2. Family medicine Common problems in Obstetric and Gynaecology

3. Common problems zMenopausal symptom zvaginal discharge zlower abdominal pain

4. Menopausal symptom zA 49 years old lady attends your clinic and requests HRT suggested by her friend

5. Menopausal symptom zAny menopausal symptom zneed? zany contraindication zCounselling

6. Climacteric symptom zSymptomatic or not zVasomotor symptom hot flushes night sweating palpitation headache zatrophic tissue vaginal dryness, dyspareunia, vaginitis, urinary symptom, thin dry skin, dry hair, brittle nail zpsychological depression, lethargy, loss of concentration, irritability, poor libido

7. Menopausal symptom zAssessment zHx : severity of climacteric symptom z Any contraindication medical /surgical problem family hx abnormal uterine bleeding z Risk factors: osteoporosis cardiovascular disease

8. Contraindication zMedical /surgical problem existing breast carcinoma existing endometrial carcinoma venous thrombosis acute liver disease zfamily hx of carcinoma zabnormal uterine bleeding need to R/O pathology before prescribing

9. Risk factors zOsteoporosis : prolong oligomenorrhoea/amenorrhoea premature menopause excessive intake of alcohol/caffeine low body mass index, short stature family hx of osteoporosis drugs medical condition zcardiovascular disease : existing cardiovascular disease family hx, hypercholesterolaemia, smoking, DM, hypertension, obesity

10. Counselling zRisk Vs. benefit zother alternatives zDuration

11. Risk Vs benefit Benefit zprevention of osteoporosis bone loss after menopause: affecting femoral neck and lumbar spine can prevent osteoporotic fracture one stop oestrogen tx : protection largely loss zPrevention of cardiovascular problem indirect evidence suggesting administration of estrogen reduces cardiovascular risk by 50 %, esp.. those high risk Risk zdevelopment of breast cancer slightly increase in risk after 5 years usage of oestrogen zother S/E breast sensitivity /fluid retention/return of menstruation/PV spotting

12. Management zGeneral Diet exercise social activity, relaxation zHRT Optional bone density scan over spine and hip

13. HRT zFor those need HRT zestrogen +/- progesterone zform: oral, percutaneously, transdermally/subcutaneous implant zvaginal administration of estrogen: short term tx to lower genital tract choice of HRT zestrogen only( e.g. Premarin) zcombined cyclical( e.g.. Premelle Cycle, Prempak) zcombined continuous (e.g. Premelle) ztibolone weak oestrogen, androgenic and progestrogenic properties zselective estrogen receptor modulator(SERMs) reduced risk of breast and endometrial cancer

14. HRT zHow long? zFor those symptomatic : 2 -3 years zFor those prevention of osteoporosis: more than 5 years with continuous assessment

15. HRT Monitoring zBP, general exam, breast exam. z2 yearly mammogram zduring interval: Self breast examination zAny abnormal vaginal bleeding for those combined cyclical HRT: regular bleeding zIx if persist irregular bleeding for those with continuous type of HRT: amenorrhoea after 4 months zmay have PV spotting zif persist : suggest stop HRT and perform EB