Endocrine Abstracts

A 59-year-old woman with 46XY complete androgen insensitivity syndrome was referred back to our service. She also has history of hypertension and migraines. She was gonadectomised at the age of 15 years and treated with Ethinylestradiol. She married and was able to have enjoyable sex without the need for vaginoplasty or dilators. However, at 54 years she was firmly advised to stop Ethinylestradiol due to satisfactory bone density and “risks of HRT outweighing benefits”, and so her treatment was progressively reduced to zero over the course of a year and she was discharged from follow-up. She immediately developed pronounced severe vasomotor symptoms (sweating and flushing) that did not abate over time, along with other adverse clinical features, including scalp hair loss, palpitations, arthralgia, urinary frequency, fatigue, and vaginal dryness that almost immediately ended her sex life. Overall, her quality of life went from “good” to “poor”. A repeat DEXA scan showed osteopenia at the hip with normal density at spine (T score of -1.7 and -0.7 respectively). It was explained to her that the landmark WHI study (2002) found no excess risk of breast cancer in women lacking a uterus on oestrogen-only HRT. Moreover, whereas the synthetic oestrogen Ethinylestradiol is associated with increased risks of hypertension, migraine and venous thromboembolism, these risks are far lower with native 17, beta Estradiol (E2), particularly if given transdermally. She was therefor started on Estradiol patches along with supplementary vaginal oestrogen for vulvovaginal atrophy, and also referred to community gynaecology to assess whether resumption of penetrative intercourse might be feasible. In Endocrinology, it is common practice to consider withdrawal of HRT for hypogonadal women in their mid-50s. However, it is crucial to deliver the right message, which is “We really wanted you to continue taking HRT until now, but from this point onwards, the choice is yours based upon your current risk benefit profile and quality of life issues”, rather than “You”re 54 years” old and so it’s definitely time for you to stop HRT.