H.R.T. 2011

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H.R.T.
Dr. Sylvia Bond
11/05/2011
Aims for session
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To be confident with a menopausal
presentation
Structure history taking
Share management decision, based on
evidence
Provide safe, logical prescribing
Menopause
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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
Use of HRT
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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
Effectiveness of symptom
control
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Hot flushes 94%
Night sweats 92%
Irritability 79%
Tiredness 67%
Dyspaurenia 73%
Frequency of micturition 37%
Skin wrinkles 50%
Overall benefited 89%
Side Effects of HRT
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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
S/E cont.
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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
Compliance
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30%
20%
10%
40%
Do not fill script
Stop< 9/12
Take irregularly
Taking regularly at 1 year
Contraindications to HRT
ABSOLUTE
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Pregnancy
Undiagnosed abnormal vaginal bleeding
Breast or Endometrial Cancer
Severe liver disease
PMH Thrombosis
Migraine with aura
Contraindications
RELATIVE
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Endometriosis- 6/12 after TAH
Fibroids
PMH Benign Breast cysts
MI/CVA- 6/12
Gallbladder disease
Major surgery- stop 4/52 prior
Not Contradicted- Caution
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Controlled Hypertension
Epilepsy
Diabetes
Varicose Veins
FH Breast Cancer
Risks/benefits
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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
Long-term Benefits
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Osteoporosis
Bowel cancer
?Alzheimer's
Long-term Risks
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Breast Cancer
Endometrial cancer, If unopposed
Venous thrombosis
Gallbladder disease
?Ovarian cancer
?CVD
HERS the Heart and
Estrogen/progestin Replacement
Study 1998
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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
HERS
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Early harm and late benefit
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Needed primary prevention study
Women’s Health Initiative
2002
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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
WHI cont
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Stopped at 5.2 yrs
29% increase in CHD
41% increase in CVA
26% increase in Breast Cancer
100% increase in VTE
WHI cont
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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
WHI Oestrogen only arm 2004
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CHD
Breast cancer
Colorectal caner
CVD
Deaths
Down 42%
Down 28%
Down 41%
0% Change
Down 27%
Million Women Study 2003
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Oxford
Case controlled
Observational
Diverse range of HRT (Questionnaire)
Age 50-64 (mean age 57)
Attending for mammogram in UK (Bias)
MWS
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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.
Risk of Breast Cancer
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12 per 1000 after 15 years HRT
Comparable to risk of;
alcohol,obesity,having no children,
having late first pregnancy or late
menopause
Current advice on HRT
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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
Duration of use
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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
Assessment for HRT
History
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LMP/Bleeding pattern
Document symptoms
Need for contraception
Hysterectomy
PMH VTE/CHD/CVA
Liver disease
FH Breast Cancer/ Osteoporosis
Examination
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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.
Opportunistic Health
Promotion
Don’t forget the QOF points!!
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Smoking
Alcohol
Diet- Low Cholesterol and High Calcium
Weight bearing exercise
Stress
Chronic disease management
Types of HRT
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Tablets
Patches
Implants
Nasal spray
Gel
Vaginal ring
Pessary
Vaginal cream
Types of HRT
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Hysterectomy – Oestrogen alone
Peri-menopausal – Cyclical HRT
Post-menopausal – Continus Combined
Local vaginal/urological symptoms Topical
Double script charge!
Equivalent doses
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Premarin 0.625mg
Oestrodiol 1mg tab
Oestrodiol 50mcg patch
Alternatives to HRT
“Natural remedies”
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Black Cohosh
Kava Kava
Angus Castus
Red Clover
Magnesium/Zinc
Phytoestrogens (Soya/yam)
Evening Primrose Oil
Alternatives to HRT
Medical Rx
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Antidepressants – SSRIs
Calcium and VitD
Biphosphonates
Dixarit - Clonidine
Explaination
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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
Follow up
Initial 3/12, then 6 /12
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Nurse lead clinics
BP/Weight
Symptom control
Side effects
Any change in personal or family history
Problem solving
Oestrogen s/e
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Mastalgia
Flushes
Cramps
Headaches
BTB
Weight gain
Rash with patch
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Change preparation
Change
Oestridiol/Premarin
Change dose
Problem solving
Progesterone s/e
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PMT
Acne
Risk of CVD/ Lipids
Risk of breast cancer
Weight gain
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Reduce from 14 to 7
days per cycle
Change type. MPA
lipid friendly
CCT over 54yrs, >
12/12 since LMP
Tibolone
Femoston
(Dydrogesterone)
Lack of libido
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Tibolone (Livial)
Testosterone implant
TAH and BSO
FADS, female androgen deficiency
Tired, loss of libido, headache,
depression
Chronic fatigue syndrome
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Often ass. with PMS
Low plasma Oestradiol levels
Low bone density
Rx Transdermal Oestrogen +/Testosterone
Conclusion
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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.
Learning Log
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What did you learn?
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What will you do differently?
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Further learning needs?
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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