The smart way to learn. The smart way to teach.

MRCOG PART 2 SBAs and EMQs

Course PAID
notes	336
EMQ	1502
SBA	2115

Do you realy want to delete this discussion?

Forum >>

ESSAY 199 - HRT

Page 1 of 1 [1]
		Posted by Sarwat F. Mon Jul 17, 2006 06:23 am
Various issues that will be reviewed include long-term benefits for ostoporosis prevention, alzheimers disease and colorectal cancer. I will assess her risk of osteporosis by asking about the high risk factors for osteoporosis like family history of ostoporosis, past history of any fractures, history of use of steroids, autoimmune disease like thyrotoxicosis, history of prolonged amenorrhoea in reproductive age. I will check her body mass index as low body mass index is a risk factor for osteoporosis. I will tell her that HRT is associated with decreased risk of osteoporosis. Regarding alzheimers disease I will tell her that initially data regarding benefit of HRT for alzheimers disease was conflicting but recently studies are showing protective effect for alzheimers disease. Obviously history of alzheimers disease in the family makes her at high risk of the disease and HRT would be beneficial in this case. Regarding colorectal cancer, HRT is again beneficial especially those at high risk due to preexisting bowel disease or family history. Regarding risks of HRT I will tell her that prolonged use of HRT more than 5 years is associated with increased risk of breast cancer, this has been shown by studies but the risk is increased by 8/100000 woman. Also it was initially thought that HRT is beneficial for coronary artery disease but recent studies have shown that it is associated with increased risk of cardiovascular disease. Other risks include risk of thromboembolism, again history of any thromboembolic event in the past or any high risk factor like family history of thromboembolic events is associated with higher risk. Type of HRT especially progesterone component is important and progesterone with lower risk of thromboembolism can be prescribed. There is risk of endometrial cancer with unopposed estrogen but not with sequential HRT. In the light of these risks and benefits she has to make a decision whether to continue this medication for prolonged use or not. Other options apart from HRT include tibolone which is a synthetic steroid with estrogenic, progestogenic and mild androgenic properties. SERMs that is selective estrogen receptor modulators can be considered which have estrogenic effect on bones and antiestrogenic effect on breast and endometrium however they are associated with hot flushes but this can be offset by addback therapy of low dose estrogen. Recently low dose HRT is being prescribed which has lower risk of above mentioned side effects and is quite beneficial. Alternatives to HRT can be considered starting from lifestyle modification like regular exercise. Various studies have shown the beneficial effects of exercise on short term symptoms of mood swings as well as osteoporosis prevention. She can be explained about the beneficial effects of cutting down smoking, tea coffee and intake of calcium and vitamin D. Calcium and vitamin D are important as regular intake is associated with decreased risk of osteoporosis. Other options for osteoporosis prevention include bisphosphonates which donot have any risk of breast and endometrial cancer and are effective for osteoporosis. Various herbal preparations are available like soy and black cohosh but definite data regarding their efficacy and safety is lacking.
		Posted by Balakrishnan V. Mon Jul 17, 2006 08:41 am
Harmone Replacement Therapy ( HRT) is associated with long term risks of thrombosis, breast and endometrial cancer and coronary heart disease as well as benefits of relief of postmenopausal symptoms, vaginal dryness, and mood swings. For reduction in risk of osteoprosis and alzheimer\'s disease it has to be taken for long time. I will take detailed history to assess effect of HRT on her symptoms and development of any risk factor in past 2 years of HRT use like breakthrough bleeding, any pain or tenderness in legs, medical problem like diabetes, hypertension, ischemic heart disease. If her quality of life has improved on HRT and she wishes to continue it and there are no risks I will weigh the benefits against risks of HRT with her so she can make an informed choice. The long term effects of HRT depend on the type, duration and route of administration of HRT. Long term use of HRT is associated with coronary heart disease and stroke. She will need to do regular checkup of her bloodpressure, cholesterol and ECG. It is also associated with increased risk of breast cancer. Risk increases after five, ten, fifteen years of use to 2, 6 and 12 more cases per 1000 women and returns to risk of non user after five years of discontinuation of HRT. She will be encouraged to do self examination of breast and take part in breast cancer screening mammography programme. Risk of endometrial carcinoma also increases, although more with unopposed oestrogen therapy than with sequential combined estrogen and progestogen. In case of any vaginal bleeding she has to undergo investigations to rule out endometrial cancer. The risk of thrombo embolism increases in post menopausal women due to age, parity, obesity, immobility and medical problems. HRT further increases this risk. The risk is more during first year of use and in those with personal or family history of VTE. Transdermal therapy is associated with low risk of VTE. I will counsel her regarding signs and symptoms of VTE and advice her to seek early advice in case she has suspicion of VTE. I would give her alternative of HRT like progestogens such as northisterone or megestrol or SSRIs like paroxetine can be used for hot flushes. Topical oestrogen (pessary) or lubricant can be used for vaginal dryness. I will give her written information and review appointment so she can has time to think and consider her choice of continuing or discontinuing HRT.
		Posted by Srivas P. Mon Jul 17, 2006 09:38 pm
Relief of vasomotor symptoms is the commonest indication for HRT and is given only short term for between 2-5 years, with review for risk benefit profile annually. Since she has already taken sequential HRT for 2 years it should be enquired if her symptoms have now improved and if not, her present complaints, its severity and their effect on her quality of life. Any persisting hot flashes, vaginal dryness, dyspareunia, urinary frequency, recurrent UTI urgency should be asked. Usually these symptoms would have disappeared with 2 years of HRT. If her symptoms have disappeared, HRT should be weaned off as HRT is not to be given for long periods and is not advocated for primary prevention of CHD or osteoporosis and its effect on prevention of Alzheimer?s disease is uncertain. She should be reassessed again for HRT if her symptoms recur after stopping HRT or they did not completely disappear and she wishes to continue for some more years. She should be given advice on alternative therapies other than HRT. If the woman has vaginal dryness and dyspareunia, use of local estrogen therapy and vaginal moisturizer are effective alternatives. If she is not averse to ammenorrhoea now, it is better to change to combined continuous HRT as sequential HRT does not completely eliminate the risk of endometrial cancer when estrogen replacement therapy is given alone in first half of cycle. Before continuing with HRT her, we should look for recent history of VTE, attacks of migraine while on HRT, prolonged immobility, myeloproliferative disorders, current breast cancer, and severe Hypertension. She should be told that the risk of VTE doubles in postmenopausal woman without HRT and increases three fold to 30/100000 Woman per year with HRT. The findings of the large WHI study should be discussed with her and she should be told that the risk of CHD, breast cancer, Stroke and VTE increases by +7, +8, +8 +18 cases respectively per 10000 woman per year while risks of colonic cancer and osteoporotic fractures decreases by -6 and -5 cases respectively per 10000 woman per year. She should be told that primary prevention of CHD and osteoporosis depends on healthy life style choices?cessation of excess smoking, alcohol, weight control, regular weight bearing exercises, calcium and Vit D to prevent osteoporosis and CHD can be reduced by lipid lowering agents, regular exercises and anti hypertensives if she is hypertensive. Alternatives to HRT should be considered if she is now high risk for HRT or she is now averse to continuing with HRT with the risks associated with it. She should be told that alternative medicines may control her menopausal symptoms 50-60 % compared to nearly 80-90 % with HRT. Pharmacologic alternatives like alpha 2 agonists, beta blockers, SSRIs, SNRIs and gabapentine have been tried with varying good results. Phytoestrogens containing iso-flavones, lignans found in Soy and red clover are under trial with reasonable results and best given in specialist centres. Herbals like Black cohosh, kava kava have been found to be hepatotoxic while Ginseng interacts with Warfarin. Acupuncture, reflexology, hypnotherapy and homeopathy are under trial while reiki and yoga may relax and diminish a lot of her perceived complaints and are worth a trial.
		Posted by Remi A. Tue Jul 18, 2006 05:01 am
Since she has been on HRT for two years,its important to enquire about the effect of HRT on her symptoms-if there has been a good response,She should be told that she may be weaned of HRT,as she only need to take it for a short period[2-5 yrs] for menopausal symptoms.Enquire should also include the predominant menopausal symptom-vaginal dryness is amenable to local estrogen,with reduced side effect profile compared to other routes. Before further discussion about risk/benefits of long-term HRT,a risk assessment for HRT Should be done.Family/personal history of Breast Ca,family history of osteoporosis,history of cadiovascular disease,and personal history of DVT, and presence of uterus would help guide approach to further counselling. She should be told that Long-term HRT would reduce risk of osteoporosis[but need to be taken for >10-15 yrs],reduce incidence of Alzheimer\'s disease,colorectal cancer,tooth loss,macular degeneration.But,may increase risk of gall bladder disease. However,she should be told that primary preventive measures like regular exerscice,healthy eating would also prevent osteoporosis,if she does not have other predisposing risk [family history,thyroid disease] HRT would also increase risk of having Breast Ca-risk is extra 4/1000 for 5yrs,8/1000 for 10 yrs.The risk is not significant if taken for less than 5yrs. There is increased risk of endometrial Ca[with oestrogen only,and sequntial HRT,with presence of uterus].HRT Would not prevent cardiovascular disease,and its associated with increased risk of pulmonary embolism and stroke.The risk highest in the first year of use.There is also increased risk of VTE-highest in the first year.Personal history of VTE and presence of thrombophilia would further increase the risk. Discussion should also include medical alternatives like Gabapentin,SSRIs[Fluoxetine] which may be of benefit for menopausal symptoms,but no effect on osteoporosis.Biphophonates,SERMS are alternatives i for osteoporosis,but has no effect on menopausal symptoms. There is weak evidence for effectiveness for alternative medicine methods. Information leaflets should be provided and a second appointment given, if necessary.
		Posted by Ismatara B. Tue Jul 18, 2006 03:12 pm
There are various issues to discuss about the risk and benefit of HRT. At first a thorough history about her LMP, menopausal symptoms, weather improves or not, any persisting hot flashes, sleep disturbance, night sweats, vaginal dryness, dyspareunia, urinary frequendy,urgancy,UTI,presence of uterus, smoking, sedentary lifestyle. It is important to make a cardiovascular risk assessment-past history of MI, CVA, angina, hypertension, family history of ischemic heart disease. F/H or personal history of venous thromboembolism, osteoporosis, and breast cancer should also be discussed. She should be explained that risk benefit depend on type of HRT ( oestrogen only, or oestrogen + progesterone(O+P), sequential or continuous combined, duration, route of use and age of the woman. Current advice suggest that oestrogen treatment should be used for treatment of specific symptoms and low bone density but not the first choice therapy.And also sugests that progesterone dose can be reduced to 7days instead of 14 days with reduced intolerance and risk of breast cancer. Current study shows that usually menopausal symptom disappear within 2 years of HRT, if so HRT should be stopped. If her symptom again recurs, then HRT can be restarted and continued upto another 3 years and should be reviewed with a discussion of current view of risk benefits profile yearly. If she has vasomotor symptoms only, then either oral or transdermal oestradiol with cyclical progestrogen for endometrial protection should be given. if vaginal dryness is main complaint, topical oestrogen (pessery/tab) may be adequate. In randomised trials proven benefits of HRT is an improvement of vasomotor symptoms, osteoporosis, and colorectal carcinoma. She may have a window opportunity of primary long term protection against CHD and perhaps strokes and Alzheimer\'s disease if she is symptomatic but no place of secondary protection and should be discouraged if she had cardiovascular events, as stroke, heart attacks increase. She will not have any benefit after 60 yrs of age. She should be reviewed about increased risk of venous thromboembolism increased 2-3 fold, specially increased if she has a personal or F/H of venous thromboembolism, she should be considered alternative therapy. She should be discussed about risk of breast cancer- this is associated with longterm use. Use of HRT for 5, 10 and 15 yrs would cause 2,6 and 12 extra risk of breast cancer per 1000 women. The risk decreases after discontinuation of HRT. A mammogram should be performed each year and breast examination every 6 months. There are risk of endometrial carcinoma which is reduced by combined O+P replacement. Other risk including gallbladder, drug sideeffects, abnormal bleeding requires investigation. She should be discussed about alternative to HRT: Change of lifestyle ( exercise, avoid caffeine, smoking, alcohol, and taking Calcium, Vit-D decrease the risk of osteoporosis. Phytoesrogen, bisphosphonate, tibolone, SERMs are another option to prevent bone loss. SERMs are unsuitable to reduce vasomotor symptoms. Progestogen (norethisteron,megesrol), SSRI(fluoxetine) are effective in reducing vasomotor symptoms. Various herbal like soy, black cohosh, red clover, kava kava are available but definitive data regarding their efficacy are lacking. She should be given written information and a review appointment should be arranged to give her time to think and consider her choice of continuing or stopping HRT.
		Posted by OJO AJIBADE . Tue Jul 18, 2006 09:15 pm
The long term benefits of HRT(hormone replacement therapy) are:Prevention of ostoporosis & colo-rectal cancer.Other possible benefits include improvement in alzheimer\"s disease;tooth loss and improvement in skin and hair.This benefits will be evident after taking it for at least 5 yrs The risks are: increased risk of breast and endometrial cancer;gall bladder disease and abnormal vaginal bleeding.The latter may necessitate treatment .She will be informed that HRT does not protect against coronary artery disease but is associated with its increased riskand stroke. She will be informed that having taking Hrt for 2 years it is essential to be reviewed to decide whether to continue with it or stop it altogether. Menopausal symptoms that would have improved include vasomotor symptoms like hot flushes; night sweats and vaginal dryness.She will be counselled that menopausal symptoms are transient and advised to stop it because of the increase risks highlighted above.If vaginal dryness occur she will need to take local lubrication or oestrogen tablets per vaginal She will be informed that the risks described become significant after taking HRT for 5 or more years .If she agrees it will be stopped and advised to report if there is further complaints/symptoms. If she does not;then alternatives treatment eg progestogens eg norethinsrerone or selective serotonin reupake inhibitors eg paroxetine will be discussed.SERM may also be prescribed since the vasomotor symptoms have been relieved .If she wishes to continue;she will be reassessed again to find out if new risk factors has developed eg history of angina;smoking etc. and again informed about above risks and benefits too allow her make informed decision. She will be informed that the overall risk of these disorders in women taking it is small.
		Posted by Aroosha B. Tue Jul 18, 2006 10:37 pm
Important issues that would be reviewed with her apart from discussion of risks and benefits of long term use of HRT include place of HRT in modern practice and alternative to HRT and if this woman will opt for continuation of use of HRT , various conditions which contraindicates its use , its routes and types and side effects and need for monitoring are to be discussed. As regards long term benefits , HRT does protect from osteoporosis but this protection last as long as she will continue taking it. The risk of hip fracture between the age of 50 ? 60 is to 1:2 per thousand cases in non users of HRT compared to 0-1 per thousand cases in HRT users. Another benefit of long term use of HRT is reduction of risk of colonic cancer.in woman aged between 50 ? 60 years there are three case of colonic cancers reported in 1000 non-HRT users compared to 2 cases in 1000 HRT users . As regrds its risks , it is associated with increased risk of breast cancer.In a woman between 50 to 70 years of age , the risk of breast cancer is 45 per thousand in non ?users of HRT. While this risk increases to 2 ,6, 12 extra cases after 5 , 10 and 15 years use of HRT. Its use also increases psychological and surgical morbidity because of increased number of mammographically guided or open breast biopsy. However most of the studies showthat HRT does not increases mortality because of close surveillance and early detection of breast cancer .this risks lasts as long as HRT is taken and reverts back to normal after 5 years of stopping HRT . I will also inform her that HRT is associated with increased risk of CA endometrium esp if estrogens are taken alone or if sequential combined HRT is continued for more than 5 years as is the case in this particular lady.HRT does not protect against heart disease as previously deemed . Rather it increases the risk in first year of use, esp HRT which contain conjugated estrogen and medroxy progesterone acetate . HRT also slightly increases the risk of stroke for woman in 50s from 3/thousand to 4/1000 in non users and users of HRT respectively .the risk of VTE is also increased with long term use of HRT whih is 3/1000 in 50s to 7/1000 in both non users and users of HRT for 5 years respectively. In contrast to previous thought research currently states that HRT has no beneficial effect on mental functioning (alzheimers disease) . Rather it increase s the risk of dementia in later life. As the main benefit of long term use of HRT is prevention against osteoporosis , HRT is no longer recommended as its first line of choice of treatment and prevention . The dietary and life style modification are the best way to protect bones. If treatment is needed , other drugs like biophosphonates , SERMS , tibulone are preferred .Only in case of the failure of , HRT is advised . As regards lifestyle and dietary modification , I will discuss with the lady different measures , like adoption of healthy and balanced diet , increased use of vegetables and fruits , increase in intake of calcium and VIT D and avoidance of alcohol , smoking caffeine , soft drinks and high protein diet helps in alleviation of menopausal symptoms and long term risk of menopause. I will also discuss with her that regular weight bearing exercise best of which is brisk walking does help her in preventing the bone loss . Other alternative treatment includes biophoshanates and tibulone which prevents against ostoporosis.SERMS are espp useful in prevention and treatment of vertebral fractures but it does not relieve vasomotor symptoms and slightly increases the risk of VTE. As regards control of vasomotor symptoms , use of norethisterone and medroxyprogesterone are helpful ..Local application of vaginal estrogen is also helpful in cases of urogenital atrophy. If this woman opts for HRT after the above discussion , then it is also important to discuss with her the contraindications for the use of HRT which is unlikely in this case as she is already on HRT but it includes active cancers of uterus and breast , active liver disese and active VTE. Moreover the different routes and types of HRT , their advantages and disadvantages are to be brought in discussion .side effects of HRT like (breast tenderness , leg cramps , headache etc.) and measures to decrease these side effect is to be revealed to the patient.if this woman wants to continue HRT for long term , more than 5 years , I will advise her to change sequential combined HRT to continuous combined HRT as it is associated with increased risk of ca endometrium. If she refuses to take HRT for relief of vasomotor symptoms I will discuss with her the alternative like use of norethisterone 5 mg od or medroxyprogesterone 40 mg od along with diet and life style modification which are helpful. I will give her information leaflet and she will be given adequate time to make informed choice regarding use or non use of HRT.
		Posted by Vinayak B. Thu Jul 20, 2006 12:54 am
I would like to enquire about menstrual periods . nature of her menopausal symptoms( hot flushes,depression, general ill filling ), severity of symptoms and effect of symptoms on her daily life . how are the symptoms now. Why she is on sequential Hrt. Whether she is aware of difeerent types of hrt preparation , routes used and regimens ( sequential/ combined). AS continuous combined regimen is more protective for ca endometrium as compared to sequential pills . Any problems faced during these two years such as oedema over legs calf muscle tenderness and would like to enquire for family history of thrombophilia .. I would like to know whether she has any family or personal history of breast cancer, colorectal cancer. Risk factor for osteoporosis ( lean body mass,smoking,steroid treatment) or positive family history . Would like to know the cervical smear history. And ant positive medical history such as diabetes/stroke/cvd i would like to have active participation through out the discussion from patient to know her wishes .. Based on previous discussion on symptoms and personal and family history medical disorders I would like to inform her present status of hrt treatment. Hrt information is based on various trials (WHI.HERS,Million women study) yet at some issues are still unresolved and need further randomised trial . Few facts are hrt should not be used for primary or secondary prevention of cardiovascular risk . it does not protect from acute myocardial infarction. Absolute risk of stroke also increased no protective role to prevent stroke. The major issue which is about hrt and breast cancer . it increases with duration of use of hrt 2/1000 at 5 yrs 7/1000 at 7 yrs 7/1000 at 10 yrs . this risk is independent of family history of breast cancer or age at which it started . Risk comes to normal once stopped for 5 yrs. It protects from benign diseases. But advanced stage is detected in hrt users though mortality not high. It also affects mamographic assessment due to calcified shadows seen on breast.. Importance of self breast examination is told to patient. Hrt also increases cholecystitis and stone formation. It has alsobeen shown that incidence of venous thrombosis is increased in 1 st year but since this patient is using for more than 2 yrs venous risk may be less. Proved benefits are in relieving hot flushes , decresing osteoporosis and hip and vertebral fractures , colorectal cancer protection, and reduction in dental caries Some possible positive effects are redction in type 1 diabetes mellitus, improved cognitive and memory function in less than 65yrs . . but these beneficial effects to be balanced with adverse effects as discussed above. Hrt treatment should be indivisualised.with annual surveillance of possible adverse outcomes. Should be stopped when it is necessary. As far as possible should be given with lowest possible dose and for short duration upto 2 yrs as advised by CSM . maximum upto 4/5 yrs.It may be possible that her symptoms are relieved as only 25% will continue to have hot flushes for more than 2 yrs. I f symptoms are persistant Alternative therapies for hot flushes such as dietary modification with soyaproteins. Venflaxamine/ gabapentine discussed with patient . for osteoporosis SERMS / biophosponateds introduced .Leaflets are given to patient . Next appt arranged to re discuss her views and plan further check ups . if she still wants to continue Hrt continuous combined pill option discussed with her. Contraception advice given . Discussion and choice of patient mentioned clearly in notes. Womens wishes respected .
		Posted by Freha Z. Thu Jul 20, 2006 05:15 am
Before the issues related to HRT are discussed a detaled history should be taken. She should be asked about symptom relief after taking HRT, about withdrawl bleed and her prefered route of adminstration. Has she developed any contraindications like liver disease, unexpained vaginal bleeding and other medical disorders like Hypertension, Diabetes, MI and clots in leg. The benefits of HRT include prevention of osteoporosis, cardiovascular disease, alzheimers disease and treatment of oestrogen deficiency syndrome, vasomoter syndrme.Osteoporosis effects 1 in 3 women while 1in 12 men. Therefore risk factors for osteoporosis should be carefully evaluated. Conversely, the major risk associated with hormone therapy is breast cancer after 10 years of use. However after 5 years of discontinuation the risk becomes equal to non user. Threfore she should be advised breast self examination and participate in breast screening programme.Unopposed oestrogen therapy increases the risk of endometrial cancer unlike combined or sequential therapy. Moreover relative risk of developing thromboembolic disease is 3/10000 users per year. Risk is higher with positive family and personal history. If she finds withdrawl bleed inconvenient she should be offered combined preparation. For minimal urogenital symptoms oestrogen creams can be offered. She shoud know that HRT is not contraception and she needs to take contraception if she is still menstruating which is difficult to know while on sequential HRT. This can be diagnosed by measuring FSH. If she has developed menopause she still needs to take contraception for a further one year. She should be involved in decision making process and her concerns should be addressed. Information should be backed up with leaflets. She should be offered regular follow up.
		Posted by Remi A. Thu Jul 20, 2006 07:18 am
Thanks for correcting my essay. Would you consider writing much about effect on menopausal symptoms appropriate,since the question was specific about the woman\'s intrest in long-term effect.Moreover,is not appropriate to recommend possibility of discontunation,if her symptom have improved by taking HRT for two years,taking into consideration the side effects and risk of HRT even in low-risk women.
		Posted by adnan S. Thu Jul 20, 2006 03:06 pm
The issues to be discused on long term use of oral sequential HRTare benefits like prevention of osteoporosis,colorectal carcinoma,possibly Alzhemers disease ,macular degeneration and tooth loss.The risks are endometrial cancer and breast caner gall bladder disease. History is obtained prior to providing advice regarding her personal or family history of breast cancer .The background risk of breast cancer at the age of 50yrs is 45/1000,this risk increases 2,6,and 12 cases /1000woman after 5,10,and 15 years of use of HRT if they started at the age of 50years,this risk fell on discontinuing HRT ,with no excess risk after 5years.As she is using sequential HRT for menopausal symptoms which are transient and of short duration for which she needs HRT for 1-2yrs but definitely <5yrs ,after 5yrs the risks outweighs the benefit,if she wants to continue needs to have regular follow up with mammogram each year and breast examination every 6 months. .History of irregular bleeding PV ,prolong or heavy bleeding is enquired if present should be investigated to r/o endometrial cancer as long term use of sequential HRT is associated with endometrial cancer. The relationship of ovarian cancer and HRTis controversial.For the prevention of osteoporosis use of 5-10 years of HRT around the menopause doas not confer enough protection to reduce the risk of hip fracture around the age of 70.HRT has to be taken life long.HRT has been shown to reduce the incidence of vertebral fracture if there is family h/o of osteoporosis or previous h/o fracture alternatives of HRT like SERMS bibphosphonates can be considerd along with oral calcium and vitamin D,and doing excesise..HRT may delay or prevent the onset of Alzheimers disease but in woman with established disease it is not effective in prevention of disease progression and cognative functions.HRT is associated with lower risk of colon cancer ,macular degeneration &cataract and tooth loss.Written information is provided after verbal counselling so that she can take informed choice.