HRTHRT

In a nutshell for all the blokes out

there

In a nutshell for all the blokes out

there

diagnosisdiagnosis

Clinical hx FSH limited value as levels fluctuate

May be of value in symtomatic women under 40y

FSH >30

Clinical hx FSH limited value as levels fluctuate

May be of value in symtomatic women under 40y

FSH >30

AlsoAlso

Lifestyle Smoking Alcohol Exercise caffeine

Lifestyle Smoking Alcohol Exercise caffeine

indicationsindications

Early menopause (<45yrs)

Under 65yrs with vasomotor symptoms

Not to be used for prevention of osteoporosis

Early menopause (<45yrs)

Under 65yrs with vasomotor symptoms

Not to be used for prevention of osteoporosis

What to discuss at first consultationWhat to discuss at first consultation

Risks and benefits Expected duration of treatment

Symptoms will return when stopped

Need assessment annually

Contraception req

Risks and benefits Expected duration of treatment

Symptoms will return when stopped

Need assessment annually

Contraception req

benefitsbenefits

Relief of vasomotor symptoms

Urogenital symptoms Osteoporosis Prevention ca colon (by 20%)

mood

Relief of vasomotor symptoms

Urogenital symptoms Osteoporosis Prevention ca colon (by 20%)

mood

HarmsHarms

CVD Increased risk of CHD and CVA

Breast cancer Endometrial cancer Ovarian cancer VTE dementia

CVD Increased risk of CHD and CVA

Breast cancer Endometrial cancer Ovarian cancer VTE dementia

HRT and Br CaHRT 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

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

Absolute contraindications Relatively few: Acute phase MI, pe, DVT Active endometrial or brCa

Pregnancy Undiagnosed br mass Abnormal vaginal bleeding Severe active liver disease

Relatively few: Acute phase MI, pe, DVT Active endometrial or brCa

Pregnancy Undiagnosed br mass Abnormal vaginal bleeding Severe active liver disease

Initial assessmentInitial 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

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 preparationWhat preparation

Elleste duet - woman has ‘period’

Elleste duet conti - no ‘period’

Elleste solo - oestrogen only

Elleste duet - woman has ‘period’

Elleste duet conti - no ‘period’

Elleste solo - oestrogen only

Other considerationsOther considerations

CV risk of >20% Diabetes BMI >30 FH br Ca

1 pre-menopausal or 2 post-menopausal

CV risk of >20% Diabetes BMI >30 FH br Ca

1 pre-menopausal or 2 post-menopausal

Changing to continuous

Changing to continuous

May want to consider at 54 yrs

Does increase risk of CVD and brca

May want to consider at 54 yrs

Does increase risk of CVD and brca

Bleeding on cyclicalBleeding 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

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 HRTcontinuous 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

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

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)

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

Progesterone side effects

Mood swings, headaches, acne, fluid retention

If persists Reduce duration (not <10d)

Reduce dose Change prog Change to long cycling regime

Mood swings, headaches, acne, fluid retention

If persists Reduce duration (not <10d)

Reduce dose Change prog Change to long cycling regime

Follow - upFollow - up

3 monthly, then 6 monthly

And then yearly Compliance, bleeding patterns, S.Es

Talk about coming off Smears and mammograms

3 monthly, then 6 monthly

And then yearly Compliance, bleeding patterns, S.Es

Talk about coming off Smears and mammograms

stoppingstopping

Shortest possible time

Usually within 5 years

Symptoms will recur Stop abruptly or gradually

Shortest possible time

Usually within 5 years

Symptoms will recur Stop abruptly or gradually

How long to continueHow long to continue

Shortest possible time

Ideally within 5 yrs

Shortest possible time

Ideally within 5 yrs

stoppingstopping

Cold turkey Premique low dose for a couple of months

1 every other day

Cold turkey Premique low dose for a couple of months

1 every other day

Other optionsOther options

SSRIs Clonidine Black cohosh Topical oestrogens

SSRIs Clonidine Black cohosh Topical oestrogens

contraceptioncontraception

Barrier IUD IUS Low dose COC instead of HRT

Continue for 1 years after LMP in over 50s

2yrs in under 50s

Barrier IUD IUS Low dose COC instead of HRT

Continue for 1 years after LMP in over 50s

2yrs in under 50s