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H.R.T. Dr. Sylvia Bond 11/05/2011 . Aims for session. To be confident with a menopausal presentation Structure history taking Share management decision, based on evidence Provide safe, logical prescribing. Menopause. Date of last menstruation Normally 45-55 years

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H.R.T. Dr. Sylvia Bond 11/05/2011


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slide1

H.R.T.

Dr. Sylvia Bond

11/05/2011

aims for session
Aims for session
  • To be confident with a menopausal presentation
  • Structure history taking
  • Share management decision, based on evidence
  • Provide safe, logical prescribing
menopause
Menopause
  • Date of last menstruation
  • Normally 45-55 years
  • Perimenopause several years
  • Oestrogen and Progesterone decrease
  • FSH (>32) and LH increase
  • Postmenopausal > 12/12 since LMP
use of hrt
Use of HRT
  • USA 80% and UK 10% in 1990s
  • 2-5 years symptom control
  • 5-10 years or for life for prevention Osteoporosis and other less certain areas
effectiveness of symptom control
Effectiveness of symptom control
  • Hot flushes 94%
  • Night sweats 92%
  • Irritability 79%
  • Tiredness 67%
  • Dyspaurenia 73%
  • Frequency of micturition 37%
  • Skin wrinkles 50%
  • Overall benefited 89%
side effects of hrt
Side Effects of HRT
  • Genitourinary – Fluid retention/ BTB/Menorrhagia/Dysmenorrnoea/PMT/ Cystitis/Candida
  • Breasts – Mastalgia/Glacotorrhoea
  • Nausea/Vomiting/Bloating/Jaundice
  • Skin – Chloasma/ Hair gain or loss
  • Eyes – Intolerance to contact lens
s e cont
S/E cont.
  • CNS – Headache increase or decrease/dizziness
  • CVS – Thrombosis/Cramps
  • Mental state – Mood swings/Depression
  • Weight change/redistribution
  • Any other s/e a woman believes is related will affect compliance
compliance
Compliance
  • 30% Do not fill script
  • 20% Stop< 9/12
  • 10% Take irregularly
  • 40% Taking regularly at 1 year
contraindications to hrt absolute
Contraindications to HRTABSOLUTE
  • Pregnancy
  • Undiagnosed abnormal vaginal bleeding
  • Breast or Endometrial Cancer
  • Severe liver disease
  • PMH Thrombosis
  • Migraine with aura
contraindications relative
ContraindicationsRELATIVE
  • Endometriosis- 6/12 after TAH
  • Fibroids
  • PMH Benign Breast cysts
  • MI/CVA- 6/12
  • Gallbladder disease
  • Major surgery- stop 4/52 prior
not contradicted caution
Not Contradicted- Caution
  • Controlled Hypertension
  • Epilepsy
  • Diabetes
  • Varicose Veins
  • FH Breast Cancer
risks benefits
Risks/benefits
  • HELP!!
  • Evidence changing
  • Trials poor quality
  • Public concern/ Media hype
  • Be prepared
  • Evaluate what your patient has heard and how much they want to know
long term benefits
Long-term Benefits
  • Osteoporosis
  • Bowel cancer
  • ?Alzheimer's
long term risks
Long-term Risks
  • Breast Cancer
  • Endometrial cancer, If unopposed
  • Venous thrombosis
  • Gallbladder disease
  • ?Ovarian cancer
  • ?CVD
hers hers hers the heart and estrogen progestin replacement study 1998
HERSHERS HERS the Heart and Estrogen/progestin Replacement Study 1998
  • Placebo controlled study
  • Secondary prevention/established CHD
  • Average age 66.3 years
  • Increase HDL/decreased LDL
  • Non-sig increase CHD at 1 year
  • Non-sig decrease CHD at 4 years
slide16
HERS
  • Early harm and late benefit
  • Needed primary prevention study
women s health initiative 2002
Women’s Health Initiative2002
  • Prempo ( not available in uk)
  • Premarin 0.625mg and 2.5mg MPA
  • 8,506 ASYMPTOMATIC WOMEN
  • Age 50-79 yrs, average 63 yrs.
  • 23% above 70 yrs
  • Not primary prevention
  • 40% were on statins/ antihypertensives
  • 7.7% had had Coronary thrombosis
whi cont
WHI cont
  • Stopped at 5.2 yrs
  • 29% increase in CHD
  • 41% increase in CVA
  • 26% increase in Breast Cancer
  • 100% increase in VTE
whi cont1
WHI cont
  • Decrease in Hip and Vertebral fracture and Colonic Cancer
  • CVD only increased in women who started HRT 20 Yrs after menopause
  • Non-sig REDUCTION if started within 10 yrs
whi oestrogen only arm 2004
WHI Oestrogen only arm 2004
  • CHD Down 42%
  • Breast cancer Down 28%
  • Colorectal caner Down 41%
  • CVD 0% Change
  • Deaths Down 27%
million women study 2003
Million Women Study 2003
  • Oxford
  • Case controlled
  • Observational
  • Diverse range of HRT (Questionnaire)
  • Age 50-64 (mean age 57)
  • Attending for mammogram in UK (Bias)
slide22
MWS
  • 30% increase in breast cancer in women taking unopposed oestrogen
  • Risk starts at 1 year and disappears after Rx stopped.
  • 9364 had breast cancer, 2224 were excluded? Why.
risk of breast cancer
Risk of Breast Cancer
  • 12 per 1000 after 15 years HRT
  • Comparable to risk of; alcohol,obesity,having no children, having late first pregnancy or late menopause
current advice on hrt
Current advice on HRT
  • Use for symptoms or low bone density
  • NOT secondary prevention of CVD
  • Do not commence after 60yrs
  • In symptomatic women ? Prevention CHD and Alzheimer’s
  • ? reduce Progesterone to 7 days
duration of use
Duration of use
  • Clock starts ticking at 50 yrs
  • Asymptomatic or <1yr 18%
  • 1-5yrs 56%
  • 5+ yrs 26%
  • Still symptomatic in 60s 10%
  • May be reluctant to stop at 5yrs
  • Wean off gradually
assessment for hrt history
Assessment for HRTHistory
  • LMP/Bleeding pattern
  • Document symptoms
  • Need for contraception
  • Hysterectomy
  • PMH VTE/CHD/CVA
  • Liver disease
  • FH Breast Cancer/ Osteoporosis
examination
Examination
  • Blood Pressure
  • Weight
  • PV if abnormal bleeding
  • Cervical Smear If due
  • Mammogram as part of national screening programme only
  • FSH if hysterectomy or irregular bleed, <45yrs, if contraception an issue.
opportunistic health promotion don t forget the qof points
Opportunistic Health Promotion Don’t forget the QOF points!!
  • Smoking
  • Alcohol
  • Diet- Low Cholesterol and High Calcium
  • Weight bearing exercise
  • Stress
  • Chronic disease management
types of hrt
Types of HRT
  • Tablets
  • Patches
  • Implants
  • Nasal spray
  • Gel
  • Vaginal ring
  • Pessary
  • Vaginal cream
types of hrt1
Types of HRT
  • Hysterectomy – Oestrogen alone
  • Peri-menopausal – Cyclical HRT Double script charge!
  • Post-menopausal – Continus Combined
  • Local vaginal/urological symptoms - Topical
equivalent doses
Equivalent doses
  • Premarin 0.625mg
  • Oestrodiol 1mg tab
  • Oestrodiol 50mcg patch
alternatives to hrt natural remedies
Alternatives to HRT“Natural remedies”
  • Black Cohosh
  • Kava Kava
  • Angus Castus
  • Red Clover
  • Magnesium/Zinc
  • Phytoestrogens (Soya/yam)
  • Evening Primrose Oil
alternatives to hrt medical rx
Alternatives to HRTMedical Rx
  • Antidepressants – SSRIs
  • Calcium and VitD
  • Biphosphonates
  • Dixarit - Clonidine
explaination
Explaination
  • How to take
  • Side effects
  • Risks/Benefits
  • Consider written info/Loan books or videos
  • 10 min appt time is running out!
  • Discuss and review with questions
  • Practice nurse role in counselling
follow up initial 3 12 then 6 12
Follow upInitial 3/12, then 6 /12
  • Nurse lead clinics
  • BP/Weight
  • Symptom control
  • Side effects
  • Any change in personal or family history
problem solving oestrogen s e
Mastalgia

Flushes

Cramps

Headaches

BTB

Weight gain

Rash with patch

Change preparation

Change Oestridiol/Premarin

Change dose

Problem solvingOestrogen s/e
problem solving progesterone s e
PMT

Acne

Risk of CVD/ Lipids

Risk of breast cancer

Weight gain

Reduce from 14 to 7 days per cycle

Change type. MPA lipid friendly

CCT over 54yrs, > 12/12 since LMP

Tibolone

Femoston (Dydrogesterone)

Problem solvingProgesterone s/e
lack of libido
Lack of libido
  • Tibolone (Livial)
  • Testosterone implant
  • TAH and BSO
  • FADS, female androgen deficiency
  • Tired, loss of libido, headache, depression
chronic fatigue syndrome
Chronic fatigue syndrome
  • Often ass. with PMS
  • Low plasma Oestradiol levels
  • Low bone density
  • Rx Transdermal Oestrogen +/- Testosterone
conclusion
Conclusion
  • HRT has a vital role in the wellbeing of many perimenopausal women.
  • One dose does not fit all.
  • Symptomatic women should be offered information and choice.
  • HRT does not have a role in life-long prevention of osteoporosis or CVD.
learning log
Learning Log
  • What did you learn?
  • What will you do differently?
  • Further learning needs?
references
References
  • British Menopause Society.

www.thebms.org.uk

  • John Studd FRCOG. Chelsea and Westminster Hospital London. www.studd.co.uk
  • HERS JAMA 1998
  • WHI JAMA 2002
  • MWS LANCET 2003