1 / 42

H.R.T. Dr. Sylvia Bond 11/05/2011

H.R.T. Dr. Sylvia Bond 11/05/2011 . Aims for session. To be confident with a menopausal presentation Structure history taking Share management decision, based on evidence Provide safe, logical prescribing. Menopause. Date of last menstruation Normally 45-55 years

fathi
Download Presentation

H.R.T. Dr. Sylvia Bond 11/05/2011

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript


  1. H.R.T. Dr. Sylvia Bond 11/05/2011

  2. Aims for session • To be confident with a menopausal presentation • Structure history taking • Share management decision, based on evidence • Provide safe, logical prescribing

  3. Menopause • Date of last menstruation • Normally 45-55 years • Perimenopause several years • Oestrogen and Progesterone decrease • FSH (>32) and LH increase • Postmenopausal > 12/12 since LMP

  4. Use of HRT • USA 80% and UK 10% in 1990s • 2-5 years symptom control • 5-10 years or for life for prevention Osteoporosis and other less certain areas

  5. Effectiveness of symptom control • Hot flushes 94% • Night sweats 92% • Irritability 79% • Tiredness 67% • Dyspaurenia 73% • Frequency of micturition 37% • Skin wrinkles 50% • Overall benefited 89%

  6. Side Effects of HRT • Genitourinary – Fluid retention/ BTB/Menorrhagia/Dysmenorrnoea/PMT/ Cystitis/Candida • Breasts – Mastalgia/Glacotorrhoea • Nausea/Vomiting/Bloating/Jaundice • Skin – Chloasma/ Hair gain or loss • Eyes – Intolerance to contact lens

  7. S/E cont. • CNS – Headache increase or decrease/dizziness • CVS – Thrombosis/Cramps • Mental state – Mood swings/Depression • Weight change/redistribution • Any other s/e a woman believes is related will affect compliance

  8. Compliance • 30% Do not fill script • 20% Stop< 9/12 • 10% Take irregularly • 40% Taking regularly at 1 year

  9. Contraindications to HRTABSOLUTE • Pregnancy • Undiagnosed abnormal vaginal bleeding • Breast or Endometrial Cancer • Severe liver disease • PMH Thrombosis • Migraine with aura

  10. ContraindicationsRELATIVE • Endometriosis- 6/12 after TAH • Fibroids • PMH Benign Breast cysts • MI/CVA- 6/12 • Gallbladder disease • Major surgery- stop 4/52 prior

  11. Not Contradicted- Caution • Controlled Hypertension • Epilepsy • Diabetes • Varicose Veins • FH Breast Cancer

  12. Risks/benefits • HELP!! • Evidence changing • Trials poor quality • Public concern/ Media hype • Be prepared • Evaluate what your patient has heard and how much they want to know

  13. Long-term Benefits • Osteoporosis • Bowel cancer • ?Alzheimer's

  14. Long-term Risks • Breast Cancer • Endometrial cancer, If unopposed • Venous thrombosis • Gallbladder disease • ?Ovarian cancer • ?CVD

  15. HERSHERS HERS the Heart and Estrogen/progestin Replacement Study 1998 • Placebo controlled study • Secondary prevention/established CHD • Average age 66.3 years • Increase HDL/decreased LDL • Non-sig increase CHD at 1 year • Non-sig decrease CHD at 4 years

  16. HERS • Early harm and late benefit • Needed primary prevention study

  17. Women’s Health Initiative2002 • Prempo ( not available in uk) • Premarin 0.625mg and 2.5mg MPA • 8,506 ASYMPTOMATIC WOMEN • Age 50-79 yrs, average 63 yrs. • 23% above 70 yrs • Not primary prevention • 40% were on statins/ antihypertensives • 7.7% had had Coronary thrombosis

  18. WHI cont • Stopped at 5.2 yrs • 29% increase in CHD • 41% increase in CVA • 26% increase in Breast Cancer • 100% increase in VTE

  19. WHI cont • Decrease in Hip and Vertebral fracture and Colonic Cancer • CVD only increased in women who started HRT 20 Yrs after menopause • Non-sig REDUCTION if started within 10 yrs

  20. WHI Oestrogen only arm 2004 • CHD Down 42% • Breast cancer Down 28% • Colorectal caner Down 41% • CVD 0% Change • Deaths Down 27%

  21. Million Women Study 2003 • Oxford • Case controlled • Observational • Diverse range of HRT (Questionnaire) • Age 50-64 (mean age 57) • Attending for mammogram in UK (Bias)

  22. MWS • 30% increase in breast cancer in women taking unopposed oestrogen • Risk starts at 1 year and disappears after Rx stopped. • 9364 had breast cancer, 2224 were excluded? Why.

  23. Risk of Breast Cancer • 12 per 1000 after 15 years HRT • Comparable to risk of; alcohol,obesity,having no children, having late first pregnancy or late menopause

  24. Current advice on HRT • Use for symptoms or low bone density • NOT secondary prevention of CVD • Do not commence after 60yrs • In symptomatic women ? Prevention CHD and Alzheimer’s • ? reduce Progesterone to 7 days

  25. Duration of use • Clock starts ticking at 50 yrs • Asymptomatic or <1yr 18% • 1-5yrs 56% • 5+ yrs 26% • Still symptomatic in 60s 10% • May be reluctant to stop at 5yrs • Wean off gradually

  26. Assessment for HRTHistory • LMP/Bleeding pattern • Document symptoms • Need for contraception • Hysterectomy • PMH VTE/CHD/CVA • Liver disease • FH Breast Cancer/ Osteoporosis

  27. Examination • Blood Pressure • Weight • PV if abnormal bleeding • Cervical Smear If due • Mammogram as part of national screening programme only • FSH if hysterectomy or irregular bleed, <45yrs, if contraception an issue.

  28. Opportunistic Health Promotion Don’t forget the QOF points!! • Smoking • Alcohol • Diet- Low Cholesterol and High Calcium • Weight bearing exercise • Stress • Chronic disease management

  29. Types of HRT • Tablets • Patches • Implants • Nasal spray • Gel • Vaginal ring • Pessary • Vaginal cream

  30. Types of HRT • Hysterectomy – Oestrogen alone • Peri-menopausal – Cyclical HRT Double script charge! • Post-menopausal – Continus Combined • Local vaginal/urological symptoms - Topical

  31. Equivalent doses • Premarin 0.625mg • Oestrodiol 1mg tab • Oestrodiol 50mcg patch

  32. Alternatives to HRT“Natural remedies” • Black Cohosh • Kava Kava • Angus Castus • Red Clover • Magnesium/Zinc • Phytoestrogens (Soya/yam) • Evening Primrose Oil

  33. Alternatives to HRTMedical Rx • Antidepressants – SSRIs • Calcium and VitD • Biphosphonates • Dixarit - Clonidine

  34. Explaination • How to take • Side effects • Risks/Benefits • Consider written info/Loan books or videos • 10 min appt time is running out! • Discuss and review with questions • Practice nurse role in counselling

  35. Follow upInitial 3/12, then 6 /12 • Nurse lead clinics • BP/Weight • Symptom control • Side effects • Any change in personal or family history

  36. Mastalgia Flushes Cramps Headaches BTB Weight gain Rash with patch Change preparation Change Oestridiol/Premarin Change dose Problem solvingOestrogen s/e

  37. PMT Acne Risk of CVD/ Lipids Risk of breast cancer Weight gain Reduce from 14 to 7 days per cycle Change type. MPA lipid friendly CCT over 54yrs, > 12/12 since LMP Tibolone Femoston (Dydrogesterone) Problem solvingProgesterone s/e

  38. Lack of libido • Tibolone (Livial) • Testosterone implant • TAH and BSO • FADS, female androgen deficiency • Tired, loss of libido, headache, depression

  39. Chronic fatigue syndrome • Often ass. with PMS • Low plasma Oestradiol levels • Low bone density • Rx Transdermal Oestrogen +/- Testosterone

  40. Conclusion • HRT has a vital role in the wellbeing of many perimenopausal women. • One dose does not fit all. • Symptomatic women should be offered information and choice. • HRT does not have a role in life-long prevention of osteoporosis or CVD.

  41. Learning Log • What did you learn? • What will you do differently? • Further learning needs?

  42. References • British Menopause Society. www.thebms.org.uk • John Studd FRCOG. Chelsea and Westminster Hospital London. www.studd.co.uk • HERS JAMA 1998 • WHI JAMA 2002 • MWS LANCET 2003

More Related