Female Hormone Replacement Therapy.

There are two main approaches to female HRT treatments, which one is chosen will depend mainly on age but other factors have to be taken into account.

Monthly cyclical treatment with both progesterone and oestrogen, producing a 'normal' menstrual bleed every month.
This treatment alone will not produce fertility as no eggs are being released by the ovaries.

or

Continuous treatment with a constant dose of oestrogen only which produces no monthly bleed.

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As with male HRT treatments the basic approach is to replace the hormones that are normally produced by the ovaries in response to the pituitary hormones LH and FSH.

Unlike the testes the ovaries produce 2 separate hormones in response to LH and FSH.

Oestrogen & Progesterone

Also the levels of LH and FSH in males remain fairly constant throughout the month. In females the levels change over the month as the uterus is prepared each month for the possible implantation of a fertilised egg.

Oestrogen has a similar metabolic effect to testosterone in males and is needed for number of different functions but most importantly bone growth and hardness.

Normal monthly cycle:

Progesterone is responsible for the building up of the lining of the uterine wall during the month, ready for the implantation of an egg if required. When progesterone levels fall, this lining (called the endometrium) is shed and is lost as a menstrual bleed.

During menstruation the levels of LH and FSH are at their lowest, resulting in low levels of oestrogen and progesterone in the blood. Immediately after menstruation the levels of LH and FSH rise which leads to the build up of the endometrium again.

The levels of oestrogen and progesterone rise at different rates during the cycle, allowing for the best conditions for the egg to be released by the ovary, possible fertilisation by a sperm and then implantation into the uterine wall.

Effect of Kallmann's syndrome or hypogonadotrophic hypogonadism:

In Kallmann's or HH without the influence of LH or FSH from the pituitary gland the ovaries and uterus will not be able to perform their full function. The ovaries will not release any eggs. The uterine wall will not build up and be shed each month.

In most cases the ovaries will still contain undeveloped eggs. However there are some women with Kallmann's or HH whose ovaries are not fully developed, sometimes classed as 'streak ovaries'. The doctor will probably perform an ultrasound and possibly some physical tests to determine the status of the ovaries before starting any treatment.

The majority of women with Kallmann's or HH will be first diagnosed because of the lack of menstruation. There are many different causes of a failure of menstruation (amenorrhoea) which would have to be investigated first. Kallmann's or HH will not be the first thing most doctors will think of if a woman has amenorrhea.

Also the lack of oestrogen will mean none of the normal female secondary sexual characteristics will occur.

Starting replacement treatment:

Unlike male HRT, there has to be a two step approach to female HRT.

The first step is to produce the other metabolic and physical changes that should occur before menstruation can start.

The doctor will probably start by giving low doses of an oestrogen type drug, usually in a form of oestradiol (ethinyloestradiol). This is a strong acting steroid with similar effects to testosterone in males. It should produce the physical changes such as breast development, broader hips, pubic hair growth and bone hardening. A close eye will be kept on the doses given, which will be increased gradually. A close eye will be kept on bone density to ensure the correct dose is reached. It may take over 2 years to do, but menstruation should start on this treatment. This will lead to the second stage of treatment.

Cyclical treatment:

Once your doctor is happy with the oestrogen levels the additional hormone is added. Progesterone will be required for the first 14 days of the cycle to promote the growth of the uterine wall. The progesterone is then stopped for the other 14 days of the cycle to allow the wall to be shed to give a menstrual type bleed.

This progesterone can either be given as a separate pill in addition to the oestrogen type pill taken for the whole month.

The other option is for the doctor to prescribe the combined contraceptive pill. In normal use the "pill" is a contraceptive, but it this context it provides the correct level of hormones throughout the month to produce a normal cycle.

It has to be remembered that these treatments will produce a monthly bleed similar to a normal menstrual bleed, but it will not produce fertility as no eggs are being released by the ovaries.

It requires a different form of treatment to induce fertility.

Continuous treatment:

In some cases it is not appropriate to use progesterone at all. It may be a personal choice or there may be a medical reason that no menstruation is required.

If this is the case oestrogen only is used throughout the month either in the form of patches or tablets. This in a lot of cases can be the same HRT that is offered to post menopausal women. This form of treatment usually prevents the physical symptoms seen in the menopause.

Far more importantly it will provide the level of oestrogen that is required to keep the bones strong and reduce the risk of developing osteoporosis.