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1/18

Menopause and HormoneReplacement Therapy

Sandra E. Brooks, MD, FACS, FACOAssoc!ate "ro#essor

D!rector, D!$ %& Oncolo'y

Dept. O(stetr!cs and ynecolo'y)n!$ers!ty o# Maryland School o# Med!c!ne


2/18

What is Menopause?

During the perimenopausal period (up to 10 years beforemenopause), the ovaries decrease production of the "femalehormones" estrogen and progesterone, the hormones whichallow a woman to become pregnant and to menstruate.

Hormones also affect many other functions in a womansbody such as the circulatory system, urogenitary system,

nervous system, s!eletal system, memory, seuality, s!in,vision, and teeth.

#he average age for menopause in $merican women is %1 &ecause most women will live a third of their life after

menopause, it is important to be aware of the symptoms,

systemic effects, and available treatment options associatedwith estrogen loss.


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'eproductive #ractymptoms cessation of menses, hot flashes,

decreased vaginal lubrication

igns vaginal epithelial atrophy, decreased

si*e of uterus, cervi, or ovaries +rinary #ract

ymptoms urgency, freuency, nocturia

igns urothelial atrophy, hypertonic unstable

bladder &reasts

ymptoms decreased tenderness

igns decreased si*e, fewer benign cysts

Acute Effects of Menopause


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-steoporosis

decreased trabecular bone density due to increased

osteoclastic activity

ardiovascular Disease

the most common cause of death in women

rate of /D increases steadily reaching parity with

men by age 0

lipid profile changes

increased D decreased HD

Late Effects of Menopause


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'is!s and &enefits of 2strogen 3lus

3rogestin in Healthy 3ostmenopausal4omen (4H5)16 177861779

-b:ective #o assess the ma:or health benefits and ris!s of

H'# in the +.. based on a randomi*ed controlled

primary prevention trial


6/18

16,080 Women age 50-79No prior hsterectom

8506

!remarin 0"6#5 mg$%!ro&era #"5mg$%

757'

(ontro)!)ace*o

W+ tu%


7/18

*H+ StudyHRT !ncreased R!sk o# Heart D!sease

Coronary Heart D!sease -non/#atal M+s 0!th!n 1 yr.

Stroke 21 +!ncrease !n stroke (e'an 0!th!n

yearsD3T 45"E 16;


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Conclus!ons o# *omen7s Health +n!t!at!$eStudy

HRT should not (e !n!t!ated orcont!nued #or pr!mary pre$ent!on o#

Heart D!sease

The r!sks o# card!o$ascular d!seaseand (reast cancer must (e 0e!'heda'a!nst the (ene8ts o# #racturereduct!on and postmenopausalsymptom rel!e# .


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2strogen in the 3revention of

$therosclerosis #rial


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onclusions of H2' &o o$erall (ene8t o# hormone

treatment

)ne9pected pattern o# !ncreased r!skdur!n' the 8rst year o# #ollo0/up

5 other random!:ed cl!n!cal tr!alsconclude;

HRT does not reduce r!sk o# ad$ersee$ent !n 0omen 0!th heart d!sease


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'esponse to 4H5

5mportant to note4omen with severe hot flashes were not

enrolled in large numbers

4H5 only applies to w omen %067 who are

ta!ing premarin@provera

3remarin only arm continues


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Contraindications to HRT

< "re'nancy or Breast#eed!n'.< =!$er d!sease< )nd!a'nosed $a'!nal (leed!n'.< H!story o# certa!n cancers.< H!story o# deep $e!n throm(oses

or other (lood clott!n' d!sorders"


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HRT rel!e$es Hot Flashes, 3a'!nal Drynessand +nsomn!a (ut may ha$e Side Efects

Return o# per!ods +rre'ular $a'!nal (leed!n'>spott!n' Headache &ausea Breast tenderness

Bloat!n' ?pro'esterone@ *e!'ht 'a!n ?pro'esterone@; 'enerally only /6 pounds can (e

(lamed on the hormones; the rest !s decreased meta(ol!smassoc!ated 0!th menopause, !ncreased calor!c !ntake and>ordecreased e9erc!se.

May e9acer(ate depress!on ?pro'esterone@ Enlar'ement o# uter!ne 8(ro!ds

E9acer(at!on o# endometr!os!s Flu!d retent!on ?may e9acer(ate asthma, ep!lepsy, m!'ra!ne, heart

d!sease, k!dney d!sease@ Spotty darken!n' o# the sk!n


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*ho should take HRT

'ole of H'# for any indication other thansymptomatic relief of severe hot flashes

3remature menopause

$lternatives elective serotonin re upta!e inhibitors for hot

flashes 2'=s or bisphosphonates for prevention of

osteoporosis

tatins for cholesterol /aginal estrogen or rings, lubricants for vaginal

dryness


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$lternatives to H'#

PHYTOESTROGENS There are 3 main groups: isofavones, lignans, and

coumestans. Isofavones are considered !ea"# estrogen receptor

modulators$ the% mimic the role o& estrogen. Ho!ever, the%can mimic the good actions and the not so good' the% canalso &unction to (loc" the action o& estrogen at some sites

It is still unclear !hether these her(s are sa&e &or !omen atris" &or (reast cancer or its recurrence.Recommended dose o& ).* g o& so% per serving &or a total o&+* g per da%. Medical &acts a(out so%:

o% contains 3 isofavones: -aidin, genistin, and gl%sitin.In addition to its preventive (ene/ts in cardiovasculardisease, so% has (een sho!n to reduce the &re0uenc% o&hot fashes and to reduce the incidence o& osteoporosis.

i1 studies have sho!n that so% isofavones can reducethe &re0uenc% o& hot fashes.

To mimic the t%pical 2apanese diet, !omen should get )'4mg o& so% isofavones per da%. 5 cup o& to&u 6 7* mg6 thesame hal& cup o& so%(eans 6 3 cups o& so% mil".


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Her(al "reparat!ons 8lac" cohosh: Th!s !s currently touted as the her(al

preparat!on most l!kely to pre$ent hot ashes. Cl!n!cal stud!esha$e (een done to sho0 a reduct!on !n the #reuency and!ntens!ty o# hot ashes, !mpro$ement !n 'lo(al menopausalsymptoms, and !n $a'!nal lu(r!cat!on. +t !s pro(a(ly the most0ell stud!ed o# the phytoestro'en!c her(al preparat!ons. Most o#

these stud!es 0ere not nearly as 0ell des!'ned as mostphys!c!ans 0ould l!ke,

Red Clover: This her( contains &our isofavones,including genistein, the most active component o& so%.The most popular dietar% supplement derived &rom redclover is 9romensil .

Clinical trials !ith 9romensil did surve% !omen to testtheir level o& satis&action$ 43; o& users said the% !antedto continue ta"ing it. < * mg 9romensil ta(let contains= mg o& plant estrogens. This is the e0uivalent o& onecup o& so% mil" and &our cups o& chic"peas.


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Her(al "reparat!ons >in"go (ilo(a:

This her( is commonl% used as a mood elevator or toimprove memor% and other cognitive &unctions. It has also(een documented to cause (leeding pro(lems in severalindividuals, !ith or !ithout other medicines. pea" !ith%our ph%sician i& %ou plan to ta"e this her(, especiall% i&%ou are ta"ing medicines &or (leeding or clotting pro(lems

or &or arthritis. Wild %am:

This has (een touted as a natural source o& naturalprogesterone#. It contains diosgenin, !hich is notconverted to active hormones in the (od% ho!ever, and ithas (een sho!n to have @ eAects on estrogen orprogesterone receptors.

Baginal u(ricants: There are numerous non'prescriptionvaginal lu(ricants on the mar"et such as D'E 2ell% andBagisil . ever use a !ater insolu(le preparation in thevagina, e.g. Baseline .


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'eferences and in!s1) 4riting ?roup for the 4H5 5nvestigators

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