Role Of Hormone Replacement Therapy Advantages and Side Effects of HRT

The menopause or the climacteric is a milestone in every woman’s life. Precious to any lady is her womb that bore her children and gave her periods which defined her womanhood.
The value of light is only precious when it is dark. Loss of the monthly cyclic menstrual flow not only makes a woman less woman but also poses great health risks to her body.

Menopause More Precisely

It is the permanent cessation of menses for a period of one year, co-related physiologically with decreasing estrogen levels as a result of decreased ovarian follicular function. It is more precisely labeled as FSH levels > 40 miu/ml in the above situation.

Types Of Menopause

Physiological Menopause

This occurs naturally and the age at which menopause happens is pre determined to a large extent by genetic, racial, ethnic and geographic factors.

Surgical Menopause

This is an artificial menopause created by removal of both the ovaries (oophorectomy). Ovaries may be destroyed without removal by radiation and chemotherapeutic drugs.

Hormonal Changes In Menopause

Estrogens

Atretic ovarian follicles produce a below par output of estrogen.

Progesterone

Menopause is an anovulatory state. No ovulation entails zero progesterone coming from the ovaries. However the adrenal glands do produce a nominal amount of progesterone.

Gonadotrophins

Normally developing follicles in younger women produce enough estrogen to suppress the release of pituitary gonadotrophins namely FSH and LH. This is called as negative feedback. This inhibition is lost in menopause with low estrogen levels leading to high LH and FSH levels.

Menopause Side Effects Common Problems Of Menopause

Hot Flushes

These are bouts of flushing or burning especially over the upper torso and back associated with perspiration typically occurring in about 75 % of menopausal women.

Atrophic Vaginitis

The drying out of the vaginal passage and neighboring urinary outlet leads to micro ulceration or wounding, bleeding and painful coitus or urination.

Osteoporosis

Estrogens provide substantial support to bones. Menopause leads to reduced bone density or osteoporosis. Weak bones result from reduced estrogen mediated bone mineralization and remodeling. Characterized by minimal trauma fractures of the lumbar spine (low back), Distal Radius (Wrist), Femoral Neck (Hip), Osteoporosis is an age related problem accelerated by menopause.

Breast

Mammary gland atrophy and sagging breasts are the hallmarks.

Cardiovascular

Estrogen confers cardiovascular protection to women in their reproductive years. That’s why hardly any women suffer from heart attacks before menopause. Come the climacteric and there is a dramatic increase in the rate of ischemic or coronary heart disease.
Myocardial infarctions along with blood clotting phenomena or thromboembolic disease rise significantly. Moreover, deranged lipid metabolism fuels atherogenic events facilitating cardiovascular risk.

Psychological

Mood changes consisting of easy irritability, anger, insomnia, anxiety and occasionally depression only add to this phase of life where a woman is left with not much in terms of friends or family, let alone problems of a low income, lack of spousal support and social ostracism of yet another granny!

Hormone Replacement Therapy

‘No hormones circulating in the body? Well just replace them’. This seems to be a hard pill to swallow after the hype over clinical trials such as the ‘HERS’ and ‘WHI’ studies. The answer is simple but has complex implications. Natural estrogen confers multi benefits to a woman as is manifest by its loss in menopause.
Exogenous artificial estrogen cannot accurately substitute its natural counterpart. Despite relieving menopausal problems, it is laden with unwanted adverse effects resulting from uncontrolled estrogenic action in susceptible sites like the breast, uterus and cardiovascular system.

Advantages And Benefits Of Hormone Replacement Therapy (Evalon)

HRT corrects the following deficiencies of menopause.

  • Menopausal hot flushes
  • Vaginal atrophy, dryness and Urogenital irritation
  • Useful adjunct to bisphosphonates in management of Osteoporosis
  • Lowers the risk of Colon Cancer
  • Delays age related eye problems viz macular degeneration and cataract
  • Delays age related hearing loss
  • Reduces age related tooth decay saving in dental costs
  • Delays the progression of Osteoarthritis
  • Psychological benefits include reduced anxiety, irritability, aggression and tearfulness while libido, sleep and cognition is improved.

 

Side Effects And Disadvantages Of HRT (Evalon)

HRT has the following serious risks which mandate consultation with your gynecologist prior to starting therapy and for deciding the duration or type of therapy.

Endometrial Cancer

Unopposed estrogen therapy (estrogens alone - ERT) increases the risk of endometrial Cancer two to three fold. The addition of a progestogen reduces the risk, hence menopausal women with a uterus need estrogen plus progesterone(HRT)

Breast Cancer

Estrogens increase the risk of breast cancer. Individuals with a family history of breast cancer and benign breast disease do not have any additional increase in risk.

Thromboembolism

Individuals with a previous history of thromboembolic disease are worst affected. Overall there is an increased risk with Estrogens even in those women with no such history.

Stroke

Estrogens cause significantly increased rates of Cerebro Vascular Accidents (CVA) commonly called as stroke.

HRT - Other Problems

HRT has other problems in addition to the pertinent ones highlighted above.

  • Raises triglyceride levels.
  • Increased risk of gall stones.
  • Migraine is triggered by estrogens alone, addition of progesterone reduces this.
  • Estrogens reduce the efficacy of many medications including anti seizure drugs. (DILANTIN/DEPACON/TEGRETOL), anti HIV Retroviral Therapy (VIRAMUNE), anti tuberculosis Therapy( RIFADIN).
  • Diabetics, Hyperlipidemics (high lipids/cholesterol), Heart Patients, women with clotting problems, Liver disease, Breast cancer and Endometrial cancer patients should not use Estrogens or HRT.

HRT Therapy

HRT involves the use of exogenous estrogens either alone or in combination with progesterone in various routes of delivery such as oral tablets (EVALON/ PREMARIN/ LYNORAL), Skin creams/ patches (ALORA/CLIMARA), Vaginal creams(ESTRACE/ VAGIFEM/ ESTRING)

Estrogens (Evalon)

Various derivatives of estrogens are used as HRT/ERT. Ethinyl Estradiol (LYNORAL), Esrtadiol Valerate (CLIMARA), Conjugated Estrogen (PREMARIN), Micronized Estradiol, Piperazine Estrone (ESTROPIPATE) and estriol (EVALON)
EVALON is used as either 1mg or 2 mg strength per day singly (in women with no uterus) or in combination with Progestogens (PROVERA/ DEVIRY – women with a uterus).
The advantages/ benefits as well as the risks/side effects of EVALON have been listed earlier and are essentially applicable to all estrogens.
Evalon (Estriol) is a ‘bio – identical’ and naturally occurring estrogen that has the advantage over other forms of Estrogen with very little effects on breast tissue and practically the lowest effect on endometrial tissue. EVALON is even preferred over Conjugated Estrogen (PREMARIN) which was once considered the novel ERT/HRT. For more details see the presentation below.

Advances In HRT - Tibolone (Livial/ Tibofem/ Xyvion)

It is a 19- Nortestosterone drug possessing estrogenic activity, weak progestogenic and weaker androgenic activity. This drug has been around for quite a while now and it could seem stale to label it as an advance in HRT. It is superior to estrogens only because it has negligible estrogenic side effects while retaining an equal ability as EVALON in relieving menopausal symptoms.

HRT And The FDA

Both EVALON and TIBOLONE are not approved by the US FDA . However they are time tested and proven safe all over the world.