Hormone replacement therapy

Hormone replacement therapy ( HET ; English hormone replacement therapy , HRT ) refers to the medical use of hormones to treat symptoms that can be attributed to a relative or absolute deficiency of one or more hormones. In a narrower sense, hormone replacement therapy refers to the administration of medication during menopause ( menopause in women and menopause virile in men) and as an accompanying gender reassignment measure for transsexuality . The term itself is controversial because it is a subtype of hormone therapy ( HT or e.g. menopausal hormone therapy ( MHT ) or postmenopausal hormone therapy ( PHT , PMHT )) and does not completely replace endogenous hormone metabolism.

Postmenopausal hormone replacement therapy

Treatment principles

Postmenopausal hormone replacement therapy aims to alleviate the symptoms by changing endogenous hormone production in women. Since this is an elective measure, particularly high demands must be placed on medical information on advantages and disadvantages, risks in long-term treatment and the essential facts. The only indication for peri- and postmenopausal hormone replacement therapy is the treatment of peri- and postmenopausal symptoms such as hot flashes and atrophy of the vaginal mucosa and vulva (see climacteric ). The prevention of diseases (e.g. osteoporosis ) is not an indication for hormone therapy.

In principle, either monotherapy with estrogens (estrogen therapy (ET)) or sequential therapy with estrogen and gestagen (estrogen progestin therapy (EPT)) can be carried out; the selection depends on various factors. The dosage of the hormones is based on the lowest dose with which the menopausal symptoms can be adequately treated. The dosage form available are tablets as well as plasters, creams and gels for transdermal application and estrogen-containing creams or ovules , pessaries and vaginal rings for the local treatment exclusively of urogenital complaints such as z. B. colpitis available. The selection of the application form should correspond to the patient's request for advice from the doctor. In the case of disorders of lipid metabolism with hypertriglyceridemia, Picker et al. Oral treatment, in familial coagulation disorders, patients with migraine or epilepsy , Douketis advised transdermal application.

Before starting treatment

Before starting hormone replacement therapy, a comprehensive medical history should be carried out, including the family history. A pelvic exam with a Pap test and a chest exam are also needed. Blood pressure and body weight before starting treatment should be documented.

Contraindications

The following are contraindications (contraindications) for hormone replacement therapy:

• deep vein thrombosis or post- pulmonary embolism
• known blood clotting disorders
• severe liver disease
• a breast cancer
• diagnostically unexplained bloody discharge from the vagina
• severe, poorly treatable heart failure
• therapy-resistant hypertension
• systemic lupus erythematosus
• Endometrial cancer (relative contraindication, individual decision)

Control during treatment

After the start of hormone replacement therapy, the effectiveness of the treatment should be checked regularly, including medical check-ups. Above all, it should be assessed whether the menopausal symptoms to be treated are declining and whether there is satisfaction with the treatment and its results. In the further course, regular, annual check-ups should take place with recording of blood pressure, body weight and gynecological check-ups including an examination of the breast. Performing a PAP smear and a mammography is recommended every two years, paying attention to existing screening and preventive programs.

End of treatment

There is currently no generally binding recommendation on the duration of hormone replacement therapy; initiation, implementation and termination must be decided individually in a dialogue between the woman concerned and the treating doctor. However, the indication to continue the therapy should be reviewed annually. The treatment must be stopped in any case if one of the above-mentioned contraindications occurs.

Weighing the pros and cons

Since there is currently no general recommendation for performing hormone replacement therapy, the advantages and disadvantages must be weighed up prior to therapy. Individual factors play an important role here:

advantages

• The positive effect on menopausal symptoms has been proven 
• Hormone replacement therapy prevents atrophy and inflammation of the urogenital area
• A reduction in climacteric depression is brought about
• Treatment with estrogens reduces postmenopausal osteoporosis and the associated fractures
• Decreased risk of developing colon cancer (only with combined estrogen-progestin therapy)

disadvantage

• Increased risk of developing breast cancer (mammary carcinoma) (depending on various factors)
• Increased risk of deep vein thrombosis and pulmonary embolism
• Increased risk of gallbladder inflammation
• Cognitive disorders are not positively influenced, the probability of developing dementia seems to be slightly increased
• Increased progression of existing colorectal cancer

Pharmacoepidemiology of hormone replacement therapy

Comprehensive data on the pharmacoepidemiology of the use of hormone replacement therapy preparations are available for the Federal Republic of Germany from several population-representative studies that were carried out from 1984 to 1999 . The data from these long-term planned federal health surveys also enable the use of HRT preparations to be shown in connection with the clinical-chemical parameters of the users.

History of hormone replacement therapy

Hormone replacement therapy for women going through menopause began in the late 1960s in the form of estrogen monotherapy. However, this led to an increased incidence of corpus carcinoma . Sequential hormone replacement therapy with estrogen and gestagen began at the end of the 1970s, and this resulted in a decrease in the incidence of corpus cancer.

In the last decade of the 20th century and at the beginning of the 21st century, hormone replacement therapy was carried out to an increasing extent and thus also the object of large-scale scientific studies. The discontinuation of part of the so-called WHI study (women's health initiative) in 2002 caused a stir.

criticism

Due to the results of several international studies, hormone replacement therapy has become a controversial topic. Critics have long suspected that taking hormone preparations would increase the risk of developing certain types of cancer in the long term. The so-called One Million Women Study , a long-term observational study in which one million exclusively British women took part , caused a sensation in Germany in the summer of 2003 . The group of participants who took hormone preparations had a significantly higher number of breast cancers than the group of those who did not receive hormone replacement therapy. The exact details provide information about whether pure estrogen therapy, sequential estrogen-progestogen therapy was carried out and whether the participants had their uterus removed at the time of therapy or not.

Since the publication of these results, there has been a controversial and sometimes very emotional discussion about the advantages and disadvantages of hormone replacement therapy. Long-term assessments of the benefits of hormone replacement therapy, including the assumption that estrogens can lower the risk of dementia because it improves blood circulation in the brain, have been refuted by clinical studies since June 2004. A new evaluation in the American medical journal showed that the risk of dementia is, on the contrary, slightly increased.

Animal protection groups criticize the production conditions for the preparation Premarin (in Germany: Presomen). The urine of pregnant mares, which is obtained in specialized farms and contains a mixture of conjugated equine estrogens, is required for production.

In the USA in particular, hormone replacement therapy was also marketed from a lifestyle perspective. Often women were suggested in media reports that their skin would stay firmer by taking the hormones. In fact, there is no scientific study that could prove this effect. More recent studies from Austria, in which cosmetic products were not examined, however, seem to confirm that female sex hormones in the collagen fiber layer of the skin have a positive effect in terms of smoothing out wrinkles. This was advertised decades ago by the cosmetics industry by offering ointments containing creamed hormones (placenta tubing).

See also

• Androgenic , virilizing sex hormones
• Estrogens , the most important female sex hormones
• Gender reassignment measure for intersexual and transsexuality
• Progestogens , next to estrogens, the second important class of female sex hormones

literature

• Bernhilde Deitermann: Hormone therapy during and after the menopause: Rethink prescription practice! in: Gerd Glaeske, Katrin Jahnsen: GEK-Arzneimittelreport 2003, Ansgard-Verlag, St. Augustin
• Petra Kolip (Ed.): Femininity is not a disease. The medicalization of physical upheavals in women's lives. Weinheim and Munich 2000
• US Preventive Services Task Force (May 2005) Hormone Therapy for the Prevention of Chronic Conditions in Postmenopausal Women: Recommendation Statement. (AHRQ Publication No. 05-0576), Agency for Healthcare Research and Quality, Rockville, MD
• Evidence Report / Technology Assessment: Management of Menopause-Related Symptoms ( Memento of May 28, 2010 in the Internet Archive ) - US Department of Health and Human Services, (AHRQ Publication No. 05-E016-2) March 2005 (PDF file)
• Jürgen Klauber, Bernd Mühlbauer, Norbert Schmacke, Annette Zawinell, Ed .: Scientific Institute of the AOK , Bonn 2005: Menopause in hormone therapy - information sources and medical attitudes in practice , ISBN 3-922093-37-X

Web links

• Hormone therapy in the peri- and postmenopause , interdisciplinary S3 guideline, AWMF 015/062, publisher: DGGG, 2009.
• Women's Health Initiative Memory Study (March 4, 2010 memento on the Internet Archive ). (WHIMS) (English) PDF ( Memento from June 10, 2010 in the Internet Archive )

Individual evidence

1. ↑ Hulley S et al. Randomized trial of estrogen plus progestin for secondary prevention of coronary heart disease in postmenopausal women . Heart and Estrogen / progestin Replacement Study (HERS) Research Group. JAMA. 1998 Aug 19; 280 (7): 605-13. PMID 9718051 . Full text at PubMed Central
2. ↑ Rossouw JE et al. Risks and benefits of estrogen plus progestin in healthy postmenopausal women: principal results From the Women's Health Initiative randomized controlled trial . JAMA. 2002 Jul 17; 288 (3): 321-33. PMID 12117397 . Full text at JAMA
3. ↑ Pickar JH et al. Effects of hormone replacement therapy on the endometrium and lipid parameters: a review of randomized clinical trials, 1985 to 1995 . At J Obstet Gynecol. 1998 May; 178 (5): 1087-99. PMID 9609589 .
4. ↑ Douketis JD et al. A reevaluation of the risk for venous thromboembolism with the use of oral contraceptives and hormone replacement therapy . Arch Intern Med . 1997 Jul 28; 157 (14): 1522-30. PMID 9236553 .
5. ↑ "Consensus recommendations for hormone therapy (HT) in climacteric and postmenopausal"  (PDF). German Society for Gynecology and Obstetrics V. (as of September 2006)
6. ↑ "Recommendations for use of hormone replacement therapy in climacteric and postmenopausal"  (PDF). German Society for Gynecology and Obstetrics V. (as of September 2006)
7. ^ "Evaluation of the DGGG for the implementation of hormone replacement therapy, as of April 2008"
8. ↑ "Consensus decision of the DGGG"
9. ↑ Doubt JE, O'Brien WH. A meta-analysis of the effect of hormone replacement therapy upon depressed mood . In: Psychoneuroendocrinology . 1997; 22: 189-212. Erratum in: Psychoneuroendocrinology 1997 Nov; 22 (8): 655. PMID 9203229 .
10. ↑ ^{a b} Chlebowski RT et al. Estrogen plus progestin and colorectal cancer in postmenopausal women . N Engl J Med. 2004 Mar 4; 350 (10): 991-1004. PMID 14999111 . Full text at the NEJM
11. ↑ Grodstein F et al. Postmenopausal hormone use and cholecystectomy in a large prospective study . Obstet Gynecol. 1994 Jan; 83 (1): 5-11. PMID 8272307 .
12. ↑ Y. Du: Use of steroid hormones for contraception and for estrogen replacement therapy in Germany. Dissertation, Free University of Berlin 2005
13. ^ Y. Du, HU Melchert, M. Schäfer-Korting: Hormone replacement therapy in Germany: determinants and possible health-related outcomes. Results of National Health Surveys from 1984 to 1999. In: Maturitas . Volume 52, Number 3-4, 2005 Nov-Dec, pp 223-234, ISSN  0378-5122 . doi: 10.1016 / j.maturitas.2005.01.014 . PMID 16040212 .
14. ^ Findings from the WHI Postmenopausal Hormone Therapy Trials. Women's Health Initiative
15. ^ V. Beral, u. a .: Ovarian cancer and hormone replacement therapy in the Million Women Study. In: Lancet. Volume 369, Number 9574, May 2007, pp. 1703-1710, ISSN  1474-547X . doi: 10.1016 / S0140-6736 (07) 60534-0 . PMID 17512855 .
16. ↑ Breast cancer risk drops again after discontinuing hormone replacement therapy deutsche-apotheker-zeitung.de, on February 12, 2009

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