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AFTER MID

TOTAL LEC: 35

Gynaecology

  

 Dr. Ikhlas

Lec 35 - Hormones in Gynaecology

DR. IKHLAS - LEC 6

مكتب املدينة


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Hormones In Gynecology

Note: this Lecture has been edited by the students, the original lecture is
found on the website (www.muhadharaty.com)

Hormonal replacement therapy

Estrogen

:

There is general agreement that hormonal replacement therapy for post
menopausal  patients  should  be  started  with  the  minimum  effective
dose of estradiol
and increased only if it is needed.

Exogenous estrogen is problematic since it is associated with increased
risk  of  breast  cancer  development,  heart  disease  and  venous
thromboembolism
.  It  has  been  also  implicated  in  increasing  the  risk  of
ovarian tumors because of the improper ovulation induction programs.
It can be given systemically or locally.

The  minimum  effective  doses  of  currently  available  systemic  estrogen
are: (* the doses are not for memorization)

o  0.3 - 0.625 mg oral conjugated equine estrogen (Premarine)
o  1 mg oral micronized estradiol
o  25-50 mcg transdermal estradiol
o  25-50 mg implant
o  150 mcg nasal estradiol
o  50 mcg estradiol ring 

NOTE:  an  exception  to  this  low  dose  rule,  are  women  with  premature
ovarian failure
who need HIGH dose of estrogen. Such high doses can
also be used to induce puberty in certain diseases when it is required.


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Routes of administration:

- Oral route: which is partially metabolized by the liver and do not fully
restore the natural ratio of estradiol to estrone which is 2:1.

- Transdermal patch: used twice or once weekly.

- It can also be administered transnasally in a pulsed manner. The nasal,
gel,  and  ring  preparations  should  be  combined  with  progestogen  in
females with preserved uterus.

-  Local  (vaginal):  recent  vaginal  creams  contain  preparations  of  estriol
(0.01%  estriol  cream  and  pessaries)  and  do  not  produce  endometrial
hyperplasia.

- Premarine cream: can potentially cause endometrial hyperplasia and
should  not  be  used  for  more  than  3  months  without  progestogenic
opposition.  Premarine  cream  increases  the  vascularity  of  the  vagina,
hence it is used in the treatment of atrophic vaginitis. At the beginning,
tingling  sensation  and  itching  should  be  expected  due  to  the  resultant
vasodilatation. It must be taken for 5 days continuously and stopped for
the next 2 days
for a period of 3 months.

Progestogen

Their aim is to protect the endometrium. It is generally accepted that a
female  commencing  HRT  to  start  with  a  sequential  regimen  involving
taking estrogen continuously for the whole month while progesterone is
used for only 12 to 14 days).

Types: 

•  C19  -  testosterone  derived  progestogen  (Norethisterone,

Norgestrel , Levonorgestrel,)

•  C21  -  progestrone  derived  progestogen  (Dydrogesrone,  Medroxy

progesterone acetate, Cyclogest, Crinone gel)


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NOTE:  Norethisterone  can  regulate  the  menstrual  cycle  but  it  causes
hirsuitism, so it should not be given to patients with PCOS.

So  a  woman  of  reproductive  age  group  complaining  of  irregular

cycle  can  be  treated  with  Progesterone  given  either  for  the  last  two
weeks of the menstrual cycle meaning in the Luteal phase or from day 5
till day 21
of the menstrual cycle (which has a better effect). If bleeding
continues and the regimen was not beneficial we can increase the dose.

Persistent bleeding for more than 6 months warrants Investigations by
ultrasound and endometrial biopsy. 

 

Side effects:

includes  fluid  retention  and  androgenic  side  effects  such  as  acne,
hirsuitism and mood swings .

To minimize these side effects we can decrease the dose or duration of
the  treatment.
 We  can  use  intra  uterine  system  or  Drospirenone
(Spironolactone analogue that is found in YASMIN preparations ).

Tibolone (Livial):

( )ﻣﮭم

Works  by  mimicking  the  action  of  Sex  hormones  (has  estrogenic,
progestogenic and Androgenic activity)  

It  helps  in  treatment  of  hot  flushes  and  night  sweats  and  prevents
osteoporosis. The dose is taken as 2.5 mg /day countinously. 


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Contraindication of HRT: 

o  Personal or family history of breast cancer.
o  Hormone dependant tumors.
o  Unexplained vaginal bleeding.
o  Liver disease or renal disease.
o  High level of TG or Cholesterol
o   Thrombophilia
o  Angina or MI
o  Migraine
o  Gallstonee
o  Porphyria
o  Patient with history of endometrial cancer 

 




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