1. Hormone Replacement Therapy
in Premature Ovarian Failure

2. HRT in POF Vs Natural Menopause
►True example of replacement therapy Vs
extension therapy
►Started at time of diagnosis AND continued till
natural age of menopause
► No long-term ill effects (WHI study) as
estrogen years are not increased
►Full dose long-term Vs low dose short-term
►5-10% will resume spontaneous ovulation &
menstruation

3. Tailor HRT According to Type of POF

4. Type I POF - Prepubertal

5. Individualize the Treatment

7. 14 years Turner’s mosaic

8.  Counseling of the girl & parents
 COC pills
Occasionally can conceive

10. Types of HRT Regimens

11. Estrogen Preparations- Indian Market
Market name
Molecule
Strength
Prep
Dose
Evalon
Estriol succinate
1.0mg
Tab
8-16mg/day
Premarin
CEE
0.625mg
Tab
0.625mg/day
Progynova
Esradiol valerate
1.0mg/2mg
Tab
2mg/day
Estraderm patch
Or Susten 50
Estradiol
25/50/100 цg
patch
1 every 4 days
50 цg
E 2 Gel
Or Sandrena gel
Estradiol
1.5mg/2.5g
1mg/gm
Dermal gel
Once a day
Estaspray
Estradiol
0.375mg
Dermal spray
1-3 accutations/day
Premarine gel
CEE
0.625mg/gm
Evalon gel
Estriol
1mg/gm
E 2 Gel
Estradiol
0.025mg/gm
Vaginal gel
Daily x 2weeks
then twice a week

12. Transdermal Estrogens
Estragel
1.5mg/2.5g OD
EstaSpray 0.375mg BD

13. Oral estrogens
• Blood levels
• Lipoproteins
LDL
↓
HDL
↑
Lpa
↓
Prevent oxidation yes
TGL
↑
• CRP
↑
• SHBG, TBHG ↑
• Coagulation factors ↑
Transdermal
more stable, square dose curve
↓ or same
same
↓ or same
yes
same
No effect
No effect
less effect
Currently there appears to be no clear advantage of the
transdermal over the oral route

14. Progesterone preparations-Indian Market
Drug
Route
Sequential (10-14 days) continuous
MPA
Oral
5mg daily
2.5mg daily
Norethisterone
Oral
1mg daily
0.3 mg daily
Norethindrone
Oral
2.5mg daily
0.5mg daily
Dydrogesterone
Oral
10mg daily
5mg daily
Drospirenone
Oral
-
2mg daily
Natural progesterone
Oral
300mg daily
200mg daily
Natural progesterone
Vaginal
200mg daily
100mg daily
Natural progesterone
Vaginal gel
45mg daily
45mg daily
LNG-IUS
Intra-uterine
_
20mcg daily

15. Various options
Tibolone
• 0.625 mg premarin +
o
MPA 5mg 12 days
o
o
• Estragel/estaSpray
+ LNG IUS or MPA
o
• Angeliq 1 OD
o
o
o
Steroid
Metabolites are active
Mildly estrogenic
progestogenic
androgenic
Amenorrhoea
Good for VMS, libido, bones
No change in breast density
Endometrial bleeding -5%

16. Type III POF - Iatrogenic
• Sudden & precipitous fall of estrogens –
severe symptoms VMS, risk of CHD,
osteoporosis, suicidal depression
• Lack of androgens – lack of energy & libido
• Need to start ET early while in the hospital &
full dose or may be higher dose

17. HRT in Surgical Menopause

18. HRT in Cancer Survivors

19. Stem Cell Transplant - POF

20. HRT - POF

21. Premature ovarian failure
Not your failure