Transcript Hormone replacement therapy: practical considerations

Hormone replacement therapy:
practical considerations
Marco Gambacciani
and Nick Panay
The emerging concepts in HRT
• Timing (window of opportunity)
– Early start
– Maintenance of estrogenic benefits
• Patient selection
– Avoiding generalized prescribing
• Personalization
– Tailoring dose to patient
– Continuation and tapering the dose with age
Why lower HRT doses?
• Continued efficacy with fewer side-effects
and possibly fewer risks
• Potential for greater acceptance by women
• Improved continuance to achieve potential
long-term health benefits
• Efficacy in prevention of osteoporosis is not
compromised
HRT: maximizing efficacy, minimizing problems
Estrogenic side-effects
• Exceptions to low starting dose of E2
– Premature ovarian failure
– Severe osteoporosis
– Predominance of psychological
problems, e.g. climacteric
depression
HRT indications
• Vasomotor symptoms
• Urogenital symptoms
• Joint and muscle pains, mood swings, sleep
disturbances and sexual dysfunction
• Prevention of osteoporosis and related fractures
• Prevention of atrophy
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Epithelia
Skin
Connective tissue
Intervertebral disks
IMS Updated Recommendations, February 2007
HRT potential benefits I
• CVD
– HRT improves many aspects of the metabolic
syndrome and reduces the risk of diabetes
– There is evidence that HT may be cardioprotective
if started around the time of menopause and
continued long-term (often referred to as the
‘window of opportunity’ concept)
– In women less than 60 years old, recently
menopausal, without prevalent cardiovascular
disease, the initiation of HT does not cause early
harm, and may reduce cardiovascular morbidity
and mortality
IMS Updated Recommendations, February 2007
HRT potential benefits II
• CNS
– HRT initiated around the time of menopause
or by younger postmenopausal women is
associated with a reduced risk of Alzheimer’s
disease
• Combined HRT may reduce the risk of colon
cancer
IMS Updated Recommendations, February 2007
Principles of hormone treatment
• HRT should not be recommended without
there being a clear indication for its use
• Counselling should convey the benefits
and risks of menopausal HT in simple
terms, e.g. absolute numbers rather than
as percentage changes from a baseline
• This allows a woman and her physician to
make a well-informed decision about HRT
IMS Updated Recommendations, February 2007
Principles of hormone treatment
• Whether or not to continue therapy should
be decided at the discretion of the wellinformed hormone user and her health
professional, dependent upon the specific
goals and an objective estimation of
benefits and risks
• There are no reasons to place mandatory
limitations on the length of treatment
IMS Updated Recommendations, February 2007