Female Hormone Replacement Treatment Options.

Female HRT options follow the same principles as with male HRT, i.e. in the replacement of the hormones that are low or absent in KS or HH.

The major hormone that causes female sexual characteristics is oestrogen, increasingly now spelt American-style as estrogen even in the UK.

Estrogen is also essential for maintaining bone density and skin thickness (thinner skin tends to wrinkle). A second hormone, progesterone is also required for the correct maintenance of the uterine lining (endometrium), unless a woman has had a hysterectomy.

Estrogen and progesterone are normally produced by the ovaries in response to the pituitary hormones LH and FSH. In KS and HH there is no stimulation of the ovaries and they do not produce either mature eggs or the hormones progesterone and estrogen.

In women of pre-menopausal age a cyclical treatment of estrogen is normally prescribed with the addition of progesterone for 12 to 14 days to allow a withdrawal bleed to occur. This is typically monthly, but it could equally well be taken quarterly for greater convenience. In older women, continuous-combined bleed-free preparations can be used. Prolonged estrogen-alone therapy without progesterone is inadvisable as it predisposes to overgrowth of the womb lining, which can eventually turn cancerous.

HRT will not induce fertility in females with KS or HH as there is no stimulus for egg production. It will however allow for normal sexual function and development. Without HRT females on HRT may experience vaginal soreness and dryness. The use of HRT with both estrogen and progesterone will help to alleviate this.

Since female HRT is a fairly standard treatment in post menopausal women there are lot of products available that can be prescribed. Some products will be estrogen only or alternatively a combination product of estrogen and progesterone. However, they have all been formulated so as to contain the lowest possible doses sufficient to prevent hot flushes in 90% of postmenopausal women, rather than to maintain bone density and secondary female characteristics in younger women with IHH or Kallmann’s syndrome.

Some doctors in the past have prescribed the standard oral contraceptive pill for females with KS or HH as it is a combination of estrogen and progesterone, has the advantage of being free on prescription, and is widely taken by lots of women anyway. However this treatment is less favoured these days as the body remains estrogen deficient for 1 week in 4 (the “pill free week”), which is not ideal. Moreover the synthetic estrogens used in the pill aren’t detected by laboratory estrogen assays, so that the only guide to whether the dose is adequate are individual sense of well-being and serial measurements of bone density.

Media concerns about breast cancer risk in particular, but also of stroke, with HRT have always had a high profile, but the excess risks from published studies seem to be almost entirely confined to women who took HRT for 5 years or more in their 60s and 70s. IHH women of premenopausal age should not be put off by media scare stories that do not apply to women in their situation. The best advice would seem to be as follows:

1. If you an IHH woman on HRT, you should stop taking it sometime between the age of 50 and 58 years.

2. Within this age-range, factors favouring continuing HRT towards age 58 would include: having started HRT late in life, having had a long-break without treatment earlier in life, being slim and having a lower bone density.

3. Women in their 60s and 70s able to take estrogen-alone HRT because they have had a hysterectomy, largely escape the increased risk of breast cancer and stroke seen in those taking classical estrogen/progesterone HRT. One option for other women, though, is to take estrogen alone, but have a Mirena IUD (Coil) inserted to prevent the womb lining building up.

4. Women who are overweight or smoke (and thus have a higher baseline risk of vein thrombosis, are better off taking transdermal, rather than tablet HRT.