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H.R.T. Dr. Sylvia Bond 11/05/2011

H.R.T. Dr. Sylvia Bond 11/05/2011 . Aims for session. To be confident with a menopausal presentation Structure history taking Share management decision, based on evidence Provide safe, logical prescribing. Menopause. Date of last menstruation Normally 45-55 years

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H.R.T. Dr. Sylvia Bond 11/05/2011

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  1. H.R.T. Dr. Sylvia Bond 11/05/2011

  2. Aims for session • To be confident with a menopausal presentation • Structure history taking • Share management decision, based on evidence • Provide safe, logical prescribing

  3. Menopause • Date of last menstruation • Normally 45-55 years • Perimenopause several years • Oestrogen and Progesterone decrease • FSH (>32) and LH increase • Postmenopausal > 12/12 since LMP

  4. Use of HRT • USA 80% and UK 10% in 1990s • 2-5 years symptom control • 5-10 years or for life for prevention Osteoporosis and other less certain areas

  5. Effectiveness of symptom control • Hot flushes 94% • Night sweats 92% • Irritability 79% • Tiredness 67% • Dyspaurenia 73% • Frequency of micturition 37% • Skin wrinkles 50% • Overall benefited 89%

  6. Side Effects of HRT • Genitourinary – Fluid retention/ BTB/Menorrhagia/Dysmenorrnoea/PMT/ Cystitis/Candida • Breasts – Mastalgia/Glacotorrhoea • Nausea/Vomiting/Bloating/Jaundice • Skin – Chloasma/ Hair gain or loss • Eyes – Intolerance to contact lens

  7. S/E cont. • CNS – Headache increase or decrease/dizziness • CVS – Thrombosis/Cramps • Mental state – Mood swings/Depression • Weight change/redistribution • Any other s/e a woman believes is related will affect compliance

  8. Compliance • 30% Do not fill script • 20% Stop< 9/12 • 10% Take irregularly • 40% Taking regularly at 1 year

  9. Contraindications to HRTABSOLUTE • Pregnancy • Undiagnosed abnormal vaginal bleeding • Breast or Endometrial Cancer • Severe liver disease • PMH Thrombosis • Migraine with aura

  10. ContraindicationsRELATIVE • Endometriosis- 6/12 after TAH • Fibroids • PMH Benign Breast cysts • MI/CVA- 6/12 • Gallbladder disease • Major surgery- stop 4/52 prior

  11. Not Contradicted- Caution • Controlled Hypertension • Epilepsy • Diabetes • Varicose Veins • FH Breast Cancer

  12. Risks/benefits • HELP!! • Evidence changing • Trials poor quality • Public concern/ Media hype • Be prepared • Evaluate what your patient has heard and how much they want to know

  13. Long-term Benefits • Osteoporosis • Bowel cancer • ?Alzheimer's

  14. Long-term Risks • Breast Cancer • Endometrial cancer, If unopposed • Venous thrombosis • Gallbladder disease • ?Ovarian cancer • ?CVD

  15. HERSHERS HERS the Heart and Estrogen/progestin Replacement Study 1998 • Placebo controlled study • Secondary prevention/established CHD • Average age 66.3 years • Increase HDL/decreased LDL • Non-sig increase CHD at 1 year • Non-sig decrease CHD at 4 years

  16. HERS • Early harm and late benefit • Needed primary prevention study

  17. Women’s Health Initiative2002 • Prempo ( not available in uk) • Premarin 0.625mg and 2.5mg MPA • 8,506 ASYMPTOMATIC WOMEN • Age 50-79 yrs, average 63 yrs. • 23% above 70 yrs • Not primary prevention • 40% were on statins/ antihypertensives • 7.7% had had Coronary thrombosis

  18. WHI cont • Stopped at 5.2 yrs • 29% increase in CHD • 41% increase in CVA • 26% increase in Breast Cancer • 100% increase in VTE

  19. WHI cont • Decrease in Hip and Vertebral fracture and Colonic Cancer • CVD only increased in women who started HRT 20 Yrs after menopause • Non-sig REDUCTION if started within 10 yrs

  20. WHI Oestrogen only arm 2004 • CHD Down 42% • Breast cancer Down 28% • Colorectal caner Down 41% • CVD 0% Change • Deaths Down 27%

  21. Million Women Study 2003 • Oxford • Case controlled • Observational • Diverse range of HRT (Questionnaire) • Age 50-64 (mean age 57) • Attending for mammogram in UK (Bias)

  22. MWS • 30% increase in breast cancer in women taking unopposed oestrogen • Risk starts at 1 year and disappears after Rx stopped. • 9364 had breast cancer, 2224 were excluded? Why.

  23. Risk of Breast Cancer • 12 per 1000 after 15 years HRT • Comparable to risk of; alcohol,obesity,having no children, having late first pregnancy or late menopause

  24. Current advice on HRT • Use for symptoms or low bone density • NOT secondary prevention of CVD • Do not commence after 60yrs • In symptomatic women ? Prevention CHD and Alzheimer’s • ? reduce Progesterone to 7 days

  25. Duration of use • Clock starts ticking at 50 yrs • Asymptomatic or <1yr 18% • 1-5yrs 56% • 5+ yrs 26% • Still symptomatic in 60s 10% • May be reluctant to stop at 5yrs • Wean off gradually

  26. Assessment for HRTHistory • LMP/Bleeding pattern • Document symptoms • Need for contraception • Hysterectomy • PMH VTE/CHD/CVA • Liver disease • FH Breast Cancer/ Osteoporosis

  27. Examination • Blood Pressure • Weight • PV if abnormal bleeding • Cervical Smear If due • Mammogram as part of national screening programme only • FSH if hysterectomy or irregular bleed, <45yrs, if contraception an issue.

  28. Opportunistic Health Promotion Don’t forget the QOF points!! • Smoking • Alcohol • Diet- Low Cholesterol and High Calcium • Weight bearing exercise • Stress • Chronic disease management

  29. Types of HRT • Tablets • Patches • Implants • Nasal spray • Gel • Vaginal ring • Pessary • Vaginal cream

  30. Types of HRT • Hysterectomy – Oestrogen alone • Peri-menopausal – Cyclical HRT Double script charge! • Post-menopausal – Continus Combined • Local vaginal/urological symptoms - Topical

  31. Equivalent doses • Premarin 0.625mg • Oestrodiol 1mg tab • Oestrodiol 50mcg patch

  32. Alternatives to HRT“Natural remedies” • Black Cohosh • Kava Kava • Angus Castus • Red Clover • Magnesium/Zinc • Phytoestrogens (Soya/yam) • Evening Primrose Oil

  33. Alternatives to HRTMedical Rx • Antidepressants – SSRIs • Calcium and VitD • Biphosphonates • Dixarit - Clonidine

  34. Explaination • How to take • Side effects • Risks/Benefits • Consider written info/Loan books or videos • 10 min appt time is running out! • Discuss and review with questions • Practice nurse role in counselling

  35. Follow upInitial 3/12, then 6 /12 • Nurse lead clinics • BP/Weight • Symptom control • Side effects • Any change in personal or family history

  36. Mastalgia Flushes Cramps Headaches BTB Weight gain Rash with patch Change preparation Change Oestridiol/Premarin Change dose Problem solvingOestrogen s/e

  37. PMT Acne Risk of CVD/ Lipids Risk of breast cancer Weight gain Reduce from 14 to 7 days per cycle Change type. MPA lipid friendly CCT over 54yrs, > 12/12 since LMP Tibolone Femoston (Dydrogesterone) Problem solvingProgesterone s/e

  38. Lack of libido • Tibolone (Livial) • Testosterone implant • TAH and BSO • FADS, female androgen deficiency • Tired, loss of libido, headache, depression

  39. Chronic fatigue syndrome • Often ass. with PMS • Low plasma Oestradiol levels • Low bone density • Rx Transdermal Oestrogen +/- Testosterone

  40. Conclusion • HRT has a vital role in the wellbeing of many perimenopausal women. • One dose does not fit all. • Symptomatic women should be offered information and choice. • HRT does not have a role in life-long prevention of osteoporosis or CVD.

  41. Learning Log • What did you learn? • What will you do differently? • Further learning needs?

  42. References • British Menopause Society. www.thebms.org.uk • John Studd FRCOG. Chelsea and Westminster Hospital London. www.studd.co.uk • HERS JAMA 1998 • WHI JAMA 2002 • MWS LANCET 2003

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