I want to start HRT please

1
I want to start HRT please

• Samadhi Reid
• NPT VTS

2
History taking

• Age (52 year old)
• Why does she think she wants HRT?
• What are her expectation?
• Symptoms
• Hysterectomy or not?
• Menstrual hx check for IMB, PCB and Smear hx
• Flushing or sweating
• Urinary symptoms and loss of libido
• (Tiredness, anxiety, irritability, poor sleep
  etc.)

3
History taking cont..

• PMH
• Breast Ca (do you examine your breasts?)
• DVT
• risk factors for CVD (inc smoking)
• FH of above
• DH
• Previous experience of HRT
• Anti epileptics
• If on thyroxine, check TFT as dose may need to
  be ?
• Contraception

4
Management

• Check BP, Weight/ BMI
• Explain what menopause/ peri-menopausal period is
• Reassurance short lived symptoms
• Complementary medicines - ? Red clover ? Soy
• Clonidine - placebo
• Simple measures - cotton wear, fans, avoiding
  triggers, exercise, relaxation techniques

5
HRT

• Contraindications
• Ca breast/ endometrial
• Thromboembolic disease (inc AF)
• Liver disease (raised LFT)
• Indications
• Early menopause - cont until 50 yrs
• Hysterectomy - 14 have early menopause
• Relief of symptoms of oestrogen deficiency

6
Choice of HRT

• Tablets, patches, implants,
• vaginal pessary/ gels/ creams/ rings
• Topical preparations
• For vaginal dryness and atrophic vaginitis
• No progesterone is needed, but limit use to
  3-6/12 if intact uterus
• HRT Androgen implants for loss of libido

7

• No uterus
• Oestrogen only
• Add progesterone, if there is a hx of
  endometriosis
• Intact uterus
• Peri menopausal or first 12/12 since last period
• Withdrawal bleed essential
• Progesterone for the last 2/52
• Check FSH/LH if on cyclical HRT (start of pack)/
  pill (end of pill free week) or
• Stop HRT for 6/52 and check levels

8

• After the first 12/12 of menopause
• Can have a continuous combined preparation or
  Tibolone (Livial)
• Side Effects
• Oestrogen HRT - fluid retention, breast symptoms,
  nausea, headaches
• Progesterone HRT - headache, bloating, weight
  gain, depression

9
Follow up

• Review in 3/12
• Review SE, Check BP and weight
• Increase dose if still symptomatic
• Erratic bleeding common in the first 3/12
• CC preparations - spotting for 12/12 common, Ix
  if gt 12/12
• Review 6 - 12 monthly after

10
Stopping HRT

• Ideally lt 5yrs
• Warn re withdrawal flushes
• Stop in cold weather, halve the dose for 1/12
• Need to discuss pros and cons of HRT

11
Risk and Benefits of HRTOxford General Practice
Library Womens health Oxford Press
12
Thank you!