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MRCOG PART 2 SBAs and EMQs

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Essay 319 - HRT

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		Posted by L S. Wed Feb 10, 2010 09:30 pm
LS: (a) Discuss the available routes of delivering HRT and their advantages and disadvantages [12 marks]. The first route is oral which the first choice is usually. The advantages of this route are they are cost effective, acceptable to most patients with beneficial effect on cholesterol metabolism. The disadvantages are sometimes high doses are required to relieve symptoms due to variation in absorption and increases triglycerides due to its affect on liver protein synthesis. The next route is via transdermal (patch, gel or nasal spray). The advantage of this route is that it avoids gut and liver breakdown and allows lower doses to be used. The other advantages are that it avoids bolus first pass effect on liver therefore less adverse effect on gallbladder disease and coagulation factors and it produces more physiological hormone levels than oral doses. The disadvantages are they are generally more expensive and patch adhesive site sensitivity may occur. Topical route is the next available HRT. The advantage of this is it helps women with only urogenital symptoms of menopause and avoids adverse systemic effect s of HRT. The disadvantage is cannot be offered to women with both urogenital and systemic effect as very little reaches systemic circulation. The final possible route is intrauterine system (Mirena coil) which is licensed in UK for delivering progestogen part of HRT. The advantages are reducing persistent progestogenic side effects of oral HRT or if contraception is required along with HRT in perimenopausal women. The disadvantages it might be considered invasive by some women and risk of perforation and infection during insertion. (b) What would you tell her about the risks of HRT? [8 marks]. The absolute increase in risk of taking HRT is small as compared to risk associated with smoking or those associated with morbid obesity. The risk of breast cancer is increase as that to a woman with naturally delayed menopause and is about 2.8%. The risk of breast cancer is associated with duration of use and short term use is associated with only a small increased risk. This risk falls after cessation of use and disappears within five years of stopping. Endometrial cancer risks due to unopposed estrogens are for women with a uterus. Oral HRT has been associated with increased risk of venous thromboembolism (blood clots in legs or lungs). This risk is higher in combined HRT than oestrogen- only preparations and is more likely to occur during the first year of use. This risk may be lower with transdermal HRT. Gallbladder disease risk is increased with HRT which may be also associated with ageing and obesity.
		Posted by Naheed M. Wed Feb 10, 2010 10:14 pm
NM A. The options for hormone replacement therapy (HRT) are oestrogen-only, progestogens and combines oestrogen +progesterone preparations. The routes of administration for oestrogen are oral tablets, nasal spray, vaginal ring, transdermal patch or gel, implant and vaginal tablet or cream. Progestogens can be used in form of tablet, implant and intrauterine system (IUS). Combined HRT preparations are used in the tablet form. Nausea and vomiting is more related with oral tablet forms and other systemic side effects are also observed such as fluid retention, breast tenderness, headache, leg cramps, dyspepsia. These adverse effects usually resolve with increasing duration of use or dose reduction and change of route of administration. For women who suffers vaginal symptoms vaginal tablets , gels and pessaries can be the best option as they avoid systemic side effects and improve vaginal dryness and dyspareunia. Transdermal implants and intrauterine system are good where there is problem of compliance (forgetting taking pill) while implants involve the risk of tachphylaxis and need to monitor estradiol levelsbefore insertion and careful dose usage. For the women with higher risk of venousthromboembolism (VTE)transdermal patch is preferred as it is associated with reduced the risk of VTE compared to oral preparations and has same efficacy for menopausal symptoms and prevention of osteoporosis as oral preparations. Transdermal patch may cause skin reactions and blisters rarely. Oral preparations of combined preparation are used cyclically in perimenopausal woman who get advantage of monthly bleeding. Continous combined preparations is used for menopausal woman and is very effective relieving the menopausal symptoms but is associated with erratic vaginal bleeding in some cases which warrants investigation. In cases where uterus is not present estrogen only methods can be used to avoid progestogenic side-effects while in women where oestrogen only preparations are problematic and have bothersome hot flushes progestogen-only (Megestrol) can be used. There is no evidence that use of HRT in treated cases of endometrial carcinoma increase the risk of recurrence Oestrogen+ progestogens can be used for oestrogen sensitive tumors. B. I will tell her about the risks associated with HRT such as increased risk of breast cancer. It is associated with the duration of use 38/1000 risk for 5 years use and 51/1000 for 10 years use. Those who stops HRT for more than 5 years the risk is equivalent to the risk of non-users. HRT is associated with 2-3 fold higher risk of VTE and those with family history or any other evidence of VTE risk may undergo thrombophilia screening before using HRT. HRT doesn’t confer protection from the risk of coronary heart disease but is associated with higher risk of coronary heart disease. The risk is highest in first year of use especially for those who have previous event. It may increases the risk of hypertension and stroke and gall bladder disease. There are also risks of the side effects of different preparation of drugs such as nausea vomiting, headache breast tederness, bloating, etc. Weight gain is not associated with HRT. There is current data indicating that current use of HRT is associated with ovarian cancer. I will tell her that she is not at higher HRT related uterine risks (endometrial hyperplasia/ carcinoma ) as she doesn’t have a uterus.
		Posted by SYAMALRANJAN S. Wed Feb 10, 2010 11:25 pm
(a) Discuss the available routes of delivering HRT and their advantages and disadvantages [12 marks]. Available routes of delivering HRT are oral route and non-oral routes. HRT may be oestrogen only replacement, progestogen only or combination of oestrogen and progestogen. Oestrogen can be administered orally (tablet ) or in the form of trans- dermal(patch, gel, cream) vaginal (tablet , cream , ring). Other routes may be in the nasal spray form or implant. Progestogen is used in oral tablet form or trans-dermal patch or intrauterine system. Combination are used orally in tablet form. Advantages of oral routes are easy availability, less information about intake and use procedure. It is also low cost and has predictive good absorption, probable good compliance , acceptance and satisfaction. Disadvantages are gastrointestinal side-effects (such as nausea , vomiting , bloating )and drug modification by liver. There may be increase in triglyceride levels, CRP, prohypertensive and prothrombotic factors. These are due to first-pass liver impact. Advantages of non-oral routes are also easy to apply or use after getting proper information. It enters the blood directly and without modification. No first-pass liver metabolic effect and may have less possible systemic side-effects and complications (such as VTE risk). It is more preferable than oral routes. It is more helpful particulary where local symptoms such as vaginal dryness, dyspareunia are presenting symptoms( for using vaginal applications) Disadvantages are less wide availability, more costly. It may have less predictive absorption, may be messy or may cause local allergy or irritation. It needs more education and informations for drug using procedures. b) What would you tell her about the risks of HRT? [8 marks]. I will enquire about her menopausal symptoms severity and impact on her quality of life. I will tell that there is slight increase in risk of thromboembolic diseases. Risk is particularly increased in first year of use more in those having risk factors(such as history suggesting previous personal or family history of VTE or thrormbophilia). There is increase in risk of breast cancer associated with long-term use of HRT (>5 years). In a 50 year old woman oestrogen + progestogen HRT for 5 and 10 years increases risk to 38 and 51 per 1000 respectively(back ground risk 32 per 1000 over 15 years). The risk of breast cancer in women who have discontinued HRT for 5 years is similar to that in never users. Oestrogen-only HRT also associated with increased risk of breast cancer. I will inform her that HRT does not confer protection against heart diseases but may increase risk of coronary artery diseases and stroke especially in the first year of use in women with a previous event. I will tell her about increase in risk of gall bladder disease and drug side-effects (potential side-effects of oestrogens / progestogens such as nausea , vomiting, bloating, headache, breast tenderness ). I will inform that overall risk of complications in women taking HRT remains small. As she had hysterectomy , no risk related to uterus and progestogen is not required ( which is important for endometrial protection). I will provide her written information.
		Posted by SRABANI M. Thu Feb 11, 2010 04:08 am
SM a.HRT can be delivered by oral route as well as non- oral route.This lady had total abdominal hysterectomy already,hence she needs orestrogen alone & does not need progestogen.Furthermore, combined HRT may entail a greater risk of breast cancer than oestrogen alone. HRT can be given orally , nasal spray, transdermal patch/ gel, vaginal ring , vaginal gel , subcutaneous implant or vaginal tablet or cream. Oral tablets are easily available, cost-effective and there is no clear advantage of using non- oral route over the oral route in majority of women.Disadvantages of oral route are , some substances synthesised by liver can be affected by oral preparation.Oral oestrogen also increase hepatic production of SHBG.Also production of certain coagulation factors & lipids may be affected differentially by the route of administration.Other side effects are bloating,breast tenderness, nausea,headache, leg cramps& dyspepsia.Patient compliance is also important factor in oral route. Side effects of progestogen is not applicable to this lady as she does not need endometrial protection & hence progestogen Advantages of using transdermal route are it confers lower risk of VTE & gallbladder disease and also it mimics natural route of oestrogen delivery.It is cheap & cost-effective, Transdermal route can be used various medical conditions where oral route can not be used ( VTE,). Transdermal HRT can be patches or gel.Two patch technologies exist- alcohol based reservoir patches and matrix patches.Skin reaction is one disadvantage of transdermal HRT but it is more common with matrix patches than reservoir patches. Oestradiol implant s are crystalline pellets of oestradiol that are inserted subcutaneously under local anaesthetic & release oestradiol over many months.Advantages of implants are , once it is inserted, patients do not have to remember to take their drugs.Disadvantages are, it needs trained clinician to fit them as well as to remove them ,it may remain effective for many years & can not easily be removed.Tachyphylaxis is another concern with implants where recurrence of menopausal symptoms while implant is still releasing adequate level of oestradiol. Advantages of vaginal HRT are cost effective & easy to apply ( mayr be a bit messy if cream is used), it avoids systemic side effects like nausea, dyspepsia, headache etc.It can be used in some women who can not tolerate or does not want to take systemic HRT.It helps to reduce local symptom like vaginal dryness.Systemic absorption with oestradiol vaginal tablet or ring is low, hence no systemic side-effect , hormone level remain within postmenopausal range.But conjugated equine oestrogen cream is well absorbed from vagina & can cause endometrial stimulation in non-hysterectomised women ( not in this lady) b. Oestrogen replacement after 50 yrs is associated with increased risk of breast Ca similar to that associated with delayed menopause.The risk of breast cancer in women who have discontinued HRT for 5 yrs is similar to that in never user.women with past history of breast Ca should see oncologist before starting HRT.Unopposed oestrogen therapy is associated with increased risk of Endometrial ca in non-hysterectomised woman.There is evidence that current use of HRT increases risk of ovarian Ca .Although HRT is protective against cardiovascular diseases in both oestrogen alone & combined , but conjugated equine oestrogen in hysterectomised women provided no overall protection against myocardial infarction or coronary death in 7 yrs use.HRT is also associated with 2-3 fold increased risk of venous thromboembolism.Transdermal is safer than oral in this respect.When a woman on HRT develops VTE, it should be discontinued.Women should be well informed about this risk factor & should have ready access to medical assessment if needed.Also it is very important to take family history & personal history of VTE before starting HRT.No evidence of HRT causing weight gain.HRT is also known to increases risk of gall bladder disease although it is less with transdermal than oral prep
		Posted by H H. Thu Feb 11, 2010 06:14 am
This patient will require estrogen only preparation as HRT as she had a hysterectomy. Available routes include, oral tablets, nasal spray, dermal patches, sub dermal implants, vaginal rings, local vaginal tablets and creams , and skin gels. Oral tablets are easily accessable , cheap and have good compliance, but has the disadvantage of 1st pass to the liver after absorption which can change or delay its action.There is more risk of venous thrombosis and effect on lipid metabolism. Nasal sprays as well all the following estrogen preparations go directly to the blood without first passing to the liver ,giving more rapid action., however nasal sprays may cause nasal irritation and are not suitable for patients who have nasal allergy. Dermal patches are said to have lesser effect on venous thrombosis and is a new way of delivering HRT, however has the disadvantage that some people are not comfortable with it and it may detach. Subdermal implants has the advantage of long duration of action (does not need reapplication or changing) ,up to 6 months, but has the disadvantage of production of hormone resistance and tachphylaxis. Vaginal rings also have long duration of action, but may produce problems during sex and might be dislodged. Vaginal tablets and creams are of value in patients with atrophic vaginitis and can be used to relieve symptoms for longer duration than the recommended duration for HRT of less than 5 years, however creams are messy and might cause patient discomfort. I will tell her that this form of HRT is associated with 2-3 fold increase in the risk of venous thrombo embolism. Studies have shown that estrogen only HRT was not associated with increased risk of breast cancer, and as she has had the womb removed ,will have no risk of endometrial cancer.There is no evidence of increase in risk of ovarian cancer. I will tell her that there is increased risk of stroke ,but the risk of coronary artery disease is not increased. I will tell her that there is increase in risk of gall stones, fluid retention and headache. There is minimal risk of increase in blood pressure. I will tell her that her risk is increased if she suffers from migraine with an aura, has history of venous thrombosis, has personal or family history of breast cancer or has history of cardiovascular problem .
		Posted by M E. Thu Feb 11, 2010 06:41 am
SAM a) Treatment should be targeted towards her symptoms. Since she had a previous hysterectomy HRT regimens need not include progesterone since there is no risk of endometrial hyperplasia. The oral route is usally the first choice of HRT offered especailly for vasomotor symptoms. It has the advantage of being cost effective and is readily accepted by the patients. It has a beneficial effect by increaseing HDL levels, lowering LDL levels. There is however the disadvantage that it raises triglyceride levels by affecting liver function. It increases the risk of gall bladder disease in patients with previous gallstones. High doses of medication required to achieve alleviation of menopausal symptoms due to variation in absorption. Also maximum relief of vasomotor symptoms usually take 3 months to be achieved. High doses of estrogen is associated with nausea, headache fluid retention and this may cause poor compliance. All oral preparations contain lactose and in sensitive patients can cause GI disturbances. The transdermal route can be used eg. nasal spray, patch or gel preparations. A lower dose of estrogen is required since it has the advantage of avoiding breakdown in the gut and liver. Since it avoids the liver it does not alter coagulation factors and cause gall bladder disease. Therefore it can be used in patient at higher risk of developing venothromboembolism. Transdermal preparations have the disadvantage of being more expensive. Also there is a risk of sensitivity or allergies for the adhesive used in the patch. Topical estrogen prepartions can be used for relief of urogenital symptoms such as vaginal dryness and dyspareunia. It has the advantage that very little oestrogen reaches the circulatory system, hence the side effects are minimal. However it has the disadvantage that it may take up to a year for symptoms to improve. b) HRT is associated with a 2-3 fold increase in the risk of venothromboembolism. THis risk is highest during the first year of use. Increased risk if stroke and myocardial infarction especially in the first year of use. It also causes increase in triglycerides. Estrogen replacement is assocaited with increased risk of breast cancer. However the risk returns to that of a non HRT user afte 5 years of discontinuation. The current use of HRT is associated with increased risk of ovarian cancer and increases with duration of use. Vasomotor symptoms of menopause tend to be short lived and most HRT can be discontinued after 2 years. Side effects from estrogen therapy include headaches, fluid retention, breast tenderness and nausea. I will inform her that the risk of HRt is small compared to the background incidence of complications.
		Posted by Mark C. Thu Feb 11, 2010 07:54 am
a) The routes of delivery are oral, nasal, transdermal, implant or local. If there are side effects with any route, HRT route can be changed and side effects are likely to improve. The oral route is good for generalized symptoms (e.g. vasomotor symptoms, osteoporosis). It is also possible to give tibolone po which has androgenic symptoms hence can improve libido. Unfortunately these medications undergo first pass liver metabolism and are associated with the highest risk of VTE. There is also the discomfort of daily tablets. The nasal route gives a lower dose without liver metabolism. These can cause nasal irritation and are also daily. The transdermal route also avoids liver first pass metabolism and are associated with a lower risk of VTE. The patch can be applied on a weekly basis. The disadvantages are that the patch can get detached without realizing and there can be local skin irritation. An implant can be used, and this is inserted and has a 6 month duration. A testosterone implant can also be used to improve sexual function and libido. It may be painful / uncomfortable to insert, and if there are any side-effects e.g. headaches, mood swings these last for the duration of the implant\'s life. Local delivery is also possible which has little systemic uptake. It only relives vaginal symptoms and may be uncomfortable to apply. b) The absolute risks of these side-effects are low although it is not advisable to use HRT for longer than ten years. There is increased risk of breast cancer (background risk 32/1000, whilst 5 years after oestrogen and progesterone it is 38/1000 and after 10 years 51/1000). There is also increased risk of VTE and cerebro vascular disease. There is also associated gall bladder disease and hypertensive disease. Written information would be provided.
		Posted by Ulduz A. Thu Feb 11, 2010 08:06 am
UA a)HRT can be delivered by oral and transdermal ways,by implants,by vaginal way,by gels,by nasal and intrauterine ways. Oral way is more common,more flexible and has lower cost.Oral preparations has short half-life and more flexibility.The disadvantage is that high level of oestrogen will be delivered to the liver,which is increasing risk of gallstone formation na increased triglyceride level. Patches are an alternatives to tablets if woman do not want to take tablets or they have side-effects.The main side-effect is skin irritation which has removed from matrix patches.They are more expensive than tablets which is another disadvantage. Implants(25-50 mcg implanted oestrogens) are lasting for 6 months and they can be given with testestorone to restore and increase libido.Disadvantage is that they need surgery to be inserted and removed. Nasal preparations(150 mcg transnasal oestrogen) having advantages of minimising side-effects ofchronically increased oestrogenas breast tenderness. Vaginal rings(50 mcg oestradiol silicone ring) and gels and tablets deliver oestrogen locally and do not cause endometrial hyperplasia in women with uterus. Intrauterine system(Mirena) containing 52 mg levonergestrel can be used as progestagenic arm of HRT for wonmen with uterus.they can be used for long time(3 years)But their insertion is painful,uterine perforation is a risk. b)HRT is associated with increased risk of breast cancer.Use of HRT for 5,10 and 15 years would cause 2,6,and 12 extra breast cancers per 1000 women.The risk of breast cancer cancer in women who have discontinued HRT for 5 years is similar to that never users. The risk of thromboembolism is increased in HRT users.Risk of VTE is increased 2-3-fold.Trans-dermal oesrtogen containing HRT safer than oral HRT with respect to VTE. Risk of gallbladder disease increased ,especially with oral preparations. Written information provided.
		Posted by Bee N. Thu Feb 11, 2010 10:31 am
A 50 year old woman with a 6 months history of menopausal symptoms requests hormone replacement therapy. She had a total abdominal hysterectomy five years ago for a large fibroid uterus. (a) Discuss the available routes of delivering HRT and their advantages and disadvantages [12 marks]. (b) What would you tell her about the risks of HRT? [8 marks]. A) Having had a hysterectomy, she does not require progesterone for protection against endometrial carcinoma. the various routes through which estrogen can therefore be delivered for hormone replacement will include the oral tablets. The advantage this has is that it is relatively effective and dosage can easily be controlled. The disadvantage is that compliance is required as patient must remember to take it daily. Through this route it also has more systemic side effects especially predisposing to VTE due to its effect on the liver during first pass mechanism. It can also be delivered as a gel applied on the skin daily. This has the advantage of bypassing the first pass but also needs daily compliance. The nasal spray is also effective however getting a steady therapeutic blood level is a challenge with this route and dosage adjustment difficult. Advantage with this route is ease of usage. The patch is another mode of topical application which has the advantage of once or twice weekly application but has disadvantage of causing blisters and irritation at site of application. Implants are equally as effective as other topical routes. It has advantage of once every 6 months insertion sub-dermally but has disadvantage of requiring minor surgery under local anaesthsia for insertion. There is there risk of infection at site of insertion. Removal if intolerable will also require minor surgery. Vaginal ring is also very effective and is applied weekly. This has the disadvantage of possibly making patient uncomfortable and interfering with intercourse. It is however usuful for does who cant cope with compliance of daily administeration and are not tolerating patches due to irritation. Vaginal estrogen creams are quite useful for those with predominantly urogenital symptoms with as little as possible getting into systemic circulation to cause side effects. B)The risk of HRT in this particular situation would include increased risk of breast cancer when used for more than 5 years of approx 45 in 1000. This risk reduces back to that of the general population 5 years after discontinuation of treatment. Her risk of VTE is increased 2 - 3 folds. This is especially in the 1st year of use. If she has family history of VTE it will be worth while checking for thrombophilia screening. If she has history of VTE then it is prefarable not to use it. This risk is more significant if she takes HRT in a form that passes through the first pass mechanism such as the pills.She has increased risk of stroke and coronary heart disease. It has been found that her risk of developing ovarian cancer also rises slightly. This should be taken into consideration along with other risk factors for ovarian cancer taking note that hysterectomy also slightly reduces her risk for ovarian cancer.I will also inform her that her risk of gall bladder disease is slighyly increased. I will inform her of the side effects of the drug which include headache, abdominal bloating, fluid retention,breast tenderness, and nausea.
		Posted by Sarika N. Fri Feb 12, 2010 08:36 am
A 50 year old woman with a 6 months history of menopausal symptoms requests hormone replacement therapy. She had a total abdominal hysterectomy five years ago for a large fibroid uterus. (a) Discuss the available routes of delivering HRT and their advantages and disadvantages [12 marks]. Hormone replacement therapy is effective for symptomatic releif of menopausal symptoms and its use justified when symptoms adversely effect quality of life. As patient had hysterectomy the lowest dose of estrogen without progesterone can be prescibed in the absence of contraindications and full information of risks and benefits for this treatment should be given. The treatment should be prescribed for the shortest period of time, with minimum effecti dose and reapprased annually.Patient should be advised to avoid HRT if active cardiovascular disease, stroke, personal or in first or second degree relative history of thromboembolism. HRT is contraindicated if there is a history of breast cancer. Advantages are the relief of vasomotor symptoms, improving psychological well- being, prevention of osteoporosis, reducing symptoms of uro-genital atrophy, also some studies suggested of reducing the risk of colorectal cancer. The choice of way of taking HRT depends on individual preference, indication and convinience. Oestrogen can be given in the form of tablet by mouth, which gives good control of vaso motor symptoms, but can be associated with premenstrual -like side effects , abdominal pain, bloating. Also estrogen can be given in the form of patches, which should be changed every week or 3-4 days, depends on preparation, or implant. Both of those methods avoid first-pass metabolism and may be more convinient to the patient, the risk of VTE slightly reduced. Implants should be changed every 4-8 months by trained professional, but the estrogen levels should be checked prior to this. In presence of vaginal dryness local estrogen can be given as a short term course. Selective estrogen receptor modulator containing the same risk of VTE as estrogen containing HRT, but does not protect from vaso- motor symptoms. (b) What would you tell her about the risks of HRT? [8 marks]. Patient should be informed that the information regarding HRT is controversal. There is some evidence that HRT does not prevent coronary heart disease and should not be prescribed for that. There is slightly increased risk of stroke. The risk of VTE is doubled in women with HRT, especially in the first year of use and they should be educated for signs and symptoms of thromboembolism, alsao it is reduced with non oral use. The risk of breast cancer is increased and related to the duration of HRT use, this excess risk disapears within 5 years of stopping. Patient should be advised to have regular mammographic examination. Long term use of HRT is associated with small increase risk of ovarian cancer, but non dependant on type of preparation or mode of administration. Patient should be given written information regarding the available options and alternatives to HRT, but the evidence is unclear. Psychological support is important part of the consultation.
		Posted by Chitra.s M. Fri Feb 12, 2010 01:36 pm
women with tota abdominal hysterectomy will require only estrogen to treat her menopausal symtoms in HRT. Estrogen can be delivered through oral, transdremal, vaginal,subcutaneous & through intranasal route. The most common route of delivering HRT is the oral route . Advantages are it is noninvasive, does not require the assitant of medical person when compared to subcutaneous route( implants),it is known to lower plasma levels of LDL& lipoprotein (a)& increase the level of HDL, hence suitable in women with increased levels of LDL. Disadvantages areneeds compliance ,increases the level of fasting triglycerides, hence not suitable to use in women with hypertriglyceridemia, diabetes mellitus.As it undergoes first pass metabolism in liver it may be affected by liver enzyme inducing drugs hence not suitable to use in women taking anti epileptic drugs, also in women with gallbladder , liver disease, cronh,s diesase. It is als known to alter the haemostatic system more in women with throbophillias , making them more prone for VTE. Trans dremal route in patch /gel form.Avantages are, it avoids the first pass metabolismhence can be useful in women taking liver enzyme inducing drugs. Reduces the fasting level of triglycerides.Delivers stable level of estrogen hen ce useful in women with migrainewith out aura,as flutucating levels of estrogen as in oral route is a trigerring factor for migraine attack. Disadvantages are skin reactins , dislogdement of the patch, can decrease the level cardiprotective HDL.Implantshas the advantage of no need to remember to take medications.disadvantages are needs medical supervision to initiate and to stop the treatment. women may develop tachyphylaxis to estrogen.Vaginal route as pessary, cream, ring has the advantage f being the mst effective for m to treat urogenital symtoms, minimal systemic side effects.Dis advantage include requirement of long term treatment as symtoms may recurr after stoping the treatment. I will councel the women that absolute risks are minimal if used for 1-2 years for releveing the menopausal symtoms.I will inform the risk of VTE is increased by 2-3 fold with use of HRT in the first year of use and inform the signs and symyoms of VTE, so that seek medical help immediately.The risk of coronary heartdisease and stroke is increased in the first year of use. I wil tell her that risk of breast cancer is increases with increased duration of use and it is about 2,6,12 extra cases per 1000 HRT users above background risk of her age.I t is nessecary to inform her that risk reduces to that of nonusers after 5 years of sttopping the drug.Risk of ovarian cancer is also increased.sytmic effects wil also be informed like nausea, weight gain and breast tenderness. Iwill provide her the information leaflet.
		Posted by fluffy F. Fri Feb 12, 2010 10:58 pm
From fluffy a) As she has undergone a total abdominal hysterectomy , she will only need estrogen replacement therapy. The oral route , available as conjugated equine estrogen or estradiol has the advantage of relieving vasomotor symptoms , hot flushes, vaginal dryness, ,with response usually achieved by 3 months after usage.It protects against bone loss and protects against osteoporosis.It has some psychological benefit with improvement in feeling of well being and avoidance of depression.It has some protective effect against macular degeneration, alzheimers and tooth loss.It has protective effect against colorectal cancer.The disadvantages are it has higher risk of venous thromboembolism compared to other routes of delivery. The transdermal estrogen patch , has the advantage of relieving vasomotor symptoms and has reduced risk of venous thromboembolism. The disadvantage is the cost factor and patient compliance due to adherence to changing the patch at a specified interval.The estrogen vaginal ring , has the advantage of relieving hot flushes and vaginal dryness as it acts locally and systemic absorption is less . It has the advantage of reduce risk of venous thromboembolism compared to the oral estrogen tablets.The disadvantage is dyspareunia , increase in cost and patient compliance to regular change in the estrogen ring as per schedule. Vaginal estrogen cream, can be used to relieve vaginal dryness and avoid vaginal atrophy , the disadvantage is , it is only recommended for 3 -6 months . Other modes of admininstration are by nasal spray and rarely by implants . b)The risk of cardiovascular complications is increased as evidenced by the WHI trial.There is increased risk of myocardial infarction, stroke and pulmonary embolism in patients on HRT compared to non users.Risk of cardiovascular risk is 7 in 10,000 users of HRT .risk of stroke 8 in 10,000 users of HRT. There is increased risk of breast cancer , however if usage is only for 5 years , the risk of breast cancer is same as the background risk of 32/ 1000 over 15 years.The risk of breast cancer increases to 2/10,000 with 5 years usage , 6/10,000 with 10 years usage and 12/10,000 with 15 years usage at age of 50 years. There is increased risk of ovarian cancer in HRT users. There is increased risk of venous thrombo- embolism 2-3 times higher compared to non users. Other estrogen related risks are fluid retention, breast tenderness, leg cramps and headaches.
		Posted by Seham S. Sat Feb 13, 2010 01:24 am
SE-SA (a) HRT for this patient will be oestrogen only therapy. Oral route is the most common .It has the advantages of easy administration and can be taken at any time of day. It is convenient , cheap and usually tolerated. Disadvantages include nausea,dyspepsia,bloating,headache and breast tenderness. Also activation of certain hepatic enzymes resulting in synthesis and release of sex hormon binding globulin. It may have effect on coagulation cascade as proved by increase risk of venous thrombo embolism (VTE). Transdermal route either patches or gel form have the advantages of avoiding hepatic first pass and remain oestrogen : esteron ratio 2:1 so, it is highly physiological.Another advantage is it is available in varying strengths so, it could be tailored to patient needs. Subcutaneous implants in which positioning of a pellet of oestrogen in subcutaneous tissue ,usually in lower abdomen under aseptic codition and local anaesthesia. It has the advantages of being well tolerated and obviate the need for daily or weekly action by the patient.Significant increase in bone mass in hip and spine is another advantage. The disadvantages are rare as some reported cases of tachyphylaxis in which patients requesting re-implantation at progressivly shorter intervals. Also,annual check of oestradiol in plasma which in most centers is not allowed to increase > 1000pmol/L . Oestradiol could be used transnasaly in pulsed fashion which is thought to have the advantage of maintaining the benefits while minimizing the side effects of chronicaly elevated oestrogen as breast tenderness. Local route as vaginal rings which deliver oestrogen for 3 months has the advantage of providing effective relief of local symptoms and avoid systemic side effects . The disadvantage is it is licened for 3m use in UK and for 1 year in Europe. Vaginal creams and tablets could also be used localy witout systemic side effects. (b) HRT does not protect and is associated with increase risk of coronery artery disease and stroke especialy in 1st year of use.Risk of breast cancer in long term use ( >5y ) after age of 50y is increased,however if HRT is discontinued for 5y the risk is similar to thatof never users. Women who develop breast cancer while on HRT,they have bigger tumours and more advanced disease. VTE risk is increased 2-3 folds in HRT users especialy in 1st year . If VTE developed HRT should be discontinued.Transdermal oestrogen is safer than oral route with respect to VTE. Gall bladder diseases are increased. Woman should be infrmed that the overall risk is still small and benefits may overcome the risks. Written information should be given .
		Posted by Harry B. Sat Feb 13, 2010 02:25 am
HB A. The available routes of delivering HRT for this woman are oral, transdermal (skin patches and gel), subcutaneous implants and vaginal preparations (Cream, pessary and ring) The oestrogen tablets or tibolone can be given orally. The advantages are ease of taking the tablets with minimal interventions. The disadvantages are difficulty remembering taking tablets everyday, gastrointestinal disturbances such as nausea and undergoes first pass metabolism in the liver and hence can cause adverse drug interaction with other liver enzyme inducing drugs, interference with haemostatic system increasing the risks of VTE. The oestrogen HRT when used as a transdermal preparation such as gel (once daily or on alternate days) or the patches (once or twice weekly) have the advantage of not taking the tablets for women who find difficulty in swallowing, by-passes the first pass metabolism in the liver minimising the risks of VTE and causes sustained release of oestrogen in the circulation. The disadvantages are of being more expensive, can cause skin reactions and dislodgement of patches. The oestrogen implants need to be given subcutaneously by a trained professional, the advantages of which are availability of physiological levels of oestrogen over a long period (6 months) and bypasses the liver metabolism. The disadvantages are of the need for a trained professional and the risk of tachphylaxis. The vaginal preparations are best if this woman has only urogenital symptoms, act locally and minimal amount is absorbed systemically and hence decrease the adverse effects. The disadvantages are patient compliance as women find creams ‘messy’ and the dislodgement of the rings. B I would reassure her that the benefits of short term use of HRT (1-2 years) outweigh the risks associated with them. I would inform her the increased risk (2-3 folds) of venous thrombo-embolism (VTE) and risks are higher if she is known to have inherited or acquired thrombophilia or family history of VTE, in which case she needs opinion of the haematologist and transdermal preparations would be beneficial with throboprophylaxis. I would advise her about the symptoms of VTE and advise her to seek medical review. The risk of breast cancer is also increased with use of HRT, particularly high after 5-10 years of use. I would advise and teach her about self breast examination and to have regular breast cancer screening. The cardiovascular risk of myocardial infarction and stroke are increased especially if she has any risk factors and would advise her about the benefits of regular exercise, diet and to stop smoking (if smoking). The risks of gall bladder disease is also increased.
		Posted by shmaila S. Sat Feb 13, 2010 06:52 am
DR SAS (a) this patient will benefit from estrogen only HRT and do not need progestogens to protect endometrium due to previous hysterectomy. the route of HRT administration will depend on patients symptoms and choice. estrogen only HRT is available in the form of patches.advantages of patches are that they are easy to use. patients dont need to remember taking tablet everyday. patches are available that need to be changed either every 3rd or 4th day, or once a week.they are places under the waist area.. disadvantges of patches are that they can give skin reactions/allergy and patient needs to remember the days whgen they need to be replaced. estrogen only HRT are available in the from of implants as well. once given they only need to be resited at regular interval, mostly quarterly.disadvantages are that implants once given cannot be retrieved and dose cannot be adjusted as well. if patients has got mostly local effects of lack of estrogen like vaginal dryness, estrogen impregnated vaginal rings can be prescribed as well.vaginal pessaries of estrogen for local application can be given as well. advantages of local applications are that they are good at resolving local synmptoms without systemic effects, and can be used on long term bases. disadvantges are that they can messy to use and also has no effect on symptoms like hot flushes and night sweats. (b) risks of HRT
		Posted by R S. Sat Feb 13, 2010 07:06 am
a… HRT can be given via oral, transdermal or vaginal route. Hysterectomised women will need only estrogen as there is no risk of endometrial cancer. It can relief hot flushes and reduce bone mineral density loss. Oral estrogen is available as conjugate equine estrogen 0.625 mg. Its advantages is that it relief vasomotor symptoms significantly like hot flushing and sleep disturbances. This route is acceptable to most women. Dose can be adjusted as lower doses (0.3mg) are equally effective with fewer complications. The disadvantages of oral route is that it pass via enterohepatic circulation, therefore, its associated with increased incidence of venous thromboembolism more than other routes. It can also cause gall bladder disease. Some women may experience nausea and vomiting. Efficacy reduced if the woman develops gastroenteritis. Estradiol patch can also relief hot flushes. It bypasses the liver so associated with less risks of VTE. Its disadvantages are that it need to remember to change the patch weekly, also occasionally, skin reaction might occur at site of patch. Patch can be detached without notice. It does not improve genital atrophy. Vaginal estrogen can be given as cream, tablet, gel or ring. It relief genital atrophy symptoms like superficial dyspareunia, soreness and urinary frequency and has minimal systemic level, it carries less incidence of systemic complications. The disadvantages are that it’s less effective in relieving vasomotor symptoms and reduction of bone resorption. b… HRT is associated with 2-3 fold raise in incidence of VTE. This is due to estrogen effect on coagulation factors. The risk increase with prolonged use and return to non – user risk after 3 months of stopping HRT. Further more there is increased incidence of stroke, transient ischemic attack and coronary heart disease. However, there is emerging evidence that HRT might be cardioprotectve if administered within 5 years of menopause. Moreover, there is increased risk of developing breast cancer; the back ground risk is 32:1000 in 15 years. The incidence will be 38:1000 women with 5 years of use and 51:1000 with 10 years of use. The risk is less if only estrogen is used in comparison with estrogen and progesterone administration. The risk will return to non user after 5 years from discontinue treatment. In addition there is slight increase in risk of developing ovarian cancer (<1:1000). However, general, the over all risks remain low.
		Posted by shmaila S. Sat Feb 13, 2010 12:16 pm
DR SAS, sorry about this interrupted answer.please mark it. (b) i will councel her that HRT is helpful in controlling post menopausal symptoms like hot flushes, night sweats,osteoporosis, vaginal dryness, decrease libido,low mood and depression. however HRT is not side feect or risk free and should be taken in lowest possible doses and least time posible.women should be councelled that HRT is associated with three fold increased risk of venous thromboembolism in the abscence of any other underlying risk factors for thromboembolism.there is a small increased risk of breast cancer is women taking estrogen containing HRT for more than 5 years and the risk returns to normal if HRT is discontinued.there is a small increase in the risk of having ovarian cancer. HRT also increases the risk of endometrial cancer but as she had hysterectomy so it does not apply to her. there is a small increased risk of having stroke. The Women Health International trail shows that HRT is not cardioprotective and should not be used for protection of cardiovascular system.
		Posted by Dr Dyslexia V. Sun Feb 14, 2010 01:25 am
X a) This fifty year old woman who would probably benefit from estrogen only therapy as total abdominal hysterectomy is already done and progestogen are not required . The most commonest route of delivery of HRT is the oral route. The advantage include the relief of menopausal symptoms such as flushes, irritability, insomnia and so forth. The preparation is ideal for her would be a low dose ERT. It has other benefit include reduction invertable fractures, reduces osteoporosis, decreases the onset of alzheimer’s, relief’s urogenital symptoms of vaginal atrophy and reduces risk of colorectal cancer. The oral preparation usually comes as a single daily dose which is easy for compliance and affordability. However, the oral preparation goes through the first pass hepatic metabolism which increases in the unwanted increase of prothombotic factor. The other disadvantage of hormone replacement therapy also increase in breast cancer, myocardial infarction, stroke, increase in ovarian cancer and gallbladder disease. The local preparation of hormone replacement therapy include the weekly patches such as Climara, three monthly vaginal ring, such as Fem ring, vaginal premarin cream application or premarin tablet application. The patches are easily usable but are associated with dislodgement and erratic absorption when exposed to direct sunlight. The Fem ring is unique and it’s compliance is good in view of three monthly insertion. It is associated rarely with toxic shock syndrome and the symptoms of this should be watched out for the user. It is also uncomfortable to be inserted and could hinder with coitus. These vaginal preparation are associated with less risk of VTE compared to oral preparation. The premarin cream are also commonly used to relieve urogenital symptoms but its usage for more than 3 month should be accompanied by progestogen if the uterus is present. b) The risk of HRT includes the relative risk of increase in breast cancer from a background rate of 32/1000 at the age of 50 to 38/1000 after 5 years of usage and 51/1000 after 10 years of usage. Other risk include the risk of increase in coronary artery disease and increase in stroke. Major disadvantage also include the increase in venous thromboembolism as increases the production of prothrombotic factors. There is also increase in ovarian cancer by 2 to 3 fold. Besides this major risk there is also moderate systemic estrogen side effects such as fluid retention, breast pain and nausea and headache.
		Posted by Green K. Sun Feb 14, 2010 10:20 am
Green: a) Oral estrogen only tablets. Advantage includes effective resolution of vasomotor symptoms such as hot flushes, irritability and improves general well-being. Disadvantages include a higher dose required due to first-pass metabolism by the liver. This causes increased risk of VTE and gall stones compared to other methods of administration. It also needs to be taken on a daily basis to have sustained effect. Increased risk of recurrent breast cancer in patients with history of breast cancer. Estrogen patches enable a lower dose of estrogen required due to transdermal absorption avoiding the metabolism of the liver. It is recommended as the method of choice for administration of estrogen in patients with increased risk of VTE. Disadvantages include the need replace patch every 1-2 weeks. Patch may cause allergic reaction on the skin or may fall off without being noticed. Vaginal cream, pessaries or ring where it improves irritative urogenital symptoms such as urge, urgency and urge incontinence and vaginal atrophy. Disadvantage is that the effect is mainly to the local tissues and would not improve systemic menopausal symptoms. Needs to be administered daily. Estrogen implants placed in the subcutaneous layer of the buttocks or abdomen has similar effect to patch or gel. It only requires administration every 6 months. Disadvantage is that it requires administration by a doctor. Administration may be painful. Scarring and infection of the skin may occur.Patient may experience menopausal symptoms as the drug strength reduces nearer to the end of the 6 months period. Estrogen nasal spays enable pulses of estrogen be given on a daily basis. Avoids risk of high dose oral estrogens. Disadvanage include non- sustained effect of estrogen. Nasal spays may also cause nasal irritation. b) Increased risk of breast cancer by 1-2 extra cases in 5 years of taking estrogen only HRT. Risk reduced to population levels after stopping treatment. Increased risk of VTE especially in the first year of use by 2 fold. Risk is increased to 8 fold in patients with tendencies to forming blood clots due to genetic mutation involving clotting factors . Increased risk of coronary heart disease and stroke especially in the first year of use. Slight increased risk of ovarian cancer if estrogen only HRT used more than 5 years. Increased risk of worsening established Alzheimer\'s disease. Provide patient information leaflet on hormone replacement and its risk.
		Posted by Lilantha W. Sun Feb 14, 2010 12:43 pm
(a) The advantages of ral route of delivery of HRT are that it is easy to administer and to control. It may be more acceptable for women who used to take contraceptive pills. Disadvantages are due to first pass metabolism by the liver requiring higher doses to be taken orally in order to achieve reasonable plasma levels. This inceases incidence of gastro-intestinal (GI) side effects such as nausea and vomiting which can hamper compliance. Absorption can be cffected by the condition of the GI, particularly if the women takes broad spectrum antibiotics. In order to maintain a steady plasma concentration of the hormone, it should be taken daily which can be forgotten by the woman compramising the complience. If she is on hepatic enzyme inducers such as carbamazapine, the bioavailability of HRT diminishes. Higher HRT doses of the oral route incerase risk of systemic adverse affects. Transdermal route of delivery has advantages of bi-passing the first-pass metabolism by the liver, hence, mimics effects of natual hormones in the body. Transdermal patches are applied 1-2 times a week which enhances complience. HRT gels can be applied when ever it is faesible, which may be acceptable for some women. Disadvantages are that patches can be fell off without recognition. They can cause skin irritation and rash. They are not suitable for women with some skin conditions such as widespread psoriasis, eczema. Patches may not be cosmetically acceptable for some women. Advantages of vaginal route of administration are that if HRT is indicated for urogenital atrophy e.g. dry vagina, dysparunia; its effects can be chieved in the place that it is being administered. Systemic absorption is not high with most of vaginal preperations which will reduce risk of systemic adverse effects such as breast cancer and venous thromboembolism (VTE). Disadvantages of vaginal route are that HRT containg rings can interfere with sexual intercourse. Rarely, the vaginal cream increasees the risk of the male parner getting exposed to oestrogens at the intercourse with its improper use. Woman may find the ream ‘messy’. Pessaries can be difficult administer properly. Tablets can fall off. Advantages of oestrogen implants are longer duration of action, which is 6-9 months, high complience due to the fact that it is usually inserted every 6 moths. It bi-passes the first-pass metabolism and the depot preperation ensures a steady plasma concentrations for most of its effective period. Disadvantages are that it requres a trained professional to administer it subcutaneously by a minor procedure which can be painful. Risk of insertion site infection and scarring is there. There is a small risk of tachyphylaxis. Once inserted, it is nearly impossible to remove/reverse. The nasal spray has the benefit of administering easily. It is readily absobed by the nasal mucosa and it bi-passes the first-pass effect of the liver. Disadvantages are unsteady plasma levels which can provoke symptoms and nasal irritation which can cause problems for some women. (b) I will inquire about hermenopausal symptoms, risk factos for breast cancer, ovarian cancer, VTE cardiovascular disease and her wishes regarding HRT in order to counsel her regarding risks of HRT. I inform her that taking estrogen replacement therapy (ERT) alone should be sufficient, which carries lesser risks than combined HRT. Although combined HRT increses the risk of brest cancer by 4 additional cases for 1000 users, use of estrogen only less than 7 years does not appear to have increased the risk of breast cancer. This is particularly relevant if you take vaginal estrogens or transdermal estrogens. However, other risks of HRT remain unchanged whether it is ERT or HRT. The risk of VTE is incresed 2-3 times particularly in the first year of starting ERT. Inheritent thrombophilias will incease this risk of VTE upto 8 fold. If she is high risk of developing VTE, the ERT is contraindicated. ERT increses risk fo developing coronary heart diesase and stroke. The risk is heighest in the first year of commencing HRT. Appropriate risk assessment is done before advicing her, including history of smoking history, family history, BMI, blood pressure. Risk of gall baldder disease is high with the use of HRT. There is a small increase of developing ovarian cancer. Generally, risks of developing these diseases depend on the duration of ERT use, its mode of delivery and prehaps the dose. The safest routes of administration can be vaginal and transdermal. Moreover, most of these risks would be eliminated after stopping HRT. There are complementary thrapies of which the risks can be vary and might not be well-known. Hence, it is important to make an informed choice considering all pros and cons. I will offer her information leaflet and another appointment as necessary.
		Posted by Bgk H. Sun Feb 14, 2010 11:03 pm
a. There are few available route of administration for HRT. The choice depends of the availability of the HRT, patients’ choice and their menopausal symptoms. Systemic symptoms like hot flushes, night sweats, insomnia and irritability may need systemic administration like oral, patch or spray. Local symptoms like vaginal dryness and atrophy may only need local application like oestrogen cream. The commonest route will be by orally. It has the advantage of easy and widely available. It also cost effective way of administration. The effectiveness of alleviating the menopausal has been proven. However its disadvantages are the need to remember taking it in daily basis. It may take 4 weeks to have the efect and about 3 moths for maximal effect. It also cause a lot of unwanted gastrointestinal discomfort such as vomiting and nausea. Its effectiveness may also be altered if the patient taking liver enzyme inducer medication at the same time and not suitable for patient with fulminant liver disease. The other method is patch. Its advantages include easy application with once a month administration. It also avoids first pass effect and not altered by liver enzyme function. But the disadvantage is sometime patient may develop reaction toward te patch The new other method is nasal spray, it has similar efficacy with easier way of administration.. Another option of administration is intravaginal device which has sustained hormonal release. It has the advantage of easy administration and monthly application. It also has the advantage of the avoiding the first pass effect. Another available method is by skin application which has systemic effect. It is a very easy way of administration but may have not consistent dose for each application There is local application such as the oestrogen cream local application. There is effective in treating local cause of menopausal effect such as vaginal dryness. It has the advantage of avoiding the unwanted systemic effect of the hormone and very effective. Patient must be given information on each of the route of administration. Patient decision must be respected. b. There is risk of the individual hormone like progesterone causing water retention, mood instability and GIT complication. And Oestrogen has the effect of nausea and vomiting. As she has uterine fibroid, there is a small risk of the fibroid change in size. Further monitoring of the fibroid size needed if it becomes symptomatic. General risk of HRT includes risk of coronary heart disease especially on the first year of use. Risk of developing of Deep Vein Thrombosis especially on the first year of use. There is also increase risk of developing breast cancer from 32 in 1000 for non user for 15 years to 38 and 51 for 5 and 10 years of usage respectively. There is also the risk of developing gall stone in patient taking HRT. There is also possible risk of developing endometrial cancer in sequential HRT adminsitration.
		Posted by SUNDAY A. Mon Feb 15, 2010 06:41 am
sos The available routes include oral, topical preparation, vaginal tablets/ pessary, Transdermal (patches), Implant. The oral route is commonly used and acceptable to most patients with good systemic effect. It also allows usage as required .The disadvantage is that it needs to be taken daily, patient can forget and occurrence of systemic side effect is common The topical route is best suited for those with localised urogenital symptoms Such as vulva, vaginal atrophy since there is limited systemic absorption. The disadvantage is that it may be messy and may stain underwear. It may be less useful to control other menopausal symptoms. The advantage of vaginal tablet or pessary is that it’s easy to apply; it’s not messy and does not stain underwear. Its acts locally with little systemic absorption. The disadvantage is that it may not be suitable for women with other symptoms of menopausal aside vulva, vagina atrophy or dryness. The advantage of Transdermal patch is that is does not require daily dosing; patch can be changed twice weekly. It avoids the oral route for those who are aversed to taking oral medication with possible reduction in systemic side effect. The disadvantage is that it can cause skin irritation; the patch can fall off making it less effective. HRT can also be given and delivered as an implant. The advantage is that this can be long acting – up to 6 months with good systemic effect. The disadvantage is that it may cause irreversible side effect, it may cause pain at site of injection. I would inform her of her increased risk of breast cancer particularly if HRT is used beyond 5 years. This risk returns to baseline 5years after use of estrogen containing HRT. I would also inform her of increased risk of coronary artery disease. I would inform her of her increased risk of venous thromboembolism about 2-3 fold that of baseline population. I would also inform her about her increased risk of stroke particularly with estrogen based preparation. I would counsel her about the increased risk of ovarian cancer (if the ovaries were conserved at previous hysterectomy).
		Posted by AFSHEEN M. Tue Feb 16, 2010 11:03 am
A 50 year old woman with a 6 months history of menopausal symptoms requests hormone replacement therapy. She had a total abdominal hysterectomy five years ago for a large fibroid uterus. (a) Discuss the available routes of delivering HRT and their advantages and disadvantages [12 marks]. (b) What would you tell her about the risks of HRT? [8 marks]. a)Available routes include oral,transdermal patches, gels,implants and mirena IUS.Oral route is cost effective,easy to use, highly acceptable,has great patient satisfaction and suitable for those with systemic symptoms.However, has greater risk of VTE,compliance can be a problem and local urogenital symptoms may take a long time before relief. Patches are useful in women with poor compliance with tablets or those who want to avoid other routes,bypass GI metabolism,therefore suitable for those on hepatic enzyme inducing drugs and have lower risk of VTE when compared with oral route but has risk of site application reactions and lost patches in extreme temperatures. Gels are especially suitable for those with local urogenital symptoms such as vaginal dryness and urinary urgency and therefore avoids risks of systemic HRT;however, is not suitable for women with systemic vasomotor symptoms. Implants have better compliance,reliable,provide an oppurtunity for regular reviews and lower risk of VTE,when compared with oral route;but can be associated with pain and discomfort at insertion and may require sutures at the application site,as well. Mirena IUS is also licenced for use as HRT either alone or with estrogen only preparations,for upto 4 years.It is effective,no compliance problems and can stay for a long time; however, can be associated with pain or discomfort at insertion,irregular bleeding and crampy pain upto 4-6 months after insertion, and small risks of perforation and expulsion.Also, may cause breast tenderness, bloatedness,mood swings,depression and acne in some women. b)I will explain that HRT is generally safe but associated with some serious side effects.Risk of coronary heart disease(CHD) is increased in those with established disease already.It increases risk of stroke, MI and pulmoary emblosim in those with no previous history of CHD.Estrogen alone HRT also does not confer any protection. Risk of breast cancer is also increased with 2,6 and 12 additional cases per 1000 women with 5,10 and 15 years use of HRT.Women on HRT need regular follow ups; and that HRT can cause difficulty in interpretation of mammograms. However,risk tends to declines after stopping HRT.Progestogens confer no protection. Risk of endometrial cancer is increased with unopposed estrogen stimulation in women with intact uterus;however, as she has had hysterectomy,she will need estrogen only HRT. Risk of ovarian cancer increases with duration of use and is not affected by route of administartion or type of preparation. Risk of VTE increases especially in those with personal or family history of previous VTE,obese (BMI >30),smokers and those with sedentary life styles.Universal screening is not recommeded,except for those who have a personal or family history of VTE.IF multiple risk factors or high risk thromobophilias present such as anti thrombin 3 deficency,homozygous factor 5 leiden mutation or combined defects, HRT should be avoided and specialist help should be seeked.Those with asymptomatic thrombophilis should have tailor made plans, with specilaist involvement and after full counselling about risks. I will explain symptoms and signs of VTE and advise her to seek medical help if concers and provide written information.
		Posted by Atashi S. Tue Feb 16, 2010 06:35 pm
(a) As this pt had a hysterectomy oestrogen only is sufficient to relieve her symptoms. Available routes of delivering HRT including oral tablet, subdermal implants,percutaneous oestrogen gel, transdermal patch,vaginal cream and vaginal tablet. Conjugated equine oestrogen .625 mg or 1.25 mg is to be taken orally daily to relieve vasomotor symptoms. Oral oestrogen therapy give rise to plasma oestrone level.As it need daily intake pt compliance is low . Drug interaction may occur with some enzyme inducing agent like carbamazipine, phenothiazine,fluconazole.Subdermal implants are inserted subcutaneously over the anterior abdominal wall using local anesthesea.17 beta oestradiol implants 25mg,50mg, 100mg are available can be kept for 6 months.This implants maintain physiological oestradiol and oestrone ratio. Percutaneous oestrogen gel,1 gm applicator of gel, delivering 1 mg of oestradiol daily, is to be applied daily on to the skin of anterior abdominal wall or thigh.Effective blood level of oestradiol 90 to120 pgm/ ml can be maintained.Effective for reliving vasomotor symtoms and it avoids gastric side effect.Transdermal patch it contains 3.2mg of 17 beta oestradio,releasing about 50 microgram of oestradiol. Physiological level of oestradiol and estrone is maintained.it sholud be applied below the waist line and changed twice a week. Advatage of this route is lower risk of VTE than oral route.Conjugated vaginal oestrogen cream 1.25 mg daily is effective in case of atropic vaginities. (b ) I will tell her use of HRT in the 1st year associated with an increased risk of coronary artery disease. Risk of breast cancer at age 50 45 per 10000 over 20 year and 32 per 1000 over 15 year. Oestrogen replacement after the age of 50 associated with an increased risk of breast cancer similar to that associated with delayed menopause. Relative risk 1.35(cI 1.20 -1.49).Use of HRT for 5, 10, and 15 years would cause 2,6 and12 extra breast cancer per 1000 women. Risk of breast cancer in women who have discontinued HRT for 5 years is similar to that in never users. current use of HRT is associated with increased risk of ovarian cancer,incidence of ovarian cancer increased with increasing duration of use, but did not differ significantly by type of preparation used, its constituents, or mode of administration.HRT is associated with 2 to 3 fold increase in the risk of venous thrmboembolism.Systemic side effect includes fluid retention,breast tenderness, nausea, headache, leg cramps, dyspepsia- usually resolve with increasing duration of use.