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HRT

HRT. In a nutshell for all the blokes out there. diagnosis. Clinical hx FSH limited value as levels fluctuate May be of value in symtomatic women under 40y FSH >30. Also. Lifestyle Smoking Alcohol Exercise caffeine. indications. Early menopause (<45yrs)

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HRT

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  1. HRT In a nutshell for all the blokes out there

  2. diagnosis • Clinical hx • FSH limited value as levels fluctuate • May be of value in symtomatic women under 40y • FSH >30

  3. Also • Lifestyle • Smoking • Alcohol • Exercise • caffeine

  4. indications • Early menopause (<45yrs) • Under 65yrs with vasomotor symptoms • Not to be used for prevention of osteoporosis

  5. What to discuss at first consultation • Risks and benefits • Expected duration of treatment • Symptoms will return when stopped • Need assessment annually • Contraception req

  6. benefits • Relief of vasomotor symptoms • Urogenital symptoms • Osteoporosis • Prevention ca colon (by 20%) • mood

  7. Harms • CVD • Increased risk of CHD and CVA • Breast cancer • Endometrial cancer • Ovarian cancer • VTE • dementia

  8. HRT and Br Ca • Risk depends on type of HRT • Revert to normal 1yr after stopping • Risk increases with duration of use • After 10 yrs • Combined: 19 extra cases per 1000 • Unopposed oestrogen: 5 extra cases per 1000

  9. Absolute contraindications • Relatively few: • Acute phase MI, pe, DVT • Active endometrial or brCa • Pregnancy • Undiagnosed br mass • Abnormal vaginal bleeding • Severe active liver disease

  10. Initial assessment • Hx • esp risk factors for CVD, hx of Br ca or VTE • BP, BMI, bloods (serum lipids • smoking • Breast awareness - screening program • Cervical screening • Lifestyle advice • Document discussion of risks

  11. What preparation • Elleste duet - woman has ‘period’ • Elleste duet conti - no ‘period’ • Elleste solo - oestrogen only

  12. Other considerations • CV risk of >20% • Diabetes • BMI >30 • FH br Ca • 1 pre-menopausal or 2 post-menopausal

  13. Changing to continuous • May want to consider at 54 yrs • Does increase risk of CVD and brca

  14. Bleeding on cyclical • GI upset, compliance, drug interactions • Options: • Try stopping- see if stops • If thought to be due to hrt • Increase dose of progesterone or change type of progesterone

  15. continuous HRT • Irregular bleeding in 40% in first 4-6m • Check - Was she at least one year post menopausal • Investigate if continuing for > 6 months, becomes heavier, or occurs after amenorrhoea • Options come off HRT and see if stops • Refer urgently if continues after 4 weeks

  16. Oestrogen side effects • Fluid retention, bloating, breast tenderness, nausea • Most resolve with time (within 12 weeks) • If persistent • Reduce dose • Change type of oestrogen • Change route (transdermal)

  17. Progesterone side effects • Mood swings, headaches, acne, fluid retention • If persists • Reduce duration (not <10d) • Reduce dose • Change prog • Change to long cycling regime

  18. Follow - up • 3 monthly, then 6 monthly • And then yearly • Compliance, bleeding patterns, S.Es • Talk about coming off • Smears and mammograms

  19. stopping • Shortest possible time • Usually within 5 years • Symptoms will recur • Stop abruptly or gradually

  20. How long to continue • Shortest possible time • Ideally within 5 yrs

  21. stopping • Cold turkey • Premique low dose for a couple of months • 1 every other day

  22. Other options • SSRIs • Clonidine • Black cohosh • Topical oestrogens

  23. contraception • Barrier • IUD • IUS • Low dose COC instead of HRT • Continue for 1 years after LMP in over 50s • 2yrs in under 50s

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