Slide 1

Slide 2 HORMONE REPLACEMENT, AN OVERVIEW DR SARAH WHITFIELD Slide 3 Aims To increase confidence in dealing with menopausal symptoms in women. To increase knowledge with regards counselling a woman about HRT and prescribing it. Objectives Look at who HRT can be prescribed for Contra-indications to HRT Benfits versus risks Types of HRT How long? When to stop Alternatives to HRT Case Studies to apply what we have learnt Slide 4 WHO NEEDS HRT? Women with Premature ovarian failure. Age RISKS CVD. RC data from Danish osteoporosis trial, reduced incidence CHD by 50% if commenced within 10 year of menopause. [window of opportunity for primary prevention]. BUT WHI RCT, small increase incidence CHD first 12 months. In women > 60 and large dose Cognition Obervational data, improvement if HRT started early in menopause, possibly reduces long term risk Alzheimers but further trials needed Evidence form well designed studies e.g WHI, no significant improvement in memory or cognitive function with HRT in older PM women Increases risk dementia in women 65-79 Slide 13 RISKS CONTINUED Breast cancer WHI small increased risk, MWS raised concerns Recent critique of both, number of key flaws on both which limit the ability of the trials to establish a causal association Ovarian Cancer Conflicting data Endometrial cancer Unopposed E therapy increases but largely neutralised with use progesterone Sequential combined HRT may be associated with small increase Continuous combined significant reduction Colorectal cancer Reduction [no data on transdermal] Slide 14 WOMENS AGE AND RISK Up to age 50 No risk 50-60 Benefits outweigh risks 60-70 Benefits = Risks [over 60 swap to transdermal route] >70 Risks outweigh benefits Slide 15 OESTROGEN ONLY HRT Women without a uterus Oral tablet (daily). Transdermal patch (once weekly or twice weekly) or gel (daily). Vaginal ring (Estring ), creams, and pessaries. Non oral oestrogen avoids first pass effect through liver, doesnt increase risk VTE Conjugated [equine] or estradiol, both deemed natural. Synthetic oestrogens e.g ethinyloestradiol not suitable Slide 16 OESTEROGEN/PROGESTERONE HRT Perimenopausal women Need to be on combined cyclical preparations. Progesterone is needed for some part of the cycle as endometrial protection from the uterus. It is easiest to prescribe in a one tablet preparation. There are 2 types; 1/ Monthly cyclical regimen; oestrogen is in every daily tablet, progesterone is in 10-14 tablets at the end of each cycle. Expect monthly withdrawal bleed after progesterone finished. This is the usual regimen. 2/ 3 monthly cyclical regimen, oestrogen daily, progesterone for 14/7 every 13 weeks. Only one available is Tridestra Norethisterone and levonogestrel [norgestrel]; more androgenic [patches container either of these, no other progesterones] Dydrogesterone and medroxyprogesterone; less androgenic and often better tolerated Drospirenone; less androgenic, may be useful in women who c/o fluid retention in progesterone phase Slide 17 OESTROGEN/PROGESTERONE COMBINED HRT Postmenopausal Women Can be switched from cyclical to continous combined preparations [no bleed except poss irreg first 6 months, refer if spotting after 6 month]. May be difficult to decide when they become postmenopausal [1 year after amenorrhoea] 54 years [80% women postmenopausal] Previous amenorrhoea or raised FSH and been on HRT for several years likely postmenopausal. Oral tablet (daily). Transdermal patch (once weekly or twice weekly): In transdermal combined hormone replacement therapy (cyclical or continuous) the progestogen is either combined into the patch or given separately as a tablet. Slide 18 HOW LONG? WHEN TO STOP POF, up to age 51-52 then discuss further risks benefits For peri/postmenopausal, advised for some time in view of WHI and MWS is smallest dose, shortest period of time. Very recently, thinking up to age 60 probably benefits outweigh risks. 60-70 benefits equal risks, and over 70 no place for HRT. How to stop? Abrupt or reduced dose over 2-3 months Slide 19 LIFESTYLE ADVICE FOR MENOPAUSAL SYMPTOMS Hot flushes and night sweats: Taking regular exercise and losing weight (if applicable) may reduce the severity and frequency of flushes. Wearing lighter clothing, sleeping in a cooler room, reducing stress, and avoiding possible triggers (such as spicy foods, caffeine, smoking, and alcohol) may also be helpful in reducing these symptoms. Sleep disturbances: Avoiding exercise late in the day and maintaining a regular bedtime can improve sleep. Mood and anxiety disturbances: Adequate sleep, regular physical activity, and relaxation exercises may help. Cognitive symptoms: Exercise and good sleep hygiene may improve subjective cognitive symptoms. Slide 20 ALTERNATIVES TO HRT Clonidine marginal benefit of clonidine over placebo SSRIs A significant amount of evidence exists for the efficacy of SSRIs such as fluoxetine and paroxetine in treating vasomotor symptoms; Gabapentin, hot flushs use is limited by side effects such as drowsiness Tibolone. synthetic steroid hormone oest, prog and androgen properties] CVA increased 2.2 fold [risks outweigh benefits age > 60]Increase risk endometrial Ca [increased risk with duration of use, may causes spotting first 6 months] Increase risk breast ca Slide 21 OTHER ALTERNATIVES Red clover Black cohosh Phytoestrogens Slide 22 LETS LOOK AT SOME CASES! Slide 23 SUMMARY HRT prescribed before the age of 60 has a favourable benefit/risk profile. It is imperative that women with POF are encouraged to use HRT at least until the average age of the menopause. If HRT is to be used in women over 60 years of age, lower doses should be started, preferably with a transdermal route of administration