Hormone Replacement TherapyDr Belinda Magnus

Menopause - Background Vasomotor symptoms affect around 80%

women during the menopause – severe in 20%

Median symptom duration 4 years – up to 12 years in 10%.

NB Diagnosis is usually clinical based on typical symptoms - 1yr amenorrhoea > 50yo, 2 yrs < 50yo

HRT – Indications for Use For women with premature/ early

menopause (<40yo or <45yo respectively) until the age of natural menopause – around 51yo

For treating menopausal symptoms where risk:benefit ratio is favourable in FULLY INFORMED women

Do not start in women over 60yo

Benefits of HRT MOST EFFECTIVE RX AT REDUCING

VASOMOTOR SYMPTOMS – within 4/52, maximum improvement by 3mo, improves sleep & mood

Also: Improves urogenital symptoms (sexual function/ recurrent UTIs); reduces osteoporosis risk; can reduce incidence of CHD if started within 10 years of menopause (controversial – see risks); possibly reduced risk colorectal ca with combined HRT.

Risks of HRT (1) RISK-FREE until age of natural

menopause VTE: low in healthy women under 60yo.

Over 60yo – risks much higher, esp if obese/ smoking/ previous VTE.

Stroke: Not increased in women under 60yo. Lower risk with transdermal oestrogens; effect may be dose-related.

Risks of HRT (2) Breast cancer: still contentious No increased risk with oestrogen-only up to 5

yrs Combined HRT ↑ risk but greatest over 60yo Generally, absolute risk increase is small –

approx 1 extra case of breast ca per 1000 women/ annum – similar to risk with obesity/ nulliparity/ late menopause/ drinking 2-3 units of alcohol per day

Risk returns to non-user within 5 yrs of stopping Combined HRT also increases breast density and

risk of abnormal mammogram – important

Risks of HRT (3) Endometrial ca: Oestrogen-only in

women with uterus – so not given Ovarian ca – conflicting evidence,

possibly increased risk but the only RCT on this concluded no increased risk

CHD: Increased risk in woman starting this over 60yo

Contraindications to HRT Undiagnosed abnormal vaginal bleeding VTE Active or recent angina/ MI Suspected/ current/ past breast ca Endometrial ca or other oestrogen-dependent

ca Active liver disease with abnormal LFTs Uncontrolled HTN Pregnancy or breastfeeding If women want it – refer for specialist advice

Starting HRT (1) ↓ ↓ Uterus Hysterectomy (total) ↓ ↓ ↓ Periods? Postmenopausal? Oestrogen ↓ ↓ Cyclic HRT Continuous combined HRT

Starting HRT (2)

If subtotal hysterectomy – 3mo cyclic HRT + if withdrawal bleed = uterine tissue → continuous combined, if no withdrawal bleed → oestrogen alone

Monitoring HRT (1) F/U 3mo initially after starting - BP, weight, symptoms,

bleeding Erratic bleeding common in first 3-6mo – if persisting

afterwards, needs further inv Monthly cyclic preparations should produce regular,

predictable bleeds towards the end/ soon after progestogen phase

If bleeding heavy/ irregular on cyclic HRT, can double progesterone dose or ↑ duration to 21 days

Progesterone SE (eg: fluid retention/ weight gain/ mood swings) can halve progesterone dose or ↓ duration to 7-10 days

Monitoring/ Stopping HRT (2) Reassess at least annually Can consider FSH if previously normal if

symptom-free for 1-2 years to consider stopping

If stopping – can decrease dose first if on high dose to try and minimise Sx

Alternative Forms of HRT Oral most common Non-oral (eg: patches/ gels) avoid 1st-pass

metabolism through the liver so are more suitable for eg: nausea/ liver disease/ malabsorption/ thrombosis/ enzyme-inducing drugs

HRT is NOT a contraceptive – <50yo and risk-free can use COCP for contraception + relief of menopausal Sx, no COCP if >50yo.

Alternatives to HRT (1) Vaginal atrophy/ urogenital symptoms –

topical oestrogen first-line eg: tablet/ cream/ pessary/ vaginal ring

Mirena licensed as alternative for endometrial protection (4 years) with oestrogen component if get SE with other progestogens/ contraception still needed/ persistent bleeding on cyclical HRT + normal inv

Alternatives to HRT (2) Tibolone: good for libido, less good than

HRT for flushing; no need for cyclical progestogen; can use with uterus but only post-menopause; may increase risk breast/ endometrial ca + stroke; not to use in >60yo due to stroke risk

Clonidine: for flushing only; can cause hypotension; causes severe dry mouth; have to wean down to stop.

Case 1 45yo woman – early menopause Severe flushing, not sleeping well, high-

powered job in City and needs to be alert, works long hours.

Has read on internet and worried ++ about HRT risks – grandmother had breast cancer age 70yo

What do you counsel her?

Case 2 53yo woman – menopause started age

51 Severe flushing, night sweats, irritability. What other questions to ask? What decides if she can have HRT?

What risks do you have to tell her about?

Case 3 60yo woman – been on HRT since 53yo for

severe flushing + other vasomotor symptoms ‘I can’t possibly come off HRT, my symptoms

were so bad before.’ High chol, HTN (well controlled) Taking Ellest duet Conti How do you counsel her and what are the

options? What if her symptoms were mainly vaginal

dryness during sex/ recurrent UTIs?

THE ENDAny Questions?