Hormone Replacement Therapy

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Hormone Replacement Therapy

• Aleem Qureshi

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Menopause

• Immediate Symptoms
• Flushing and night sweats
• Skin changes vaginal dryness, breast reduction,
  loss of skin elasticity
• Mood changes mood swings, energy loss,
  concentration loss
• Long term Effects
• Loss of bone density
• ?Heart disease ?Alzheimers

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Benefits

• Proven and licensed for
• Symptomatic relief
• Prevent and treat osteoporosis

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Modes of Administration

• Tablets bleed monthly, three monthly or not at
  all
• Patches
• Implants
• Gels
• Vaginal

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Progesterone

• Any woman taking HRT who has not had a
  hysterectomy must take combined HRT

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Absolute contraindications

• Pregnancy
• Active venous thromboembolism
• Severe active liver disease
• Endometrial or breast cancer (active)

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Relative contraindications

• Uninvestigated abnormal PV bleed
• Undiagnosed breast lump
• Previous endometrial or breast cancer

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• Strong family history of breast cancer (screen
  for BRCA1/2 if 2 relatives under 45 with breast
  cancer)
• Previous VTE
• FH of VTE

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HRT and VTE

• Previously thought HRT did not have effect on VTE
• Now known to increase VTE by x 3
• Transdermal has less risk than oral

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HRT and VTE

• Non HRT user 1 in 10 000
• HRT user 3 in 10 000
• Pregnancy 6 in 10 000

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HRT and VTE - RCOG

• Counsel all women about risk of VTE
• Inform of signs and symptoms and to seek help
• No indication for routine thrombophilia screen to
  start HRT
• Assess for risks of VTE, past history or family
  history
• Women with personal or FH should have
  thrombophilia screen but try and avoid HRT

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Monitoring Women on HRT

• Review after 3 months
• Review yearly for symptoms, side effects, check
  BP

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HRT and CVS

• Heart disease increases after menopause
• Early studies showed decrease in MI
• More recent studies showed no reduction and trend
  to increased MI in first year of use
• No longer use to protect against cardiac disease

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HRT and Brain

• New data suggest HRT increases risk of stroke
• Small increase from 3 per 1000 to 4 per 1000 for
  5 years use by 50 year old
• ? Observational study suggest decrease risk and
  delayed onset of Alzheimers

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HRT and Breast Cancer

• Most studies suggest increased incidence of
  breast cancer with long term use
• Risk increases within 1-2 years of starting HRT

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Womens Health Initiative HRT Trial 2002

• Study in USA
• RCT
• Over 8000 women in each group
• One group on oral HRT

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• Terminated early at 5 years due to risks
• Study designed to look at long term risks
  especially cardiac
• No benefit in CHD and breast disease

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Womens Health Initiative HRT Trial 2002

• Increased risks
• Breast Cancer
• CHD
• Stroke
• Decreased risks
• Colorectal ca
• Hip Fracture

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Million Women Study

• 1 084 110 UK women aged 50-64 between 1996-2001
• HRT use and cancer incidence and death
• Half had used HRT

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• Current users more likely to develop breast
  cancer than never users
• No difference for route or dose
• Risk returns to baseline 5 years after stopping
• Use of HRT in UK over past 10 years has caused 20
  000 extra breast cancers

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Young women and HRT

• Premature menopause
• Favourable to give until 50
• Should remain on HRT until 50
• Then use HRT as second line treatment for
  osteoporosis

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Osteoporosis

• Over 200 000 fractures in UK each year
• Annual NHS cost 940 million
• 1/3 of women will get fracture due to osteoporosis

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Risk Factors

• Female
• Smoking
• Alcohol
• Early menopause
• Steroids
• Low BMI, diet
• Family History
• Medical problems Hyperparathyroid, cushings

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NICE recommendations

• Prevention no treatment cost effective
• Lifestyle changes only
• In confirmed cases bisphosphonates first line
• HRT/Raloxifine second line

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Type of symptoms and progestogen choice If
symptoms are PMS-like, try a less androgenic
progestogen (MPA, dydrogesterone) For loss of
libido, try a more androgenic progestogen
(norethisterone, norgestrel or levonorgestrel)
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Future of HRT

• Short term use (lt 5 years) for severe menopausal
  symptoms
• Not lifestyle or youth pill
• No evidence of cardiac benefits
• Increased risk of breast cancer
• Protect bones but better non-HRT drugs now
  available