Transcript Everything you need to know about HRT

EVERYTHING YOU NEED TO
KNOW ABOUT HRT
Urvi Vyas
MENOPAUSE
The last menstrual period
 >12 months amennorhoea with no other cause in
women >50 years
 Occurs earlier in smokers
 High production of FSH and LH as the negative
feedback from oestrogen diminishes

CLINICAL FEATURES
Vasomotor- hot flushes
 Urogenital- vaginal dryness and atrophy,
recurrent UTI’s and incontinence
 Psychological- irritability, confusion, loss of
libido, depression
 CVS- increased risk of ischaemic heart disease
 Osteoporosis- decreased bone density

MANAGEMENT
Oral tablets- oestrogen only, opposed oestrogen,
continuous combined oestrogen and progesterone
therapy
 Patches
 Creams
 implants

INDICATIONS FOR HRT
Early menopause, continue until age 50
 Hysterectomy before the menopause, even if the
ovaries are conserved
 Relief of symptoms during the menopause
 2nd line treatment of osteoporosis for women >51
years

CHOICE OF PREPARATION
For women without a uterus i.e had
hysterectomy- give oestrogen alone
Premarin, Progynova, Harmogen
 For women with an intact uterus- progesterone is
required for the last 12-14 days of the cycle to
prevent endometrial proliferation
Prempack, Nuvelle, Trisequens
 Continuous combined oestrogen and progesterone
therapyKliofem, Premique, Climesse

CONTRAINDICATIONS
Oestrogen-dependent cancer i.e. endometrial
cancer
 History of breast cancer
 Active or recent arterial thromboembolic disease
(angina or MI)
 VTE
 Liver disease
 Dubin-Johnson and Rotor syndromes

EVIDENCE REGARDING RISKS
The womens health initiative (WHI) (JAMA
2002;288;321) RCT of 16000 asymptomatic post
menopausal women aged 50-79, randomised to
continuous combined HRT or placebo.
 A small increase in the rates of
breast cancer (from 30 to 38)
coronary heart disease (from 30 to 37)
stroke (from 21 to 29)
VTE (from 16 to 34)

A decrease in
colorectal cancer (from 16 to 10)
hip fractures (from 15 to 10)
 Overall global risk was 15% higher in the HRT
group
 Compounding factors were that the average age
was 63, older than the UK average, and
continuous combined HRT rather than cyclical
HRT was used

THE MILLION WOMEN STUDY
Epidemiological cohort study looking at women’s
HRT use when invited for breast screening, and
then followed up to look at breast cancer
development (Lancet 2003;362:419)
 All women on HRT had a higher breast cancer
risk than never users
 The risk was highest with combined preparations
 The absolute risk remains small eg for 1 000
women taking combined HRT for 5 years there
would be 6 extra cases of breast cancer

Oestrogen-only HRT and tibolone are associated
with small increases in endometrial cancer
 Combined HRT decreases endometrial cancer
risk
 But combined HRT is associated with a greater
increase in breast cancer risk than oestrogenonly or tibolone
 Because breast cancer is more common, overall
there is greater overall risk of cancer with
combined HRT

HRT AND BREAST CANCER RISK
Your pt aged 50, has a 6.1% risk of getting breast
cancer in the next 30 year.
 If she takes combined HRT for 3 years the risk
rises to 6.41%
 For 5 years, to 6.7%
 For 10 years, to 7.69%
 With oestrogen only HRT, after 5 year the risk is
6.28%
(BMJ 2005:331:347)


The risk/benefit ratio is favourable to treat
menopausal symptoms, in fully-informed women,
using the lowest possible doses for the shortest
possible time
WHEN LONG TERM HRT NEEDED
Long term combined preparations are less safe
than oestrogen alone
 Consider using oestrogen alone with an IUS
 Consider Tibolone

TIBOLONE
1st line treatment for menopausal sx
 2nd line therapy for prevention of osteoporosis
 2.2 times inc risk of stroke
 Inc risk of endometrial cancer, risk increases
with duration of use
 Increased risk of having breast cancer diagnosed,
lower than for combined HRT, risk returned to
baseline within a few years of stopping treatment
 Decreases HDL

TOPICAL CREAMS
Deliver oestrogen locally to vaginal tissues:
pessaries, creams, rings
 No progesterone is needed but use is limited to 3
months if uterus is present

ALTERNATIVES
Clonidine may reduce flushing symptoms but has
many side effects
 Beta-blockers may be used for palpitations and
tachycardia
 Antidepressants and sedatives can be used if
symptoms persist
 Calcium, vitamin D, Bisphosphonates for
osteoporosis

COMPLEMENTARY TREATMENTS
Black cohosh-seems to ease hot flushes but long
term effects are unknown
 Red Clover-conflicting evidence, some species
contain coumarins so unsuitable for women who
take anticoagulants such as warfarin
 Dong quai, evening primrose oil, vitamin E and
ginseng are no better than placebo
 Kava has been linked to cases of serious liver
damage and so should be avoided
