Hormone replacement therapy (HRT) is administered to perimenopausal and postmenopausal women. There are several reasons why HRT will become increasingly important in the future:

• an aging population.  In 1990, there were 467 million postmenopausal women worldwide.   According to the World Health Organization, this figure is expected to increase sharply to reach a total of 1.2 billion by 2030.  In the industrialized world, women can now expect to spend about one-third of their lives in a postmenopausal state.

• a changing lifestyle, whereby women want to maintain their active lifestyle well into their postmenopausal years.

• a greater acceptance of HRT, as more better products become available

The leading drug is an estrogen replacement only drug (ERT).  ERT shows benefits not only in terms of relieving menopausal symptoms (hot flashes, mood swings, vaginal dryness), but also in the prevention of serious geriatric disorders such as:

• development of osteoporosis 

• cardiovascular disease, which is the leading cause for mortality in postmenopausal women

• mental degradation (Alzheimer disease)

Transdermal/transcutaneous or subdermal estrogen + intrauterine levonorgestrel 

HRT regimen, however, are not free from adverse effects, particularly orally administered combined (estrogen + progestogen) postmenopausal hormone replacement therapy.  With these preparations, there is a slightly increased risk of cardiovascular disease and breast cancer. Evidence suggests that one of the safest and best tolerated combination in postmenopausal women is to deliver progestogens directly to the uterine mucosa, instead of orally, combined with transdermal/transcutaneous or subdermal estrogen as this regimen could avoid reversal of the beneficial effect of systemic estrogen replacement therapy.

Progestogens are needed to suppress the endometrium and eliminate the risk of endometrial cancer. Local intrauterine therapy is the most effective and safest route of administration and prevents menstrual bleeding due to the local effect of the hormone.

Much debate is going on at present related to the benefits of HRT. Estrogen replacement therapy (ERT) is likely to be beneficial in preventing cardiovascular disease if initiated early in the postmenopause and if oral progestogens are avoided.  The transdermal and subdermal route of administering estrogens is probably safer than when estrogens are administered orally as the first pass liver effects are avoided. Estrogens prevent osteoporosis.  The evidence is also growing that estrogens are neuroprotective.
Go to www.menopausesociety.be for abstracts of recent publications on the menopause.

 

Further reading
Journal	Title	Availability
Annals New York Academy of Sciences (Accepted)	Miniature Intrauterine Drug Delivery Systems	abstract
		full text article
Contraception 2002;66:93-99	Contraception and treatment in the perimenopause with a novel “frameless” intrauterine levonorgestrel-releasing drug delivery system	abstract
		full text article
Maturitas 2003;44:237-245	Performance and acceptability of intrauterine release of levonorgestrel with a miniature delivery system for hormonal substitution therapy, contraception and treatment in peri- and postmenopausal women	abstract
		full text article