HRT

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HRT
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MENOPAUSAL SYMPTOMS AND CHANGES

• Loss of oestrogen
• Short term- irregular periods, hot flushes and
  night sweats, vaginal dryness, stress
  incontinence.
• Longer term- osteoporosis, heart disease.

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• Loss of progesterone-
• Does not cause symptoms like oestrogen.
• If oestrogen supplementation is given is needed
  to protect the endometrium.

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INDICATIONS FOR USE

• New data has significantly changed practice.
• Main indication now troublesome menopausal
  symptoms.
• Also still recommended in women with early
  menopause until the age of 50 years.

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MILLION WOMEN STUDY

• Epidemiological study.
• ALL women on HRT had an increased risk of breast
  cancer.
• Highest risk with combined preparations.
• Risk increases with duration of use, BUT
  decreases when stopped.

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• Also looked at Tibolone. Found to increase risk
  of breast cancer but to a lesser degree than
  combined HRT.

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Absolute risks

• These remain small.
• For combined HRT there would be 6 extra cases per
  1000 women over five years and 19 extra cases in
  10 years.
• Oestrogen only HRT is lower with 2 extra cases
  over 5 years and 5 extra cases over 10 years.

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WOMANS HEALTH INITIATIVE

• Stopped three years early due to evidence of
  increased risks of continuous combined HRT.
• Significantly increased risk of Coronary heart
  disease, breast cancer, stroke and venous
  thromboembolism.
• Decreased risk of Colonic cancer and hip
  fractures.

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• Oestrogen-only arm stopped early this year as an
  increased risk of stroke and dementia was found.

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Different populations?

• Average patient age was 63, with is significantly
  older than in the UK.
• Did not look at cyclical HRT.
• Only looked at oral preparations.

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WHO TO PRESCRIBE FOR?

• ???

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MENOPAUSAL SYMPTOMS

• For many women with menopausal symptoms the
  benefits outweigh the risks of short term
  therapy.
• Highly effective for vasomotor symptoms and
  alleviates hormone related mood change and
  insomnia.
• Both systemic and vaginal oestrogen will help
  atrophic vaginitis.

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• Treat at lowest effective dose and review yearly.
• Women should be counselled regarding long term
  risks if wishing to continue treatment after five
  years.

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PREVETION OF OSTEOPOROSIS

• No longer indicated as first line to prevent
  osteoporosis.
• Risks outweigh benefits as treatments with less
  adverse effects are available.
• Can be considered in women unable to tolerate
  bisphosphonates or those who do not respond to
  treatment.

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CENTRAL NERVOUS SYSTEM DISORDERS

• WHI showed no beneficial effect of HRT on
  Alzheimer's disease, and showed an increase in
  all-cause dementia in women on HRT.
• Does not treat endogenous depression, but may
  reduce night sweats and insomnia.

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LOSS OF LIBIDO

• Common in post-menopausal women.
• Cause usually multifactorial and not due to
  menopause alone.
• For some (few) women oestrogen in combination
  with androgens may be effective, as may tibolone.

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CARDIOVASCULAR DISEASE

• Previously thought to be beneficial.
• Risks of stroke and possibly myocardial
  infarction now found to be higher on HRT.
• Therefore no evidence to use as primary or
  secondary prevention of CHD.
• Women should have their coronary heart disease
  risk assessed before starting HRT and after any
  cardiovascular event.

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PREMATURE MENOPAUSE

• No conclusive evidence as yet.
• Current advice is to use until the age of 50
  years.
• This is felt to bring the risks of breast cancer
  to equal that of a woman who did not have a
  premature menopause.

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Cumulative cancer risk
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Cardiovascular risk
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Benefits
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PREPARATIONS

• Can be given as tablets, patches, creams, gels,
  and implants. Progesterone can be given using
  IUS.
• Varying patient acceptability.

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LOCAL SYMPTOMS

• Vaginal dryness alone can be treated by topical
  oestrogen creams or pessaries. These will
  sometimes help with incontinence.
• If combined with other symptoms responds to
  systemic HRT.
• Can have variable systemic absorption so care
  over log term if uterus is present.

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COMBINED CYCLICAL HRT

• Women who are still having periods or menopausal
  symptoms.
• Will produce a withdrawal bleed.
• Can be converted to continuous HRT after 2-3
  years.
• Patients have to pay for two prescriptions in
  many cases.
• Does NOT provide contraception.

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COMBINED CONTINUOUS HRT

• Period free version.
• Spotting may occur, especially on low dose
  preparations.
• Can be started straight off if no menstrual
  period for 1 year.
• Progesterone not available in patch formation but
  mirena coil can be used.

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SUMMARY

• Main indication is symptomatic menopause.
• New data indicates less favourable riskbenefit
  ratio.
• Patients need to be aware of long term risks and
  have a yearly review.
• Consider topical vaginal treatment if only local
  symptoms.