Hormone Replacement Therapy

HRT involves administration of estrogen and progesterone hormones to counteract their dipping levels during menopause. Earlier ERT (Estrogen Replacement Therapy) was followed but this is now replaced by combined hormone therapy. HRT provides relief from symptoms such as increased fatigue and irritability and depression. Hormone Replacement Therapy is usually followed for a few months or a couple of years.

HRT is known to prevent or alleviate any bone loss that leads to osteoporosis. Women who have been on HRT experience enhanced sexuality and improved pelvic floor muscles. It may prove beneficial in preventing Alzheimer's disease and macular degeneration. Cyclic hormone therapy involves taking estrogen pills for 25 days, switching to progestin in between 10 - 14 days and then taking a combined pill for the next 25 days. Stopping the HRT for about 4 days brings on the menstrual bleeding.

The other form of administering HRT is continuos or combined therapy - whereby estrogen and progestin are taken everyday in combined form. Women on HRT complain of a bloated feeling as well as terrible headaches and fluid retention.

HRT Side Effects Some women experience post-menopausal bleeding when on HRT. Tender and swollen breast are yet another side effect of HRT. Swelling of the legs and increased weight are also noticed by women on HRT. Other associated risks of HRT are increased incidence of venous thrombosis or worsening of any existing liver condition. Long-term use of HRT is associated with breast cancer.

HRT patch

An HRT patch is an alternative to hormone tablets and vaginal creams. When ingested in tablet form, the hormone moves from the stomach and intestines to your liver. This necessitates higher dose of estrogen to be administered. HRT patches allow the skin to absorb estrogen through the bloodstream. HRT patches are worn on any location below your waist.

But it must never be applied on or near the breasts. Women suffering from sore or irritated skin must not use HRT patches. Vaginal creams containing estrogen are yet another method of administering HRT. This reduces the feeling of dryness experienced by most peri-menopausal women.

GnRH

Gonadotropin-releasing hormone (GnRH) is a neurohormone consisting of ten amino acids which is produced by the arcuate nuclei of the hypothalamus. It is integral for starting the reproductive hormone cascade.

GnRH is secreted in the hypothalamus which is part of the brain. The hypothalamus is part of the 'Hypothalamus - Pituitary - Gonad' axis which regulates the reproductive system in men and women. Secretion of GnRH by the hypothalamus is delivered through a direct pathway between the hypothalamus and pituitary. GnRH stimulates the synthesis and secretion of two gonadotrophins namely, lutenizing hormone (LH) and follicle stimulating hormone (FSH) by the anterior pituitary gland. Controlled by internal and external factors, GnRH acts in a negative feedback loop. For instance, if there is excess FSH, LH or testosterone, then these hormones will inhibit GnRH production.

Lifestyles can also affect GnRH secretion. Lack of exercise, poor diet, opiad drugs and excessive stress can negatively affect GnRH production. What is so striking in GnRH is that under normal circumstances, GnRH is released at intervals of 90 to 120 minutes. Hence, in patients with GnRH deficiency, the releasing hormone should be administered in pulses. Constant administration of GnRH also suppresses gonadotropin secretion especially in children in puberty stage and in men with prostate cancer.

Why is GnRH treatment used?

This hormone is produced by the hypothalamus and it stimulates the pituitary gland to produce LH and FSH. Lack of GnRH in the hypothalamus can halt testosterone production in the testicles of men. In women, abnormal GnRH levels can be responsible for ovulatory disorders.

This is commonly used when Clomid treatment has not stimulated egg follicles to develop on the ovaries. GnRH works effectively to replace the natural GnRH in women and men who do not produce enough of it. Failure of release of GnRH can result in deficiency that can be partial or complete.

In a woman who is not ovulating because of lack of stimulation from hypothalamus.

In a man who is not producing sperm because his hypothalamus is not stimulating the hormones that trigger sperm production.

The use of GnRH can result in multiple pregnancies.

Some studies report that the pregnancy rate after treatment with GnRH is about 20%.

Side effects

Some side effects include:

• Breathing trouble
  
• Swelling of face, lips, tongue and throat
  
• Itching and redness at the site of the intravenous catheter
  
• Infection at the site of the IV catheter
  
• Ovarian hyper stimulation syndrome - GnRH poses less risk of this syndrome than does human menopausal Gonadotropin and other treatments for ovulation.

The small pump that is used for GnRH may bother some people and treatment requires daily monitoring by a doctor.

Although clinicians and scientists have observed the findings of olfactory disturbances and reproductive dysfunction, the syndrome comprising complete GnRH deficiency and lack of olfactory senses is named Kallmann Syndrome after the American geneticist Kallmann who identified this disorder in 1944.

Treatment

The choice of therapy depends upon the patient's desire to achieve one or more of the following options:

• Secondary sexual characteristics
  
• Fertility
  
• Bone and muscle mass

In males, treatment is decided to provide androgen replacement. The patient's age, potential adverse effects of therapy, patient's desire for fertility are considered. In the prepubertal male, GnRH stimulates penile growth, body and facial hair growth, bone and muscle development and voice changes. Androgens also stimulate growth hormone production, contributing to the adolescent growth spurt. Male androgen deficiency can result in social ridicule and therefore starting androgen therapy around age 14-15 is prudent.

Oral, injectable and transdermal and implantable pellets formulation are available for treatment of males with Kallmann syndrome. Oral androgen preparations should not be used due to their toxic effects on the liver and adverse effects on lipids. Injectable long-acting testosterone are low-cost, relatively safe and effective. The disadvantages include intramuscular injection and non physiologic pattern of testosterone over the dosing interval. There could be wide swings in libido in some men.

Transdermal patches and gel preparation of testosterone are currently available - adverse effect with these formulations include skin reactions at the application. In females as in males, treatment depends upon age and fertility desires. Estrogen replacement is a must to prevent osteoporosis.

Oral preparations, transdermal patches, vaginal cream and rings are available for standard hormone replacement therapy. Transdermally administered 17 beta estradiol has been shown as an effective regimen for preventing bone loss in normal menopausal women.

Women with intact uterus receive a cyclical progestin to accompany estradiol treatment. Optimal hormone therapy depends upon whether the patient has primary or secondary amenorrhea. Gradual dose escalation results in optimal breast development and allows time for young woman to adjust psychologically to her physical maturation.

Uterine Prolapse

The uterus lies in the pelvic cavity supported by connective tissue and pubococcygeus muscle. Uterine Prolapse is a condition where the uterus slides from its normal position into the vaginal cavity. This can be attributed to loss of muscle tone or weakening of the muscles holding the uterus against the pelvic wall. Uterine prolapse can occur due to aging or childbirth trauma on account of large babies or difficult labor. Other causes for uterine prolapse include pelvic tumor, obesity and chronic constipation. Lack of exercise and tight corsets can lead to uterine prolapse. Lack of adequate rest in the post pregnancy stage or heavy manual work can lead to uterine prolapse.

A woman suffering from uterine prolapse suffers lower back pain. There is a feeling of bearing down or heaviness in the pelvis. There may be increased frequency in urination and pain during sexual intercourse. A woman might suffer discomfort in the lower abdomen and heavy menstrual periods. Difficulty in passing stools, hemorrhoids and urinary tract infection might be noticed due to complications owing to uterine prolapse. A pelvic examination reveals any uterine Prolapse or protrusion of the cervix into the lower part of the vagina.

Treatment Options : In severe cases, reconstructive surgery restores the uterus to its correct position and then strengthens the pelvic floor. Sacral Colpopexy Sacrocolpopexy is a surgical procedure for reconstructing the pelvic organ.

Treatment for uterine prolapse depends on the degree of prolapse and the woman's age and general health condition. Vaginal pessaries may be able to hold the uterus in place for mild uterine prolapse. But there may be side-effects such as irritating and foul smelling discharge and ulcerations. Kegels exercises can go a long way in strengthening the pelvic floor muscles. Hormone therapy such as estrogen replacement can prevent further weakening of the pelvic muscles. Hysterectomy is the surgical option to treat uterine prolapse. Uterine prolapse can be prevented with good antenatal care and proper rest and following correct lifting techniques.