Transcript HRT 2011 - My Surgery Website

The Menopause and HRT
Learning objectives
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Be aware of how women may present
Discuss some of the management options
Consider contraception at the menopause
Demystify some of the preconceptions re
condition and treatment
• Have some idea of the choices available
• Are any HRT preps better : which ones when?
Menopause
• How might it present?
• How do you diagnose it?
Symptoms/Problems
• Physical
• Psychological
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Vasomotor flushing
Less skin collagen
Vaginal dryness
Urinary tract prolapse
Reduced Bone mineral
density
• Increased CVS risk
Insomnia
Reduced concentration
Anxiety
Lethargy
Reduced libido
Menopause
• Average age 51
• 80% post menopausal by 54
• By 1y flushes have stopped in 70%......30% still
have them at 5y
• Decreased no. of follicles, ovaries fail and
don’t respond to pituitary hormones
‘’I think I may be menopausal’’
• Why do they come?
‘’I think I may be menopausal’’
• Women often come to check/for reassurance (similar
to ‘I’m pregnant consultation)
• 80% do not want HRT
• They want advice and info
• Less than 50% of women prescribed hrt are using it
at 1 year
• Websites of use
http://www.cks.library.nhs.uk/menopause
• http://www.womens-healthconcern.org/help/factsheets/fs_hrtrisksbenefits.html
• What could you discuss in a consultation?
Consultation ideas
Peri or post menopausal?
Is it surgical/chemo related?
Promote health
Diet, exercise, breast awareness, mammograms, stop smoking, BP ?lipids,
?depression screening, ?urinary symptoms screening
Assess osteoporotic risk
Contraception
? Tests…FSH/LH,
No point if >45 (levels fluctuate massively)
If <45 +no periods can indicate premature menopause
?Another reason for symptoms
FSH/LH>15 + oestradiol <70pmol/l
2 FSH >30iu/l 6 wks apart
If taking FSH in menstruating women day 2-3 of menses
Case 1
• 44 yr woman
• Had menopause 7 years ago, her HRT was
stopped after 5 years
• Flushing is now ‘ruining her life’
• Thoughts? Votes for action?
Early menopause
• In women with a natural or surgical
menopause before age 45yrs HRT may be
used until the approx age of natural
menopause with no theoretical risk above and
beyond baseline
• The increase in bone density outweighs the
risk of CVD and breast cancer
What types of HRT are there?
What types of HRT are there?
• Are they the same?
Class Actions
Oestrogen
• Vasomotor Symptoms
• Bone Protection
• Urogenital Tract
Progesterone
• Endometrial Protection
• ……….breast tissue
Sequential
• Reg controlled bleeds
• Pt preference
• (cyclical Symptoms)
• (Double charge)
Continuous combined
• Amenorrhoea 90%
• Less blood loss/anaemia
• Better endometrial
protection
• ?less ovarian cancer
• Better compliance
• Cheaper
• (initial irreg btb)
Example preparations
• Continuous combined
– Ellest duet conti
– E.g premique
• Oestrogen only
– Elleste Solo
– Patches/gels/implants
• Cyclical HRT
– Elleste-Duet
– Premique calender pack
14 white (oest) and then
14 green (oest+prog)
– Prempak-C
Progestogens
• C19 derivatives
– Norethisterone
– Levonorgestorel
More androgenic
More likely to cause side
effects
• C21 derivatives
– Medroxyprogestogen
acetate
– Dydrogesterone
• Less androgenic
• Drospirone
(spironolactone deriv)
Tibolone
• Tibolone increases risk of breast cancer (less
than combined HRT)
• Tibolone- combines oestrogenic and
progestogenic activity with androgenic activity
(if poor libido/post endometriosis surgery)…
reduces TG : good for Type 2
DM/oophorectomy
Side Effects
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Oestrogenic
Fluid retention
Bloating
Breast tenderness
Nausea
Headache
Dyspepsia (take with food)
Consider changing dose, changing
oestrogen or changing delivery
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Progestogenic
(In a cyclical pattern)
Fluid retention
Breast tenderness
Mood swings
Depression
Acne
Backache
Reduce progestogen duration
to 10 days per cycle, change
progestogen c19/21
derivatives, delivery
Side effects
• Most side effects disappear if the woman
persists beyond 12 weeks with the
preparation
What to expect
• Cyclical HRT causes a regular withdrawal bleed
near the end of the progestogen phase
• The aim of continuous combined HRT is to
avoid bleeding but irreg bleeding may occur
during early treatment-if this continues > 6m
an endometrial assessment is required
Monitoring
• Review after 3 months and then annually
• Discuss bleeding pattern
• Weight and BP (6/12-annually)
HRT
• BNF states, HRT is suitable for relieving vaginal atrophy or
vasomotor symptoms, not 1st line for osteoporosis …
– National Osteoporosis Society 2011 now say if in 50s and
Sx + bone loss: first line…
• If Sx are local only: most effective Rx is Topical…
– Ovestin or Vagifem
every night 2/52, then 2-3 per week, repeat as necessary
Ovestin
Vagifem
Are there any alternatives?
Alternatives to HRT for flushes
• Some Evidence
• Red Clover (isoflavones)
6/52<
• Sage
• Clonidine
• Phytooestrogens (soya
beans, chickpeas, cereals)
• SSRIs
• Venlafaxine+Gabapentin
• Black cohosh
• Exercise
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No Evidence
Vitamin E
St Johns Wort
Evening primrose
Why do people want alternatives?
Risks: suggested by WHI and MWS
• Increased risk of VTE and CVA
• Increased risk of endometrial cancer (if oestrogen
alone)
• Increased risk of breast cancer (related to duration of
use, combined only, dissipates within 5yrs of
stopping)
• Doesn’t prevent CHD/reduce cognitive decline.. But
may if younger…
• CSM advise minimum effective dose for shortest
duration
• Problems with trials….
HRT and breast cancer: initial
findings
• Hrt increases the risk of breast cancer starting
from the end of the 3rd year, risk reverts to
normal 1 yr after stopping
• Risk increases with duration of use
• Breast cancers in women on HRT are larger
and more advanced than those in women on
placebo
• Data from Women’s Health Initiative
Risks: suggested by WHI and MWS
Later analysis
• 50-59 or within 10y of onset of menopause
– CVD: trend for reduction
– Breast Ca : combined only-not sign if confounding factors
taken into account. Sign reduced if oestrogen alone.
– Ovarian Ca: MWS only, only seen on Oestrogen alone (ie
hysterectomised) ? Sign
– Endometrial Ca: unopposed oestrogen. If C/C no risk
– CVA: starting <60 no incr v non users
– Osteoporosis : only validated treatment for younger
women-combined hrt reduces risk of hip fractures 0.66
(0.45-0.98) NNT 200 for 1 year
Breast cancer
• 14/1000 women aged 50-64 are diagnosed with breast cancer
each year
• 15.5/1000 women aged 50-64 on oestrogen only HRT dx
breast cancer/year
• 20/1000 women aged 50-64 on combined HRT are diagnosed
with breast cancer/year
• 31/1000 women aged 50-79 are diagnosed with breast cancer
each year
• 31/1000 women aged 50-79 on oestrogen only HRT are dx
with breast cancer each year
• 35/1000 women aged 50-79 on combined HRT are diagnosed
with breast cancer/year
Harms
• Cardiovascular disease – combined hrt RR1.29
coronary heart disease, RR1.41 stroke (50-79)
• Breast cancer as described
• Endometrial cancer sequential combined hrt
increases risk by 2 cases per 1000 women over 10yrs
(unopposed oestrogen 5) continuous combined :
reverses hyperplasia_ no increase
• Venous thromboembolism, hazard ratio 2.1 (extra 4
cases per 1000 women on hrt for 5yrs)
Contraindications
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Pregnancy/Breastfeeding
Oestrogen depdt cancer
Angina/MI
VTE
Liver disease
Untreated endometrial hyperplasia
Undiagnosed vaginal bleeding
Special Cases
• Migraine : fluctuating levels can trigger
• Valvular heart disease on warfarin: may incr
bleeding
• Endometriosis (may worsen)
• Hyperlipidaemia: ok with statins: choose lipid
friendly (C21)
• Hypertension: equine can occ trigger incr BP
• Epilepsy: may alter doses needed: transdermal
prob better
When would you stop HRT?
• Immediate stop?
• Other reasons to stop?
Stop if
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Sudden onset severe chest pain
Sudden SOB
Leg pain and ?DVT
Severe headache
Hepatitis/Jaundice
BP > 160/100
Prolonged immobility
Stop HRT 4-6 wks before major surgery
Case 2
• Clara is 52, she has been on HRT for 5 months
• She cant bear the bleeding and comes in teary
as doesn’t want flushes to return
• What do you want to know?
• What could you do or consider?
Bleeding on HRT
• If on a cyclical combined HRt check when the
bleeding is (should be regular and predictable at end
of prog phase)
• Check – compliance
• ?Interactions
• Try a stop in HRT
• ?Other reasons
• If bleeding stops try changing progestogen
• Refer 2 week rule if bleeding continues after HRT has
been stopped for 4 wks
Bleeding on HRT
• Refer non urgently if change in pattern of withdrawal
bleeds and breakthrough bleeding persisting more
than 3/12
• On continuous combined there is a 40% risk of
bleeding in the 1st 4/12
• Check that they were 1 yr post bleed before
commencing
• ~If continues >6/12 then investigate
• If bleeding commences after ammenorrhea on the
prep then investigate
Stopping HRT
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Stop gradually wean off over 6/12
Half dose for 2-3 months
¼ dose for 3/12 then stop
Patches may be cut to achieve this
Don’t reduce the progestogen if on a cyclical regime
If continuous reduce both simultaneously
Review after 1 month if symptoms have recurred consider
restarting at lowest dose
• If only vaginal symptoms then topical oestrogen's
Consider contraception?
• HRT is not contraception
• When is it safe to assume contraception no
longer needed?
Pat
• Pat is 43, she’s been on depo for 6 years and
loves it,
• What should you consider/advise?
June
• June is 48, She has a mirena in, shes
amenorrhoeic and having lots of hot flushes.
She wants to know about HRT and whether
she is ‘going through the change’
Contraception
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HRT is not contraception
If LMP >2yrs ago and <50 yrs is prob ok
If LMP >1yr ago and >50 is prob ok
FSH raise does not guarantee
Jan
• Jan is 50, She has a mirena (for 2 years)
• She hasn’t had any periods since the first 3
months, she wants to know if she still needs it.
Mirena
• Mirena +oestrogen
• Mirena is now licensed for endometrial
protection as the progestogenic part of HRT
combined with a small amount of oestrogen
may control hot flushes
• (4yrs)
Other Questions?