Hormone Replacement Therapy (HRT)

Last updated 20.09.12

 

Definition

-  Administration of oestrogen &/or progesterone to replace decreased levels postmenopausally

 

Features

-  Routes: PO, transdermal, gel or vaginal

-  Assess 2m 6 then 12 months after commencing

-  Regular uterine surveillance if unopposed oestrogen

-  In menopause

-  Increased risk of CVD if 70+

-  Possibly decreases risk of CVD in started early ie: 50s

-  Not for preventing disease unless premature menopause

 

Selection

-  Use lowest possible dose to control S/S

-  Trial off HRT every 2yrs to see if still needed

-  Progesterone is only required if uterus still in situ to prevent endometrial hyperplasia

-  Oestrogen only required if absent uterus (Hysterectomy)

-  Combined HRT if uterus present

-  Cyclical therapy if <12 months amenorrhoea

-  Continuous therapy if >12 months amenorrhoea

-  Urogenital symptoms use vaginal oestrogen

-  Tibolone

Progesterone Options

-  IUD: Mirena

-  PO: Provera, Primolut N

Oestrogen Options

-  Oral tablets, topical patch or gel or vaginal cream or pessary

-  Either combined with PG or in patients without a uterus (Hysterectomy)

Lower Dose Oestradiol

-  PO: Estrofem/Progynova (PBS) (1mg), Ovestin (2mg), Premarin (0.3mg conjugated equine oestrogen)

-  Transdermal patch: Climara 25 (PBS)(25mcg/24hrs weekly), Estradot 25/37.5 (PBS) (twice weekly), Estraderm 25 MX (PBS)(25mcg/24hrs twice weekly)

Medium Dose

-  PO: Estrofem/Zumenon/Progynova (PBS)(2mg), Premarin (0.625mg conjugated equine oestrogen)

-  Transdermal patch: Climara (50mcg/24hrs weekly), Estradot/Estraderm 50 MX (50mcg/24hrs twice weekly)

-  Gel: Sandrena (1mg gel daily) (PBS)

High Dose (all PBS)

-  Transdermal patch: Climara 75 (75mcg/24hrs weekly), Estradot 75 (75mcg/24hrs twice weekly), Estradot 100 (100mcg/24hrs twice weekly), Climara 100/Femtran 99 (100mcg/24hrs weekly), Estraderm 100 MX (100mcg/24hrs twice weekly)

Vaginal Therapy

-  Ovestin cream 1mg/g (PBS)

-  Ovesting ovula pessary 0.5mg (PBS)

-  Vagifem pessary 25mcg (PBS)

Combination Therapy Options

COC: consider if <50yrs, no significant risk of CVD, non-smoker, not at risk of DVT, PE

-  Cyclical

-  Used for perimenopausal women until 12+ months amenorrhoea

-  Progesterone for 14 days out of every 28 days

-  Trisequens: 1 or 2mg Oestridiol/1mg Norethisterone

-  Femoston: PO 2mg Oestradiol/10mg Dydrogesterone (PBS)

-  Estalis sequi: 50/140 or 20/250 transdermal patch twice weekly (PBS)

-  Continuous

- Used once 12months amenorrhoea or 12months cyclical HRT

- Low Dose

-  Angeliq 1/2: PO 1mg Oestradial/2mg Drospirenone

-  Kliovance: PO 1mg Oestradiol/0.5mg Norethisterone

-  Livial/Xyvion: 2.5mg Tibilone

-  High Dose

-  Kliogesy: PO 2mg Oestradial/1mg Norethisterone

-  Premia 2.5 or 5 Continuous: PO 0.625mcg Conjugated Equine Osterogen/2.5mg or 5mg Medroxyprogesterone

-  Estalis continuous 50/240 or 50/250: transdermal patch 50mcg Oestradiol/140mcg or 250mcg Norethisterone twice weekly (PBS)

 

Indications

-  Menopause

-  Symptomatic women at onset

-  Decreases hot flashes: frequency 77%, severity 87%

-  Improvement of mood swings, vaginal dryness

-  Generally not appropriate in older asymptomatic women

-  Decreases risk of fractures from osteoporosis

-  Decreased risk of colorectal Ca

 

Contraindications

-  DVT, PE

-  x4 risk in first year

-  x2 risk ongoing if E+P

-  Stroke

-  Oestrogen dependant tumours

-  Breast Ca

-  Combined E+P increased risk after 5yrs use

-  Oestrogen alone may decrease risk slightly

-  Endometrial Ca (esp if E+P)

-  Abnormal LFTs

-  Liver disease

 

Side Effects

-  Nausea

-  Breast tenderness (especially with oral oestrogen)

-  +/- Weight gain (thought to be from menopause not from HRT)

-  PMS

-  Irregular/withdrawal bleeding

-  Increased risk of

-  Breast Ca: 4:1,000 vs 3:1,000

-  DVT, PE

 

 

 

References

 

  www.menopause.org.au/images/stories/education/docs/Menopausal_hormone_replacement_therapy_-_A-Prof_Rod_Baber.pdf

Australian Menopause Society: HRT