(2008 BPAC)

Summary

Urogential symptoms

• vaginal oestrogen

Hysterectomy

• continuous oestrogen

Intact uterus

Premature menopause (\<40)

• continue HRT until 50

• low dose OCP or

• cont oestrogen + cyclic/continuous progestin or

• Tibolone

Menopausal transition

• low dose COC

• continuosu oestrogen + cyclic progestin 14d each cycle (d 15-28) + contraceptoin

• continuous oestrogen + LNG releasing IUD

Post menopausal

• continuous oestrogen + continuous progestin

• continuous oestrogen + cyclic progesting or LNG IUD

Background

• 10% women seek help from GP

• HRT popular until 2002

  • evidence emerge of signifant risks

• most effective treatment for symptoms of menopause

Risk / Benefit

• consider:

  • treatment goals

  • benefits

  • risks

• factors to consider:

  • time of menopause

  • impact of symptoms on QoL

  • Underlying risk of:

    • CVD

    • Stroke

    • VTE

    • cancers

    • other conditions

  • Suitability of other treatments

Combined treatment

• risks

  • breast ca

  • Coronary heart disease

    • first year of use

  • dementia and cognition

    • >65yo

  • gall bladder disease

  • stroke VTE

  • ?ovarian cancer

• benefits

  • vasomotor

  • urogenital

  • sleep disturbance

  • osteoporotic #

  • colorectal cancer

  • ?DM

Oestrogen only

• Risks

  • endometrial cancer (if uterus present)

  • gall bladder disease

  • stroke

  • VTE

  • ?ovarian

• Benefits

  • as per Combined

  • ?depression

Contraindications

• previous breast cancer

• previous or high risk of CV disease

• previosu or high risk of VTE

• Dementia

HRT not recommended for prevention of chronic illness

Indications

• vasomotor:

  • hot flushes

  • night sweats

  • improvement may be seen within 4 weeks

  • short term use (1-2yrs) appropriate as flushes disappear within few years of menopause in about 2/5 women

• urogenital symptoms:

  • dyness

  • soreness

  • dyspareunia

  • increase urinary frequency/urgency

  • occur in 50%

  • topical vaginal oestrogen may provide benefit

  • response can take several months

  • systemic absorption minimal

Management/dosing

use lowest dose, for shortest duration possible

women beginning treatment

• 0.3mg conjugated oestrogen or

• 0.5-1.0mg 17-B-oestradiol or oestradiol valerate (low dose)

women who have had hysterecotmy

• oestrogen only

• continusous

women with uterus

• add progestogen to protect endometrium

  • oral

  • intrauterine system

• low dose prepacked regimens can be used initially

perimenopausal/recent menopause

• combined sequential treatment

  • oestrogen daily with progestogen 10-14 days/month

• oestrogen started on first day of menstrual bleed

• progestogen 14 days later

  • withdrawal bleeding should then starrt at time that next period would be expected

-

postmenopausal for ≥1yr

• combined continuous treatment

  • oestrogen and progestogen daily

  • may cause irregular bleeding in first 6-12 months of daily use

women with premature menopause may have more severe symptoms == higher doses of HRT

adverse effects

• irregular bleeding = combined regimes

• nausea

• breast tenderness

• symptoms decrease over time

• lowering dose = reduce these effects

Monitoring

• before treatment

  • cardiovascular risk assessment

  • up to date breast and cervical screening

  • DEXA = case-case

  • Endometrial investigation not usually required

    • unless intermenstrual bleeding or bleeding after 1-2 years no periods

• during treatment

  • BP

  • others done as indicated

Discontinue

• 75% women stop HRT 2 years; usually without seeing GP

• attempted withdrawal appropriate after 1-2yrs

  • see if symptoms resolved

• 50% recurring if treatment stopped

• stop abruptly vs taper

  • arguments….

  • give women choice

• if return of symptoms:

  • restart

  • dose slowly decreased over next 3-6 months

  • non hormonal

alternatives

• Lifestyle

  - Exercise

  • weight managment

  • smoking

  • stop caffeine/etoh

• SSRI

• Tibolone

  • synthetic steroid

    • weak oestrogenic

    • progestogenic

    • androgenic

• Soy produces

• evening primrose oil

Risks/benefits

Osteoporosis

• reducing risk osteoporotic # and increaseing bone density

• life long use required to prevent bone #

• not first line for women with B low BMD

• Hazard:

  • 0.76 (0.69-0.85) combined

  • 0.70 (0.63 -0.79) oestrogen only

Coronary heart disease

• conflicting evidence

• timing hypothesis

• increase in first year of treatment

• most were over 64 at time of trial entry

• Hazard

  • 1.24 combined (1.00-1.54)

  • 1.92 first year (1.09-3.01)

  • Oestrogen only (0.95-1.16)

-

Stroke

• increased

• absolute risk = lower for women under 60 in whom menopause occured within previous 5 years

• Hazard

  • combined 1.41 (1.07 - 1.85)

  • Oestrogen 1.39 (1.10-1.77)

Dementia

• doesn’t prevent cognitive decline

• 2 fold increase in >75 if taking

Ovarian cancer

• evidence conflicting

• HRT - esp oestrogen only

  • increased risk

  • 1.28

VTE

• signifiant increase in risk

• greatst first 102 years of treatment

• absolute risk small - baseline = 1.7 events per 1000

  • 1.95 combined, 1.47 oestrogen

breast cancer

• increases risk of diagnosis/recurrence

• oestrogen only doesn’t appear to increase risk

• 1.24 for combined (1.01-1.54)