Minimal dose combined hormonal replacement therapy for menopausal women

Hormone therapy following breast and uterine cancer

Cancers of the breast and endometrium, although hormonally-dependent, are not complete contraindications to hormonal replacement therapy. About 70% of women with endometrial cancer will be completely cured of their disease using appropriate surgical techniques and therefore can be given oestrogen without in any way compromising their long-term survival. In fact oestrogen will probably allow such women to survive longer with a higher quality of life. Most postmenopausal women with cancer of the breast should be offered an impeded oestrogen such as tamoxifen as their first line of hormonal treatment. There may be improvement in the vagina and bone calcium content following the use of this 'anti-oestrogen' but some women will continue to suffer from vasovagal symptoms. Women with breast cancer which is small, node-free and relatively non-aggressive may also do well on HRT. Because of the influence of progestogens in reducing oestrogen receptor production, in reducing the expression of various growth factors and in inducing apoptosis, it is wise to administer high-dose progestogens to these women as well as oestrogen. There is no clinical evidence that HRT administered to such women will induce any increase in tumour growth or recurrence. Women with a disease-free survival of 10 or more years can also be regarded as 'cured' and can also be offered oestrogen in conjunction with high-dose progestogens. Finally, those women with known secondary spread but who are severely disadvantaged by their oestrogen deficiency symptoms should be offered high-dose progestogens first and if their symptoms persist, then have oestrogen added to the regimen till the symptoms subside.

The effect of low-dose piperazine oestrone sulphate and low-dose levonorgestrel on blood lipid levels in post-menopausal women

Prolonged used of oestrogens has been shown to reduce the risk of arteriosclerotic heart disease by increasing the levels of circulating high density lipoprotein cholesterol. It has also been shown that progestogens derived from the 19-nortestosterone molecule will reverse this beneficial effect when given in 250-500 mg doses. When levonorgestrel was used in doses as low as 30 micrograms daily, there was no change in cholesterol levels over a period of 6 mth, suggesting that the adverse effect of the androgenic type progestogens is dose-related and is probably only significant when extremely high dosages are administered.

Differential clinical response to oestrogens after menopause

An analysis of vasomotor, psychological, and physical symptoms of 136 women who were receiving piperazine oestrone sulphate (Ogen) and conjugated equine oestrogens (Premarin) after menopause has shown differences in responses which can be explained only if it is accepted that the two oestrogenic compounds have differing effects on various parts of the body. Premarin (0.625 mg) was found to be more potent at inducing withdrawal bleeding than Ogen (1.25 mg), whereas Ogen was more effective than Premarin in alleviating hot flushes and some psychological symptoms. A hypothesis involving metabolism of oestrone to the catecholamine, 2-hydroxyoestrone, is postulated, which explains why these differences occur. It is further suggested that better selection of oestrogens to suit particular postmenopausal symptoms should be encouraged when prescribing oestrogen for women after menopause.