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

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:
1 Concerns 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?