1. Hormone replacement therapy: practical considerations Marco Gambacciani and Nick Panay

2. The emerging concepts in HRT Timing (window of opportunity) –Early start –Maintenance of estrogenic benefits Patient selection –Avoiding generalized prescribing Personalization –Tailoring dose to patient –Continuation and tapering the dose with age

3. Why lower HRT doses? Continued efficacy with fewer side-effects and possibly fewer risks Potential for greater acceptance by women Improved continuance to achieve potential long-term health benefits Efficacy in prevention of osteoporosis is not compromised

4. HRT: maximizing efficacy, minimizing problems Estrogenic side-effects Exceptions to low starting dose of E2 –Premature ovarian failure –Severe osteoporosis –Predominance of psychological problems, e.g. climacteric depression

5. HRT indications Vasomotor symptoms Urogenital symptoms Joint and muscle pains, mood swings, sleep disturbances and sexual dysfunction Prevention of osteoporosis and related fractures Prevention of atrophy –Epithelia –Skin –Connective tissue –Intervertebral disks IMS Updated Recommendations, February 2007

6. HRT potential benefits I CVD –HRT improves many aspects of the metabolic syndrome and reduces the risk of diabetes –There is evidence that HT may be cardioprotective if started around the time of menopause and continued long-term (often referred to as the ‘window of opportunity’ concept) –In women less than 60 years old, recently menopausal, without prevalent cardiovascular disease, the initiation of HT does not cause early harm, and may reduce cardiovascular morbidity and mortality IMS Updated Recommendations, February 2007

7. HRT potential benefits II CNS –HRT initiated around the time of menopause or by younger postmenopausal women is associated with a reduced risk of Alzheimer’s disease Combined HRT may reduce the risk of colon cancer IMS Updated Recommendations, February 2007

8. Principles of hormone treatment HRT should not be recommended without there being a clear indication for its use Counselling should convey the benefits and risks of menopausal HT in simple terms, e.g. absolute numbers rather than as percentage changes from a baseline This allows a woman and her physician to make a well-informed decision about HRT IMS Updated Recommendations, February 2007

9. Principles of hormone treatment Whether or not to continue therapy should be decided at the discretion of the well- informed hormone user and her health professional, dependent upon the specific goals and an objective estimation of benefits and risks There are no reasons to place mandatory limitations on the length of treatment IMS Updated Recommendations, February 2007