Combined Hormone Replacement Therapy Research Articles

A local audit evaluating bone health in patients with functional hypothalamic amenorrhoea secondary to an eating disorder and a review of the application of hormone therapy in this clinical setting.

It is widely known that estrogen has a fundamental role to play in skeletal homeostasis. In the most reductionist sense, the action of estrogen can be surmised as anti-resorptive. Estrogen prevents the break-down of bone. It therefore follows that estrogen deficiency states, such as the menopause and functional hypothalamic amenorrhoea (FHA), are often characterised by increased bone remodelling and disrupted skeletal homeostasis. FHA is the cessation of menstruation secondary to abnormal signalling between the hypothalamus and pituitary gland due to deficient pulsatile secretion of Gonadotrophin Releasing Hormone (GnRH). Functional hypothalamic amenorrhoea is frequently a consequence of women suffering with eating disorders. The development of FHA secondary to eating disorders is an evolutionary adaptive response to chronic metabolic energy deficiency. Fundamentally, preservation of life is biologically prioritised over dispensable physiological process such as reproduction. Consequently, the hypothalamic-pituitary-ovarian (HPO) axis fails, which disrupts menstrual function and ovulation, culminating in a state of estrogen deficiency. One of the most important and long-lasting deleterious consequences of FHA is disrupted skeletal homeostasis and bone loss. Estrogen replacement, most commonly in the form of combined hormone replacement therapy (HRT) or the combined oral contraceptive pill (COCP), is advised for women with an early menopause to prevent bone loss. Arguably, estrogen replacement should also be utilised in the context of FHA. However, the optimum estrogen regime for women with FHA remains under-researched and so management is not evidence-based.

#292 : Combination of Hormone Replacement Therapy and Ovarian Stimulation as Endometrial Preparation Strategy for Refractory Thin Endometrium

Background and Aims: The aim of the case study is to demonstrate that combination of hormone replacement therapy with controlled ovarian stimulation is effective to improve endometrial thickness (ET) in difficult cases of thin endometrium. Method: The patient is a 35-year-old, nulliparous with primary subfertility for six years. She had PCOS with history of right salphingo-oophorectomy done for benign serous papillary cystadenoma. The male partner had severe oligoasthenoteratozoospermia. He started on FSH injections for three months with slight improvement in sperm parameters. She then underwent an IVF cycle and obtained five blastocysts. We struggled with thin ET with one failed frozen embryo transfer (FET) and two abandoned cycles. The patient was started with hormone replacement therapy on day one menses with tablet progynova 4 mg six hourly together with estrogel 3 g eight hourly transdermally. A scan was performed on day one menses and endometrial thickness was 4.5 mm. The serum progesterone and luteinizing hormone was baseline. A repeat scan for ET was done on day seven menses and was noted to be 6.4 mm. She was given another four days of oral and transdermal estrogen and the ET remained 6.4 mm at day eleven menses. We decided to perform low dose ovarian stimulation with recombinant FSH 150 IU daily. She was then seen on day fourteen menses for repeat scan. The ET only marginally increased to 6.7 mm. We increased the injection to 225 IU daily. On day eighteen menses, her ET was 7.8 mm and we triggered with HCG 5000 IU. She had her FET done on day twenty-five menses. Results: Her BHCG two weeks later was 948.3 U/L. The pregnancy is currently ongoing at 18 weeks. Conclusion: A combination of hormone replacement therapy and ovarian stimulation enables the exogenous and endogenous estrogen to act synchronously on the endometrium to achieve better endometrial thickness for implantation.

Turner syndrome transition clinic in the West of Scotland: a perspective.

Turner Syndrome (TS) is the commonest chromosomal abnormality in females. Establishing and maintaining long-term follow-up after transition to adult endocrine services, to allow for essential lifelong surveillance of hypertension and cardiovascular disease, and optimal hormone replacement, remains a challenge. A TS transition clinic was established with the aim of supporting successful transfer and establishing long-term follow-up in adult endocrine services. Our objectives are to evaluate the success of our TS transition service primarily in achieving and maintaining follow-up after transfer to adult services and to assess the adequacy of health surveillance post-transition with a specific focus on cardiac monitoring and hormone replacement. A departmental database was used to identify young people whose care had transferred to adult endocrine services. An electronic case record was utilised to obtain clinic attendance and relevant clinical information on cardiovascular monitoring and hormone replacement therapy (HRT). Forty-six (n=46) young people transferred to adult endocrine services during the observed 20-year period, 1998-2017. Thirty-six (n=36) had transferred prior to 2015, of whom sixteen (n=16, 44%) are lost to long-term follow-up at 5 years. Overall, 41 (89%) patients have had cardiac imaging surveillance since transferring, However, only 30 (73%) of these were carried out at the recommended frequencies. All 20 women in established follow-up have had cardiac imaging. Five out of the 46 (11%) patients do not have any documented cardiovascular monitoring. Forty (86.9%) women have had a documented BP measurement. Nineteen of the 20 women who are in 5- year established follow-up have a documented blood pressure. Five (11%) women are not on HRT, while two (4%) remain on oestrogen-only HRT. Thirty-seven (80.4%) women are on combined HRT, only eight (21.6%) are on the recommended form of oestradiol. Two (4%) are not on HRT due to normal ovarian function. A significant proportion of girls with TS are currently lost to adult endocrine services. Strategies to improve long-term endocrine follow-up are needed to ensure lifelong health needs and adequate hormone replacement are met. Whilst similar parameters are monitored in adult endocrine services a group of patients may be at risk of receiving inadequate HRT and developing cardiovascular complications.

Sex steroid hormones and epilepsy: Effects of hormonal replacement therapy on seizure frequency of postmenopausal women with epilepsy-A systematic review.

Hormonal replacement therapy (HRT) is used for symptomatic treatment of menopause. Some evidence suggests a proconvulsant effect of estrogen and an anticonvulsant role of progesterone. Thus, the use of exogenous sex steroid hormones might influence the course of epilepsy in peri- and postmenopausal women with epilepsy (WWE). We conducted a systematic review on the impact of HRT on the frequency of seizures of WWE. PubMed and Scopus were searched for articles published from inception until August 2022. Abstracts from the past 5 years from the European Academy of Neurology and European Epilepsy Congresses were also reviewed. Article reference lists were screened, and relevant articles were retrieved for consultation. Interventional and observational studies on WWE and animal models of estrogen deficiency were included. Critical appraisal was performed using the revised Cochrane risk-of-bias tool for randomized trials and ROBINS-E tool. Of 497 articles screened, 13 studies were included, including three human studies. One cross-sectional study showed a decrease in seizure frequency in WWE using combined HRT, a case-control study showed an increase in comparison with controls, and a randomized clinical trial found a dose-dependent increase in seizure frequency in women with focal epilepsy taking combined HRT. Ten studies addressing the impact of HRT in rat models were also included, which showed conflicting results. There is scarce evidence of the impact of HRT in WWE. Further studies should evaluate the harmful potential, and prospective registries are needed for monitoring this population.

HRT in Women Undergoing Pelvic Clearance for Endometriosis—A Case Report and a National Survey

The optimal hormone replacement therapy (HRT) in women who have undergone pelvic clearance for endometriosis remains uncertain with insufficient evidence. The purpose of this case report and the national survey was to highlight the potential HRT-related risks and to establish current HRT practice in this group of women. The case was a 45-year-old woman presenting with recurrence of severe chronic pelvic pain while on oestrogen-only HRT (EO-HRT) for five years after subtotal hysterectomy and bilateral oophorectomy for severe endometriosis. MRI revealed multiple peri-cervical endometriomas and severe right hydroureter/hydronephrosis with complete right renal parenchymal loss. The survey was a 21-item questionnaire administered electronically using SurveyMonkey. It was reviewed and approved by British Menopause Society and British Society of Gynaecological endoscopy and was sent to their members as well as NHS Gynaecologists. A total of 216 physicians responded including 120 (55.6%) Gynaecology Consultants and 96 (44.4%) GPs/Nurses in Menopause clinics. Overall, 68.6% of responders prescribe combined HRT (C-HRT), 11.1% tibolone, 13.0% EO-HRT and 7.8% varied HRT. Fifty-one percent prescribe the progestogen component of C-HRT indefinitely, 22% for 3-6 months and 27% for varied durations. In conclusion, this study highlights the real risk of endometriosis recurrence in EO-HRT users after pelvic clearance for endometriosis. The survey revealed that only two thirds of Gynecologists/Menopause practitioners prescribe combined HRT in this group of women.

Use of Hormonal Therapy Increases the Risk of Venous Thrombosis in COVID-19 Patients; Results of 1071 Patient Cohort

Introduction Coagulopathy is a well-recognized complication of COVID-19, with an incidence of thrombotic events as high as 31% in patients who are critically ill from COVID-19 infection. Estrogen-containing hormonal therapies are also well known to increase the risk of thrombosis. There have been no studies evaluating if estrogen-containing hormonal therapies potentiate thrombotic risk during COVID-19 infection, and there is no consensus on the clinical role of holding hormonal therapy during infection. We performed a large retrospective cohort study to evaluate the thrombotic risk of estrogen therapy during COVID-19 infection in both pre-menopausal and post-menopausal patients. Methods To assess the association between hormonal therapies and thrombosis in COVID-19 patients, we collected data on all female Oregon Health & Science University patients aged 18-80 years who tested positive for COVID-19 between 12/2020 and 2/2022 and were on hormonal therapies. We included a comprehensive range of hormonal therapies to ensure an accurate representation of both pre-menopausal and post-menopausal patients. The experimental group consisted of patients on combined hormonal contraceptives and hormone replacement therapy via the oral and transdermal routes, which have all been associated with increased thrombotic risk. The control group consisted of patients with a progesterone intrauterine device or on topical estrogen, neither of which is associated with an increased thrombosis risk. Pregnant individuals and patients on therapeutic anticoagulation before testing positive for COVID-19 were excluded. We collected data on demographics, vaccination status, thrombotic risk factors, venous thrombotic events, and outcomes (Table 1). The continuous variables were not normally distributed, and p-values were calculated using the Mann-Whitney test. The p-values for the categorical variables were calculated using Fisher's exact test. We then performed cox proportional hazards regression analysis to assess the thrombotic risks between control and experimental groups, while controlling for potential confounding variables. Venous thrombotic events were defined as pulmonary embolism (PE), deep vein thrombosis (DVT), cerebral vein sinus thrombosis (CVST), or hepatic vein thrombosis that occurred within 6 months of testing positive for COVID-19. Results In total, 1071 individuals met inclusion criteria. The experimental group included 546 patients, 407 on combined hormonal contraceptives (CHC) and 139 on oral or transdermal hormone replacement therapy (HRT). The control group included 525 patients, 410 with a progesterone intrauterine device and 115 using topical estrogen creams. The control and experimental groups were similar in all demographics and thrombotic risk factors, except for age (P<0.001) and body mass index (BMI) (p<0.001). There were no differences between groups in the rate of hospitalization for COVID-19, ICU stay for COVID-19, or death. There were 2 venous thrombotic events with an event rate of 1.3% in the control group and 9 events with a rate of 2.3% in the experimental group (p= 0.065). All of these events occurred within 2 months of COVID-19 positive test results. Increasing age (p<0.001) was significantly associated with a higher venous thrombosis risk. A cox proportional hazards regression analysis was utilized to evaluate the hazards ratio (HR) of venous thrombosis between groups, controlling for age and BMI. Patients in the experimental group had a HR of 5.76 (CI 1.24-26.77, p=0.026) for venous thrombotic events. In this model, the HR was 1.06 for age (CI 1.02-1.11, p=0.003) and 1.05 for BMI (CI 1.01-1.10, p=0.018). Conclusion Overall, this data suggests that estrogen-containing oral and transdermal hormonal therapies increase the risk of thrombosis in COVID-19 positive patients, although absolute risks were small. Thrombotic risk was also associated with increasing age and higher BMI. Based on these findings, providers may consider temporarily discontinuing hormonal therapies in patients with COVID-19 who are at high risk for thrombosis, especially older patients, those with a higher BMI, and those on higher doses of oral estrogen. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

A comparison of invasive lobular carcinoma with other invasive breast cancers at Tygerberg Academic Hospital.

The second most common histological subtype of invasive breast carcinoma is invasive lobular carcinoma (ILC) occuring with a frequency 10-15% in Western countries and approximately 5%, in Africa, the Middle East and Asia (AMA). Combined hormone replacement therapy (CHRT) is a risk factor for the development of ILC which is infrequently diagnosed at our centre.This study aimed to investigate the incidence and clinicopathological characteristics of ILC as compared to invasive breast carcinoma of no special type (IBC-NST). Clinical and pathological data on breast carcinoma patients attending the breast and endocrine unit at Tygerberg Academic Hospital since 2017 have been recorded on a Stellenbosch University REDCap® database. IBC-NST was the most frequent subtype diagnosed (83.9%) and ILC the second most common subtype (5.2%). Most ILCs were of luminal B intrinsic subtype, and the median size was slightly smaller than IBC-NST. There were significantly more grade 2 ILCs than IBC-NSTs (81.5% vs 50.9%). There was no statistical difference between stage and histological subtype. ILC has clinicopathological differences when compared to IBC-NST, although these were less pronounced in this study. The prevalence of ILC was similar to numbers reported in AMA. We hypothesise that there may be a discrepancy in the prevalence of ILC between public and private healthcare systems in South Africa, and that it may be due to differing trends in prescribing CHRT.

A comparison of invasive lobular carcinoma with other invasive breast cancers at Tygerberg Academic Hospital

BACKGROUND: The second most common histological subtype of invasive breast carcinoma is invasive lobular carcinoma (ILC) occuring with a frequency 10-15% in Western countries and approximately 5%, in Africa, the Middle East and Asia (AMA). Combined hormone replacement therapy (CHRT) is a risk factor for the development of ILC which is infrequently diagnosed at our centre.This study aimed to investigate the incidence and clinicopathological characteristics of ILC as compared to invasive breast carcinoma of no special type (IBC-NST METHODS: Clinical and pathological data on breast carcinoma patients attending the breast and endocrine unit at Tygerberg Academic Hospital since 2017 have been recorded on a Stellenbosch University REDCap® database RESULTS: IBC-NST was the most frequent subtype diagnosed (83.9%) and ILC the second most common subtype (5.2%). Most ILCs were of luminal B intrinsic subtype, and the median size was slightly smaller than IBC-NST. There were significantly more grade 2 ILCs than IBC-NSTs (81.5% vs 50.9%). There was no statistical difference between stage and histological subtype CONCLUSION: ILC has clinicopathological differences when compared to IBC-NST, although these were less pronounced in this study. The prevalence of ILC was similar to numbers reported in AMA. We hypothesise that there may be a discrepancy in the prevalence of ILC between public and private healthcare systems in South Africa, and that it may be due to differing trends in prescribing CHRT

Role of Estrogens in Menstrual Migraine.

Migraine is a major neurological disorder affecting one in nine adults worldwide with a significant impact on health care and socioeconomic systems. Migraine is more prevalent in women than in men, with 17% of all women meeting the diagnostic criteria for migraine. In women, the frequency of migraine attacks shows variations over the menstrual cycle and pregnancy, and the use of combined hormonal contraception (CHC) or hormone replacement therapy (HRT) can unveil or modify migraine disease. In the general population, 18–25% of female migraineurs display a menstrual association of their headache. Here we present an overview on the evidence supporting the role of reproductive hormones, in particular estrogens, in the pathophysiology of migraine. We also analyze the efficacy and safety of prescribing exogenous estrogens as a potential treatment for menstrual-related migraine. Finally, we point to controversial issues and future research areas in the field of reproductive hormones and migraine.

Современные принципы восстановления нарушенной антитромбогенной активности эндотелия сосудистой стенки в период перименопаузы

Hormonal changes during perimenopause cause impairment of the antithrombogenic activity of the vascular wall (ATAVW), which is one of the factors leading to the development of atherosclerosis. Pharmacological and non-pharmacological methods of treatment contribute to the restoration of ATAVW. Objective. To study the effect of complex treatment including intravenous laser blood irradiation (ILBI) and combined hormone replacement therapy (HRT) with low and ultra-low doses of estrogen on ATAVW in patients with secondary cardiomyopathy (SCM) during perimenopause. Patients and methods. This study included 90 perimenopausal women diagnosed with SCM who had decreased ATAVW and received different treatment to relieve menopausal symptoms. Patients were divided into three groups depending on the choice of treatment: group 1 (control) was treated with a multivitamin complex, group 2 – with low-dose combined HRT based on 1 mg estradiol + ILBI, group 3 – with ultra-low-dose combined HRT based on 0.5 mg estradiol + ILBI. The follow-up period was 3 years. ATAVW was assessed during screening, at 6, 12, and 36 months after inclusion in the study. At each visit we determined ATAVW, anti-aggregation activity with graphical registration, anticoagulant, and fibrinolytic activity. Results. In the groups with HRT + ILBI, positive dynamics were achieved in all parameters of AAVW: an increase in the antiaggregation, anticoagulant, and fibrinolytic activity of the vascular wall both before and after compression test during the whole period of follow-up. The positive statistically significant (p &lt; 0.001) dynamics of these ATAVW parameters were noted after 6 months of treatment and persisted throughout the entire follow-up and treatment period. Conclusion. The use of ILBI in combination with low-dose or ultra-low-dose HRT in perimenopausal patients with SCM and decreased ATAVW led to the improvement of ATAVW, which resulted in the increase in anticoagulant, anti-aggregation, and fibrinolytic activity. Key words: endothelium, antithrombogenic activity, vascular wall, secondary cardiomyopathy in perimenopause, intravenous laser blood irradiation, hormone replacement therapy

Endocrine Disorders and Genital Infections Impair Gynecological Health in APECED (APS-1).

ObjectiveIn autoimmune polyendocrinopathy-candidiasis-ectodermal dystrophy (APECED) defects in the autoimmune regulator gene lead to impaired immunotolerance. We explored the effects of immunodeficiency and endocrinopathies on gynecologic health in patients with APECED.DesignCross-sectional cohort study combined with longitudinal follow-up data.MethodsWe carried out a gynecologic evaluation, pelvic ultrasound, and laboratory and microbiologic assessment in 19 women with APECED. Retrospective data were collected from previous study visits and hospital records.ResultsThe study subjects’ median age was 42.6 years (range, 16.7-65.5). Sixteen patients (84%) had premature ovarian insufficiency, diagnosed at the median age of 16.5 years; 75% of them used currently either combined contraception or hormonal replacement therapy. In 76% of women, the morphology and size of the uterus were determined normal for age, menopausal status, and current hormonal therapy. Fifteen patients (79%) had primary adrenal insufficiency; three of them used dehydroepiandrosterone substitution. All androgen concentrations were under the detection limit in 11 patients (58%). Genital infections were detected in nine patients (47%); most of them were asymptomatic. Gynecologic C. albicans infection was detected in four patients (21%); one of the strains was resistant to azoles. Five patients (26%) had human papillomavirus infection, three of which were high-risk subtypes. Cervical cell atypia was detected in one patient. No correlation between genital infections and anti-cytokine autoantibodies was found.ConclusionsOvarian and adrenal insufficiencies manifested with very low androgen levels in over half of the patients. Asymptomatic genital infections, but not cervical cell atypia, were common in female patients with APECED.

Features of pulmonary thromboembolism in women

Pulmonary artery embolism (PAE) is usually a diagnosis of exclusion. Verification of a more common pathology takes time, which may become critical for treatment of pulmonary embolism and saving the patient's life. Since PAE is an acute disease, the time window for medical care largely determines the prognosis. Therefore, the differential diagnostic process should include thromboembolism already at the first visit. It is important to determine risk factors for PAE taking into account the patient's personality and gender. Obtained data may help the physician to determine quickly the expedience of visualizing studies, such as ventilation/perfusion scintigraphy, angiopulmonography, computed tomographic angiopulmonography. For women, it is important to collect specific information, such as the presence of large uterine fibroids, use of combined oral contraceptives or hormonal replacement therapy; to ask how long ago the patient had pregnancy and delivery, whether she has thrombophilia or oncological diseases.

British Menopause Society tools for clinicians: Progestogens and endometrial protection.

Progestogen administration is required to oppose naturally produced or administered estrogens to provide endometrial protection. Within HRT regimens, this should be delivered for at least the same duration as that produced during the luteal phase of the monthly cycle and in the recommended doses to protect against the risk of endometrial hyperplasia and endometrial cancer. This includes progestogens administered for 12-14days a month in sequential regimens and continuous daily intake in continuous combined HRT regimens. Shorter durations and lower doses of progestogen intake are likely to be associated with an increased risk of breakthrough bleeding, endometrial hyperplasia, and endometrial cancer.

The effect of hormone replacement therapy on the survival of UK women: a retrospective cohort study 1984-2017.

ObjectiveTo estimate the effect of estrogen‐only and combined hormone replacement therapy (HRT) on the hazards of overall and age‐specific all‐cause mortality in healthy women aged 46–65 at first prescription.DesignMatched cohort study.SettingElectronic primary care records from The Health Improvement Network (THIN) database, UK (1984−2017).Population105 199 HRT users (cases) and 224 643 non‐users (controls) matched on age and general practice.MethodsWeibull‐Double‐Cox regression models adjusted for age at first treatment, birth cohort, type 2 diabetes, hypertension and hypertension treatment, coronary heart disease, oophorectomy, hysterectomy, body mass index, smoking and deprivation status.Main outcome measuresAll‐cause mortality.ResultsA total of 21 751 women died over an average of 13.5 years follow‐up per participant, of whom 6329 were users and 15 422 non‐users. The adjusted hazard ratio (HR) of overall all‐cause mortality in combined HRT users was 0.91 (95% CI 0.88−0.94), and in estrogen‐only users was 0.99 (0.93−1.07), compared with non‐users. Age‐specific adjusted HRs for participants aged 46–50, 51–55, 56–60 and 61–65 years at first treatment were 0.98 (0.92−1.04), 0.87 (0.82−0.92), 0.88 (0.82−0.93) and 0.92 (0.85−0.98) for combined HRT users compared with non‐users, and 1.01 (0.84−1.21), 1.03 (0.89−1.18), 0.98 (0.86−1.12) and 0.93 (0.81−1.07) for estrogen‐only users, respectively.ConclusionsCombined HRT was associated with a 9% lower risk of all‐cause mortality and estrogen‐only formulation was not associated with any significant changes.Tweetable abstractEstrogen‐only HRT is not associated with all‐cause mortality and combined HRT reduces the risks.

PGRMC1 Promotes Progestin-Dependent Proliferation of Breast Cancer Cells by Binding Prohibitins Resulting in Activation of ERα Signaling.

Simple SummaryCombined menopausal hormone therapy is associated with increased breast cancer risk in postmenopausal women. In our previous studies, progesterone receptor membrane component 1 (PGRMC1) was shown to play a role in progestins’ elicitation of enhanced proliferation of breast cancer cells. Here we describe a potential mechanism by which PGRMC1 contributes to breast cancer progression via interaction with prohibitins, inhibiting their function as transcriptional repressors. This facilitates estrogen receptor alpha (ERα) transcriptional activity and enhances oncogenic signaling upon treatment with certain progestins, including norethisterone and dydrogesterone. Our data underline the contribution of PGRMC1 to especially hormone receptor positive breast cancer pathogenesis and demonstrate the need for further studies to understand its role in cancer.In previous studies, we reported that progesterone receptor membrane component 1 (PGRMC1) is implicated in progestin signaling and possibly associated with increased breast cancer risk upon combined hormone replacement therapy. To gain mechanistic insight, we searched for potential PGRMC1 interaction partners upon progestin treatment by co-immunoprecipitation and mass spectrometry. The interactions with the identified partners were further characterized with respect to PGRMC1 phosphorylation status and with emphasis on the crosstalk between PGRMC1 and estrogen receptor α (ERα). We report that PGRMC1 overexpression resulted in increased proliferation of hormone receptor positive breast cancer cell lines upon treatment with a subgroup of progestins including norethisterone and dydrogesterone that promote PGRMC1-phosphorylation on S181. The ERα modulators prohibitin-1 (PHB1) and prohibitin-2 (PHB2) interact with PGRMC1 in dependency on S181-phosphorylation upon treatment with the same progestins. Moreover, increased interaction between PGRMC1 and PHBs correlated with decreased binding of PHBs to ERα and subsequent ERα activation. Inhibition of either PGRMC1 or ERα abolished this effect. In summary, we provide strong evidence that activated PGRMC1 associates with PHBs, competitively removing them from ERα, which then can develop its transcriptional activities on target genes. This study emphasizes the role of PGRMC1 in a key breast cancer signaling pathway which may provide a new avenue to target hormone-dependent breast cancer.

Should Exogenous Estrogens Be Stopped for Surgery in Transgender Women?

Should Exogenous Estrogens Be Stopped for Surgery in Transgender Women?

A cross-sectional national questionnaire survey assessing the views of members of the British Menopause Society on the management of patients with unscheduled bleeding on hormone replacement therapy.

To explore the views of members of the British Menopause Society on the management of women with unscheduled bleeding on hormone replacement therapy. An electronic cross-sectional questionnaire survey. Investigations, treatment options and preferences for the management of women with unscheduled bleeding on hormone replacement therapy. A total of 91/178 (51%) clinicians investigate patients with unscheduled bleeding within three to six months of starting sequential hormone replacement therapy (seq-HRT) versus 83/178 (47%) for continuous combined hormone replacement therapy (con-HRT). A total of 52/178 (29%) versus 54/178 (30%) would investigate unscheduled bleeding continuing beyond six months while 18/178 (10%) versus 26/178 (15%) would investigate within three months. Assessment is requested as urgent by 88/176 (50%) clinicians, routine by 47/176 (27%) and a two-week-wait-suspected cancer referral by 41/176 (23%). A total of 97/178 (55%) clinicians would continue seq-HRT and refer versus 117/178 (66%) for con-HRT. A total of 46/178 (26%) clinicians would change the progestogen preparation in women with unscheduled bleeding on seq-HRT. For women on con-HRT, 12/178 (7%) clinicians would change to seq-HRT and 8/178 (5%) to the Mirena IUS. The Mirena IUS is the preferred progestogen for 81/178 (45%) of clinicians when prescribing hormone replacement therapy. There is a varied approach in the practise amongst British Menopause Society members to managing women with unscheduled bleeding on hormone replacement therapy. Further research is needed to determine the optimal assessment pathways for women with unscheduled bleeding on hormone replacement therapy.

Evaluation of Bleeding Characteristics among Menopausal Women at Maternity Hospitals in Baghdad City

Background: Bleeding can happen in postmenopausal women for several reasons. Women on hormone replacement therapy, for example, can experience vaginal bleeding for a few months after starting the hormones. It's also possible for a woman who thought she'd gone through menopause to start ovulating again. Bleeding is a possibility if this happens. Postmenopausal bleeding can be caused by a range of different factors. Polyps, endometrial hyperplasia, and endometrial atrophy are all common triggers, abnormal bleeding can be considered for sequential (cyclical) regimens if a woman has heavy or persistent bleeding at the end of the progesterone process or after the progesterone phase, or if bleeding occurs at an unplanned time during the cycle. For women on tibolone or ongoing combined HRT combination the production of amenorrhea can take up to six months. Bleeding should also be considered rare in these women if it occurs after six months of treatment or if it occurs after the establishment of amenorrhea, In a menopausal woman, postmenopausal bleeding (PMB) refers to any uterine bleeding (other than the expected cyclic bleeding that occurs in women taking cyclic postmenopausal hormone therapy). Around 5 percent of office gynecology visits are accounted.Aims of the study: To evaluate bleeding characteristics among menopausal women and to assess women menstrual cycle and reproductive history.Methodology: This study was conducted at maternity hospitals in Baghdad city to evaluate of sexual life problems among menopausal woman. This study was started in January \ 2021 to February \ 2021, The data regarding sexual life problems was achieved through the answering of women that attending maternity hospitals, the study consist of (200) women with menopausal age which were selected according to inclusion criteria (Women at menopausal age, Women with post-menopausal bleeding). The data are analyzed through the use of descriptive statistical analysis and inferential statistics.Results: women are suffering of moderate post-menopausal bleeding as indicated by moderate mean scores among all items related to characteristics except item of “Bleeding with mucous material” that show high and item of “Bleeding occurs during sexual intercourse” that show low.Conclusion: Most of menopausal women are suffering of moderate post-menopausal bleeding.Recommendations: Health care facilities provide physical and psychological counseling for menopausal woman and their husbands educate menopausal woman and their husbands about special needs of woman with post-menopausal bleeding in their sexual life.

Continuous combined low-dose hormone replacement therapy in perimenopause: an algorithm of choice

In the age of broad medical options, women’s health has received sufficient attention. The different periods of a woman’s life are characterised by specific physiological changes, based on the age-related characteristics of the reproductive system. The onset of menopause can have a negative impact on health in varying degrees. Clinicians have a clear understanding of the effects of estrogen deficiency and the therapeutic options for managing it with menopausal hormone therapy (MHT) and alternative methods of treatment. However, to date, methods for optimising and individualising the correction of menopausal disorders continue to improve. The individualization of MHT is aimed at increasing the efficacy of menopausal management and minimizing possible adverse events. Individualization is based on the selection of a hormone drug taking into account age, menopausal status, somatic health of the woman and her main complaints against the background of estrogen deficiency. The next stage of transformation of MHT concerned the composition of the drugs and the doses of their components. The evolution of the estrogenic component began with the use of conjugated estrogens, whose metabolism is not fully clarified, and stopped at the production of bioidentical estrogens (17p-estradiol and estradiol valerate), which in their structure are as close as possible to ovarian estradiol. The type, dose and combination of estrogens and progestogens determine the severity and specificity of the effect of the hormone. This article will present a clinical case study of the low- and ultra-low-dose combination of 17p-estradiol and dydrogesterone (E/DG).

Hormone Replacement Therapy and Risk of Severe Asthma Exacerbation in Perimenopausal and Postmenopausal Women: 17-Year National Cohort Study

The impact of hormone replacement therapy (HRT) on clinical outcomes in menopausal women is uncertain. To investigate the association between use of HRT and severe asthma exacerbation in perimenopausal and postmenopausal women with asthma. We used the Optimum Patient Care Research Database, a population-based longitudinal primary care database in the United Kingdom, to construct a 17-year (January 1, 2000, to December 31, 2016) cohort of perimenopausal and postmenopausal (46-70 years, N= 31,656) women. We defined use of HRT, its subtypes, and duration of HRT use. Severe asthma exacerbation was defined as an asthma-related hospitalization, emergency department visits due to asthma, and/or prescription of oral corticosteroids. Analyses were undertaken using multilevel mixed-effects Poisson regression. At baseline, 22% of women were using any HRT, 11% combined HRT, and 11% estrogen-only HRT. Previous, but not current, use of any (incidence rate ratio [IRR]: 1.24, 95% confidence interval [CI]: 1.22-1.26), combined (IRR: 1.28, 95% CI: 1.25-1.31), and estrogen-only HRT (IRR: 1.18, 95% CI: 1.14-1.21), and longer duration (1-2 years: IRR: 1.16, 95% CI: 1.13-1.19; 3-4 years: IRR: 1.43, 95% CI: 1.38-1.48; 5+ years: IRR: 1.32, 95% CI: 1.28-1.36) of HRT use were associated with increased risk of severe asthma exacerbation compared with nonuse. The risk estimates were greater among lean women (body mass index [BMI] <25 kg/m2) than among heavier women (BMI 25-29.9 kg/m2 and ≥30 kg/m2) and higher among smokers than nonsmokers. Use of HRT and subtypes, particularly previous, but not current, use and use for more than 2 years, is associated with an increased risk of severe asthma exacerbation in perimenopausal/postmenopausal women with established asthma. Lean women and smokers are at greater risk than heavier women and nonsmokers, respectively.