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MRCOG PART 2 SBAs and EMQs

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ESSAY 225 - HRT

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		Posted by Srivas P. Fri Feb 2, 2007 06:51 pm
a)I would enquire about nature of her symptoms. I will tell her that HRT will improve her symptoms like hot flashes, restlessness, night sweats, headache and vaginal dryness but may not have much improvement on urinary incontinence. She may have psychological benefit due to symptom control. HRT will improve her bone mineral density and reduce risk of vertebral and hip fractures when taken over 18-24 months but it has to be taken life long for continued benefit. It is likely to improve her skin texture, prevents tooth loss, macular degeneration and cataract. HRT offer some protection against colonic cancer---6 fewer cases per 10000 woman/year according to WHI study. Prevents onset of Alzheimer?s disease but may have no effect on established disease. b)WHI trial recommends that HRT should not be given for secondary prevention of CHD as it increases the risks of CHD and stroke especially in the first year of use and decreases after that. The increase in risk may be 7 extra cases of CHD/10000 woman over 1 year use and 8 extra cases of Stroke /10000 women over one year, above her baseline risk. It also increases her risk of embolism. Baseline risk of VTE is 5/100000 woman per year in pre menopausal woman and is doubled to 10/100000 woman in post menopausal woman without HRT. Her risks are tripled to 30/100000 woman when she takes HRT. The risk is increased in first year of use and in those with family history of VTE. Similarly her risks of breast cancer too are increased. Her baseline risk at the age of 50 years is 45/1000 woman over 20 years. Her risk of breast cancer are increased as 2, 6 and 12 extra breast cancers per 1000 women when HRT is used over 5, 10 and 15 years respectively. Her risk of VTE after discontinuation of HRT for 5 years, become equal to never users. Estrogen alone HRT and sequential HRT increase her risk of uterine cancer while combined continuous HRT is not associated with similar risk. HRT may be associated with increased risk of gall bladder disease and may cause enlargement of fibroid and activation of endometriosis. c)Her menopausal symptoms are best controlled by HRT but it is usually given for 2-5 years as risks are more than benefits if given over longer periods and symptoms are usually transient. But before prescribing HRT I will assess her suitability for it?family or previous history of VTE- here I will tell her she would need to be tested for heritable increased clotting tendencies called thrombophilia. H/O immobility due to trauma or surgery, History of inflammatory bowel diseases, nephritic syndrome, H/O any cardiac event angina/MI, history of hypertension. Presence of 2 or more of these risk factors contraindicates HRT. Hot flushes and night sweats improve with HRT but she would need oral preparation while her symptoms of vaginal atrophy can be taken care off by local estrogen creams. I would suggest she takes continuous combined estrogen so that she will not have withdrawal bleeding as she is very likely to resent return of menses. This woman who has had her period till 6 months back, loss of fertility and menopause cannot be assumed. HRT alone does not provide contraception. She would need barrier contraception or POP till at least 55 years when 96% women are menopausal. Two FSH levels of more than 30 IU/l, 1-2 months apart confirms menopause and contraception may be stopped. I will tell her about risks and benefits of HRT so that she can make informed decision. Written information would be given, I will her about general measures which prevent CHD and osteoporosis like healthy life style. This involves cessation of excess smoking, alcohol, weight control, regular weight bearing exercises. Calcium and Vit D prevent osteoporosis and CHD can be reduced by lipid lowering agents, regular exercises. II will tell her about alternatives to HRT ?if HRT is contra indicated, she is averse to HRT and also to tell her about alternatives available. I will tell her these medicines may control her menopausal symptoms 50-60% compared to nearly 80-90% with HRT. They are pharmacologic alternatives like alpha 2 agonists, beta blockers, SSRIs, SNRIs and gabapentine and provide varying good results. Phytoestrogens containing isoflavones, lignans found in Soy and red clover, Herbals like Black cohosh, kava kava have been found to be effective and are under trial and best given in specialist centers. Acupuncture, reflexology, hypnotherapy and homeopathy are also under trial while reiki and yoga may relax and diminish a lot of her perceived complaints.
		Posted by neera B. Fri Feb 2, 2007 09:24 pm
a) I will tell her that HRT relieves hot flushes and night sweats very effectively. Improvement is noticed by the end of one month and complete effect is evident by the end of three months of therapy. I shall tell her that dryness in the vagina is improved and recurrent urinary tract infections are prevented with HRT . It may help mood changes . It has been shown to prevent Alzheimer\'s disease and orodental disease . It is associated with a decrease in incidence of colorectal cancer. HRT helps to maintain bone mass as long as it is taken , but once stopped it does not confer long term protection from fractures. Written information will be provided . b) I will tell her that the relative risk of venous thromboembolism is increased 2-3 fold with estrogen -progestogen HRT, although the increase in absolute risk is very small. I shall counsel her about the symptoms of thromboembolism and provide her 24 hr Helpline no. I shall counsel her that there is increased risk of cancer brest with HRT , and the increase in risk is same as with each year of delayed menopause. There are 2 , 6 and 12 extra cases of breast cancer per 1000 women taking HRT after 5 , 10 and 15 years of HRT intake respectively. Thus self palpation of breast is essential. After 5 years of stopping HRT , risk of breast cancer returns to that of never users . Latest evidence shows increased of ischemic heart disease, stroke and pulmonary embolism in HRT users , though the absolute risk is small. I shall tell her that only estrogen HRT and sequential HRT are associated with increased risk of cancer endometrium but continuous combined HRT does not increase this risk. There is a small increase in gall bladder disease and benign breast disease in HRT users . Leaflets will be given. c)I will tell her that estrogen - progestogen HRT effectively relieves menopausal symptoms but is associated with increased risk of venous thromboembolism, cancer breast and coronary disease. Tibolone is efective for hot flushes , night sweats , maintains bone mass , but may cause irregular bleeding , greasy skin and achne. It is also associated with increased risk of cancer breast . only progesterone is also effective in relieving vasomotor symptoms but the doses needed to do so increase the risk of venous thromboembolism and cancer breast . I will tell her non hormonal options like venla flaxine which is effective for vasomotor symptoms but causes nausea. It does not have effect on VTE and breast. Transdermal clonidine is effective against hot flushes and has minimal side effects. Gabapentine, isoflavones and black cohosh have been found effective in treatment of hot flushes by some studies but more evidence is needed. St. Johns wart is effective for depression. Acupuncture , reflexology and homeopathy have ben found effective in a small number of studies. Written information will be provided to enable her to make an informed choice .
		Posted by Fahima A. Sun Feb 4, 2007 12:24 am
a) HRT is beneficial & very effective for vasomotor symptoms like hot flushes, night sweats. It is also effective in urogenital symptoms like vaginal dryness, urgency. Vaginal oestrogen is effective here than oral form. It is associated reduced mood swing with improvement of psychological well being. HRT increases bone mass density & reduces osteoporesis, though it is not first line recommendation for this purpose. HRT reduces the incidence of colorectal cancer, periodontal disease, macular degeneration of lens and possibly Alzheimer?s disease ( not well established). b) HRT is associated increased risk of breast cancer. Risk of breast cancer at the age of 50 is 45 per 1000 & with the use of HRT 2,6,12 extra cases of breast cancer per 1000 women in 5, 10 and 15 years. HRT is associated with 2-3 fold increased rusk of deep vein thrombosis (DVT) in postmenopausal women. Risk is higher if there is personal and family history of DVT. Transdermal estrogen has less risk than oral oestrogen. As previously believed HRT does not decrease the of ischaemic heart disease rather it increases it. In WHI trial it shows that continuous combined HRT increases the risk of coronary heart disease, stroke and pulmonary embolism. Unopposed eostrogen increases the risk of endometrial carcinoma. however continuous combined HRT is not associated with it. c) As the women is suffering from debilitating menopausal symptoms HRT is highly effective and first line recommendation for it. oestrogen available in oral and transdermal form. Oral estrogen is available estrogen only, sequential use ( progesterone 10 days per cycle) with withdrawl bleeding and continuous combined. continuous combined has better endometrial protection than the other two but increase risk of breast cancer due to progestogen. She can be recommended oestrogen tablet with Mirena coil for endometrial protection. Transdermal oestrogen can be used as patch given every 3 weeks has a lower risk of DVT. Body temperature, sweating can effect the efficacy or patient might feel discomfort/ allergy. Subdermal implant can be given every 6 months is not effected by sweating or temperature but requires surgical procedure to insert. With both the method Mirena coil can be used for endometrial protection. Progestogen in bolus doses reduces the incidence of vasomotor symptoms but associated with higher risk of breast cancer. Apart from hormone life style changes with exercises, stoppage of smoking, reducing alcohol intake can reduce the incidence of vasomotor symptoms but will not prevent totally. Some herbal medicine like zingseng, black cohosh, red clover has been tried effectiveness was not fully evaluated. Nonhormonal medicine like Venlafaxine, a SSRI has been trying, seems effective but needs more research before recommendation.It may cause nausea & vomiting. Clonidine an alpha agonist both oral & subdermal form is also being trialed, results are waiting. Alternative medicine like acupuncture, hypnotherapy, homeopathy are also tried , may be beneficial in some cases. After discussion about all available options with their pros & cons I will give information leaflet.
		Posted by Freha Z. Sun Feb 4, 2007 01:14 am
(a)She should be told that HRT is effective in relieving menopausal symptoms. HRT is recommended for short term use(2-3years) for relief of menopausal symptoms. It is also effective in relieving urogenital symptoms and improves psychological symptoms. When used long term it can prevent osteoporosis and reduce the incidence of vertebral fractures. It can also help against Alzheimers disease, macular degeneration, tooth loss and bowel cancer. (b)She should know that HRT is associated with 2-3 fold increased incidence of VTE. The risk factors of VTE should be evaluated in her. HRT may be avoided if there is Personal or family history of VTE. With use of HRT there is increased risk of Breast cancer. 2 extra cases of breast cancer may be diagnosed per 1000 women in 5 yearsof use. However 5 years of stopping treatment brings the risk down to that of non users. Therefore breast cancer screening is recommended. If unoppsed oestrogen or sequential HRT is given there is increased risk of endometrial cancer. Risk is not increased with combined preparations. HRT may also increased cardiovascular events in first year of use and it does not prevent against cardiovascular disease. She may experience side effects of oestrogen therapy such as fluid retention, breast tenderness, nausea and headache which usually resolve with reducing dose. side effects of progestogen include mastalgia, depression acne and fluid retension which may resolve with changing type or route of progestogen. (c)Life style changes, and exercise may improve the symptoms. She should be advised reduction in alcohol/caffeine intake which may reduce frequency and severity of symptoms. If urogenital symptoms also present it can be improved by topical oestrgens. Although transdermal oestrogens are not effective for vasomotor symptoms. For vasomotor symptoms combined or sequential oestrogens will be required. Progetogens such as Megestrol are effective if she has contraindications to oestrogen use. Non hormonal preparations like SERMS are also effective in relieving menopausal symptoms. They also increase the risk of VTE. Complementry therapies such as black cohosh and acupucture can provide some relief. All the information should be backed by leaflets and women should be encouraged to make informed decision.
		Posted by Yasser S. Sun Feb 4, 2007 05:50 am
She should be told that the benefits of HRT are mainly dependent on her symptoms. The use of HRT can be beneficial in reducing her menopausal symptoms of hotflushes, depression, restlessness, night sweats and headaches. It can be helpful to reduce the vaginal dryness, dyspareunia and discomfort. Other benefits are the reduction of risk of fractures due to decreased risk of osteoporosis. It is also beneficial in reducing the risk of colorectal cancers.. It is also known to reduce the risk of Alzeihmers disease to one third. Major risks are that of VTE, stroke and breast cancer. The risk of venous thrombosis in one individual is small but issignificant in patients with previous thromboembolism. The risk of benign breast disease is increased. There\'s also an increased risk of heart attack in elderly patients. These risks are increased with long term use. Other disadvantages are the side effects associated with estrogen and progesterone content of the HRT. Main side effects associated with estrogens are leg cramps, nausea, headaches, bloating and nipple sensitivity. Unwanted effects of progesterone are bloating, mood disturbances, depression, bleeding, premenstrual tension and dysmenorrhea. Patients with a uterus will experience cyclical bleeding which can be unacceptable with sequential treatment. Most of these side effects can however be improved by alternative doses of estrogens, changing the route of administration or changing the type of estrogen. Risk of breast cancer falls when HRT is discontinued with no access risk after 5 yrs of discontinuation. Use of HRT is absolutely contraindicated in women with breast cancer.She should be provided by written information. She should be told that the treatment options available for her pharmacological and non pharmacological. Modifications in life style may be helpful like avoidance of alcohol and caffeine can reduce the vasomotor symptoms. Aerobic and sustained regular excercises may be helpful. Before embarking on any sort of treatment she should appreciate the concept that the treatment is based on individual needs and risk assessment. HRT can be useful for her debilitationg menopausal symptoms especially hot flushes. It can also be useful in reducing the risk of fracture. Local estrogens applications can be used to reduce her urogenital symptoms. There\'s no evidence that local estrogen application in therapeutic doses is associated with any risks. Stress incontinence cannot be treated by estrogens. Metabloc effects of estrogens depends on the route of administration. Raloxifene ( SERMS) can reduce the risk of vertebral fractures in the women with osteoporosis. It is not associated with increased risk of breast cancer. Tibolone (estrogenic, progestogenic and endrogeic properties) is effective for vasomotor symptoms but is associated with risk of breast cancer but reduced as compared to HRT. Complementary therapies like evening prime rose, phytoestrogens, soy, st john\'s wort and other herbs can confer some benefit but are not proven by evidence. Complementary interventions like acupuncture and reflexology can also provide some benefit. The efficacy of all the alternatives is lower than the use of HRT.
		Posted by Parveen Q. Sun Feb 4, 2007 07:15 am
The benefits of HRT include relieving vasomotor symptoms, insomnia, depression, and decresed risk of cancer colon. It conserves bone mass, improves balance, prevents fall, and there by prevents vertebral and hip fractures. The improvement in vasomotor symptoms occurs within 4weeks, and the maximium effect occurs in 3moths. It has to be used for an year to avoid recurrences. It delays or prevents the onset of alzeheimer\'s disease . Recurrent uti can be prevented by oestrogen replacement, though the dose and duration is not established. It is involved in wound healing, reduces the dryness of eyes, and cataract formation. It reduces the tooth loss. i will tell her that observational studies suggest that it has protective effect on heart due to the changes in the lipoprotein, coagulation, insulin sensitivity, and endothelial function. It has no place in the secondary prevention of CVS disease ,but it is still indicated in a symptamatic woman of her age for long term CVS and neurological benefit. For woman of 60-79 years, it can cause early harm before any benfit could be established. The WHI and MWS has caused an alarm by reporting the increased incidence of heart attacks, strokes, venous thromboembolism, breast cancer on HRT users. The incidence of stroke and heart attacks were on older woman , using premarin alone. Risk of breast cancer is more on combined HRT, and it is related to the dose and duration of treatment. But those who develop breast cancer on HRT have a better prognosis than non users and there is a reduction in mortality. The risk falls with the cessation of HRT and disappears within 5years of stopping HRT. There is little evidence that it increases the risk in those with the family history of breast cancer. The risk for endometrial cancer is 2-3 times for estrogen users than those of nonusers. The death due to endometrial cancer is also increased and it is related to the duration of use. The risk remains for 5 or more years after stopping the unopposed estrogens. The risk of VTE is 3 per 10,000 for those on HRT , whereas it 1 per 10.000 for those without HRT. Progesterone alone also increases the risk. Those with the family and personal history of thromboembolism should be evaluated and advises about the risk of recurrence. There are various alternatives available for HRT but patient has to be told that they are not as effective as HRT. Replens, a vaginal bioadhesive moisturiser is an alternative to sysemic or vaginal HRT for atrophic vaginitis. Progestogens were considered as an alternative to combined HRT in those with the contraindication to estrogens like in breast cancer and in VTE . The dose required for controlling the vasomotor symptoms , increase the risk of VTE, and also the after the WHI study , it is not an appropriate alternative. Among SSRIs and SNRIs ,which are used for relieving vasomotor symptoms, convencing data exsist for SNRIs . The major side effect is nausea which leads to non compliance. Beta blockers has been postulated as a possible option but trials are disappointing. Alpha -2 agonists , clonidine, as a transdermal preparation is effective for hot flushes. Natural progesterone creams , extracted from soya and yam are reported by some to have relieved menopausal symptoms, . It has no effect on bone or endometrial protection. Soy isoflavones , and red clover are useful in relieving the hot flushes. Black cohosh, is useful in controlling menopausal symptoms for 6months. The side efffects are GI upset, rashes, and hepatotoxicity. It has no effect on the breast. St.John\'s wort is found to be effective in relieving depression but effect on vasomotor symptoms are not proven. Therewas no significant difference between reflexology and non specific foot massage in relieving vasomotor symptoms. Traditional chinse herbal medicines have shown to be no more effective than placebo. Acupuncture has been found to be effective in reducing the vasomotor symptoms . It is found to be effective in those on tamoxifen for breast cancer and the effect can remain for 3months after treatment. Homeopathy, is one of the accepted therapies , and available sometimes in NHS . It relieves vasomotor symptoms, stress, and psycological symptoms. Alteration in life style, reduction in alcohol intake, cessation of smoking, high frequency low impact exercise. vitamin supplements can reduce the severity of symptoms. Patient has to be given leaflets and names of support groups and allowed to have an informed choice.
		Posted by M M A. Sun Feb 4, 2007 08:08 am
A] Menopause has many implications on women\'s quality of life regarding physical , social and psychological aspect. This lady should be told that HRT has been used to ameliorate postmenopausal symptoms and there is good evidence that it is effective in relieving hot flushes and night sweats. Also HRT can improve her psychological well being. HRT also protects against osteoporosis and it might slightly increase bone density in the first 18-24 months with future decrease of incidence of vertebral fractures. We inform her that HRT can minimize symptoms of urogenital atrophy but this will take up to one year to improve. Data is available that HRT can delay or prevent the onset of Alzheimer\'s disease and also decrease incidence of colorectal carcinoma, cataract and macular degenerations. B] We should assure also that she fully understands the risks associated with HRT intake. We tell her that there is an increased risk of coronary heart disease especially in the first year of HRT intake and this may be related to un diagnosed underlying thrombophilia or the use of high dose HRT or due to increase thrombogenesis. We should inform her that HRT is associated with a 2-3 fold increase in the risk of venous thromboembolism especially if she has a family history of venous thromboembolism in first or second degree relative or previous personal history of VTE, also if it has been proved that she carry certain types of congenital thrombophilia. We should tell her also that the estrogenic component of HRT will increase risk of breast cancer especially if it is used more than 5 years, and if the woman on a current use of HRT and develop breast cancer, the tumours will be bigger with more advanced disease, however, this risk will decrease back to the level of that of general population within 5 year of discontinuation of HRT. Also there is an increase incidence of endometrial cancer whether she use estrogen alone or oestrogen and progesterone sequentially but risk is not increased if she use combined HRT continuously. C] We tell her that treatment options can be done after assessing her risk factors taking in consideration her symptoms and her wishes, treatment could be hormonal or non hormonal. If it is appropriate to give hormonal treatment, we can prescribe for her sequential combined HRT, the oestrogen could be conjugated equine oestrogen 0.3 - 0.625 mg orally or oestradiol 1-2 mg or estradiol patch 25 -50 microgram or oestradiol implant50 mg every 6 months. The progestogenic component should be prescribed for at least 10 days each cycle, this could be orally like norethisterone 1 mg or medroxyprogesterone acetate 10 mg or levonorgestrel 75 microgram, or could be used as patch for 14 days like norethisterone 170 mcg or levonorgestrel 175 mcg. Other choice is to use continuous combined HRT using norethisterone 0.5 mg orally or norethisterone 170 mcg patch or 2.5 mg medroxyprogesterone acetate orally or 5 mg Dydrogesterone. Sometimes Progestogen alone can be used to minimize vasomotor symptoms like megestrol. Also we can advice her about life style modifications, we encourage regular exercise with reduction of caffeine and alcohol intake, also we encourage intake of food that contain phytoestrogens like soy and red clover. If hormonal treatment is inappropriate we can offer her alternative drugs like transdermal clonidine, there is evidence that it is effective in relieving vasomotor symptoms. Other choice is serotonin or noradrenalin re-uptake inhibitors like fluoxetine and venlefaxine which is very effective agent. We can tell her that there is data which support the efficacy of gabapentine in relieving hot flushes, it is originally anti-epileptic agent. Acupuncture and homeopathy can also be advised. These alternative treatments can reduce symptoms by 40-50% in comparison with a reduction of 80-90 % when using the traditional HRT.
		Posted by Abi T. Mon Feb 5, 2007 02:11 am
a)HRT is effective in reducing vasomotor symptoms such as hot flushes, mood swings and night sweats and topical preparations are effective in relieving symptoms of urogenital atrophy. It also reduces loss of bone density with some gain in density if taken over 18-24 months but must be taken life long to be continually effective. There is improvement in psychological wellbeing secondary to relief of vasomotor symtpoms. It delays the onset of Alzheimers but not beneficial in established disease. There is a relative reduction in risk of developing colorectal CA. b) Continuous combined HRT has been shown to increase the risk of coronary heart disease in the WHI trial and hence should not be prescribed as secondary prevention. There is also an increased risk of coronary disease events in the first year of use in women who have CHD. There is a 2-3fold increased risk of developing VTE. HRT increases thrombophilic factors and the association between risk of VTE in the 1st year of use and HRT may be due to an underlying thrombophilic disorder. The risk of developing breast CA in women taking HRT over the age of 50 is also increased over baseline risk and further increases are due to length of use, ie. there is an extra 2,6 and 12 cases per 1000 women for 5,10 and 15 years of use respectively. This risk is reduced to never users risk after 5 yeras discontinuation. Mortality form breast CA is also increased as women on HRT tend to have more advanced disease. Risk of endometrial CA is 4x that in premenopausal women with unopposed estrogen therapy. The sequential preparations have an increased risk of endometrial CA but not the continuous combined. Gall bladder disease is also increased on HRT. The risk of ovarian CA is controversial. c) She has the choice of hormonal, non hormonal and alternative treatments and the risks, benefits and side effects discussed.In a woman with an intact uterus, she should be prescribed a combined estrogen and progesterone preparation. As she is amenorrhoeic she may prefer a continous combined prearation which is a no bleed preparation. Sequential combined preparations have better cycle control in women who wish to have a monthly bleed or better cycle control. These have different routes of administration ie, oral, transdermal, gel ,subcutaneous implants and topical. The transdermal route has less risk of VTE compared to oral. However there may be skin reactions with patches. Subcutaneous implants may be convenient for women who do not want a daily regimen but the endometrium must be protected with progestogens. She must be warned of the side effects of estrogen and progesterones eg, bloating, nausea, depression and mastalgia. Progestogens such as megesterol have shown modest benefits in relieveing vasomotor symptoms but there are concerns with risk of breast CA. Doses needed to acheive symptom control also increase risk of VTE. Clonidine is an alpha 2 agonist an evidence shows that transdermal preparation is more effective in relieveing vasomotor symptoms than oral. SERMs such as Raloxifene have been shown to be protective against osteoporotic fractures and reduce LDL cncentrations but not effective for vasomotor symptoms. The SSRIs and SNRIs are also effective in treating hot flushes, with venlafaxine being the most effective agent.Long term benefit has not been proven. Gabapentin is also used for relief of vasomotor symptoms but is restricted for use in specialist centres. Black cohosh,phytoestrogens and acupuncture have been shown to be effective in relieving vasomotor symptoms but their side effects and insufficient data on long term risks and safety limit their use. Homeopathy is another alternative but larger trials are needed to demonstrate benefits. A modification in lifestyle measures has been shown to reduce severity and frequency of menopausal symptoms, such as reducing caffeine and alcohol and doing regular exercises.
		Posted by Dr Saibal S. Mon Feb 5, 2007 09:26 am
A.Iwould explain to the woman that the benefits of HRT depend upon individual symptoms like hot flushes and night sweats which is relieved in a majority.It improves irritability, depression,insomnia and memory but this might be a placebo like effect .Hrt would also benefit urinary symptoms like dyspareunia, vaginal dryness,frequency and urgency which is due to estrogenisation of urogenital tissues a nd therefore may improve libido.HRT prevents bone loss and delays osteoporosis thereby preventing vertebral and hip fractures but need to be taken for a long time.it prevents cataracts and macular disease. B. I would explain to her that the risks include increased risk of breast cancer in both combined and estrogen only HRT .Most of these cancers are at advanced stages and bigger size though risks nullify 5 years after stopping HRT.They also cause increased risk of stroke, myocardial infarction,pulmonary embolisation though the absolute risks are small.They cause increased( 2-3 times)chances of thromboembolism and the combined sequential HRT is associated with increased incidence of endometrial cancer.It also increases chances of gall stones, increase growth of fibroids and worsen endometriosis. The estrogen and progestogen components may cause nausea , headache, mastalgia, leg cramps and bloating though they do not cause weight gain. C. The available treatment options would depend upon whether her uterus is intact in which case progesterone has to be given for endometrial protection which could be continuous or sequential.This would cause symptoms like withdrawal bleeding and mastalgia which might be unacceptable to her. Personal history of breast cancer and thromboembolism contraindicate hormonal HRT as they cause breast cancer and increased risk of VTE. Risk of VTE is decreased with dermal patches though progesterone needs to be taken if uterus intact ,which can also be the Mirena coil. If her symptoms are urogenital ,topical estrogens in the form of gels or ring pessaries reduce dryness, dyspareunia,frequency and nocturia. Alpha agonists taken in conjunction has been shown to reduce stress incontinence.Vaginal moisturisers likr Replens is similarly effective as topical estrogens.I would also explain about alternative therapy like lifestyle modification by stopping smoking and alcohol and leading an active life which reduce menopausal symptoms. Complementary methods like soy, primrose oil, st. johns wort are helpful but efficacy is less than HRT and evidence about active ingredients and side effects is not clear.Similarly therapies like accupuncture, homeopathy and reflexology though helpful ,evidence is lacking about efficacy and risks. I would respect the womans preferences about what she would like for her symptoms.
		Posted by SWATI M. Mon Feb 5, 2007 09:22 pm
a) About the benefits of the HRT,I will tell her that HRT is effective to control the menopausal symptoms. It improves the sense of well being and quality of life. Vaginal dryness will be improved and local treatment is more effective. HRT prevents the loss of bone density till the time it is taken but has no carry over effect. HRT educes incidence of colonic cancer with prolonged use.It may prevent / delay onset of Alzeimher disease. Tooth loss and macular degeneration reduces. b) Risk of breast cancer increases significantly with use of HRT for more than 5 years. Use of HRT increases risk of ischeamic heart disease after 50 years of age if she has high risk factors such as smoking. Risk of endometrial cancer increases with estrogen alone / sequential HRT than continuous combined HRT and in her case sequential HRT will be preferred as she has ammenorrhea for 6 months. Risk of VTE increases with HRT particularly 1st year of use which is a potentially fatal complication.The risk of VTE is higher with familial thrombophilia and oral HRT. There is small increase in risk of stroke and pulmonary embolism but absolute risk is not increased. Systemic side effects due to estrogen are fluid retension, nausea .The progestogenic side effects are mood swings depression and breast tenderness .The risk of gall bladder disease increases with HRT. c) One of her option is use of sequential HRT. Estrogen can be given oral, transdermal gel/patch. Progesteron can be given oral / IUD- mirena if she is willing for amenorrhea / as a contraceptive or has experienced progestogenic side effects previousely with use of OC pills. Medroxyprogesterone acetate 40 mg orally is another option if she is wants to avoid use of estrogen. Local treatment with estrogen is appropriate for vaginal dryness. Alteration in life styles such exercise, reducing caffeine intake may be helpful. Complementary therapy such as acupuncture, hypnotherapy may be tried. She should be given information leaflets to make an informed choice.
		Posted by Randa E. Tue Feb 6, 2007 01:56 am
Prior to providing advice a detailed history to assess her symptoms and their severity is important. She should know that menousal symptoms are transient and for this purpose, only short term use of HRT is required (1-2years only and not >5years). Her main benefit will be symptom control. The main symptoms expected to improve are vasomotor symptoms like hot flushes and night sweats (relieved within 4 weeks, maximum response achieved by 3 months) and vaginal dryness. There is also a general improvement in skin and hair texture. HRT is also associated with prevention of osteoporosis, colorectal cancer, possibly Alzheimer?s, macular degeneration, tooth loss and stress. These may only be achieved with long term use and does not apply with short term use to control menopausal symptoms. She should be counselled that risks depend on the type of HRT, duration of the use and to some extent the route of administration. There is an increase in the breast cancer in women on HRT at her age group being 45/ 1000 over 20 years and 32/ 1000 over 15 yearsA. After discontinuing HRT for 5 years the risk of breast cancer falls back to the same risk as non-users. However she should be told the benefit of use over 1-2 years outweighs these risks. There is also an increase in the risk of endometrial hyperplasia and carcinoma in unopposed oestrogen therapy. Sequential combined HRT(progesterone for 10 days/ cycle) is also associated with an increased risk of endometrial cancer. There is a 2-3 fold increased risk of VTE especially in the 1st year of use. She should be made aware of the signs. If VTE develops then HRT use should be discontinued. HRT is also associated with an increased risk of coronary heart disease, stroke and pulmonary embolism especially in the 1st year of use. They are also associated with an increase risk of gall bladder disease. They are associated with general systemic side effects either oestrogen related e.g. fluid retention, breast tenderness, nausea, headeache and leg cramps, or progesterone related e.g. mood swings, depression and acne. However the overall risk of these disorders in woman taking HRT remain small. The treatment option should be made jointly with the patient after making sure she fully understands the risks and she should have the choice to accept the drug provided. Adequate written information should be given. Oestrogen is available as pills, tablets, patches, nasal sprays, creams or vaginal preparations (vaginal rings, vaginal tablets, or vaginal cream). Although progestin is usually taken in pill form it is available, together with oestrogen in patch form. If vaginal dryness is the main complaint then topical oestrogens (pessary /tablet) may be adequate. Occurrence of any vaginal bleeding should prompt immediate evaluation. Progestogens like megestrol show modest relief of vasomotor symptoms. Doses that can achieve control are associated with increased risk of VTE. Furthermore they are associated with increased risk of breast cancer when used in combined HRT. Transdermal progesterone have also not been shown to be effective in the relief of vasomotor symptoms. Life style modification might be an alternative. Alternatively topical treatments like vaginal bio-adhesive moisturizers or lubricants like KJ jelly might be a chioce. Clonidine (alpha-2 agonist) is effective only by the trans-dermal route in relieving vasomotor symptoms. SSRIs(paroxetine) and SNRIs(fenlafaxine) are effective in the relief of hot flushes only over a short period of use (9 months) but SSRI?s are associated with nausea. Gabapentin have shown to relief vasomotor symptoms but their use is limited only to specialist centers. Other complementary therapies have also been used. Therapies like acuapuncture have shown to be effective in relief of hot flushes in small trails but have side-effects. ST. Johns Wort and primrose efficacy in menopausal symptoms have been unproven.
		Posted by M M A. Tue Feb 6, 2007 09:28 am
Dear Dr Paul, Regarding risk of HRT, Do we have to mention the side effects in it? Thanks.
		Posted by Srivas P. Tue Feb 6, 2007 09:32 am
Sir Don?t we have to address the necessity for contraceptive in this woman who is ammenorrhoic only for 6 months? She could probably be put on estrogen combined with LNG-IUS to take care of both menopausal symptoms and her contraceptive needs. Family Planning Guideline mentions such persons should either continue on barrier contraception / IUD / POP with HRT till natural menopause at 55 years. Alternatively high FSH levels >30IU/l on 2 occasions 8 weeks apart can be reasonable evidence of menopause and she would need further 1 year of contraception after this before it is stopped. FSH levels are unreliable when she is on COC or on combined HRT. Can you advise if I have understood this right?
		Posted by Shyamaly S. Wed Feb 7, 2007 12:21 am
A)HRT will improve vasomotor symptoms (hot flushes) within 4 weeks of use. It also confers a general feeling of well being, thereby improving her quality of life. It also improves symptoms of urogenital atrophy- dryness and soreness, thereby improving sexual function. It would improve the quality of her hair, teeth and vision. It is associated with a reduced risk of Alzheimer?s disease and Colorectal cancer. HRT also reduces the risk of osteoporosis by reducing the loss in bone mineral density particularly in the first 2 years of use, but it does not reduce the risk of fractures unless taken life long. B) HRT is associated with an increased risk of Breast Cancer, which increases, with duration of use. After 5 years of HRT use, an extra 2 women per 1000 would be diagnosed with Breast cancer. This risk declines to never user levels 5 years after discontinuation. The Breast cancer tends to be more aggressive and presents at a later stage perhaps because the increased breast density associated with HRT use makes mammography and diagnosis more difficult. HRT was previously believed to be protective again ischemic heart disease and stroke. However the WHI study showed a significantly increased risk of these diseases particularly in the first year of use. It is no longer felt to be protective against cardiovascular disease. HRT also is associated with a higher risk of thromboembolic disease. If she has a family history or previous history of thromboembolism should be offered thrombophilia screening prior to starting HRT. If she screens positive and is keen for HRT, anticoagulation should be used. The use of unopposed Oestrogen or Sequential Oestrogen/Progestogen HRT is associated with an increased risk of endometrial cancer. There is also an increased risk of gall bladder disease with HRT. The effect on the risk of ovarian cancer is uncertain. HRT is also associated with estrogenic and progestogenic side effects. These include fluid retention, breast tenderness, acne and mood swings. Unwanted effects include erratic vaginal bleeding, which may require HRT to be stopped, and the bleeding investigated. C) Conservative measures maybe used for symptom relief. These include regular exercise, reducing alcohol and caffeine intake. Non-hormonal measures may also be considered e.g. Clonidine patches and SSRIs, which reduce vasomotor symptoms. Alternative therapies such as homeopathy, acupuncture and Black Kybosh have shown promise but need further evaluation. HRT is available in different formulations. As she still has a uterus, she should not be given unopposed Oestrogen. As her last period was within the last year she should not be given continuous combined HRT. Thus the options for oral HRT are sequential Oestrogen/Progestogen formulations aiming for a regular bleed. HRT may also be given via parenteral routes- this has the advantage of avoiding hepatic first pass metabolism and minimising the risk of thromboembolic disease. The estrogenic part maybe given as a patch, implant, vaginal pessary or gel, with the endometrial protection from progestogens in the form of tablets, patches or the Mirena IUS. The advantage of topical vaginal preparations is the improved affect on urogenital atrophy which maybe one of the main problems. The Mirena also provides added contraception - other forms of HRT do not have contraceptive properties and these may be needed for at least a year after the last period. This information should also be supported in written leaflets so that the patient may consider them before making her decision.
		Posted by kiria O. Wed Feb 7, 2007 10:44 am
woman should know that HRT is effective in the treatment of menopausal symptoms and she should counselled regarding benefits and risks of HRT and before commencing HRT detailed personal and family history of VTE ,thrombopilia,breast cancer must be excluded. The risks of HRT include, increase in the risk of breast cancer in HRT user and the risk increase with prolonged use 2 in 1000 user get breast cancer at 5 years increased to 7 in1000 at 10 years of use. Also,HRT is associated with increase in the risk of VTE from 10 in 100,000 in none users to 27 in 100,000 users. Also,HRT was previously considered as cardioprotective however, studies showed that use of HRT is associated with increase in the risks of ischemic heart disease and myocardial infarction especially in woman with risk factors such as smoking,hypertension , abnormal lipid profile and high BMI. Other risk is an increase in incidance of cerebrovascular accident in HRT users compared to none users. Also, increase in the risk of endometrial hyperplasia ans endometrial cancer in estrogen only HRT in none hystrectomised women. HRT may reactivate endometriosis and fibroid growth. The main benefit is that, HRT is highly effective in treatment of vasomotor symptoms such as hot flushes,palpitation, mood swings, anaxity and others such as dysparunia and urinary symptoms. The treatment of menopausal symptoms may continue for 2years but shoudnt take longer than 5 years. HRT is protective against osteoporosis, however,it doesnt indicated for prophylaxsis as this need long term treatment and the benefits cannot outweigh the risks from such prolonged treatment. Other benefits include sensation of wellbeing, positive effect on the skin and hair and less risk of cataract. Some studies showed that HRT is associated with reduce risk of alzahemirs and lower risk of colon cancer. woman should be given information leaflets before her decision regarding comencment of HRT. Regarding other treatment options avilable for menopausal symptoms include regular exercises such as aerobics is assiciated with improvment in menopausal symptoms unlike high impact exercise which may aggrivate it. Acupuncture was found beneficial in some women but other such as primrose oil and black cohosh is not usefull. Medication such as clonidin patches is effective in treatment of hot flushes while oral clonidin is not effective. Other medication such as fluoxitin and venalfaxin are found effective in treatment of hot flushes. Hormonal treatment such as megesterol acetate is effective in treatment of menopausal symptomes. Tibolon is effective in the treatment of menopausal symptoms dosent need progestagen for endometrial protection and effective treatment of osteoporosis but associated with irregular genital bleeding. Raloxifen is not usefull in treatment of menopausal symptoms and may cause hot flushes, leg pain and VTE similar to HRT.
		Posted by sailaja devi K. Wed Feb 7, 2007 05:25 pm
I will tell her that HRT is effective in relieving the vasomotor symptoms .Hot flushes ,night sweats are relieved with in 4 wks of treatment.Improvement in psychological well-being ,may be secondary to relief of vasomotor symptoms.HRT improves psyhological problems like anxiety,irritability & poor memory.HRT prevents osteoporosis.HRT prevents bone loss , with some gain in bone weight in first few months.HRT has been shown to reduce incidence of vertebral fractures.HRT has to be taken life ?long to be effective.Use of HRT for 5 yrs around menopause do not confer protection to reduce incidence of fracture at age of 70 yrs.HRT helps to relieve urogenital symptoms like vaginal dryness,dyspareuniaurinary frequency,dysuria & nocturia.Oestrogen alone is ineffective in the treatment of stress incontinence. HRT is associated with decreased risk of colorectal cancer.HRT may delay or prevent the onset of Alzheimer?s disease,not effective in treatment of estabished disease..HRT is also associated with decreased risk of macular degeneration,cataract & tooth loss.Women should be Provided with written information. I will explain about risk ,supplement with appropriate written information to help to make her own choices. I will tell her that HRT associated with increased risk of coronary artery disease. Observational studies indicate that HRT is protective against cardiovascular disease.The WHI trail showed that continous combined HRT is associated with increased risk of coronary artery disease. With regard to breast cancer , HRT after 50 yrs is associated with increased risk of breast cancer.The effect is similar to that of delayed menopause.Use of HRT for 5,10,15 yrs would cause 2,6,12 extra breast cancers for 1000 women.The risk of breast cancer in women who have discontinued HRT for 5 yrs is similar to that in never users. Unopposed oestrogen is associated with increased risk of endometrial cancer.Continous combined HRT is not associated with increased risk of endometrial cancer.Sequential HRT where progesterone is taken for 10 days of cycle is associated with cancer. The relation between HRT & ovarian cancer risk is controversial. HRT is associated with 2-3 fold increased risk of venous thromboembolism.The risk of VTE increases with age& in postmenopausal women ,is double that of premenopausal women.Prior to commencing HRT enquire about personal & family histoy of VTE . Women should be counseled about risk of HRT ,she should be aware of symptoms of VTE & should be able to access medical help if she suspects she developed a thrombus.Transdermal oestrogen is safer than oral HRT with respect to VTE.Screening of women for thrombophilic defects prior to HRT is inappropriate. Available treatment options are hormonal therapy,alternatives to hormonal treatment. Harmonal therapy includes various routes of administration each with its own advantages & disadvantages .Various routes increase choices of treatment available.Women who find oral unacceptable will use an alternate route of administration.Supplement with written information about various routes available routes of hormonal therapy & help to make her own decisions. Oral route of ostrogen is cheap,easy to take,wide choice available ,progesterone can be co-administered & elevate HDL cholesterol .Oral has disadvantage of altered hepatic protein synthesis & elevated triglycerides .Oral route consists of oetrogens & progesterone as the she has uterus.She would be better of with sequential oestrogen & progesterone as she is 6 mon amennorhea, to have regular withdrawal bleeds. Patches & gels allows low dose pure estradiol ,maintain physiological E 2 to E1 ratio,reduce triglycerids.Patches are expensive ,progesterone can not be co administered in gel & less effect on HDL cholesterol. Advantages of implants are it is a pure estradiol,guarented compliance ,testosterone can be co-administered, it is administered as 6 mon injections & maintain physiological E 2 to E1 ratio.Disadvantages are it needs surgical procedure to insert & remove,unable to control absorption & risk of tachyphylaxis. Vaginal preparations act locally ,has local benefit if systemic treatment is contraindicated.It is messy to use, expensive & there is risk of cream being used as lubricant with over dose. Alternatives to HRT may be used if women wishes ,if concern over HRT .Discuss with the women about evidence for alternative therapies in a manner that enables them to make informed decisions. Life style changes like regular aerobic exercise improves menopausal symptoms.Reduction in consumption of alcohol & caffeine reduce symptoms. Progesterone like megesterol has modest benefit in relief of symptoms.Transdermal clonidine is effective in reliving the symptoms.Selective serotonin reuptake inhibitors & noradrenaline re-uptake inhibitors are effective in treatment of hot flushes .The studies showed short term treatment is effective , studies undertaken over long periods were found to be ineffective. The evidence that phytoestrogens are effective in the treatment of menopausal symptoms is controversial.Dietary supplements like vit C, E & selenium has not been shown to be effective.There is evidence that homeopathy & acupuncture may be effective in treatment of hot flushes. Black cohosh has been shown to be effective in treatment of vasomotor symptoms ,but there is concern about its safety & there is possibility of hepatotoxicity.Ginseng is ineffective in treatment of menopausal symptoms.
		Posted by TAIWO NURENI Y. Wed Feb 7, 2007 11:25 pm
A)I will inform her that HRT relieves hotflushes and sweating to a great deal and this effect is noticeable from ist month of use.It also improves cognitive function and mood.HRT reduces bone loss post menopause thereby reducing osteoporosis.It provide improvement in urogenital symptoms and it has also been reported to reduce onset of alzheimer\'s as well as rheumatoid arthritis. B)There is a significant increase risk in breast cancer in women on HRT compare to those not.45/1000 women have breast ca without HRT while 47/1000 in 5yrs,51/1000 in 10yrs,57/1000 in15yrs is reported in women on HRT.However the risk reduces to background risk after stopping the HRT.HRT was beieved to be cardioprotective until WHI study reported 41% increase in coronary artery diseaseas well as risk of cardiovascular accidents. There is also extra 8 cases of venous thromboembolism per 1000 women on HRT per year.There is increase risk of endometrial cancer in women on unopposed HRT with intact uterus. C)Options of treatment include the conventional HRT and the alternatives.Oral sequential estrogen is available,cheap and easy to administer but compliance and irregular bleeding are part of shortcoming.This can be used with oral progestogen for 14days monthly or LNG mirena system could be inserted to prevent unopposed estrogen effect .Synthetic estrogen like Tibolone is also good n tablet form but the breast cancer risk is similar to conventional HRT.Patches are also available,knwn to be effective but varied absorption and need to change patches monthly constitute a drawback.Estrogen implant could be inserted under local anaesthetic 6monthly thereby overcome compliance issue. Lifesyle changes like stopping smoking and alcohol with weight bearing exercise has been reported to be of benefit in reduing symptoms.Clonidine do improve hotflushes but for a short period of time.SERM like raloxifene prevents osteoporosis but risk of VTE similar to HRT.Complimentary therapy like Yoga,Acupuncture & homeopathy has been advocated but there efficacy yet to be proven.Herbal products like black cohosh,St.john\'swort are also used by some but efficacy not proven.
		Posted by Shatha A. Thu Feb 8, 2007 10:21 am
(a) The benefit of HRT includes, the relief of vasomotor symptoms, as there is good evidence to suggest that it improve symptoms within 4 weeks of use. This also associated with psychological improvement which may be attributed to the relief of hot flushes and better night sleep. It prevent bone loss and improve bone density in 18-24 months of use, however; it has to be used life long to protect against hip fracture. The use of HRT is beneficial in alleviating urogenital symptoms, it also lower incidence of macular degeneration, cataract and tooth loss. In respect to Alzheimer?s disease, HRT prevent the onset of the disease, but does not prevent progression of the disease in established cases. The risk of colorectal cancer has been shown to be reduced in HRT users. (b) The use of HRT has been shown to be associated with increase risk of venous thromboembolism. Breast cancer risk is increased with current users of HRT, the back ground risk for a 50 year old woman is 45 per 1000 over 20 year period, this risk will increase by 2 extra cases over 5 years use of oestrogen, and by 12 extra over 15 years. The use of combined HRT will be associated with more risk. However; the risk after 5 years of discontinuation of therapy will be the same as never users. The risk of endometrial cancer is increased with the use of unopposed oestrogen, and the sequential preparation, but it seems to be unaffected by the use of continuous combined preparation. The use of HRT also associated with increase risk of Cardiovascular disease, stroke and pulmonary embolism. Side effects of the oestrogen includes, fluid retention, breast tenderness, leg cramps, headache, while progesterone side effects includes acne, headache, depression, fluid retention and breast tenderness. (c) Treatment options include life style advice in the form of smoking cessation, reduce alcohol and caffeine intake, regular exercise. HRT, this patient will need combined preparation , as she has 6 months amenorrhoea the sequential combined would be advisable in the tablet form. Other option will be to take the oestrogen part in the form of tablets, implants, gel or nasal spray and can have the levonorgestrel intra uterine system for endometrial protection. Clonidine has been used to control vasomotor symptom but trials has shown it to be effective via the transdermal rout, however, it does not provide osteoprotection. Selective serotonine reuptake inhibitor such as paroxitin and flouxitin, has been shown to be effective in controlling mood swings. Some herbal medicines has been tried like black cohosh and there is evidence that it is effective in relieving vasomotor symptoms but there is some concerns about hepato toxicity. Gensing, primrose oils, vitamins c and E has been tries but there is no evidence to support their use. Acupuncture has been shown to relieve vasomotor symptoms, but associated with potential side effects like cardiac tamponade, pneumothorax and risk of hepatitis transmission.
		Posted by GBENGA O. Thu Feb 8, 2007 10:13 pm
a) HRT improves vasomotor symptoms and gives \"life\" back to the woman.It prevents vertebral fractures by increasing the bone mineral density.Though it\'s not used as a prophylaxis for oesteoporosis,it helps to prevent it in the suscepible individuals.It also helps to stem some genitorinary symptoms such as frequency of urine urethral prolapse, dry vaginal and loss of libido.It has been proven to be protective against colorectal cancer and Alzimer\'s disease. b)HRT is associated with increased risk of breast cancer if used for a long time.However,when stopped after 5 years,the risk falls to the background risk.It is also associated with thromboembolic phenomenom maily because of advancing age and statis it cuases especially the ones with estrogen.Most of them would increase risk of developing endometrial hyperplasia and endometrial cancer.Vaginal bleeding has been associated with HRT and this a cause of concern to users and may warrant investigation and sometiimes discontinuation.The initial notion that HRT is protective against coronary heart disease and ischaemic disease has been discarded by recent studies,it infact increases the risk to developing these diseases. c) Options could be non-medical and medical.The medical options could be hormonal or non-hormonal.The non-medical options include life-style cahanges,caessation of smoking,reduction in alcohol and caffein intake,regular,aerobic exercise,weight loss,diet that is fortified with calcium and vitamin D,acunpuncture,homeopathy.Non-hormonal medical options include Raloxifene which prevents vertebral fractures,bi-phosponates help with osteoporosis.Hormonal methods could be estrogen only if she\'s hysterectomised,or combined with progestogen.This could come in form of oral,patches,vaginal rings or topical especially for the genitourinary symptoms. Information leaflet is given to her to help her make an infromed choice.