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Everything you need to know about HRT

Everything you need to know about HRT. Urvi Vyas. Menopause. The last menstrual period >12 months amennorhoea with no other cause in women >50 years Occurs earlier in smokers High production of FSH and LH as the negative feedback from oestrogen diminishes. Clinical Features .

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Everything you need to know about HRT

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  1. Everything you need to know about HRT Urvi Vyas

  2. Menopause • The last menstrual period • >12 months amennorhoea with no other cause in women >50 years • Occurs earlier in smokers • High production of FSH and LH as the negative feedback from oestrogen diminishes

  3. Clinical Features • Vasomotor- hot flushes • Urogenital- vaginal dryness and atrophy, recurrent UTI’s and incontinence • Psychological- irritability, confusion, loss of libido, depression • CVS- increased risk of ischaemic heart disease • Osteoporosis- decreased bone density

  4. Management • Oral tablets- oestrogen only, opposed oestrogen, continuous combined oestrogen and progesterone therapy • Patches • Creams • implants

  5. Indications for HRT • Early menopause, continue until age 50 • Hysterectomy before the menopause, even if the ovaries are conserved • Relief of symptoms during the menopause • 2nd line treatment of osteoporosis for women >51 years

  6. Choice of preparation • For women without a uterus i.e had hysterectomy- give oestrogen alone Premarin, Progynova, Harmogen • For women with an intact uterus- progesterone is required for the last 12-14 days of the cycle to prevent endometrial proliferation Prempack, Nuvelle, Trisequens • Continuous combined oestrogen and progesterone therapy- Kliofem, Premique, Climesse

  7. contraindications • Oestrogen-dependent cancer i.e. endometrial cancer • History of breast cancer • Active or recent arterial thromboembolic disease (angina or MI) • VTE • Liver disease • Dubin-Johnson and Rotor syndromes

  8. Evidence regarding risks • The womens health initiative (WHI) (JAMA 2002;288;321) RCT of 16000 asymptomatic post menopausal women aged 50-79, randomised to continuous combined HRT or placebo. • A small increase in the rates of breast cancer (from 30 to 38) coronary heart disease (from 30 to 37) stroke (from 21 to 29) VTE (from 16 to 34)

  9. A decrease in colorectal cancer (from 16 to 10) hip fractures (from 15 to 10) • Overall global risk was 15% higher in the HRT group • Compounding factors were that the average age was 63, older than the UK average, and continuous combined HRT rather than cyclical HRT was used

  10. The Million Women Study • Epidemiological cohort study looking at women’s HRT use when invited for breast screening, and then followed up to look at breast cancer development (Lancet 2003;362:419) • All women on HRT had a higher breast cancer risk than never users • The risk was highest with combined preparations • The absolute risk remains small eg for 1 000 women taking combined HRT for 5 years there would be 6 extra cases of breast cancer

  11. Oestrogen-only HRT and tibolone are associated with small increases in endometrial cancer • Combined HRT decreases endometrial cancer risk • But combined HRT is associated with a greater increase in breast cancer risk than oestrogen-only or tibolone • Because breast cancer is more common, overall there is greater overall risk of cancer with combined HRT

  12. HRT and breast cancer risk • Your pt aged 50, has a 6.1% risk of getting breast cancer in the next 30 year. • If she takes combined HRT for 3 years the risk rises to 6.41% • For 5 years, to 6.7% • For 10 years, to 7.69% • With oestrogen only HRT, after 5 year the risk is 6.28% (BMJ 2005:331:347)

  13. The risk/benefit ratio is favourable to treat menopausal symptoms, in fully-informed women, using the lowest possible doses for the shortest possible time

  14. When Long term HRT needed • Long term combined preparations are less safe than oestrogen alone • Consider using oestrogen alone with an IUS • Consider Tibolone

  15. Tibolone • 1st line treatment for menopausal sx • 2nd line therapy for prevention of osteoporosis • 2.2 times inc risk of stroke • Inc risk of endometrial cancer, risk increases with duration of use • Increased risk of having breast cancer diagnosed, lower than for combined HRT, risk returned to baseline within a few years of stopping treatment • Decreases HDL

  16. Topical creams • Deliver oestrogen locally to vaginal tissues: pessaries, creams, rings • No progesterone is needed but use is limited to 3 months if uterus is present

  17. Alternatives • Clonidine may reduce flushing symptoms but has many side effects • Beta-blockers may be used for palpitations and tachycardia • Antidepressants and sedatives can be used if symptoms persist • Calcium, vitamin D, Bisphosphonates for osteoporosis

  18. Complementary treatments • Black cohosh-seems to ease hot flushes but long term effects are unknown • Red Clover-conflicting evidence, some species contain coumarins so unsuitable for women who take anticoagulants such as warfarin • Dong quai, evening primrose oil, vitamin E and ginseng are no better than placebo • Kava has been linked to cases of serious liver damage and so should be avoided

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