Presentation on theme: "Hormone Replacement Therapy Dr Belinda Magnus. Menopause - Background Vasomotor symptoms affect around 80% women during the menopause – severe in 20%"— Presentation transcript:
Hormone Replacement Therapy Dr Belinda Magnus
Menopause - Background Vasomotor symptoms affect around 80% women during the menopause – severe in 20% Median symptom duration 4 years – up to 12 years in 10%. NB Diagnosis is usually clinical based on typical symptoms - 1yr amenorrhoea > 50yo, 2 yrs < 50yo
HRT – Indications for Use For women with premature/ early menopause (<40yo or <45yo respectively) until the age of natural menopause – around 51yo For treating menopausal symptoms where risk:benefit ratio is favourable in FULLY INFORMED women Do not start in women over 60yo
Benefits of HRT MOST EFFECTIVE RX AT REDUCING VASOMOTOR SYMPTOMS – within 4/52, maximum improvement by 3mo, improves sleep & mood Also: Improves urogenital symptoms (sexual function/ recurrent UTIs); reduces osteoporosis risk; can reduce incidence of CHD if started within 10 years of menopause (controversial – see risks); possibly reduced risk colorectal ca with combined HRT.
Risks of HRT (1) RISK-FREE until age of natural menopause VTE: low in healthy women under 60yo. Over 60yo – risks much higher, esp if obese/ smoking/ previous VTE. Stroke: Not increased in women under 60yo. Lower risk with transdermal oestrogens; effect may be dose-related.
Risks of HRT (2) Breast cancer: still contentious No increased risk with oestrogen-only up to 5 yrs Combined HRT ↑ risk but greatest over 60yo Generally, absolute risk increase is small – approx 1 extra case of breast ca per 1000 women/ annum – similar to risk with obesity/ nulliparity/ late menopause/ drinking 2-3 units of alcohol per day Risk returns to non-user within 5 yrs of stopping Combined HRT also increases breast density and risk of abnormal mammogram – important
Risks of HRT (3) Endometrial ca: Oestrogen-only in women with uterus – so not given Ovarian ca – conflicting evidence, possibly increased risk but the only RCT on this concluded no increased risk CHD: Increased risk in woman starting this over 60yo
Contraindications to HRT Undiagnosed abnormal vaginal bleeding VTE Active or recent angina/ MI Suspected/ current/ past breast ca Endometrial ca or other oestrogen- dependent ca Active liver disease with abnormal LFTs Uncontrolled HTN Pregnancy or breastfeeding If women want it – refer for specialist advice
Starting HRT (2) If subtotal hysterectomy – 3mo cyclic HRT + if withdrawal bleed = uterine tissue → continuous combined, if no withdrawal bleed → oestrogen alone
Monitoring HRT (1) F/U 3mo initially after starting - BP, weight, symptoms, bleeding Erratic bleeding common in first 3-6mo – if persisting afterwards, needs further inv Monthly cyclic preparations should produce regular, predictable bleeds towards the end/ soon after progestogen phase If bleeding heavy/ irregular on cyclic HRT, can double progesterone dose or ↑ duration to 21 days Progesterone SE (eg: fluid retention/ weight gain/ mood swings) can halve progesterone dose or ↓ duration to 7-10 days
Monitoring/ Stopping HRT (2) Reassess at least annually Can consider FSH if previously normal if symptom-free for 1-2 years to consider stopping If stopping – can decrease dose first if on high dose to try and minimise Sx
Alternative Forms of HRT Oral most common Non-oral (eg: patches/ gels) avoid 1 st -pass metabolism through the liver so are more suitable for eg: nausea/ liver disease/ malabsorption/ thrombosis/ enzyme-inducing drugs HRT is NOT a contraceptive – 50yo.
Alternatives to HRT (1) Vaginal atrophy/ urogenital symptoms – topical oestrogen first-line eg: tablet/ cream/ pessary/ vaginal ring Mirena licensed as alternative for endometrial protection (4 years) with oestrogen component if get SE with other progestogens/ contraception still needed/ persistent bleeding on cyclical HRT + normal inv
Alternatives to HRT (2) Tibolone: good for libido, less good than HRT for flushing; no need for cyclical progestogen; can use with uterus but only post-menopause; may increase risk breast/ endometrial ca + stroke; not to use in >60yo due to stroke risk Clonidine: for flushing only; can cause hypotension; causes severe dry mouth; have to wean down to stop.
Case 1 45yo woman – early menopause Severe flushing, not sleeping well, high- powered job in City and needs to be alert, works long hours. Has read on internet and worried ++ about HRT risks – grandmother had breast cancer age 70yo What do you counsel her?
Case 2 53yo woman – menopause started age 51 Severe flushing, night sweats, irritability. What other questions to ask? What decides if she can have HRT? What risks do you have to tell her about?
Case 3 60yo woman – been on HRT since 53yo for severe flushing + other vasomotor symptoms ‘I can’t possibly come off HRT, my symptoms were so bad before.’ High chol, HTN (well controlled) Taking Ellest duet Conti How do you counsel her and what are the options? What if her symptoms were mainly vaginal dryness during sex/ recurrent UTIs?