1. Tailoring HRT to the patient Dr Bruce Davies To insert your company logo on this slide From the Insert Menu Select “Picture” Locate your logo file Click OK To resize the logo Click anywhere inside the logo. The boxes that appear outside the logo are known as “resize handles.” Use these to resize the object. If you hold down the shift key before using the resize handles, you will maintain the proportions of the object you wish to resize. www.bradfordvts.co.uk

2. Confusion! There are loads of preparations There are lots of forms There are lots of brands

3. Aims To bring order to the chaos To develop personal prescribing guidelines To enable rational selection To enable rational changes in treatment

4. Forms of HRT –Implants –Tablets –Patches –Creams –Local effect

5. Short term effects of the menopause - physical –Hot flushes –Night sweats –Headaches –Feeling dizzy –Feeling tired –Urinary symptoms –Crawling sensation under the skin –Palpitations

6. Short term effects of the menopause - Mental –Irritability –Mood swings –Anxiety –Insomnia –Loss of concentration –Lack of confidence –Memory disturbance –Loss of libido –Panic attacks

7. Medium term effects of menopause –Vaginal dryness –Dyspareunia –Urinary problems –Bladder and vaginal infections –Thinning hair –Aches and pains –Skin thinning

8. Long term effects of the menopause –Osteoporosis –Increased CHD

9. Which effects ? –Choice of initial preparation depends on effects that: 1Concerns patient 2 Concerns doctor

10. Patient Concerns –Breast cancer –Weight Gain –“Artificiality” –Periods –Duration

11. Types Oestrogen only Topical oestrogen for local effects Partial agonists Opposed oestrogen –Sequential, Monthly or quarterly bleed –Continuous combined

12. Oestrogen only Implants Skin Creams Patches Tablets 17 beta oestradiol, oestrone, conjugated equine, oestriol, Dienoestrol

13. Topical oestrogen for local effects Oestriol pessaries Oestradiol vaginal tablets Dienoestrol vaginal cream Oestradiol vaginal ring

14. Partial agonists Tibolone ? Raloxifene

15. Opposed oestrogen Sequential, Monthly or quarterly bleed Continuous combined Tablets Patches Tablets and patches Creams and tablets

16. Side effects or why change Rx ? Route related ? Avoidance of first pass metabolism ? Oestrogen effect - so change oestrogen or dose or route ? Progestogen effect - so change progestogen or dose or route

17. Quackery? ”Natural” progestogen cream Foods rich in phytooestrogens Mineral and vitamin supplements

18. Benefits Viz Risks Not as clear as some would make out Undoubtedly help short term symptoms Benefits clearer for unapposed oestrogens Breast cancer risks? CHD prevention?