Postmenopausal hormone therapy

Hormone therapy is the most effective management for menopausal vasomotor symptoms.

Approximately 70% of midlife aged women experience hot flashes and night sweats, which may persist for a decade or longer.

Vasomotor symptoms adversely affects sleep, daily functioning, and quality-of-life.

Vasomotor symptoms, common among late perimenopausal and recently menopausal women, are associated with decrease in the quality of life, difficulty concentrating, irritability, or

poorer health status, bone loss, increased risk of cardiovascular disease, and cognitive changes.

Initial observational studies suggested hormone therapy was associated with reduced risk of cardiovascular disease and dementia, but the WHI study reported increased risk of cardiovascular disease, venous thromboembolism, and breast cancer.

WHI suggested increase risk of coronary heart disease and stroke among patients to start hormone therapy after the age of 60 years, with a greater risk after the age of 70 years, and no significant increase in risk among those starting therapy before the age of 60 years or within within 10 years after the onset of menopause.

Cognition and mood are often altered during disruptive hot flashes.

Hormonal therapy in menopause has beneficial bone marrow density, reducing fracture risk and improves atrophic changes of the urogenital tract and genitourinary syndrome.

With declining estrogen levels, thermoregulatory zone narrows, leading to hot flashes in symptomatic women.

Hot flashes persist a median of 7.4 years, and that duration varies according to race or ethnic group-five years among Asian women, seven years among white women, nine years among Hispanic women, and 10 years among black women (Avis NÉ).

Low-dose intravaginal estrogen is effective management for sexual and quality-of-life symptoms associated with the genitourinary syndrome of menopause with minimal absorption of the drug and associated risk.

Risk for hot flashes include early or surgical menopause, black race, Hispanic ethnic group, high body mass index, sedentary lifestyle, smoking, stress, anxiety, depression, posttraumatic stress disorder, partner violence, sexual assault, and the use of selective estrogen receptor modulators or aromatase inhibitors.

Women should receive estrogen alone if they have no uterus, and women with a uterus requires progesterone in addition to estrogen to prevent endometrial hyperplasia.

Hormonal therapy raises very low estrogen levels of women during menopause to physiological levels that is normally seen during the reproductive years.

Menopausal hormonal therapy is safer than contraceptive doses of hormones, which are supraphysiologic, allowing ovarian suppression.

The lowest dose of hormonal therapy that manages a woman’s vasomotor symptoms are utilized.

Maximum hot flash reduction with use of hormonal therapy, takes approximately three months of use.

The most commonly used hormone formulations are the oral pill and transdermal patch but transdermal gels and virginal rings also are available.

Genitourinary syndrome menopause, with bladder, vulva, vaginal changes, affects almost half of postmenopausal women.

Genitourinary syndrome of menopause includes: vaginal dryness, burning, irritation, lack of lubrication, dyspareunia, urinary urgency and frequency, dysuria, and recurrent urinary tract infections.

Menopausal hormone therapy provides relief of hot flashes, night sweats, reduces bone loss and risk of fracture, and addresses genitourinary syndrome of menopause.

For women with a uterus, various formulations of estrogen-progesterone therapy combine both hormones: The estrogen is provided daily, while progesterone is provided daily cyclically for 12-14 days a month.

Progestogens are used in women within intact uterus to protect against uterine cancer.
 The risks of VTE and possibly breast cancer and negative effects of mood and lipid levels are lower with micronized  progesterone than with progestins.

Transdermal estrogen therapy has advantages compared with oral therapy, especially for women with obesity or cardiovascular disease risk factors.

All estrogen patches contain estradiol and your change to only once or twice weekly, and result in very stable blood levels.

The continued combined hormones typically result in amenorrhea.

Breakthrough bleeding from such hormonal therapy may occur, especially in women with early menopause transition.

Cyclic regimens result in regular, predictable withdrawal bleeding.

Causes a twofold to fourfold increase in risk for deep venous thrombosis and pulmonary embolism.

Mortality rate from ovarian cancer about twice as high among women who had taken PMH for 10 or more years compared to women who had not taken such hormones.

Observational studies indicate a reduced risk of coronary heart events with or without preexisting coronary heart disease.

Transiently increases coronary risk after starting hormone therapy in women with established coronary artery disease.

Women’s Health Initiative (WHI) reported a hazard ratio for coronary artery disease of 0.95 in the trial of conjugated equine estrogens and an hazard ratio of 1.24 in the trial of conjugated equine estrogens plus medroxyprogesterone acetate.

Womens’s Health Initiative (WHI) revealed increased risk of breast cancer, cardiovascular disease, stroke, and thromboembolic events in women taking conjugated equine estrogen and medroxyprogesterone acetate compared with placebo.

Systemic hormone therapy is the most effective therapy for vasomotor symptoms related to menopause.

Cochrane review of 24 studies found estrogen alone or in combination with progesterone reduced weekly frequency of hot flashes by 75% and the severity by 87%, with no clear differences in effect between conjugated estrogens and oral or transdermal treatment.

In the WHI trial the combination of estrogen and mrdroxyrogesterone acetate was stopped at a median of 5.6 years owing to the probability of a greater harm than benefit.

Oral and transdermal estrogens relieve hot flashes and night sweats at standard doses, with benefits typically observed within two weeks.
Lower doses of estrogen may avert excess risk the thromboembolism, breast tenderness, and unexpected bleeding, but symptom relief may take up to eight weeks.
Ultra low dose estrogen patches are approved for the prevention of osteoporosis and also reduces hot flashes.

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