1. IS HRT SAFE? Rosol Hamid Consultant O&G

2. NO

3. What is safe? Driving Swimming Crossing the street Cycling Riding a motor bike Parachute jumping Flying

4. Evolution & controversy Over 20 years HRT changed from being the elixir of youth to being considered extremely risky

5. British Menopause society& Women Health Concern recommendations 2013 Informed choice Annual evaluation HRT before 60 has a favourable benefit/ risk profile Premature menopause encourage HRT until natural age of menopause Over 60 use low dose /transdermal

6. Effects of HRT ~Estrogen is most effective for vaso motor symptoms ~improve mood in early menopause ~ improve sexual function ~ improve vaginal dryness and dyspareunia ~ help relief bladder symptoms and reduce risk of recurrent UTI

7. Other effects Protective effect against connective tissue loss Bone protection Mirena can be used to reduce progesterone effects

8. Long term effects of HRT Preserve bone density Significant reduction in heart disease Improvement in cognition Reduction in long term risk of Alzheimer's and all cause dementia

9. What about breast cancer? WHI... Small increase in breast cancer risk. 1 extra case/1000 women / year. In same WHI Estrogen alone significant decrease in breast cancer risk Recent critique of both WHI and MWS revealed flaws which limit the ability of the trials to establish causation

10. Other cancers Conflicting evidence on ovarian cancer risk Reduced risk for endometrial on continuous combined preparations. Reduce risk of colorectal cancer

11. Summary practice points Individualised decision for each woman Dosage and duration individualised Annual evaluation of pros and cons With time increased sophistication of hormonal preparations will reduce side effects

12. Key recommendations Main indication is relief of vaso motor symptoms Duration should not be subject to arbitrary limits Routine advise on diet and life style Phytoestrogens offer some benefits on symptoms and on skeletal and cardiovascular systems Don't start HRT 10 years after menopause

13. Issues MPA is associated with higher risk of breast cancer than other progestogens ( American association of cancer research) Moderate increased risk of VTE may only relate to oral and not transdermal preparations (RCOG)

14. Does HRT cause breast cancer Recent decrease in incidence of breast cancer The decline occurred immediately as HRT use declined No duration lag to support the association The evidence neither supports nor refutes the theory of possible causation The associated risk of breast cancer is lower than that associated with obesity and alcohol and later reproduction

15. Benefits Re examining the evidence Reduction in cardiovascular problems Fewer risks than initially reported Neuroprotective with preservation of cognitive ability and verbal memory

16. Parkinson disease Younger age of onset in males Oestrogen has direct effect on dopaminergic functioning PD more common in women after surgical menopause May be protective from PD or has ameliorative effects on symptoms

17. Reviewing the evidence Dec 2014 HRT is the most effective treatment for menopausal symptoms In particular for younger women at the onset of menopause Hot flushes and night sweats affect 70% of women for up to 5 yrs 10% may continue for many years

18. The evidence Symptoms vary. In some can be debilitating and can affect quality of life HRT is the treatment for the menopause. WHI 2003 reported increased risk of breast cancer, VTE and stroke The re-analysis of the Women Health Initiative study in 2007 demonstrated that giving HRT for up to 10 years had fewer risks! And reduction in cardiovascular problems.

19. The evidence The Million women study 2001 suggested increased risk of breast cancer But failed to address short use to relief symptoms Women can gain the advantage and tailor treatment to reduce risk

20. Conclusion Women live long beyond the age of menopause Future….Improved formula with better long term benefits and reduced risks Quality of life