Hormone Replacement Therapy
Dr 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, 2yrs< 50yo
HRT – Indications for Use
For women with premature/ early menopause (<40yo or <45yo respectively) until the age of natural menopause – around 51yoFor treating menopausal symptoms whererisk:benefitratio is favourable in FULLY INFORMED womenDo 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 & moodAlso: 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 colorectalcawith combined HRT.
Risks of HRT (1)
RISK-FREE until age of natural menopauseVTE: low in healthy women under 60yo. Over 60yo – risks much higher,espif 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 contentiousNo increased risk with oestrogen-only up to 5yrsCombined HRT↑risk but greatest over 60yoGenerally, absolute risk increase is small –approx1 extra case of breastcaper 1000 women/ annum – similar to risk with obesity/nulliparity/ late menopause/ drinking 2-3 units of alcohol per dayRisk returns to non-user within 5yrsof stoppingCombined HRT also increases breast density and risk of abnormal mammogram –important
Risks of HRT (3)
Endometrialca: Oestrogen-only in women with uterus – so not givenOvarianca– conflicting evidence, possibly increased risk but the only RCT on this concluded no increased riskCHD: Increased risk in woman starting this over 60yo
Contraindications to HRT
Undiagnosed abnormal vaginal bleedingVTEActive or recent angina/ MISuspected/ current/ past breastcaEndometrialcaor other oestrogen-dependentcaActive liver disease with abnormal LFTsUncontrolled HTNPregnancy or breastfeedingIf women want it – refer for specialist advice
Starting HRT (1)
↓ ↓Uterus Hysterectomy (total)↓ ↓ ↓Periods? Postmenopausal? Oestrogen↓ ↓Cyclic HRT Continuouscombined 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, bleedingErratic bleeding common in first 3-6mo – if persisting afterwards, needs furtherinvMonthly cyclic preparations should produce regular, predictable bleeds towards the end/ soon afterprogestogenphaseIf bleeding heavy/ irregular on cyclic HRT, can double progesterone dose or↑duration to 21 daysProgesterone 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 annuallyCan consider FSH if previously normal if symptom-free for 1-2 years to consider stoppingIf stopping – can decrease dose first if on high dose to try and minimiseSx
Alternative Forms of HRT
Oral most commonNon-oral (eg: patches/ gels) avoid 1st-pass metabolism through the liver so are more suitable foreg: nausea/ liver disease/malabsorption/ thrombosis/ enzyme-inducing drugsHRT is NOT a contraceptive – <50yo and risk-free can use COCP for contraception + relief of menopausalSx, no COCP if >50yo.
Alternatives to HRT (1)
Vaginal atrophy/ urogenital symptoms – topical oestrogen first-lineeg: tablet/ cream/pessary/ vaginal ringMirenalicensed as alternative for endometrial protection (4 years) with oestrogen component if get SE with otherprogestogens/ contraception still needed/ persistent bleeding on cyclical HRT + normalinv
Alternatives to HRT (2)
Tibolone: good for libido, less good than HRT for flushing; no need for cyclicalprogestogen; can use with uterus but only post-menopause; may increase risk breast/ endometrialca+ stroke; not to use in >60yo due to stroke riskClonidine: for flushing only; can cause hypotension; causes severe drymouth; have to wean down to stop.
45yo woman – early menopauseSevere 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 70yoWhat do you counsel her?
53yo woman – menopause started age 51Severe 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?
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.’Highchol, HTN (well controlled)TakingEllestduet ContiHow do you counsel her and what are the options?What if her symptoms were mainly vaginal dryness during sex/ recurrent UTIs?