HRT, Raloxifene & Tamoxifen

(useful link here: GPtraining.net HRT)

Continuous Combined Oestrogen Therapy

  • Eg:
    • Elleste Duet Conti (estradiol 2mg + NET 1mg)
    • Kliofem (estradiolo 2mg + NET 1mg)
    • Tibolone (Livial) 2.5mg
  • If they’ve had a hysterectomy they don’t need progestogen –> they can have systemically absorbed oestrogen
  • Progesterone prevents endometrial hyperplasia and uterine Ca so if they haven’t got a uterus, it’s not necessary

These are roughly the same unopposed oestrogen replacement regimes:

  • 0.625mg conjugated equine oestrogens
  • 2mg estradiol
  • 2mg 17B estradiol
  • 50mcg estradiol transdermal patch
  • 50mg estradiol implant

–> But if it’s continuous HRT – you only actually need 1mg estradiol to provide osteoporosis protection

Monthly HRT Preparation (Sequential HRT)

This is for perimenopausal women who have regular periods

  • Over 28 days continuous oestrogen is given with 10-12 days of progesterone
  • minimum doses for those 12 days are:
    • 10mg medroxyprogesterone acetate
    • 0.7mg noresthisterone
    • 10mg dydrogesterone
    • 75mcg levonorgestrel
    • 150mcg norgestrel
    • 45mg prgesterone vaginal gel (alternate days)
    • 1 mg cyproterone acetate
  • Bleeding may be absent altogether but shouldnt be irregular – if it’s irregular they should be investigated, usually bleeding should occur at the same time each month.

 

Long Cycle HRT (sequential HRT)

This is for women with uteruses who are having irregular periods, it results in a bleed every 3 months – progesterone is taken 12 – 14 days every 13 weeks

  • The only licesed preparation is Tridestra – 20mg medroxyprogesterone acetate for 14 days in each 3 month cycle. – so four  bleeds per year.
  • The bleeding can be irregular to start with but this usually settles

Continuous Combined HRT (CCHRT)

If they’re post menopausal they can be given continuous oestrogen with continuous progesterone to induce endometrial atrophy

The advantage is that (particularly in older ladies) you don’t get bleding (eventually – there may be a bit of bleeding to start with)

  • if switching from sequential to CCHRT then it sholud be done at the end of a withdrawal bleed

 

Side Effects of HRT

  • women gain weight at the menopause – HRT doesn’t make that weight gain worse
  • Oestrogenic side effects (usually subside after 3 months) include:
    • Fluid retention
    • Nausea
    • Headaches
    • Breast Tenderness
    • Leg Cramps
  • Progestogenic Side Effects (normally subside after 3 months)
    • PMS
    • Bloating
    • Depression

 

Raloxifene

  • Selective oestrogen receptor modulator (SERM)
  • Has oesrogenic effects on
  • -bone (it increases mineralization)
  • Has anti oestrogenic effect on
  • -breast (reducing hyperplasia)
  • -endometrium (reducing hyperplasia)
  • Reduces LDL (bad cholesterol)
  • Does not increase HDL (good cholesterol)

Raloxifene May be an alternative for women to prevent the long term problems of oestrogen deficiency (osteoporosis and heart disease) in women who’ve had greasy cancer not having hot flushes.

It doesn’t help with hot flushes

Tamoxifen – (also a SERM) acts as a partial agonist at the endometrium (raloxifene acts as an antagonist there) so May promote endometrial hyperplasia