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HRT - PowerPoint PPT Presentation


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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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slide1

HRT

In a nutshell for all the blokes out there

diagnosis
diagnosis
  • Clinical hx
  • FSH limited value as levels fluctuate
  • May be of value in symtomatic women under 40y
  • FSH >30
slide3
Also
  • Lifestyle
  • Smoking
  • Alcohol
  • Exercise
  • caffeine
indications
indications
  • Early menopause (<45yrs)
  • Under 65yrs with vasomotor symptoms
  • Not to be used for prevention of osteoporosis
what to discuss at first consultation
What to discuss at first consultation
  • Risks and benefits
  • Expected duration of treatment
  • Symptoms will return when stopped
  • Need assessment annually
  • Contraception req
benefits
benefits
  • Relief of vasomotor symptoms
  • Urogenital symptoms
  • Osteoporosis
  • Prevention ca colon (by 20%)
  • mood
harms
Harms
  • CVD
    • Increased risk of CHD and CVA
  • Breast cancer
  • Endometrial cancer
  • Ovarian cancer
  • VTE
  • dementia
hrt and br ca
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
absolute contraindications
Absolute contraindications
  • Relatively few:
  • Acute phase MI, pe, DVT
  • Active endometrial or brCa
  • Pregnancy
  • Undiagnosed br mass
  • Abnormal vaginal bleeding
  • Severe active liver disease
initial assessment
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
what preparation
What preparation
  • Elleste duet - woman has ‘period’
  • Elleste duet conti - no ‘period’
  • Elleste solo - oestrogen only
other considerations
Other considerations
  • CV risk of >20%
  • Diabetes
  • BMI >30
  • FH br Ca
    • 1 pre-menopausal or 2 post-menopausal
changing to continuous
Changing to continuous
  • May want to consider at 54 yrs
  • Does increase risk of CVD and brca
bleeding on cyclical
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
continuous hrt
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
oestrogen side effects
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)
progesterone side effects
Progesterone side effects
  • Mood swings, headaches, acne, fluid retention
  • If persists
    • Reduce duration (not <10d)
    • Reduce dose
    • Change prog
    • Change to long cycling regime
follow up
Follow - up
  • 3 monthly, then 6 monthly
  • And then yearly
  • Compliance, bleeding patterns, S.Es
  • Talk about coming off
  • Smears and mammograms
stopping
stopping
  • Shortest possible time
  • Usually within 5 years
  • Symptoms will recur
  • Stop abruptly or gradually
how long to continue
How long to continue
  • Shortest possible time
  • Ideally within 5 yrs
stopping1
stopping
  • Cold turkey
  • Premique low dose for a couple of months
  • 1 every other day
other options
Other options
  • SSRIs
  • Clonidine
  • Black cohosh
  • Topical oestrogens
contraception
contraception
  • Barrier
  • IUD
  • IUS
  • Low dose COC instead of HRT
  • Continue for 1 years after LMP in over 50s
  • 2yrs in under 50s