Coupon Accepted Successfully!


Hormone Replacement Therapy

Based on the results of Women's Health Initiative (WHI) trial, the following are now the accepted indications for HRT:

  1. Menopausal symptoms such as hot flushes, vaginal dryness, mood swings, irritability, etc
  2. Prevention and treatment of osteoporosis
  3. Decreased libido

HRT is not given for primary prevention of heart disease.


The different hormones used are:

  1. Estrogen (E) and progesterone (P) combination:
    • As unopposed estrogen is a risk factor for endometrial hyperplasia and cancer; in women with intact uterus both E + P should be given. In hysterectomized women, only E can be given.
    • The most commonly prescribed oral estrogen is conjugated equine estrogen (CEE).
    • The most common progestin is medroxyprogesterone acetate (MPA).
  2. Testosterone:
    • The most common indication for androgens is loss of libido.
    • Testosterone by peripheral conversion to estrogen will also relieve he hot flushes.
  3. Tibolone:
    • It is considered as designer HRT It is a selective tissue estrogen activity regulator (STEAR).
    • It has estrogenic, progestogenic, and androgenic properties. -
  4. Selective estrogen receptor modulators:
    • Raloxifene is a selective estrogen receptor modulator (SERM), which binds with higher affinity to estrogen alpha receptor than the beta receptors.
    • Clinically raloxifene produces an effect similar to estrogen on skeletal and cardiovascular system, while behaving as an estrogen antagonist in the uterus and breast.
    • Raloxifene maintains a favorable lipid profile and does not exert a proliferative effect on the endometrium.
    • Effects on bone remodeling are similar to those of estrogen; there is a decrease in the incidence of fractures.
    • Unfortunately, raloxifene does not relieve hot flushes and can even worsen them.
    • There is increased incidence of venous thromboembolism.
    • Raloxifene is useful in decreasing the risk of osteoporosis.

Contraindications of Hrt

  • Active liver disease (hepatitis/tumor)
  • Thrombophilias
  • IHD
  • Complicated migraine
  • Complicated valvular heart disease
  • Breast cancer (current or past history)
  • Severe hypertension (systolic >160 or diastolic >100)
  • DM with vascular complications
  • History of thromboembolism/stroke/DVT

Nonhormonal Drugs

  1. Calcium
  2. Bisphosphonates
    • Etidronate
    • Alendronate
    • Pamidronate Risedronate
  3. Calcitonin, calcitriol, and vitamin D-400 IU / day
  4. Strontium

Nonhormonal drugs that relieve the hot flushes

  1. Clonidine
  2. Sertraline
  3. Venlafaxine
  4. Fluoxetine
  5. Gabapentin

Potential Benefits and Harms of HRT



Uncertain risks


Definite risk


 Hip fracture

 Wrist fracture

 Vertebral fracture (i.e osteoporosis)

 Symptoms of menopause

 Thromboembolic events (use of E+P not with E alone)

 Dementia

 Endometrial cancer (use of E alone)

 Coronary heart disease?

 Breast Cancer (use of E+P not with E alone)

 Stroke?

 Ovarian cancer (E+P)

 Cholecystitis

Uncertain benefits

 colorectal cancer

 diabetes mellitus



Extra Edges

  • in FSH is the sine quia non for menopause
  • M/c symptoms of menopause - Hot flushes
  • DOC for hot flashes - Estrogen (oral /transdermal) in lowest possible doses for shortest possible lime
  • If uterus of female is intact, give estrogen + progesterone
  • Side effect of raloxifene is hot flushes. Raloxifene cannot be used to treat hot flushes.
  • If Most important health hazard associated with menopause = Osteoporosis.
  • First line of management of osteoporosis - Bisphosphonates females.
  • DOC for senile vaginitis.: Estrogen cream
  • DOC for decreased libido in postmenopausal females - Testosterone
  • Coronary artery disease is the main cause of death in postmenopausal females. HRT does not decrease its incidence.
  • Premature menopause: If menopause occurs at or below the age of 40, it is premature menopause.
  • Delayed menopause: If menopause fails to occur even beyond 55 years, it is called delayed menopause.

Women's Health Initiative (WHI)

  • "The study investigated health risks and benefits of hormone therapy in healthy postmenopausal women aged 50-79 old.
  • "In the study
    • Continuous combined HRT (CEE 0.625 mg + MP A 2.5 mg 00) was given to 16,608 women with an intact uterus
      » Originally designed to run for 8.5 years - stopped early after 5.2 years (july 2002) because the evidence for harm (Breast cancer, CHD, Stroke, Pulmonary embolism) outweighed benefit (fracture reduction and colon cancer reduction)
    • Estrogen-alone (CEE 0.625 mg) was given to 10,739 women with a previous hysterectomy
      » This arm was also stopped early (February 2004 instead of March 2005) because of increased stroke risk and no heart disease benefit. The women taking only estrogen did not show an increased risk of breast cancer.

Test Your Skills Now!
Take a Quiz now
Reviewer Name