Hormone therapy at Menopause

Menopausal Hormone Therapy (MHT) is predominantly indicated for 3 purposes – Vasomotor symptoms, to reduce fracture risk and to treat genitourinary syndrome of Menopause.

Vasomotor symptoms affects 70% of mid life women. Hot flushes and night sweats affect sleep, daily functions, quality of life and affect cognition and cause mood swings. MHT is the most effective treatment for Vasomotor symptoms. In the absence of Vasomotor symptoms alternative therapies must be used to reduce fracture risks and treat genitourinary syndrome of menopause.

General notes on MHT

-MHT provides very low doses of Estrogen compared to physiologic levels and has a high degree of safety compared to Oral Contraceptive Pills.

-The lowest effective dose is used and therefore the patient must be warned that it may take a considerable time before the benefits are noted (up to 3 months).

-Only Estrogens are given for people without a uterus. Both Estrogen and Progestogens are given for women with intact uterus (to prevent endometrial hyperplasia). Estrogens are taken daily as pills or transdermal patches (once or twice a week) and as transdermal gels and vaginal rings. Progestogens are available as oral pills and are either take as a combined pill or cyclically for 12-14 days every cycle. The combined pill is preferred by many women in whom it induces amenorrhea. Cyclical Progestogens induce predictable withdrawal bleeding. Transdermal Estrogen patches are useful in obese women with cardiovascular risk factors.They have a “hepatic first pass” mechanism and do not increase coagulation factors and hepatic binding proteins, therefore they do not increase risk of DVT even in obese or thrombophilic patients. Progestogens cause drowsiness and may be taken at night.

– Women experiencing early or surgical menopause (<45 yrs) must be encouraged to use MHT till the age of 51 unless contraindicated.

– The decision to initiate MHT should involve careful assessment of potential benefits and risk.

– Optimum duration of treatment of MHT can vary from woman to woman.

Absolute Contraindications for MHT

1. Breast Cancer

2. Endometrial cancer

3. CArdiovascular disease

4. Active Liver disease

5. Undiagnosed Vaginal bleeding

Side effects of MHT

1. Increased risk of Strokes (additional 0.5 cases per 1000 women per year.

2. Increased Venous thrombotic events with Estrogen pills and not with transdermal patches.

3. Increased Breast cancer risk but only after prolonged use (4-5 yrs)

4. Gall bladder disease with Estradiol pill and not with Transdermal patches.

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