Hormone replacement therapy adverse effects

List the adverse effects of and contraindications to hormone-replacement therapy. 

Educate a patient regarding the proper use and potential adverse effects of hormone-replacement therapy. 

Hormone-replacement therapy remains the most effective treatment for vasomotor symptoms and vulvovaginal atrophy and should be considered for women experiencing these symptoms. The goals of treatment are to alleviate or reduce menopausal symptoms and to improve the patient s quality of life while minimizing adverse effects of therapy. The appropriate route of administration should be chosen based on individual patient symptoms and should be continued at the lowest dose for the shortest duration consistent with treatment goals for each patient. 

In patients with longstanding hypothyroidism and those with ischemic heart disease, rapid correction of hypothyroidism may precipitate angina, cardiac arrhythmias, or other adverse effects. For these patients, replacement therapy should be started at low initial doses, followed by slow titration to full replacement as tolerated over several months. If hypothyroidism and some degree of adrenal insufficiency coexist, an appropriate adjustment of the corticosteroid replacement must be initiated prior to thyroid hormone replacement therapy. This prevents acute adrenocortical insufficiency that could otherwise arise from a thyroid hormone-induced increase in the metabolic clearance rate of adrenocortical hormones. 

L All of the following are common adverse effects associated with drug overdose of thyroid hormone replacement therapy EXCEPT... 

Oral contraception and hormone replacement therapy are dealt with specifically in separate monographs. Here the general adverse effects of estrogens for any indication are reviewed. 

Well-designed studies of local, topical, and intradermal forms of estrogen as a means of attaining a general systemic effect have tended to show that when doses are therapeutically equivalent to those used orally the adverse effects are similar (219). However, this is a complex issue, which is discussed more extensively in connection with hormone replacement therapy. 

The evidence of adverse effects emerging from randomized trials in and around 2002 has resulted in a dramatic fall in the use of hormone replacement therapy, the use of some formulations falling by two-thirds (21). Continuing debate on the benefit to harm balance of hormonal therapy at the time of the menopause or subsequently has in the recent past hardly yielded new conclusions (22). 

Tibolone is an agonist at estrogen and progestogen receptors, with weak androgenic activity. It is given as an alternative to hormone replacement therapy, without added progestogen, and has been in use for some 30 years to treat bone loss in post-menopausal women. Some long-term studies (for example over 10 years) appear to have confirmed its safety and relative freedom from adverse effects (1). In particular there is little or no increase in thrombotic events and the incidence of breast tenderness is low. 

Hormone replacement therapy should be distinguished from the short-term therapeutic use of estrogen (or hormonal combinations) around the time of the climacteric for the relief of acute (primarily vasomotor) symptoms such treatment can generally be limited to some 6-12 months although if it is then withdrawn the symptoms may recur (4). Confusion between these two forms of treatment has led to a series of misunderstandings regarding the adverse effects of true hormone replacement therapy. 

Another variant on hormone replacement therapy involves using aU three types of sex steroid in parallel, starting from the argument that during the fertile period all three are sjmthesized by the ovary (7). A natural version of this therapy uses estradiol, testosterone (with or without dehydroepiandrosterone), and progesterone in an appropriate pharmaceutical form (for example micro-nized), so that absorption is attained without the need for 17-substitution. This approach naturally avoids some of the undesirable effects of the synthetic steroids, and has been stated to improve menopausal depression and anxiety. However, the adverse effects of all three types of component can be experienced. 

In contrast to other protein-bound drugs for which a loading dose is given to achieve rapid steady-state concentrations, a slow and stepwise increase in thyroid hormone replacement therapy is advisable. This is preferred mainly to avoid sudden cardiac adverse effects, especially in older patients with long-standing myxedema. Moreover, since thyroid hormone substitution can change the metabolic clearance of this drug, steady-state concentrations are obtained only after several months (SEDA-6, 363). 

The progestin-like drugs, their use in contraception and in hormonal replacement therapy, and their j adverse effects are considered. 

Radioactive iodine ablation therapy for hyperthyroidism is relatively inexpensive, does not require hospitalization, and is relatively free of adverse effects. It is associated with a high incidence of permanent hypothyroidism, and all patients must be warned of this and followed therecffer for the onset of hypothyroidism. Because thyroid hormone replacement therapy is generally well accepted by the patient, many specialists prefer to treat with relatively higher doses to rapidly... 

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