HRT
In a nutshell for all the
blokes out there
diagnosis
 Clinical hx
 FSH limited value as levels
fluctuate
 May be of value in
symtomatic women under
40y
 FSH >30
Also
 Lifestyle
 Smoking
 Alcohol
 Exercise
 caffeine
indications
 Early menopause (<45yrs)
 Under 65yrs with vasomotor
symptoms
 Not to be used for
prevention of osteoporosis
What to discuss at first
consultation
 Risks and benefits
 Expected duration of
treatment
 Symptoms will return when
stopped
 Need assessment annually
 Contraception req
benefits
 Relief of vasomotor
symptoms
 Urogenital symptoms
 Osteoporosis
 Prevention ca colon (by
20%)
 mood
Harms
 CVD
 Increased risk of CHD and
CVA
 Breast cancer
 Endometrial cancer
 Ovarian cancer
 VTE
 dementia
HRT and Br Ca
 Risk depends on type of HRT
 Revert to normal 1yr after
stopping
 Risk increases with duration of
use
 After 10 yrs
 Combined: 19 extra cases per 1000
 Unopposed oestrogen: 5 extra
cases per 1000
Absolute contraindications
 Relatively few:
 Acute phase MI, pe, DVT
 Active endometrial or brCa
 Pregnancy
 Undiagnosed br mass
 Abnormal vaginal bleeding
 Severe active liver disease
Initial assessment
 Hx
 esp risk factors for CVD, hx of Br
ca or VTE
 BP, BMI, bloods (serum lipids
 smoking
 Breast awareness - screening
program
 Cervical screening
 Lifestyle advice
 Document discussion of risks
What preparation
 Elleste duet - woman has
‘period’
 Elleste duet conti - no
‘period’
 Elleste solo - oestrogen only
Other considerations
 CV risk of >20%
 Diabetes
 BMI >30
 FH br Ca
 1 pre-menopausal or 2 postmenopausal
Changing to continuous
 May want to consider at 54
yrs
 Does increase risk of CVD
and brca
Bleeding on cyclical
 GI upset, compliance, drug
interactions
 Options:
 Try stopping- see if stops
 If thought to be due to hrt
 Increase dose of
progesterone or change type
of progesterone
continuous HRT
 Irregular bleeding in 40% in first
4-6m
 Check - Was she at least one
year post menopausal
 Investigate if continuing for > 6
months, becomes heavier, or
occurs after amenorrhoea
 Options come off HRT and see if
stops
 Refer urgently if continues after
4 weeks
Oestrogen side effects
 Fluid retention, bloating,
breast tenderness, nausea
 Most resolve with time
(within 12 weeks)
 If persistent
 Reduce dose
 Change type of oestrogen
 Change route (transdermal)
Progesterone side effects
 Mood swings, headaches,
acne, fluid retention
 If persists
 Reduce duration (not <10d)
 Reduce dose
 Change prog
 Change to long cycling regime
Follow - up
 3 monthly, then 6 monthly
 And then yearly
 Compliance, bleeding
patterns, S.Es
 Talk about coming off
 Smears and mammograms
stopping
 Shortest possible time
 Usually within 5 years
 Symptoms will recur
 Stop abruptly or gradually
How long to continue
 Shortest possible time
 Ideally within 5 yrs
stopping
 Cold turkey
 Premique low dose for a
couple of months
 1 every other day
Other options
 SSRIs
 Clonidine
 Black cohosh
 Topical oestrogens
contraception
 Barrier
 IUD
 IUS
 Low dose COC instead of
HRT
 Continue for 1 years after
LMP in over 50s
 2yrs in under 50s