1. HRT In a nutshell for all the blokes out there

2. diagnosis  Clinical hx  FSH limited value as levels fluctuate  May be of value in symtomatic women under 40y  FSH >30  Clinical hx  FSH limited value as levels fluctuate  May be of value in symtomatic women under 40y  FSH >30

3. Also  Lifestyle  Smoking  Alcohol  Exercise  caffeine  Lifestyle  Smoking  Alcohol  Exercise  caffeine

4. indications  Early menopause (<45yrs)  Under 65yrs with vasomotor symptoms  Not to be used for prevention of osteoporosis  Early menopause (<45yrs)  Under 65yrs with vasomotor symptoms  Not to be used for prevention of osteoporosis

5. What to discuss at first consultation  Risks and benefits  Expected duration of treatment  Symptoms will return when stopped  Need assessment annually  Contraception req  Risks and benefits  Expected duration of treatment  Symptoms will return when stopped  Need assessment annually  Contraception req

6. benefits  Relief of vasomotor symptoms  Urogenital symptoms  Osteoporosis  Prevention ca colon (by 20%)  mood  Relief of vasomotor symptoms  Urogenital symptoms  Osteoporosis  Prevention ca colon (by 20%)  mood

7. Harms  CVD  Increased risk of CHD and CVA  Breast cancer  Endometrial cancer  Ovarian cancer  VTE  dementia  CVD  Increased risk of CHD and CVA  Breast cancer  Endometrial cancer  Ovarian cancer  VTE  dementia

8. HRT and Br Ca  Risk depends on type of HRT  Revert to normal 1yr after stopping  Risk increases with duration of use  After 10 yrs  Combined: 19 extra cases per 1000  Unopposed oestrogen: 5 extra cases per 1000  Risk depends on type of HRT  Revert to normal 1yr after stopping  Risk increases with duration of use  After 10 yrs  Combined: 19 extra cases per 1000  Unopposed oestrogen: 5 extra cases per 1000

9. Absolute contraindications  Relatively few:  Acute phase MI, pe, DVT  Active endometrial or brCa  Pregnancy  Undiagnosed br mass  Abnormal vaginal bleeding  Severe active liver disease  Relatively few:  Acute phase MI, pe, DVT  Active endometrial or brCa  Pregnancy  Undiagnosed br mass  Abnormal vaginal bleeding  Severe active liver disease

10. Initial assessment  Hx  esp risk factors for CVD, hx of Br ca or VTE  BP, BMI, bloods (serum lipids  smoking  Breast awareness - screening program  Cervical screening  Lifestyle advice  Document discussion of risks  Hx  esp risk factors for CVD, hx of Br ca or VTE  BP, BMI, bloods (serum lipids  smoking  Breast awareness - screening program  Cervical screening  Lifestyle advice  Document discussion of risks

11. What preparation  Elleste duet - woman has ‘period’  Elleste duet conti - no ‘period’  Elleste solo - oestrogen only  Elleste duet - woman has ‘period’  Elleste duet conti - no ‘period’  Elleste solo - oestrogen only

12. Other considerations  CV risk of >20%  Diabetes  BMI >30  FH br Ca  1 pre-menopausal or 2 post- menopausal  CV risk of >20%  Diabetes  BMI >30  FH br Ca  1 pre-menopausal or 2 post- menopausal

13. Changing to continuous  May want to consider at 54 yrs  Does increase risk of CVD and brca  May want to consider at 54 yrs  Does increase risk of CVD and brca

14. Bleeding on cyclical  GI upset, compliance, drug interactions  Options:  Try stopping- see if stops  If thought to be due to hrt  Increase dose of progesterone or change type of progesterone  GI upset, compliance, drug interactions  Options:  Try stopping- see if stops  If thought to be due to hrt  Increase dose of progesterone or change type of progesterone

15. continuous HRT  Irregular bleeding in 40% in first 4-6m  Check - Was she at least one year post menopausal  Investigate if continuing for > 6 months, becomes heavier, or occurs after amenorrhoea  Options come off HRT and see if stops  Refer urgently if continues after 4 weeks  Irregular bleeding in 40% in first 4-6m  Check - Was she at least one year post menopausal  Investigate if continuing for > 6 months, becomes heavier, or occurs after amenorrhoea  Options come off HRT and see if stops  Refer urgently if continues after 4 weeks

16. Oestrogen side effects  Fluid retention, bloating, breast tenderness, nausea  Most resolve with time (within 12 weeks)  If persistent  Reduce dose  Change type of oestrogen  Change route (transdermal)  Fluid retention, bloating, breast tenderness, nausea  Most resolve with time (within 12 weeks)  If persistent  Reduce dose  Change type of oestrogen  Change route (transdermal)

17. Progesterone side effects  Mood swings, headaches, acne, fluid retention  If persists  Reduce duration (not <10d)  Reduce dose  Change prog  Change to long cycling regime  Mood swings, headaches, acne, fluid retention  If persists  Reduce duration (not <10d)  Reduce dose  Change prog  Change to long cycling regime

18. Follow - up  3 monthly, then 6 monthly  And then yearly  Compliance, bleeding patterns, S.Es  Talk about coming off  Smears and mammograms  3 monthly, then 6 monthly  And then yearly  Compliance, bleeding patterns, S.Es  Talk about coming off  Smears and mammograms

19. stopping  Shortest possible time  Usually within 5 years  Symptoms will recur  Stop abruptly or gradually  Shortest possible time  Usually within 5 years  Symptoms will recur  Stop abruptly or gradually

20. How long to continue  Shortest possible time  Ideally within 5 yrs  Shortest possible time  Ideally within 5 yrs

21. stopping  Cold turkey  Premique low dose for a couple of months  1 every other day  Cold turkey  Premique low dose for a couple of months  1 every other day

22. Other options  SSRIs  Clonidine  Black cohosh  Topical oestrogens  SSRIs  Clonidine  Black cohosh  Topical oestrogens

23. contraception  Barrier  IUD  IUS  Low dose COC instead of HRT  Continue for 1 years after LMP in over 50s  2yrs in under 50s  Barrier  IUD  IUS  Low dose COC instead of HRT  Continue for 1 years after LMP in over 50s  2yrs in under 50s