Menopause - NICE 23 and TOG - Latest evidence on using HRT in Menopause Flashcards
What is the prevalence of menopausal symptoms?
2/3 have hot flushes, 10-20% severe symptoms
1/3 will have symptoms for up to 5 years
20% symptoms for up to 15 years
What are the risk factors for hot flushes?
High BMI
Smoker
African American/Caucasian
Surgically-induced menopause (90% within 1st year)
In what % does HRT improve vasomotor symtpoms?
80-90%
Which botanicals have phytoestrogens?
Soy Red clover (Trifolium pretense) Black cohosh (Cimicifuga racemosa)
Avoid in breast Ca/tamoxifen use - hinder ability to inhibit breast ca
What is the advice re: HRT and gynae cancer survivors?
- ?reasonable in young women with early stage endometrial
- limited data ovarian - no adverse effect on survival/recurrence
- lack definitive evidence in cervical - tend to have ovarian conservation
- Varied evidence breast - systemic HRT likely increases risk recurrence. sparse re: vaginal but no increase in risk
What is the transdermal preparation of oestrogen in HRT?
17-beta- estradiol
What are the cardiovascular benefits of HRT?
- Reduces atherosclerosis
- Increases HDL-cholesterol
- Lowers LDL-cholesterol
- Promotes coronary artery vasodilatation
- Prevents platelet aggregation
- Decreases lipoprotein-a and inhibits LDL-cholesterol oxidation
Which herbal remedies may help menopausal symptoms short term but there is uncertain safety/interactions with other medications?
Isoflavones/black cohosh
What complementary therapies can be suggested if there is a hx of breast cancer or otherwise high risk?
St John’s wort may help vasomotor symptoms
Uncertainty re: doses/persistence of effect
Potential interactions with e.g. tamoxifen, anticoagulants, anticonvulsants…
Not for fluoxetine/paroxetine if hx of breast Ca
How often should women on HRT be reviewed?
3/12 short term symptoms - unscheduled bleeding common for this time
Then annually unless required earlier
What is the effect of HRT with regards to VTE?
Increases VTE relative to baseline population risk
Transdermal preparations back to baseline - consider if high risk for VTE esp BMI >30
If very high risk consider haematological assessment first
What is the effect of HRT on cardiovascular disease?
No increase in risk if commence <60yo
Risk factors not a contraindication if optimally managed
Slight increase in risk of stroke with PO>transdermal prep
What is the effect of HRT on T2DM?
No increased risk or adverse effect on glucose control
What is the effect of HRT on breast cancer?
Oestrogen alone - little/no increase in risk
Combined - increase in risk related to duration of treatment, reduces upon cessation
What is the effect of HRT on osteoporosis?
Risk of fragility fractures decreases while on HRT
Benefit stops when treatment ceased but if on HRT a long time may continue for longer
How is premature ovarian insuffiency diagnosed?
<40 yo
2 x raised FSH 4-6 weeks apart NOT AMH
Which trial looked at whether HRT reduced the recurrence of coronary heart disease in women with established CHD? And what were the findings?
Heart and Estrogen/progestin Replacement Study (HERS)
Did decrease recurrence of CVD events but VTE increased - older women, route and preparation may have had an effect
The Women’s Hormone Intervention Secondary Prevention Study - micronised progesterone; more favourable outcome
What were the findings of The Women’s Health Initiative Study?
- To evaluate effect of HRT on cardiovascular outcomes
- Closed early as:
- Increase in breast Ca, CVA, heart disease, VTE, gallbladder disease
- Not seen in oestrogen alone
- Reanalysed - see fewer CV effects (6/10,000 woman years) if HRT given within 10 years of menopause
Decrease in fracture rate, DM and bowel cancer
i.e. ‘window’ for short term symptom relief; does more harm if given many years after the menopause
What were the findings of the million women study?
Increase in breast Ca on combined HRT vs oestrogen alone
Women attending for screening using questionnaire
Flaws in methodology - existing breast Ca not excluded, Pts concerned on HRT more likely to attend, much data missing from follow up questionnaires
What were the findings of the 2012 Cochrane systematic review?
No indication to use HRT for primary or secondary prevention of CVD or dementia or for protection of cognitive function
Reduction of risk of bone fracture after 5 years of use
What are the effects of HRT on recently menopausal women?
After 10 years women on HRT had sig. decrease on mortality and CVD-disease with no increase in VTE, stroke or cancer
Benefits seen for up to 6 years after cessation
Conclusion - lowest dose for shortest time possible
What is the HRT advice for women with POI?
Strongly advise to take HRT until at least 50yo
What is the absolute increased risk of breast cancer risk with HRT?
6 extra cases per 1000 women for 5 years of oestrogens and progestogens
Reverts back to population risk 5 years after cessation
What type of HRT should be used in perimenoapausal women?
Continuous oestrogen/cyclical progesterone (ie sequential)
What type of HRT should be used in hysterectomised women?
Oestrogen alone
- If subtotal but endometrium seen at margin use continuous combined
What type of HRT should be used in women who have undergone endometrial ablation?
Cyclical or combined continuous
What type of HRT should be used in women who are very sensitive to progesterone?
Mirena or micronised progesterone plus systemic oestrogen
What type of HRT should be used in women who have undergone premature menopause?
May require higher oestrogen dose
What type of HRT should be used in older women?
Start with lowest dose and adjust
What type of HRT should be used in women with potential malabsorption?
Non-oral route
What type of HRT should be used in women who are post-menopausal with low libido?
Try Tibolone as first choice
What type of HRT should be used in women who do not respond to standard treatment, or young women who have surgical-induced menopause?
Consider subcutaneous implants of oestrogen
What are the common adverse effects of HRT?
Headaches, breast tenderness, bloating, muscle cramps
NOT weight gain
Usually resolve by 3/12
When should women taking sequential HRT wishing to stay on it be advised to change to continuous combined?
After 5 years of use - increase risk endometrial hyperplasia on sequential
What % of women will be menopausal aged 54?
80%
What are the relative contraindications to HRT that require referral for specialist advice?
- Existing cardiac disease
- Active liver disease
- SLE
- Previous breast cancer
- Previous ovarian/endometrial cancer
- Undiagnosed vaginal bleeding
- Previous personal/FHx of VTE
When is risk of VTE associated with HRT the highest?
After initiation and falls over the next 12 months
What is the rate of VTE with 5 years of oestrogen/oestrogen+progesterone compared with background risk for women aged 50-59?
Background - 5/1000
Oestrogen - 7/1000
Oestrogen and progesterone - 12/1000
What are the additional benefits of HRT?
- Low mood improvement
- Protection against loss of connective tissue
- ?Neuroprotective reducing Alzheimers/Parkinsons
- Prevention loss of bone mineral density
What are the ‘self help’ tips and coping strategies for women with debilitating symptoms of menopause?
- Avoid sudden temperature change (hot drinks)
- Reduce caffeine/alcohol intake
- Avoid spicy foods
- Increase exercise
- Wear layers of clothes to be able to take off and put on when necessary
- Practise relaxation techniques
- Use cooling devices e.g. facial spray, cold pillows/pads in bed
- Wear absorptive night attire
Which breast cancer treatment is ineffective with HRT?
Aromatase inhibitors
What is the effect of tibolone as HRT in women with previous breast Ca?
Increased recurrence in only those with ER+
What is the advice re: HRT in women with a family Hx of breast Ca or BRCA carriers?
- No increase if FHx
- Indicated in BRCA as young following risk reducing BSO will depend on the progesterone used/womb still in situ, but no additional risk
