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     Perimenopause several years Oestrogen and Progesterone decrease FSH (>32) and LH increase Postmenopausal > 12/12 since LMP

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         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      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.

     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     30% Do not fill script 20% Stop< 9/12 10% Take irregularly 40% Taking regularly at 1 year

Contraindications to HRT ABSOLUTE       Pregnancy Undiagnosed abnormal vaginal bleeding Breast or Endometrial Cancer Severe liver disease PMH Thrombosis Migraine with aura

Contraindications RELATIVE       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      Controlled Hypertension Epilepsy Diabetes Varicose Veins FH Breast Cancer

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    Osteoporosis Bowel cancer ?Alzheimer's

Long-term Risks       Breast Cancer Endometrial cancer, If unopposed Venous thrombosis Gallbladder disease ?Ovarian cancer ?CVD

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

HERS  Early harm and late benefit  Needed primary prevention study

Women’s Health Initiative 2002         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      Stopped at 5.2 yrs 29% increase in CHD 41% increase in CVA 26% increase in Breast Cancer 100% increase in VTE

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      CHD Breast cancer Colorectal caner CVD Deaths Down 42% Down 28% Down 41% 0% Change Down 27%

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)

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  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      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     Clock starts ticking at 50 yrs Asymptomatic or <1yr 18% 1-5yrs 5+ yrs 56% 26%    Still symptomatic in 60s 10% May be reluctant to stop at 5yrs Wean off gradually

Assessment for HRT History        LMP/Bleeding pattern Document symptoms Need for contraception Hysterectomy PMH VTE/CHD/CVA Liver disease FH Breast Cancer/ Osteoporosis

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!!

      Smoking Alcohol Diet- Low Cholesterol and High Calcium Weight bearing exercise Stress Chronic disease management

Types of HRT         Tablets Patches Implants Nasal spray Gel Vaginal ring Pessary Vaginal cream

Types of HRT     Hysterectomy – Oestrogen alone Peri-menopausal – Cyclical HRT Double script charge!

Post-menopausal – Continus Combined Local vaginal/urological symptoms Topical

Equivalent doses    Premarin 0.625mg

Oestrodiol 1mg tab Oestrodiol 50mcg patch

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     Antidepressants – SSRIs Calcium and VitD Biphosphonates Dixarit - Clonidine

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      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 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)

Lack of libido   Tibolone (Livial) Testosterone implant    TAH and BSO FADS, female androgen deficiency Tired, loss of libido, headache, depression

Chronic fatigue syndrome    Often ass. with PMS Low plasma Oestradiol levels Low bone density  Rx Transdermal Oestrogen +/ Testosterone

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  What did you learn?

 What will you do differently?

 Further learning needs?

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