Tailoring HRT to the patient 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. Tailoring HRT to the patient Dr Bruce Davies

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

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

Forms of HRT Implants Tablets Patches Creams Local effect

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

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

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

Long term effects of the menopause Osteoporosis Increased CHD

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

Patient Concerns Breast cancer Weight Gain “Artificiality” Periods Duration

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

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

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

Partial agonists Tibolone ? Raloxifene

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

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

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

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?