HRT Benefits And Risks W3

Question 1

How long should HRT be taken for

Answer 1

For vasomotor symptoms, HRT usually used for 2-3 years (initial review at 3 months to assess efficacy & tolerability)

Annual review recommended because of increased risk of side effects shown in trials

Question 2

side effects shown in trials

Answer 2

 Stroke
 Breast cancer
 Endometrial cancer
 Venous thromboembolism

Question 3

HRT in women over 60

Answer 3

Prescribed before 60 Has a favourable benefit/risk profile in healthy women

Lower doses must be started n preferably with a trqansdermal route of estradiol administration

Question 4

Oestrogen side effects of HRT

Answer 4

 Nausea and vomiting
 Abdominal cramps and bloating
 Weight changes (gain)
 Breast tenderness and enlargement
 Premenstrual-like syndrome
 Sodium and fluid retention

Question 5

Progesterone side effects of HRT

Answer 5

 More androgenic drugs (norethisterone, levonorgestrol):
 Cause greasy skin + hair
 Tend to off-set some of the protective effect of oestrogens on lipid profile
 Less androgenic drugs (dydrogesterone, medroxyprogesterone) cause progesterone-like side effects:
 Abdominal bloating
 Mood changes such as irritability, depression
 Breast tenderness

Question 6

Why do women stop taking HRT

Answer 6

Non-compliance with HRT is most commonly due to:
- Side effects of the progestogen
- Regular monthly bleed induced by combination therapy when periods had been in the process of stopping
- Weight gain §

Question 7

Short term benefits of HRT

Answer 7

Control symptoms of the peri/post meno including hot sweats, headaches, mood changes, loss of libido and thinning of hair

Question 8

Long term benefits of HRT

Answer 8

Decreased risk of osteoporosis

 Oestrogen rebalances bone re-sorption and formation thus stopping bone loss
 Possibly some bone gain during the initial 18-24 months of HRT treatment
 Bone-protective effect is probably dosage-related
 Protection lasts only as long as HRT is taken
 Continuous lifelong use would be required for HRT to be an effective method of preventing hip fractures
 Consider change to e.g. bisphosphonates when HRT not appropriate

Question 9

Risks of HRT

Answer 9

• VTE risk increased with combined or oestrogen only HRT especially in first year of use
• women with predisposing risk factors
• VTE risk is greater with oral than transdermal

Question 10

Risks of breast cancer

Answer 10

 All systemic HRT increases risk after 1 year of use
 Combined oestrogen-progesterone (particularly continuous) higher risk than oestrogen only
 No increased risk for local vaginal oestrogen
 Risk reduces after stopping but excess risk remains for over 10 years compared to women who have never used HRT

Question 11

Risks of endometrial cancer

Answer 11

 Associated with oestrogen – only HRT
 Women with uterus => addition of progestogen (minimum of 10 days per 28 day cycle) reduces risk
 Risk eliminated if progestogen used continuously

Question 12

Risks of ovarian cancer

Answer 12

 Small increased risk with both combined and oestrogen only HRT
 Excess risk disappears within few years of stopping

Question 13

Risks of stroke

Answer 13

 Risk of stroke increases with age
 Older women have greater absolute risk of stroke
 Combined and oestrogen-only HRT slightly increases this risk of stroke

Question 14

Coronary heart disease and HRT

Answer 14

 Not conclusive!!
 Before the menopause, the incidence of CHD in women is lower than in men
 After the menopause, the incidence of CHD in men and women becomes similar
 CHD is the leading cause of death in post- menopausal women

 Oestrogen alone ► no, or reduced, risk of CHD
 Oestrogen + progesterone ►little or no increase in risk of
CHD

Question 15

Tibolone

Answer 15

 2.5mg od
 Gonadomimetic
 Synthetic steroid derivative of norethisterone
 Mixed oestrogenic, progestogenic and androgenic activity
 Licensed for short-term treatment of symptoms and osteoporosis prophylaxis (2nd line)
 Same cautions/ contraindications as Oestrogen HRT

Question 16

Clonidine

Answer 16

 50mcg bd increased if required to 75mcg bd after 2 weeks
 Vasomotor symptoms especially hot flushes
 Centrally acting ꭤ-adrenergic agonist => possibly reduces noradrenergic activity in blood vessels

Question 17

What else could women use for
menopausal symptoms?

Answer 17

Anecdotal evidence for:
 St John’s Wort
 Products containing phytoestrogens
 Black cohosh
 Red clover
 Little efficacy or safety data
 Some risks
 St John’s Wort – interactions
 Liver impairment with black cohosh
 Red clover contains coumarins, interacts with warfarin
 Possible increased risk from oestrogenic effects e.g. VTE