Practical aspects of hormone replacement therapy

Summary

A great change in the attitude of the medical profession and public towards the menopause has occurred in the past 5 years in the United Kingdom. The concept of normality of the menopause is being replaced by one of a chronic deficiency state lasting for up to 20 years. In some patients this may require therapy, and clinics have now been established for this purpose. Such therapy is not without problems and practitioners should be aware of the indications, contra-indications and side-effects, as well as the benefits of hormone replacement therapy.

Contra-indications include a history of thromboembolic disease, liver dysfunction and oestrogen dependent tumours. Obesity, hypertension and oestrogen-activated gynaecological disease are relative contra-indications.

The classical indications for therapy are vasomotor instability, such as hot flushes, night sweats and palpitations, and dyspareunia or loss of libido due to atrophic vaginitis. Insomnia, fatigue and loss of drive are often associated with vasomotor attacks and respond well to oestrogen therapy, but the effect on depression and headache is less certain.

The simplest regimen for the post-menopausal woman is an oral oestrogen, such as ‘Harmogen’ 1.5 mg., ‘Premarin’ 1.25 mg., or ‘Progynova’ 2 mg. taken orally for 3 weeks out of 4. Withdrawal bleeding occasionally occurs in the week off therapy, but breakthrough bleeding is uncommon; if it occurs an endometrial biopsy by a ‘Vabra’ curette is required. Alternatively, scheduled bleeding each month can be assured by a 5-day course of a progestogen such as ethynodiol diacetate (0.5 mg.) or norethisterone (5 mg.) daily. An oestrogen-testosterone preparation is useful for patients in whom the libido does not improve with oestrogen alone.

The case for implants of oestradiol (and testosterone in some patients) is considered. Although patient acceptability is impressive it would seem to have a small place in routine management. The claim that the effective dose is less than in oral therapy requires further study.

Symptoms of oestrogen deficiency in pre-menopausal women may pass unrecognised mainly because periods, albeit anovulatory, are still occurring. These women may be effectively treated in the same way as outlined, although a smaller dose will often suffice, and the patient should be informed that such therapy has no certain contraceptive action.

Side-effects include breakthrough bleeding, breast or leg discomfort, nausea, weight gain and oedema. The incidence of thromboembolic disease, breast and corpus carcinoma is not increased by the hormone regimens outlined. As with the oral contraceptive, hormone replacement therapy for the climacteric has major benefits, but there are minor side-effects which indicate that patients should be carefully assessed and the treatment individualised.

Key Words::

• Menopause
• Climacteric
• hormone replacement therapy