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Hormone Replacement Therapy (HRT) Hormone Replacement Therapy (HRT)

Hormone Replacement Therapy (HRT) - PowerPoint Presentation

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Hormone Replacement Therapy (HRT) - PPT Presentation

A focused review for the recent recommendations and guidelines Pharmacotherapy a pathophysiologic approach 2009 Queen Marry Hospital UK 2012 Guidlines Dep of OG HRT at a Glance Pharmacotherapy a pathophysiologic approach 2009 Queen Marry Hospital UK 2012 Guidlines Dep of OG ID: 927751

2012 guidlines pharmacotherapy dep guidlines 2012 dep pharmacotherapy pathophysiologic approach 2009 queen marry hospital estrogen hrt risk therapy cancer

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Slide1

Hormone Replacement Therapy (HRT)

A focused review for the recent recommendations and guidelines

Pharmacotherapy a pathophysiologic approach 2009+ Queen Marry Hospital/ UK 2012 Guidlines (Dep. of OG)

Slide2

HRT at a Glance….

Pharmacotherapy a pathophysiologic approach 2009+ Queen Marry Hospital/ UK 2012 Guidlines (Dep. of OG)

Slide3

Approved Indications for HRT Use:

Treatment of the menopausal symptoms (Short Term)Prevention of Osteoporosis (Long Term)

Pharmacotherapy a pathophysiologic approach 2009+ Queen Marry Hospital/ UK 2012 Guidlines (Dep. of OG)

Slide4

Contraindications:

Endometrial cancer,

breast cancer

, undiagnosed vaginal

bleeding.

C

oronary

heart

disease, thromboembolism (including recent spontaneous thrombosis or in the presence of a thrombophilia)Stroke or transient ischemic attackActive liver disease.

Pharmacotherapy a pathophysiologic approach 2009+ Queen Marry Hospital/ UK 2012 Guidlines (Dep. of OG)

Slide5

Estrogens:

The main indication is the relief of vasomotor symptomsVariety of administration routes

No evidence suggests that one product is more effective than the other

ADRs include: N/V, breast tenderness, heavy bleeding, increased risk for coronary heart diseases, stroke, breast cancer, venous thromboembolism and gallstones formation.

Pharmacotherapy a pathophysiologic approach 2009+ Queen Marry Hospital/ UK 2012 Guidlines (Dep. of OG)

Slide6

Progestogens:

Should be used for women with intact uterus to reduce the risk of endometrium hyperplasia

A minimum of

12 to

14 days of

progestogen

therapy each month is required

for complete

protection against estrogen-induced endometrial

hyperplasia Pharmacotherapy a pathophysiologic approach 2009+ Queen Marry Hospital/ UK 2012 Guidlines (Dep. of OG)

Slide7

Estrogen and Progesterone

Four combination estrogen and progestogen

regimens

currently in

use

are

continuous-cyclic (sequential

) ((

scheduled vaginal withdrawal bleeding))continuous-combined ( Less bleeds)continuous long-cycle (or cyclic withdrawal) ( 6 bleeds per year) Intermittent combined (or continuous-pulsed) hormone therapy

Pharmacotherapy a pathophysiologic approach 2009+ Queen Marry Hospital/ UK 2012 Guidlines (Dep. of OG)

Slide8

Androgens

A cluster of symptoms that characterizes androgen insufficiency in women

, manifested as diminished sense of well-being, persistent

or unexplained

fatigue, and sexual function changes such as

decreased libido

, decreased sexual receptivity, and decreased pleasure, has

been reported.

Evidence of

short-term efficacy of testosterone is seen in selected populations, such as surgically menopausal women.At present, generalized use of testosterone is not recommended because the indications are inadequate, and evidence from long-term studies evaluating safety is

lacking.

Pharmacotherapy a pathophysiologic approach 2009+ Queen Marry Hospital/ UK 2012 Guidlines (Dep. of OG)

Slide9

SERM:

Selective estrogen receptor modulators (SERMs) are a group of

nonsteroidal

compounds that are chemically distinct from estradiol.

They act as estrogen agonists in some tissues, such as bone, and

as estrogen

antagonists in other tissues, such as breast, through

specific, high-affinity

binding to the estrogen receptor.The ideal SERM would protect against osteoporosis and decrease the incidence of breast, endometrial, and colorectal cancer and coronary heart disease without exacerbating menopausal symptoms or increasing the risk of venous thromboembolism or

gallbladder disease

.

To

date, no SERM meets these ideals

Pharmacotherapy a pathophysiologic approach 2009+ Queen Marry Hospital/ UK 2012 Guidlines (Dep. of OG)

Slide10

SERM

Tamoxifen: has estrogen antagonist activity on

the breast

and estrogen-like

agonist activity

on bone and endometrium

.

Raloxifene

: 2

nd G, available for prevention of osteoporosis. Raloxifene does not alleviate, and may even exacerbate, vasomotor symptoms.

Pharmacotherapy a pathophysiologic approach 2009+ Queen Marry Hospital/ UK 2012 Guidlines (Dep. of OG)

Slide11

Tibolone

Tibolone is a synthetic

steroid

with

combined estrogenic

,

progestogenic

, and

androgenic activity.Tibolone has beneficial effects on mood and libido and improves menopausal symptoms and vaginal atrophy. Tibolone protects against bone loss and reduces the risk of vertebral fractures in postmenopausal women with

osteoporosis.

Increases the risk for strokes.

Pharmacotherapy a pathophysiologic approach 2009+ Queen Marry Hospital/ UK 2012 Guidlines (Dep. of OG)

Slide12

HRT benefits

Beside symptoms relief and prevention of osteoporosis:Colon Cancer Reduction (WHI study)

H

ormone therapy appears

to have a beneficial effect on fasting glucose levels in

women with

elevated fasting insulin

concentrations.

No effect on body weight.

Pharmacotherapy a pathophysiologic approach 2009+ Queen Marry Hospital/ UK 2012 Guidlines (Dep. of OG)

Slide13

Cardiovascular Risk

Cardiovascular Disease: recent randomized clinical trials have provided no evidence of

cardiovascular disease

protection and even some evidence of harm with

HRT.

Est.-

Progest

increases the CHD risks

Estrogen only therapy has no CHD effects or has a favorable effects if the initiation of HRT was closer to the time of menopause.

Raloxifene does not affect the risk for CHD.Pharmacotherapy a pathophysiologic approach 2009+ Queen Marry Hospital/ UK 2012 Guidlines (Dep. of OG)

Slide14

Breast Cancer

Est-Progest associated with increased risk of Breast Cancer

Estrogen only HRT not affect the risk for BC.

Raloxifene

has a favorable effects in reducing the risk for BC.

Pharmacotherapy a pathophysiologic approach 2009+ Queen Marry Hospital/ UK 2012 Guidlines (Dep. of OG)

Slide15

Endometrial cancer

With unopposed estrogen HRT the risk increased within the 1st

2 years

Raloxifene

is not associated with increased risks for endometrial hyperplasia

Pharmacotherapy a pathophysiologic approach 2009+ Queen Marry Hospital/ UK 2012 Guidlines (Dep. of OG)

Slide16

Ovarian Cancer

Limited studies show the link between Ovarian Cancer and HRT, but the available data suggest that; Unopposed Estrogen regimen associated with high risk for OC and this is unlikely in the

Est-Progest

regimen.

Pharmacotherapy a pathophysiologic approach 2009+ Queen Marry Hospital/ UK 2012 Guidlines (Dep. of OG)

Slide17

VTE

May be associated with any type of HRT and appear to be a dose related.

Pharmacotherapy a pathophysiologic approach 2009+ Queen Marry Hospital/ UK 2012 Guidlines (Dep. of OG)

Slide18

Gall bladder Disease

Gallbladder disease is a commonly cited complication of oral estrogen use

.

Transdermal

estrogen

is an alternative to oral therapy

for women with high risk of

cholelithiasis

Pharmacotherapy a pathophysiologic approach 2009+ Queen Marry Hospital/ UK 2012 Guidlines (Dep. of OG)

Slide19

Dementia

Reports are inconclusive, some indicate positive effects and other shows increased risks for dementia upon using HRT

Pharmacotherapy a pathophysiologic approach 2009+ Queen Marry Hospital/ UK 2012 Guidlines (Dep. of OG)

Slide20

Premature Ovarian Failure

Premature ovarian failure is a condition characterized by sex-steroid deficiency

, amenorrhea, and infertility in women younger than

40 years.

The goal of therapy is to provide a hormone replacement

regimen that

maintains sex steroid status as effectively as the

normal

functioning

ovary.Pharmacotherapy a pathophysiologic approach 2009+ Queen Marry Hospital/ UK 2012 Guidlines (Dep. of OG)

Slide21

HRT Studies Till Now

Women’s Health Initiative (WHI)

•Women’s Health Initiative Memory Study (WHIMS)

•Women’s Health Initiative for Cognitive Aging (WHISCA)

•Heart and Estrogen/

Progestogin

Replacement Study (HERS)

•Women’s International Study of Long Duration

Oestrogen

After Menopause (WISDOM) •Oestrogen in the Prevention of Reinfarction Trial (ESPRIT) •Estrogen Memory Study (EMS) •Ultra-Low-Dose Transdermal Estrogen Assessment (ULTRA) •Study of Women’s Health Across Nations (SWAN) •Kronos Early Estrogen Replacement Study (KEEPS)

•Effect of Hormone Replacement Therapy on Cardiovascular events in recently postmenopausal women

Pharmacotherapy a pathophysiologic approach 2009+ Queen Marry Hospital/ UK 2012 Guidlines (Dep. of OG)

Slide22

Evidence-Based Hormone Therapy Guidelines for

Menopausal Symptom Management

Pharmacotherapy a pathophysiologic approach 2009+ Queen Marry Hospital/ UK 2012 Guidlines (Dep. of OG)

Slide23

Pharmacotherapy a pathophysiologic approach 2009+ Queen Marry Hospital/ UK 2012 Guidlines (Dep. of OG)

Slide24

Individualization of therapy

Because of the unlimited controversy in HRT, it should be

individualized for each patient, and each case should be treated as a special one and the regimen should be tailored as such.

This way, the patient will be more involved in the selection and will share the responsibility of any action.

Pharmacotherapy a pathophysiologic approach 2009+ Queen Marry Hospital/ UK 2012 Guidlines (Dep. of OG)

Slide25

Thanks for your attention

Pharmacotherapy a pathophysiologic approach 2009+ Queen Marry Hospital/ UK 2012 Guidlines (Dep. of OG)