Indication for HRT: Climacteric Complaints and Osteoporosis

Abstract

Professor Schneider discussed the current status of the diagnosis of postmenopausal symptoms and the indication for HRT. The diagnostics for postmenopausal women include the subjective assessment of vasomotor changes (hot flushes), psychology (mood changes), and alterations of the target tissues (urinary symptoms, vaginal discharge). It is known that oestrogen modulates serotonin synthesis and the CNS thermoregulatory set-point. One diagnostic measure is the evaluation of core temperature and the evaluation of the tendency towards thermal response due to vasodilation. There may be some destabilization due to loss of serotonin receptors.

The principal indication for HRT is for vasomotor relief in menopause. The time of treatment until an effect is seen is usually 2–4 weeks, but there is a wide range of responses, and placebo effects are known. Other therapies are not as effective as HRT. Even 18 years after menopause, 16% of women exhibit considerable vasomotor and other complaints, so that the duration of HRT use needs to be individually gauged. HRT has been shown to reduce sleep disorders, such as insomnia induced by decreased REM sleep and sleep apnea. There is no specific relation of natural menopause to mood disorders, although a subgroup of women may be subject to mood symptoms.

A further issue is the differentiation between oestrogen deficiency and female androgen insufficiency. Dyspareunia is influenced both by androgen and oestrogen deficiency. Local application of low-dose oestradiol may help here. For vulval atrophy, local androgens are appropriate, atrophic vaginitis and urinary symptoms are treated with oestrogens. Transdermal testosterone treatment increases sexual activity. In treating dryness and atrophy, HRT up-regulates the skin collagen content, therefore re-establishing skin thickness and vascularity.

Weight changes are an issue, because usually 10%–15% of body weight is gained during menopause, and it is one of the reasons that women will not accept HRT.

Bone mass depends on exercise load and calcium intake. Osteoblasts respond both to androgen and oestrogen. Exercise, with its potential to increase androgen activity, leads to an increase of bone mass. Bone mass determinations depend very much on the bone site on which this measurement is done. Bone density is associated with oestrogen levels. Substitute oestrogen also has effects on bone density, but there are about 15% women who do not respond regardless of dose. Calcium was found to be ineffective in the early postmenopause period, but shows some effect in later menopause. The combination of oestrogen and parathyroid hormone (PTH) combines antiresorptive and bone-forming drugs. PTH thickens trabeculae and bridges the gaps in bone, i.e. it is bone-forming. The alternative treatments include bisphosphonates. Different treatment effects for tabecular and cancellous bone (i.e. hip) have been shown for the various drugs used against osteoporosis.