Medical Conditions

Hormone therapy at Menopause

/ Subash Rau / Leave a comment

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.

Bromhidrosis – Bad Body Odour

/ Subash Rau / Leave a comment

Bromhidrosis refers to excessive foul smelling sweat. Other synonyms include Osmidrosis and Ozochrotia. It is diagnosed when noticeable body odour has a negative effect on an individuals self view, social interactions and Quality of Life.

2 types of Sweat glands are seen
Apocrine – It develops at puberty and usually disappears in the elderly. It usually affects axilla, anogenital (perinatal) areas and the breasts. The primary role of Apocrine glands is to secrete Pheromones.

Eccrine glands are distributed all over the body especially over the palms and soles.They are not found in the External Auditory Canal, Lips, Clitoris, Labia minora and Glans penis. Eccrine glands are primarily responsible for thermoregulation and secrete water based secretions. Eccrine Bromhidrosis can occur at any age and can be localised or generalised.

Pathogenesis of Body odour
Sweat is usually odourless and its secretion is controlled by the sympathetic nervous system. Heat, exercise, emotion, certain foods and medicines stimulate its secretion.

Apocrine glands secrete odoriferous fatty acids bound to odour binding proteins. Bacterial action releases odour causing fatty acids leading to the malodour. A variety of bacteria such as Corynebacterium, Staphylococcus, Cutibacterium (previously called Propionobacterium) and Sphinogomonas act on the apocrine secretions and produce odour. Pheromones such as Androsterone and Androsterol are also malodorous. Poor hygiene especially in diabetics and obese individuals cause odour especially with skin conditions such as Erythrasma, Intertrigo and Trichomycosis axillari.

Eccrine Bromhidrosis: Sweating leads to maceration of skin and secondary bacterial growth and skin degradation. Eccrine bromhidrosis can occur due to:
Diet – garlic, onion, curry and alcohol
Medication – Penicillins and bromides
Toxins – heavy metals
Metabolic causes – Phenylketonuria, Trimethylaminuria, Isovaline acidaemia, Hypermethioninemia.
Systemic diseases– Liver and Renal failure, Gout, Scurvy and Typhoid.

Diagnosis requires elicitation of a detailed history.
Usually Lab tests are unnecessary.

Treatment of Body Odour
1.Personal hygiene: to bathe regularly and daily but not excessively. Excess washing may cause skin irritation. Intertrigo, erythrasma need to be treated.
2.Clothing: wearing absorbent clothes/cotton clothes may help. Sweat soaked clothes need to be change immediately. Washed clothes need to be sun dried.
3.Exfoliation: to remove stratum corners may help.
Hair removal by shaving, chemical epilation, electrolysis and laser treatment may be helpful.
4.Antibiotics – applied topically may help. Topical Erythromycin and Clindamycin are commonly used. Prolonged continuous therapy may be needed.
Oral Roxithromycin 150 mg twice daily for 7-10 days may help.
5.Topical antiperspirants: Antiperspirant contain aluminium salts that plug sweat ducts and reduce seating.
6. Antifungal dusting powders may also be helpful.
7. Botulinum toxin Injection: Skin injections can temporarily reduce sweating.
8. For Refractory Localised Bromhidrosis- destruction of Apocrine glands is an option by surgical excision,Liposuction, microwave and Nd-YAG or CO2 laser can be helpful.
9. Thoracic sympathetectomy can be done with good results.

Treatment options for Axillary Hyperhidrosis (sweaty armpits)
1.Topical Antiperspirants (Aluminium containing gels) need to be applied nightly without occlusive wrappings. Topical Glycopyrrolate 2.4% can reduce sweating significantly.
2. Systemic agents – Anticholinergics- Glycopyrrolate can take up to a week for effect.
Clonidine 0.1 mg twice daily, Beta Blockers, Benzodiazepines will reduce sweating.
3. Iontophoresis
4. Microwave Thermolysis
5. Botulinum toxin injections can temporarily reduce sweating.
6. Surgery: Endoscopic thoracic sympathetectomy