Weather to take postmenopausal hormonal therapy or not is one of the most complex health care decisions facing women. It is also a complex decision for doctors to determine which of their patients will benefit from postmenopausal hormonal replacement therapy.

In the United States about 30% of postmenopausal women use hormonal replacement therapy.

Please do not forget to read my post on the benefits and risks of postmenopausal hormone therapy.

History and Examination prior to commencing hormonal therapy

A thorough history should be taken .Symptoms that are due to estrogen deficiency should be noted. The impact of these symptoms in the patients life should also be noted.

It is also important to ask tactfully about difficulties in sex life such as dyspareunia and loss of libido.

The history should include cardiovascular disease (such as angina pectoris, stroke and myocardial infarction) and skeletal system (history of fracture of the wrist,hip etc). History of osteoporosis in relatives is also important.

History of the gastrointestinal tract and liver disease is important because it might interfere with the pharmacodynamics of estrogen therapy.

A thorough gynaecological history should include medical and surgical interventions, history of irregular bleeding, history of previous biopsy etc. One should also ask specifically for history of breast disease.

All patients being considered for hormone replacement therapy (HRT) must have a physical examination by an experienced physician.This will help to identify potentially estrogen sensitive tumours in the pelvis and breast. A thorough breast and pelvic examination should be done. On pelvic examination one should look for masses suggestive of fibroids, endometriosis (past and present) and adnexial masses suggestive of ovarian tumours.

Contraindications to Hormonal Replacement Therapy:

Absolute

-Present or suspected pregnancy

-Suspected breast cancer

-Suspected endometrial cancer.

-Active acute liver isease

-Diagnosed venous thromboembolism

-Uncontrolled hypertension

Relative

-Migraine

-Uterine fibromyomata

-Past history of benign breast disease

-Chronic liver disease

-undiagnosed but suspected venous thromboembolism

Methods of administering hormonal replacement therapy

i) Oral:

The oral route is the most common route in the United Kingdom.

estrogen should be given daily,mimicking the perimenopausal daily release by the ovary.

The commonly used oral estrogen’s are:

-Oestradiol valerate 1mg or 2mg.

-Oestrone 1.25mg

-Conjugated equine estrogen 0.625 mg or 1.25mg.

The oral route cannot mimic the normal physiological ratio of oestradiol:oestrone, which should be 2:1 but it is exactly the opposite ie 1:2.

ii)Transdermal estrogen:

Patches are available in varying strengths of 28 micro gram to 100 microgram of oestradiol per day. Patches for one week are now available.

The estrogen being lipid soluble passes across the epidermis into the systemic circulation avoiding the first pass metabolism by the liver.

This route maintains the normal physiological ratio of oestrodiol:oestrone of 2:1.

Percutaneous gel with a similar mechanism of action of transdermal estrogen is also available.

iii)Subcutaneous implantation:

This is usually restricted to those who have undergone hysterectomy with or without oophorectomy. A pellet is placed in the subcutaneous tissue of the lower abdomen with local anesthetic under sterile conditions. Implants are available at strengths of 25,50 and 100 mg and reviewed at intervals of six months.

iv)Gonadomimetic therapy:

Tibilone, a synthetic steroid which exhibits progestogenic, estrogenic and androgenic activity. It is given in a dose of 2.5mg per day to women for a least one year. It supresss the symptoms and prevents bone loss

References:

Pages 2209 to 2212.Chapter 327. The menopause transition and postmenopausal hormone therapy.Harrisons Principles of Internal Medicine. Volume II.16th edition. Kasper,Braunwald,Fauci,Hauser,Longo and Jameson.

Pages 227 to 229. Chapter 19. Menopause. Gynaecology by ten teachers. Seventeenth edition. Edited by Stuart Campbell and Ash Monga.

Pages 760 to 762. Chapter 17. Menopausal syndrome.Gynaecology. CMDT 2006. Current Medical Diagnosis and Treatment 2006.45 th Edition. Edited by Lawrence M. Tierney,Jr. Stephen J McPhee, Maxine A. Papadakis.

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