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An information sheet on some medical aspects of HRT

This advice sheet was written particularly for young women who
use HRT - for example those with Turner's syndrome, who have The side effects of oestrogen treatment include nausea, experienced an early menopause or who had pitu itary disease headaches, breast tenderness, a rise in blood pressure and as a child. Everyone has a different opinion about HRT and weight gain. Usually, these side effects can be avoided by there may be disagreement with some of the content which is changing the type of preparation. Side effects of HRT are less offered in the spirit of informal advice. Also, as new research with low dose preparations and with skin patch preparations. emerges and new preparations are released, this informati on Every woman is different - with over 50 types of HRT available in the UK it is hoped that every woman will find a suitable preparation. It is also possible to prescribe each component of Introduction
HRT separately to individually tailor the mix of oestrogen, progesterone and testosterone. It may be necessary work Hormone replacement therapy (HRT) is a phrase which through several types of HRT by trial and error and be prepared describes the replacement of oestrogen to women whose own oestrogen levels are low. The body makes many hormones and in general, when a hormone is lacking it should be replaced. For example, an under active thyroid gland is treated with thyroid Risks of hormone replacement therapy
hormone and diabetes is treated with insulin. The ovary makes oestrogen, progesterone and some male hormone, Recently, we have learned that there is a higher risk of blood testosterone. Most of the debate in this area relates to the use clots in women taking HRT even with natural oestrogens. Blood clots can occur in the veins of the leg - a deep vein thrombosis. HRT should not be used if a thrombosis has happened in the Progesterone has a very clearly defined role. Progesterone past. The risk of stroke is also slightly raised in women on HRT. must be given to all women receiving oestrogen who have a There is no excess risk of cancer of the uterus with HRT as long uterus. The reason for this is that oestrogen given on its own as progesterone is also given. In young women whose ovarian can cause cancer of the uterus and this is almost completely function tends to fluctuate, there is no adverse effect on future prevented when progesterone is given. Progesterone is usually given at for 12-14 days each months to bring on a menstrual Breast cancer is a common fear for women taking HRT. Several studies have suggested that breast cancer is more common in Male hormone, testosterone, very rarely has to be replaced as it women who have taken HRT for m ore than ten years. There are is also made by the adrenal gland. Testosterone supplements good theoretical reasons why oestrogen might cause breast have been shown to improve sex drive in women after removal of cancer. By extending the "oestrogen years" by more than ten the ovaries but none of the preparations available in the UK are years (that is, by taking HRT for ten years, between the ages of 50 and 60) breast cancer becomes slightly more common. Oestrogen replacement is not usually taken by women who have Symptoms of oestrogen deficiency
had breast cancer unless symptoms of a lack of oestrogen are particularly troublesome. If there is a very strong family history of A lack of oestrogen can cause changes in mood (depression breast cancer, then it is wise to have specialist advice and and poor concentration), vaginal dryness and a reduction in consider mammography. Mammograms most effective in older energy, skin elasticity, and breast size. Perhaps the most women and screening with mammography usually starts at the common symptom of oestrogen deficiency is flushing - this can age of 45 - 50 in the UK - using HRT makes no difference to this often feel like intolerance to heat. In addition to these symptoms of oestrogen deficiency, there are hidden changes which can affect health later on in life. In particular, a lack of oestrogen causes thinning of the bones, osteoporosis, and early heart HRT and young women
disease. That is, a bone fracture or a heart attack in later life can It is likely that women who experience an early menopause have a lower than average risk of thrombosis and breast cancer. Benefits of hormone replacement therapy
Therefore, replacing oestrogen merely returns these risks to normal - just as if the ovaries were working normally. In women Oestrogen treatment is very effective at reducing and often who undergo the menopause before the age of 40, it may well completely preventing the symptoms of oestrogen deficiency. As be safe, indeed advisable, to take HRT for more than 10 years, regards osteoporosis, oestrogen can improve the density of continuing at least until the age of the average menopause at bone and prevent bone loss, although the extent of the strengthening of bone is very variable. On average there is a 25- 50% reduction in bone fractures in women who have used HRT, In some young women with an early menopause there is a compared to women who have never used HRT. chance of pregnancy. If a pregnancy is not wanted then the best form of HRT might be the oral contraceptive pill. Alternatively, if It had been thought that HRT might delay the onset of heart HRT preparations are preferred, then barrier contraception disease with estimates of a 30% reduction in heart attacks in should be used. If pregnancy is wanted then low dose HRT users. Recent reports , however, have shown that there is oestrogen replacement will not prevent a miracle pregnancy no benefit to the heart. These studies do show that taking HRT happening - indeed, most women in this situation conceive can reduce the ris k of colon cancer and possibly Alzheimer's while taking HRT. There is no risk to the baby and HRT can be stopped as soon as pregnancy is discovered as the placenta Side effects of hormone replacement therapy
If the chance of pregnancy is very low then HRT is generally better than the oral contraceptive because most forms of HRT
provide oestrogen all the time instead of just for 3 weeks out of 4
with the pill. That is, symptoms of oestrogen deficiency can
occur in the pill free week that is part of all combined oral
Oestrogen implants have been very popular in previous years, when skin patches were not available. They involve a minor surgical procedure, where the implant is inserted beneath the skin of the abdomen or buttock This page provides a background to the types of hormones available in once every six months. Implants are used less frequently now that patches HRT. The trade names of preparations keep changing – a full list of these are available, for two main reasons. Firstly, some women seem to "get is available separately. HRT preparati ons can be divided into cyclical used" to implants and find they need higher and higher doses. Secondly, forms (progesterone for 2 weeks of each cycle) which cause regular periods if side effects occur the can last a long time and it can be difficult to or continuous combined forms (constant oestrogen and progesterone) remove the implant. Progesterone does not come ‘ready packaged’ with which are designed to be ‘no bleed’. Break through bleeding with ‘no
implants and some women do not wish to take progesterone regularly. It is bleed’ preparations is common in young women. very important to take progesterone regularly in order to have a period with the implant form of oestrogen in order to avoid the risk of cancer of the Conjugated Equine Oestrogens
Conjugated oestrogens have been the most widely used type of natural oestrogen because they have been around the longest. Conjugated Vaginal oestrogen
oestrogens are extracted from the urine of pregnant mares and, although For some wo men the worst symptoms of oestrogen deficiency affect the there has been some concern about the wellbeing of these animals, there vagina – dryness and discomfort on intercourse. Oestrogen placed in the is also reassurance from the pharmaceutical company that the farming vagina can be a very effective way of relieving these symptoms. Vaginal conditions are satisfactory. It is treatment with these tablets that has given oestrogen my be used alone or as a boost to other forms of HRT which may most of the scienti fic information on risks and benefits of HRT. not be effective enough to relieve all vaginal symptoms of their own. Vaginal preparations include creams, pessaries, tablets and rings. Conjugated oestrogens are available in two doses – 0.625 and 1.25 mg. The lower dose is roughly equivalent to oestradiol valerate 2 mg, ethinyloestradiol 20 ug or oestrogen patch 50 ug. Plant oestrogens or phyto-oestrogens are available in health shops but not by pre scription. These preparations are effective in treating some of the Other ‘Natural’ Oestrogens
symptoms of oestrogen deficiency and help prevent bone loss. They are Most other tablet forms of HRT contain oestradiol valerate or a similar however, many times weaker than prescription forms of HRT and are compound and these can be extracted from soya beans but are made as unlikely to be strong enough to prevent osteoporosis in young women. synthetic copies of the natural compounds. While these preparations appear to be the same strength as conjugated oestrogen tablets, we do not Progesterone Treatments
yet have many years of scientific research to be certain of the risks and benefits of this treatment although they are likely to be as effective as For women who have not had a hysterectomy, any oestrogen treatment must be combined with progesterone, either in tablet form or with a second patch, in order to provide a menstrual bleed. One HRT preparation uses Doses of most preparations are oestradiol valerate 1 – 2 mg with one progesterone only every three months. Alternatively, progesterone and oestrogen can be given together continuously so that no periods occur. These last two options are not recommended in young women as break Synthetic oestrogens
through bleeding is more common in the young and the long term safety All oral contraceptive pills contain ethinyloestradiol, a strong synthetic of this type of HRT has not been proven in this age group. The side effects oestrogen designed to prevent ovulation. Oral contraceptive pills have of progesterone treatment include pre -menstrual symptoms of mood often been used as HRT in young women. The oral contraceptive pills, change, bloating and breast discomfort – these side effects are more however, because they are stronger than natural oestrogens and probably prominent with the stronger progesterones – norethisterone and carry higher risk of blood clotting (thrombosis) compared with HRT medroxyprogesterone and less common with dydrogesterone. All preparations. For many women with oestrogen deficiency, the oral progesterone preparations used in HRT and the pills are synthetic. contraceptives may be unnecessari ly strong for use as HRT. Also, oral contraceptives provide oestrogen for only 3 weeks in every 4 - the forth 'Natural' progesterone cream has been used and there is no information week being ‘pill free’. For women who are oestrogen deficient, the lack of yet to say this is better than the synthetic products. In fact, progesterone oestrogen over this pill free week can cause symptoms and it seems more cream can be a danger in women who have not had a hysterectomy and natural to provide oestrogen continuously which is the case in most forms who take oestrogen as well. The very low dose of progesterone on the cream does not protect the uterus sufficiently. Oral contraceptive pills are available in four doses containing 20, 30, 35 or Progesterone preparations used in HRT:
50 ug of ethinyloestradiol – the top dose is not used routinely. Tibolone
Tibolone is a synthetic hormone which has some oestrogen-like and some progesterone-like activity. This preparation is designed to prevent the symptoms of oestrogen deficiency without causing menstrual bleeding. Progesterone patches are only available as Tibolone is effective in preventing osteoporosis but the long term effects on the risk of thrombosis, heart attacks and breast cancer are unknown. Vaginal progesterone
Skin Patches and Oestrogen Gels
Skin patches are like plasters which allow oestrogen to be slowly absorbed Testosterone Replacement
through the skin – ‘transdermal’. The patches contain oestradiol which is a synthetic copy of natural oestrogen. Some are changed every 3-4 days The ovary makes about half of the supply of testosterone - the other half and others last a week. Oestrogel works in a similar way to the patch and is comes from the adrenal gland. Some women find that lower testosterone applied to arms, shoulders or thighs every day. The patches are helpful in levels reduces sex drive and energy. Testosterone replacement is reducing the side effects of the tablet forms of HRT, in particular, available in implants or tablets (Restandol). Testosterone treatment can headache, nausea and a rise in blood pressure but have a common side be difficult to balance because of the side effects of excess hair growth and effect of skin irritation. Patches are also useful for women with liver acne - for this reason testosterone treatment is not given routinely. A disease or raised triglyceride levels. Nasal oestrogen has re cently been testosterone precursor DHEA (dehyroandrosterone) is a useful way of introduced as an alternative to transdermal oestrogen. providing a boost to low testosterone levels for women. The dose of transdermal patches vary from 25 to 100 ug of oestradiol Oestrogen Implants



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Hot Flashes in Palliative Care Part 2 Authors: Carolyn Lefkowits, MD and Robert Arnold MD Background: Hot flashes (‘flushes’) are a common anddisabling symptom, particularlywhen caused by cancer treatment. Assessment of hotflashes was reviewed in April’s newsletter. This month’snewsletter will cover procedural and pharmacologicaltreatment of hot flashes. Pharmacologic Treatments: The

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