Hormonal Therapy in Gynecology

Hormones are used therapeutically in replacement therapy, contraception, and managing menopausal symptoms.
Hormone therapy (HT) should be prescribed at the lowest effective dose for the shortest possible time.
Menopause is the permanent cessation of menstruation, confirmed retrospectively after one year of amenorrhea.
The average age of menopause is 51.
Ninety-five percent of women experience menopause between ages 45 and 55.
Premature menopause occurs before age 40 (1%).
Women with premature menopause are at risk of osteoporosis and ischemic heart disease (IHD).
Management of premature menopause should include hormonal treatment (HRT) or combined hormonal contraceptives until reaching the natural menopause or 5 to 10 years afterward.
HRT can improve blood pressure/ cardiovascular (BP/CVS) risks, but both HRT and combined contraceptives offer bone protection.
Common clinical features of menopause include menstrual irregularity, vasomotor symptoms, musculoskeletal issues, psychological distress, urogenital problems, cardiovascular concerns, osteoporosis, and breast disease.

Women with a uterus require a progestogen with estrogen therapy to reduce the risk of endometrial cancer associated with unopposed estrogen.
Women who have had a hysterectomy do not require a progestogen and can use unopposed estrogen.
Estrogen has a positive effect on lipid parameters, whereas progestogens reduce these effects.
Estrogen is used to decrease menopausal symptoms such as vasomotor instability (hot flashes, flushes) and vaginal atrophy.
Indications for hormone therapy (HRT) include relief of vasomotor or other menopausal symptoms, preventing osteoporosis, and treating premature ovarian failure.
Contraindications for HRT include pregnancy, undiagnosed abnormal vaginal bleeding, active thromboembolic disorder, myocardial infarction (MI), breast disease, endometrial cancer, and active liver disease.

Irregular vaginal bleeding is common in the first 3-6 months after starting HRT.
Severe or prolonged bleeding (longer than 6 months post-amenorrhea) requires further investigation.
Adherence to treatment is important.
Peri-menopausal women should be reminded that HRT is not contraceptive.
There is no evidence that HRT causes weight gain.

Breast cancer: Women under 50 on HRT have no increased risk. Background risk is 15/1000. 2–6/1000 extra cases risk.
Ovarian cancer: Background risk is 2/1000. Less than one extra case over 5 years.
Endometrial cancer: Combined HRT protects the endometrium. Background risk is 2/1000. 4 extra cases with estrogen alone over 5 years.
Venous thromboembolism: Background risk is 5/1000. 2 extra cases over 5 years.
Cardiovascular disease: No increased risk

Estrogenic: Breast tenderness, breast enlargement, leg cramps, bloating, nausea, headache
Progestogenic: PMS-type symptoms, breast tenderness, lower abdominal pain, backache, depressed mood, acne/greasy skin, headache
Changing the type or dose and route of estrogen or progestogen help manage side effects
Some side effects can be managed with over-the-counter (OTC) remedies like primrose oil or evening starflower oil, which should be taken with food.

Follow-up at 3 months
Annual review, including effectiveness, side effects, dose, route, pros and cons.
Blood pressure (BP), cervical, and breast screenings, and osteoporosis assessment, especially around 5 years after symptom onset.
No mandatory limitations should apply for HRT treatment.
HRT should be withdrawn slowly.

Progesterone is produced in response to luteinizing hormone (LH) from the corpus luteum during the second half of the menstrual cycle and by the placenta.
Therapeutic uses of progestogens include treatment of hormonal deficiency and contraception (often used with estrogen).
Examples of progestogens: Norethindrone, norethindrone acetate, norgestrel, levonorgestrel, desogestrel, norgestimate, drospirenone, and dienogest.
Progestins are also used to manage dysfunctional uterine bleeding, dysmenorrhea, endometriosis, and infertility.