cause Vaginal bleedingdeg, Endometrial hyperplasiadeg and Endometrial carcinomadeg so, estrogens are combined with progestins in H so as to decrease the risk of Endometrial hyperplasia with Endometrial carcinoma. Indications For the use of Estrogen Alone In woman who have undergone hysterectomy (other than that for Endometrial cancer) Remember : All women who have intact uterus or even those who underwent hysterectomy for endometrial Cancer (Stage I), endometroid ovarian tumors or endometriosis or those with Severe osteoporosis should receive combined estrogen - progesterone therapy or be considered for selective estrogen receptor modulator therapy. 2. Estrogen + Progesterone When H is to be given for a period more than 2-3 months, in woman with intact uterus progesterone should be given along with estrogen as progesterone is protective against Endometrial cancer. In Perimenopausal females : low dose OCP should be given. In Postmenopausal females : OCP's Should not be used, as the amount of estrogen is higher in them than required. In such cases oestrogen should be supplemented by progesterone for last 10-12 days of treatment. Most treatment regimes are on a cyclical 3 weeks out of 4 weeks. Progesterones used in H : Medroxy progesterone acetatedeg * Dydrogesteronedeg Norethisteronedeg * Desogestereldeg Micronized progesteronedeg Disadvantages of progesterones : Weight gain * Breast tenderness Bloated feeling * Depression Note : Progesterone should not be added in hysterectomised patients because of patients intolerance to them and for the fear of their adverse effects on lipid profile and the breast. 3. Tibolone : Is a synthetic derivative of 19 noestosteronedeg. It is metabolized into isomers with three major metabolic (oestrogenic, progestogenic and androgenic) effects. At a standard dose of 2.5 mg : Tibolone has beneficial effects on Bone Vasomotor symptoms i.e. Genital tract i.e. Libido Mood prevents osteoporosis hot flushes vaginal atrophy increase libido Total HDL, LDL are not altered Triglycerides are decreased Endometrium atrophy occurs Inhibits breast cell proliferation. Major advantages : Low incidence of vaginal bleedingdeg Can be used in women with leiomyomas and endometriosis in whom conventional H may cause aggravation of symptoms.deg estrogen Receptor Modulator - (SERM) Drug used : Raloxifene It prevents osteoporosis by increasing Bone mineral density (is useful for patients who are reluctant to use H or have H/O endometriosis or high risk of Breast cancer) It also has ourable effect on lipoprotein A, LDL, homocysteine and fibrinogen It has no effect on atherosclerosisdeg, HDLdeg levels and may even increase hot flushes and Leg cramps. deg Side effects : Hot flushes, Crampsdeg, Venous thrombosisdeg and Retinopathydeg. Contraindication : * Venous Thrombosis (should not be given with estrogen) Hepatic dysfunction It should be stopped 72 hours before Surgery. Androgens (Testosterone) : The only indication for the use of androgens in H is loss of libido. Recent Advances : Phytoestrogens These are substances found in plants like Soya and are strongly oestrogenic but-non steroidal thereby reducing the potential risk of breast cancer, liver disease and other side effects of estrogen. Their daily intake reduces hot flushes by 45% within 12 weeks. They improve plasma lipid profile and therefore inhibit the development of coronary atherosclerosis. Estrillshould no be used in women with any of the following conditions : 1. Undiagnosed abnormal genital bleeding. 2. Known, suspected, or history of breast cancer. 3. Known or suspected estrogen-dependent neoplasia. 4. Active deep vein thrombosis, pulmonary embolism, or history of these conditions. 5. Active or recent (e.g., within the past year) aerial thromboembolic disease (e.g., stroke or myocardial infarction). 6. Liver dysfunction or disease. 7. Known hypersensitivity to the ingredients of the estrogen preparation. 8. Known or suspected pregnancy. There is no indication for estrogen in pregnancy. There appears to be little or no increased risk of bih defects in children born to women who have used estrogens and progestins from oral contraceptives inadveently during early pregnancy Estrogen should be used with caution In women with the following conditions : 1. Dementia 2. Gallblader disease 3. Hyperiglyceridemia 4. Prior cholestatic jaundice 5. Hypothyroidism 6. Fluid retention plus cardiac or renal dysfunction 7. Severe hypocalcemia 8. Prior endometriosis 9. Hepatic hemangiomas Extra Edge Warnings and Precautions with Estrogen administration :
Progesterone
Estrogen and progesterone
Estrogen
None