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
Download Presentation The PPT/PDF document "Hormone Replacement Therapy (HRT)" is the property of its rightful owner. Permission is granted to download and print the materials on this web site for personal, non-commercial use only, and to display it on your personal computer provided you do not modify the materials and that you retain all copyright notices contained in the materials. By downloading content from our website, you accept the terms of this agreement.
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)
Slide2HRT at a Glance….
Pharmacotherapy a pathophysiologic approach 2009+ Queen Marry Hospital/ UK 2012 Guidlines (Dep. of OG)
Slide3Approved 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)
Slide4Contraindications:
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)
Slide5Estrogens:
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)
Slide6Progestogens:
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)
Slide7Estrogen 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)
Slide8Androgens
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)
Slide9SERM:
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)
Slide10SERM
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)
Slide11Tibolone
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)
Slide12HRT 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)
Slide13Cardiovascular 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)
Slide14Breast 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)
Slide15Endometrial 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)
Slide16Ovarian 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)
Slide17VTE
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)
Slide18Gall 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)
Slide19Dementia
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)
Slide20Premature 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)
Slide21HRT 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)
Slide22Evidence-Based Hormone Therapy Guidelines for
Menopausal Symptom Management
Pharmacotherapy a pathophysiologic approach 2009+ Queen Marry Hospital/ UK 2012 Guidlines (Dep. of OG)
Slide23Pharmacotherapy a pathophysiologic approach 2009+ Queen Marry Hospital/ UK 2012 Guidlines (Dep. of OG)
Slide24Individualization 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)
Slide25Thanks for your attention
Pharmacotherapy a pathophysiologic approach 2009+ Queen Marry Hospital/ UK 2012 Guidlines (Dep. of OG)