Menopause, Hormone Replacement Therapy, HRT, HRT Programs, How is HRT administered, what is administered in HRT, estrogen, progesterone

Hormone Replacement Therapy (HRT)

HRT Programs

How exactly HRT is administered and what is administered and in what frequency is often determined by the state of the patient.

Uterus And Ovaries In Place

Uterus Removed But Ovaries Remain

Uterus, Tubes And Ovaries Removed

After Cancer Of The Endometrium or Of The Breasts

Uterus And Ovaries In Place

HRT causes the menstrual cycle and regular periods to continue for some time--until later in the postmenopausal life. The menstrual cycle must continue regularly and normally.

The hormones must be taken in a cyclic manner much in the same way as birth control pills--to produce cyclic bleeding.

Before administering HRT, make sure that there is no substantial pelvic disease, such as fibroids or endometriosis, that might be nourished by the estrogen replacement.

Methods of treatment

There are four basic alternatives.

Oral estrogen tablets are taken daily for 21 days. During the last 7 to 12 days, progestagen tablets are added to the program. Menstruation usually follows a few days after the last medication, and a new hormone cycle is begun on the fifth day of the flow.

Patches are generally used in a constant, uninterrupted manner-that is, two patches a week without cessation. In this program, progestagens are added orally for 7 to 12 days every fourth week. Menstruation is usually regulated in this manner, but menses are sometimes difficult to adjust with this approach. It requires the combined effort of patient and physician.

Injectable hormones are usually given only if other HRT forms of treatment are unacceptable. Usually administered only twice in one cycle. The initial dose contains estrogen alone and is given on the fifth postmenstrual day. A second injection containing both estrogen and a progestagen is given 10 to 14 days later, depending upon the patient's menstrual response.

Subcutaneous pellets are put in place usually at 4- to 6- month intervals and progestagens are given by mouth at 4-week intervals and for 10 to 12 days. Menstrual cycle adjustment may be difficult.

Uterus Removed But Ovaries Remain

It may be several years after hysterectomy before HRT therapy becomes necessary. It depends upon the woman's age at the time of surgery and upon the health of her ovaries. HRT is begun when menopausal symptoms appear, or when the vaginal hormone smear and/or the blood FSH indicate failing ovarian hormone production.

In the absence of the uterus there is no need to provide cyclic hormone replacement since there will be no bleeding.

The plans are as follows:

Oral estrogen tablets are taken daily without any interruption or change in the dosage level.

Transdermal estrogen continues unchanged, being replaced twice weekly.

Injections continue to be given at 2-week intervals but often can be spaced somewhat farther apart.

Subcutaneous pellets are replaced as often as necessary, at up to 6-month intervals.

Doctors disagree whether progestin is needed to be given in this situation. Many gynecologists feel that, with the uterus gone, there is no longer any risk of cancer from unopposed estrogen. Others feel that progestagens are still very important because there is growing evidence that progestagens protect the breasts against cancer, and also help with building new bones. If progestagens are given, it is done along with the constant estrogen regiment and in the same dosage range used in all the regular HRT programs.

Uterus, Tubes And Ovaries Removed

Whether HRT is necessary in this situation depends on for what reason the uterus, tubes and ovaries were removed.

If the surgery removing the uterus, tubes and ovaries was for a cancer of the endometrium, gynecologists feel that HRT should not be used after this surgery. However, some others begin hormone replacement therapy at once, in a modified way, usually employing large doses of progestagens or combining estrogen with the testosterone for the first few months.

If the surgery was for cancer of the cervix, HRT is not contraindicated.

If the surgery was undertaken for the treatment of cancer of the ovaries, HRT must be decided upon on an individual basis.

If there are no substantial contraindications to HRT, it should be started immediately after such surgery. The younger the patient, the more important this is. The administration of HRT following this surgery is similar to that after an uncomplicated hysterectomy.

After Cancer Of The Endometrium or Of The Breasts

It has always been considered incorrect to give HRT to a woman who has sustained a cancer of the endometrium or the breasts regardless of the severity of existing menopausal problems. Again, there is no universal agreement in this.

Some advocate for HRT if:

At least five years have elapsed in which they have been free of any evidence of recurrence.

Significant menopausal problems exist (osteoporosis, vaginal atrophy in young women, etc.)

The patient requests it and is absolutely and completely informed of the known risks.

There is recent evidence that proper HRT is safe to administer immediately after surgery for early (Stage 1) cancer of the endometrium.

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