The smart way to learn. The smart way to teach.
Find a course ...
BusySpR MRCOG PART II
MRCOG Part 2, MRCOG II

We have 2200 SBA, 1500 EMQs; 1200 based on 2015 - 2019 recalls. Fees: £49 =1 month, £59 =2 months, £69 = 3 months, £95 =4 months, £105 =5 months, £115 =6 months, £135 =9 months £155 =12 months.

(1) Register. (2) Log-in  (3) Click 'Join this Course' to get 1 day FREE TRIAL.

MRCOG 2 Past Questions Tutorial: GROUP 3: Sat 16/11 from 10:00 - Statistics. Sun 17/11 from 10:00 - Oncology 1. Group 2: Sat 16/11 from 19:00 - Contraception & STI. See DISCUSSIONS below for details.

 

 

roblox hack

Course PAID
notes317
EMQ1583
Best of 52247
 
 
 
Rate   
Do you realy want to delete this discussion?
Forum >> ESSAY 248 - HRT
ESSAY 248 - HRT Posted by Paul T.
Mon Aug 20, 2007 02:57 pm
A 50 year old woman with history of breast cancer treated 8 years earlier complains of severe hot flushes and seeks your advice about the use of HRT. (a) What will you tell her about the benefits of HRT? [4 marks] (b) What will you tell her about the risks associated with HRT? [11 marks] (c ) What would you tell her about alternatives to conventional HRT? [5 marks]
Posted by Mohammad H.
Mon Aug 20, 2007 06:05 pm

a-
I will tell her that HRT is effective in treatment of her hot flushes.It also provides psychological improvement may be secondary to the relief of vasomotor symptoms.IT releives vaginal dryness and it delays Alzehimer\'s disease but it is not a treatment in established cases.
It reduces osteoporosis if used for a long period but the risks of its use outweigh its benefits so, is not justifiable to use as a prophylactic of osteoporosis.It also reduces the LDL and cholesterol and rises HDL so it may be of benefit in cases without history of previous coronary disease.


b-
HRT use is associated with increased risk of breast cancer by 2,6 &12 more cases after

3,5 &10 years of use respectively.It can be associated with increase recurrence in brest

cancers with estrogen receptors so the oncologist should be included in the decision of

starting HRT therapy to her .
HRT therapy is associated with increased risk of endometial cancer if unopposed estrogen or

sequential combined regimens used.If the patient is on tamoxifen therapy ,she is also at

incresed risk of endometial cancer.
There is increased risk of venous thrombo-embolism(3 fold as compared to non users).
There is increased risk of ischaemic heart disease in patients with previous attacks.


c-
There are alternatives to conventional HRT therapy.Regular muscular excercises ,stop

smoking and reducing alchol&coffee intake reduce postmenopausal symptoms.
Tibolone which is a weak estrogenic,progestogenic and androgenic drug is effective in

releiving vaso-motor symptoms and not asociated with increase risk of breast

cancer.Selective nor-adrenaline re-uptake inhibtors(floxetine and paroxitine)and selective

serotonine re-uptake inhibtor (venlafaxine) reduces vasomtor symptoms.Clonidine subdermal

also reduces hot flushes .St.John\'s wort reduces depression.Selective ESTROGEN RECEPTOR

MODULATORS (SEMS)as ralxiofene does not improve hot flushes , increase risk of venous

thrombo-embolism but reduces osteoporosis.
progestogens alone can reduce vasomotor symptoms but reduces bone denesity.phytoestrogens

that present in soya beans,vitamin E &D are of not proved value.Acupuncture improves hot

flushes but associated with increased risk of hepatitis B ,C and HIV.
Providng written information leaflets help teh patient to take an informed decision.
Posted by Malar R.
Mon Aug 20, 2007 10:17 pm
HRT is very good at relieving hot flushes and night sweats.It also protects against osteoporosis and fractures secondary to it.It improves vaginal dryness and hence any associated dyspareunia.It may also protect against dementia and colorectal cancers.

The main risk to be discussed is the increase in breast cancer incidence. HRT is associated in bigger lesions and at a more advanced stage. In her especially, this may either cause a recurrence of her cancer or a new cancer may form. Her risk of recurrence may be higher if her initial tumour was oestrogen receptor positive.

She should be informed about the increased risk of thromboembolism with HRT, including DVT and PE.Her risk of cardiovascular disease and hypertension will also be increased.Her risk of getting stokes will be higher on HRT.HRT will also increase her risk of endometrial cancer especially if taken cyclically.

There is a variety of alternatives to HRT available and not all of them are proven to help with symptoms of menopause.

Maintaining an active lifestyle, optimum BMI, stopping smoking and alcohol and having a healthy diet may help her symptoms and provide benefits such as osteoporosis prevention.Vitamin D supplements and bisphosphonates may be used and help prevent osteoporosis and fractures.

Acupuncture, aromatherapy and reflexology are available and may be tried safely without the risks of HRT. Acupuncture has been shown to be helpful in studies.

There are also herbal remedies such as black cohosh, red clover, ginseng, evening primerose oil and st johns wort. She should be cautious with them as they may interact with any other medications she takes especially st johns wort.These remedies have not been beneficial in studies but she may try them.

Posted by Jancy V.
Mon Aug 20, 2007 11:19 pm

I will inform her that HRT relieves the symptoms of hot flushes, relief of night sweats start by 4 weeks and maximum effect is noticed at 3 months of use. HRT also helps in psychological wellbeing, due to placebo effect and due to relief of symptoms. There is improvement in vaginal lubrication especially with topical estrogens. HRT prevents osteoporosis, but life long treatment is required to prevent age related osteoporotic fractures. HRT also delays the onset of Alzheimer?s disease, but provides no benefit in already established disease. I will supplement the information with leaflets and websites

HRT increases the relative risk of coronary artery diease, stroke and pulmonary embolism according to the WHI trial. In women with established coronary artery disease, it increases coronary events in first year. In healthy menopausal women, HRT has not been shown to be cardioprotective. HRT increses the risk of development of breast cancer by 2, 6, 12 per 1000cases for 3,5 ,10 years of use respectively, risk factor being the duration of oestrogen exposure. In this woman with history of treated breast cancer, there is high risk of relapse of the disease with HRT, especially if the tumour was hormone receptor positive. HRT increases the risk of endometrial cancer , if unopposed estrogen or sequential combined regimen of less than 10 days preogesterone per cycle is used in women with intact uterus. HRT also increases the risk of ovaraian cancer compared with nonusers. Another important side effect is the increased risk of venous thromboembolism. Women on HRT have double the risk of VTE compared to nonusers. Hence in women with additional risk factors should be advised against the use of hormonal HRT. In addition there are minor side effects of HRT ? estrogen related nausea, vomiting, headache, leg cramps and progesterone related acne, fluid retension, depression. There is risk of enlargement of fibroids and reactivation of endometriosis with hormonal HRT. I would give her information leaflets and written information about the risks and benefits of treatment so that she can make an informed choice at a later appointment.

Life style modification with regular moderate aerobic exercises improves menopausal symptoms. Avoiding alcohol and caffeine is also helpful. She can use topical clinidine, which is proven to relieve hot flushes. Selective serotonin uptake inhibitors like fluoxetine, noradrenaline uptake inhibitor venlafaxine have been proven to be effective for hot flushes. Herbal, homeopathic, acupuncture treatments are alternatives to HRT, but no definite studies have been undertaken to prove their benefit. Similarly , multivitamins , soy, black cohosh have been tried but none have proven benefit.
Posted by Parveen  Q.
Mon Aug 20, 2007 11:29 pm
The benefits of HRT are relief from vasomotor symptoms, like night sweats, and hot flushes within 4weeks of use and thus improving the quality of life. It relieves urogenital atrophy, reduces vaginal soreness and dryness and thus improves the sexual function. It improves the quality of hair, reduces tooth loss, macular degeneration, but this effect can be achieved by long term use rather than short duration used to control menopausal symptoms. It reduces progression to alzeheimer\'s diseaseand protects against colon cancer. It reduces the risk of osteoporosis, by reducing the bone mineral density loss, but it does not reduce the risk of fractures unless taken for a long time.

(b) The risk of HRT is increase in risk of VET within the first year of use, the risk increases from 11/100,000 in non users to 27/100,000 in current users. Risk of breast cancer increases from 2/1000 in 5years to 8/1000 in 10years. But the risk declines like that of non users within 5years of discontinuation of the HRT. It increases the risk of coronary arterial disease, and stroke in the first year of use. It is no longer cardioprotective. There is increase risk of gall bladder disease. The effect on ovarian cancer is uncertain. There is a risk of endometrial cancer on those using sequential HRT only. Side effects due to oestrogenic and progestogenic effects are mood swings, depression, loss of libido, breast tenderness and fluid retention. One of the other side effect is erratic bleeding , which investigation. Patient should be told that the overall complications due to HRT remains small.

(c) the life style modification of reducing weight, weight bearing exercises, reduction in alcohol and smoking improves quality of life. Progestogens like norethisterone, megesterol are effective in relieving hot flushes. They are effective in those where oestrogen is contraindicated like in breast cancer and VET. Tibolone is less effective on the breast and relieves vasomotor symptoms. Natural progesterone creams extracted from soya and yam relieves vasomotor symptoms but not endometrial or bone protective. Vaginal lubricants , and topical creams are effective for vaginal dryness. Transdermal clonidine reduces vasomotor symptoms. Among SSRI, and SNRI , SNRI are found to be effective, but the compliance is reduced due to nausea. SERMS like raloxifene are unsuitable as they donot relieve menopausal symptoms, but effective in reducing osteoporosis. Complementary therapy may be effective but needs more evaluation. Black cohosh controls vasomotor symptoms, has no effect on breast ,but limited due to hepatotoxicity. St.John\'s wart relives depression but no effect on vasomotor symptoms. Acupuncture relieves vasomotor symptoms, it is effective in those on tamoxifen for breast cancer, and the effect remains for 3months after treatment. No difference between traditional chinese medicine and placebo. Homeeopathy is effective, and may be available in NHS. Biphosphonates can be offered for preventing osteoporosis. Patient has to be told that all alternative therapies are not as effective as HRT. Opinion of breast surgeon is vital in this patient. She will be given written information and names of support groups provided.
Posted by saima gulzar S.
Mon Aug 20, 2007 11:57 pm
The initiation of HRT in woman with history of breast carcinoma should be in consultation with oncologist and she should be referred to special menopause clinic.
Benefits of HRT are improvement in vasomotor symptoms such as hot flushes ,night sweats and vaginal dryness.Topical estrogens may help to improve mild urogenital symptoms(not incontinence).Onset and progression of Alzheimers disease is delayed with long term use of HRT.There is decreased incidence of vertebral fractures and osteoporosis with long term use of HRT.There is association with reduced incidence of colorectal carcinoma..HRT is associated with improvement in quality of life ,libido and mood.There is increase in collagen of skin. The use of HRT is associated with reduction in macular degeneration ,cataract and tooth loss .
(b) The risk of venous thromboembolism is increased 2-3 folds with use of HRT.There is association with increased incidence of breast cancer with long term HRT use but there are 2 extra cases of breast cancer per 1000 women after 5 years of HRT use. There is increased incidence of coronary heart disease and stroke during first year of HRT use(WHI trial) but risk increased in those with cardiovascular risk factors such as diabetes and hypertension.Use of unopposed estrogen and sequential combined HRT is associated with increase risk of endometrial carcinoma.There is increased risk of gall bladder disease.Systemic side effects of estrogen( fluid retention,headache and breast tenderness) and progestogens(acne ,mood swings and depression) and irregular vaginal bleeding may affect compliance.The woman should be provided with written informations.
(c) Alternative in form of life style modification by reducing alcohol,caffeine and smoking and motivation with weight bearing exercises may help to improve symptoms.Role of herbal medicine such as soya ,ginseng,primrose oil and st john wort is unproven. Acupuncture and reflex therapy may improve symptoms.In pharmacotherapy, Progestogens such as megestrol may help in relief of vasomotor symptoms but associated with risk of venous thromboembolism and breast cancer(as some breast cancers have progesterone receptor expression).Trandermal clonidine (not oral ) is effective in relief of vasomotor symptoms.Selective serotonoin reuptake inhibitor(SSRI) such as flouxetene helps in shot term relief of hot flushes.SERMS(selective estrogen receptor modulators) such as Raloxifene has antiestrogenic effect on breast and endometrium (causing reduction in risk of breast cancer ) and estrogenic effect on bone (preventing osteoporosis) but no effect in relief of vasomotor symptoms.They are associated with hot flushes and increase risk of venous thromboembolism.
Posted by Natalia  N.
Tue Aug 21, 2007 12:36 am
A. Benefits of HRT are related to improvement in vasomotor symptoms (hot flushes) in 80-90% of patients within 4 weeks of commencing the treatment. HRT has positive effect on psychological condition of women, it improves mood, libido and general well-being. Combined oestrogen-progesterone HRT decreases the risk of colorectal cancer. It also decreases the risk of osteoporotic fractures of hip, vertebra, and wrist. Bone mineral dencity improves within 2 years of starting HRT. Although HRT has to be taken for life to sustain prevention of osteoporosis. HRT improves vaginal dryness, especially local oestrogen preparations. It also improves skin condition, associated with decreased rate of cataract, and teeth problems.

B. HRT increases risk of brest cancer, which has been shown in large trials (for example, relative risk of breast cancer in WHI strial was 1.24). Risk of breast cancer is increased with prolonged use of HRT (more than 5 years). Breast cancer was diagnosed at a more advanced stage, and had larger size in HRT users in comparion to non-users. Such findings can be related to mammogramic changes due to HRT, and , therefore, difficulties in mammogram interpretations in such women. HRT use was studied in women with postmenopausal symptoms and previous breast study in HABITS trial. This study (as well as several other sudies in this area) was stopped early due to findings of significant number (24 in HRT users vs 7 in non-users per approximately 200 women in each group) of recurrent breast cancer in HRT users. Such effect of HRT on breast cancer is related to hormone oestrogen receptors sensitivity of breast cancer. Therefore, HRT is contraindicated in women with history of breast cancer.
HRT also associated with increased risk of cardiovascular disease in women with a history of cardiovascular disease. It\'s also associated with increased risk of thromobotic episodes, (pulmonary embolsim, stroke, VTE) and shoudl not be used for primary or secondary prevention of such conditions. HRT was thought be beneficial for congnitive function, but it does not have any role in women with already altered condition (Alzheimers disease). There is also an association between HRT use and risk of ovarian cancer. Mortality from ovarian cancer is also increased in HRT users. Unopposed oestrogen HRT in women with intact uterus is associated with endometrial cancer. Most of the information obtained on HRT is from studies of women who did not have menopausal symptoms, were late in menopause (in their sixties and seventies), and had multiple risk factors (obesity, smoking, cardiovascular disease, previous use of HRT), which may differ to women who would contribute from HRT the most in easrly menopause with severe vasomotor symptoms and no contraindication to HRT use and no risk factors.

C. Unfortunately alternatives to HRT are not as effective as HRT (50-60% relief of vasomotor symptoms by alternative preparations vs 80-90% by HRT). Life-style changes, e.g. aerobic exersice improve generall well-being and vasomotor symtoms. Avoiding consumption of caffeine and alcohol also improves vasomotos symptoms. Progesterone preparations and phytoestrogens (red clover and soy) have some effecicy in treatment of vasomotor symptoms, but should be avoided in women with oestrogen-progesterone dependant tumours (such as breast cancer). SNRIs (venlafaxine) and SSRIs (fluoxetine, paroxetine) have been shown to improve vasomotor symptoms (especially venlafaxine) as well as improve mood, sleep, and psychological well-being. Oral clonidine preparations are not effective intreatment of vasomotor symptoms, but dermal preparations are effective. None of the herbal preparations (black cohosh, evening primrose oil, dong uie, St John\'s wort, ginseng) have been shown to effective in treatment of hot flushes, though some of them are useful in treatment of depression (St John\'s wort). Acupuncture has positive effect of treatment of vasomotor symptoms, but it carries the risk of adverse effects (cardiac tamponade, pneumothorax, hepatitis). Reflexology, homeopathy and vitamin supplementation have not been shown to be effective in treatment of menopausal symptoms.
Posted by Idris O.
Tue Aug 21, 2007 04:32 am
a) I would obtain a detailed history to assess her sympton\'s and the severity and the effect on her quality of life. I would inform her menopausal symptons are transient and only short term treatment is required( 1-2yrs).
The short term benefits of HRT includes relief of menopausal sympton\'s of hot flushes,night sweats and vaginal dryness.It also
help mood changes and it is associated with improvement in skin and hair texture. It also prevents peri-odontal disease. Long term use is associated with a reduction in the risk of urogenital atrophy and urinary symptoms. There is also reduction in the risk of colorectal cancer. It prevents or delay the development of Alzheimer\'s disease and prevents hip fractures and osteoporosis.
b) The risks depends on the type of HRT, the duration of its use and the route of administration. The overall risk of complication from HRT is small.The WHI trial has shown there is an increased risk of VTE in the 1st year of use. There is also an increased risk of breast cancer after 5years of use. In patients with previous breast cancer there is the risk of reactivation of dormant tumour cells with the risk of recurrence.There is an increased risk of IHD, angina and stroke.
There is also an increased risk of gall bladder disease. The risk of endometrial cancer increases after 5years especially if oestrogen alone preparation is used. I would offer her information leaflet and address of support group. If she wishes to use HRT based on her risk benefit ratio, i would seek advice from the gynae oncologist.
c) The alternatives include life style modification of regular exercise, stop smoking and alcohol and dietary modifications may be helpful. Tibolone is effective against menopausal sympton\'s but associated with androgenic side effects of greasy skin, acne and irregular vaginal bleeding. It also increases the risk of breast cancer. The SERMS(raloxifene) are unsuitable because they do not relief menopausal symptons. Clonidine(alpa 2 agonist) is moderately effective in relieving menopausal symptons. The SSRI (paroxetine) and the SNRI( fenlafaxine) are effective in relieving hot flushes.Complementary therapy like St. John\'s Wort, phyto-oetrogens and evening primprose oil have doubtful efficacy in the relief of menopausal symptoms.
Posted by Saad A.
Tue Aug 21, 2007 01:17 pm
a.I will tell her that menopausal symptoms are transient and that HRT can be used for 02 years for their relief. .
The benifits associated with HRT are improvement in menopausal symptoms like hot flushes, night sweats. There is improvement in vaginal dryness. HRT also prevents from hair loss. HRT also prevent from tooth loss .HRT also improves improves the skin of menopausal women. The long term benifits of HRT are prevention of osteoprosis, Alzheimer\'s disease and maculopapular rash . Writteninformation and hospital contact details are provided.
b. As patient is having breast cancer so HRT will not be recommended and furthur advice in collaboration with breast surgeon and gynaecologist is needed. I will tell her that there is an increased CVS risk after one year usage .There is increased risk of stroke when HRT is used for one year. Then I will tell her that there is increased risk of VTE with HRT. There is increased risk of endometrial cancer with sequential HRT. She will be told that since she had breast cancer 08 years back HRT is not advised in such individuals. She will be told that in those persons without breast cancer HRT increase risk from 32 per 1000 women to 38 per 1000 and 51 per 1000 women at 5 and 10years respectively. After stoppage of HRT the risk of breast cancer is same as non users . She will be told that there is increased risk of gall bladder disease and bleeding per vaginal and hence may require investigations. She will be told that overall risk is lower as compared to improving quality of life. Written information and hospital contact details are provided.
c. I will tell her that continued HRT is inappropiate . Other alternatives which can improve menopausal symptoms are general health measures, which include improvement of life style measures like stopping smoking and use of alcohol. She is advised for regular exercise and diet manipulation. Complementary measures like reflexology, haemopathy will be advised. Primrose oil , phytoestrogen, black cohosh has not found to be effective. SSRI such as paroxetene are found to be effective. Progestogen such as norethisterone or megesterol are effective. Tibolone can be used .Raloxifene(SERMs)are unsuitable as they donot improve menopausal symptoms like hot flushes. Use of lubricant/topical treatment for vaginal symptoms is advised. Written information will be provided.
Posted by Valerie T.
Tue Aug 21, 2007 02:05 pm
A 50 year old woman with history of breast cancer treated 8 years earlier complains of severe hot flushes and seeks your advice about the use of HRT. (a) What will you tell her about the benefits of HRT? [4 marks] (b) What will you tell her about the risks associated with HRT? [11 marks] (c ) What would you tell her about alternatives to conventional HRT? [5 marks]

a) HRT is beneficial in the symptomatic relief of menopausal symptoms that are affecting a woman\'s quality of life. The benefits of HRT can be divided into short term and long term. The short term benefits include the relief of hot flushes and night sweats and mood swings. The long term benefits include a reduction in the risk of osteoporotic fractures but this benefit declines when the HRt is stopped. Benefits are also in the reduction in urogenital atrophy and vaginal dryness; reduced loss of tone in the pelvic floor muscles and reduced incidence of colorectal cancer.

b) There is a small but significant increase in the risk of breast cancer and should not be used in women with previous breast cancer. Combined estrogen and progestogen preparations are associated with a greater risk then the estrogen only preparations. The increased risk of breast cancer is assocated with duration of use and not the dose of the HRT. Regular mammograms would need to be done. When the HRT is stopped the risk of breast cancer returns to that of women not taking HRT.

The risks associated with HRT include a small increased risk of venous thromboembolism. If she has had an episode of thromboembolism in the past she should avoid using HRt since there is a chance of recurrence of embolism. If she also has a thrombophilia, it is not recommended because of a significant risk of recurrence of thromboembolism. Deep Vein Thrombosis can present with leg or calf pain, swelling and redness. Pulmonary embolism may present with chest pain and shortness of breath. If she develops any of these she should go immediately to the hospital to be assessed.
There is an increased risk of coronary heart disease which was shown by the Women\'s health initiative study.

c) Alternatives to conventional HRT have been of interest to women who don\'t want to use HRT or have contraindications to HRT. They are not as effective as HRT and in some cases have side effects.

The alternatives include life style measures such as a reduction in the intake of alcohol and caffeine. Regular aerobic exercise such as swimming has also been shown to reduce the incidence of hot flushes and night sweats.
Pharmacological alternatives include selective serotonin reuptake inhibitors such as fluoxetine and venflaxine. These have been shown to reduce hot flushes and night sweats; but have been limited in their use by the side effect of nausea. They may be a good alternative for her since they are not contraindicated in previous breast cancer. Clonidine, an alpha 2 agonist has not been effective.
Vitamin C and E have been used in the past but studies have shown no effect on menopausal symptoms.
Complementary therapies include phytoestrogens such as soy and red clover. Studies have shown inconsistent findings on their efficacy. Soy has also been associate dwith endometrial hyperplasia. Herbs such as black cohosh and evening primerose oil have also been used to treat menopausal symptoms. More studies need to be done to confirm efficacy of Black cohosh. Evening primerose oil has been shown to be ineffective in treating hot flushes. Complementary interventions such as acupuncture and reflexology have been shown to be effective but not as effective as combined HRT.
Posted by Natalie P C.
Tue Aug 21, 2007 03:55 pm
ESSAY
A
I would tell her that HRT can treat vasomotor symptoms like hot flushes and night sweats. It reduces urogenital atrophy and reduces vaginal dryness. It causes improved sleep and improved mood which may be due to the improved sleep and reduced vasomotor symptoms. It maintains bone and reduces the risk of osteoporosis and fractures including hip fractures (30-40% reduction).
It reduces the risk of colorectal cancer and of Alzheimers. It reduces weight gain and fat accumulation.

B
HRT is associated with an increased risk of breast cancer so if her disease was estrogen or progesterone receptor positive it may stimulate or activate her disease. Combined estrogen and progesterone therapy (EPT) has a higher risk of causing breast cancer than (estrogen) E alone according to the Womens? Health Initiative WHI trial. WHI showed a 25% increased risk while the Million Women Study MWS showed a doubled risk.
HRT causes an increased risk of endometrial cancer. If a uterus is present E alone as well as sequential or cyclic EPT is associated with an increased risk (6 times for estrogen and 3 times for cyclical EPT). Continuous combined is not associated with an increased risk and may even cause a decreased risk.
There is an increased risk of ovarian cancer. Estrogen therapy causes this more than EPT and the risk is related to the length of use where the longer use causes greater increased risk.
Venousthromboembolism VTE and pulmonary embolism PE are increased. EPT (double risk WHI trail) associated with a higher risk than E alone.
Stroke is also increased and these are mostly ischaemic strokes. Cardiovascular disease has also been shown to increased. This increased is higher with EPT than with E alone. The longer after the menopause the HRT is started the higher this increased risk and the longer it is used the higher the risk. There is an increased risk in gallbladder disease.

C
For vasomotor symptoms progestogens cause a significant improvement (almost 90% reduction) in vasomotor symptoms. Other therapies include phytoestrogens like isoflavine and in soy products and black cohosh. These have been shown to reduce vasomotor symptoms. Ginko baloba has been shown to improve memory.
Venlafaxine and SSRIs like Paroxitine have been shown to produce around a 40% reduction in vasomotor symptoms. Transdermal clonidine has been found to be effective though not oral preparations. Gabapentin has some reduction in vasomotor symptoms.
Alternatives for bone protection are Raloxitine and bisphosphonates.


Posted by Sabahat S.
Tue Aug 21, 2007 08:45 pm
a) HRT is an effective treatment ofmenopausal vasomotor symptoms.. It significantly improves night sweats, Mood swings, hot flushes within 4 ? 6 weeks of use. Short term i e 1 year ( at the most 18 months ) of HRT is required for the treatment of such symptoms. HRT also helps in preventing bone loss, osteoporosis, tooth loss, macular degeneration. But to achieve such benefits, life long HRT is required. HRT (long term) also prevents the onset of Alzheimer?s disease. Skin quality also improves with HRT use. Vaginal dryness can be treated with estrogen component of HRT. Colorectal cancer risk is reduced with HRT.
b) Since she has a previous history of breast cancer HRT is associated with an increased risk of recurrence of breast cancer. The estrogen receptor status of her previous breast cancer should be known. Her breast cancer surgeon should be contacted & regular mammograms will be required. The interpretation of mammogram will be difficult due to increased breast tissue density with HRT. There is a risk that breast cancer if it recurs will be detected at an advanced stage. The risk is further increased in case she is a carrier of a genetic syndrome (BRCA- 1 or BRCA 2). Her cardiovascular risk will be increased; especially in the first year of use (MI, coronary artery desease). I will also inform her about the increased risk of stroke (CVA).
HRT, increases the risk of VTE,Pul.embolism three times. In case she has
a personal or family of VTE , HRT is contraindicated, so also, in case she is affected with a major thrombophilia e.g antithrombin 111 deficiency.
The associated obesity & decreased mobility of post menopausal age,
increase these risks many fold.
Progestogen replacement results in side effects like bloating, breast tenderness, decreased libido. The estrogenic side effects are headache, nausea, vomiting, leg cramps.
She may have to undergo investigations for intermittent PV bleeding, while on HRT, as there is an increased risk of endometrial cancer on sequential HRT due to the estrogenic component. Her risk of Ca ovary is also increased. GB disease risk is also increased with HRT. I will give her written information to back up the discussion & enable her to make an informed choice.
c) Since she is a high-risk candidate for HRT (due to her previous history of breast cancer) alternatives to conventional HRT, should be offered to her. Life style modifications e.g cutting down on alcohol, coffee intake, regular sustained exercise e.g aerobics, or weight bearing exercise like walking are helpful.Tibolone helps in preventing bone loss. SSRI (e.g fluoxetine, paroxitine) and SNRI (venlafaxine) are helpful in the relief of menopausal vasomotor symptoms.
Vaginal gels (bioadhesive gels) or KY jelly may be helpful in vaginal dryness.
Since she has a history of breast cancer, progestogens are contraindicated. Phyto estrogens are also contra indicated for the same reason.
Acupuncture could help, but is associated with the risk of pneumothorax, cardiactamponade & transmission of hepatitis.Blackcohosh may relieve vasomotor symptoms but hepatotoxicity is a risk.St Johns wort may help in mild depression .To enable her to make an informed choice written information is also provided.
Posted by Mahmud  K.
Wed Aug 22, 2007 07:07 am
Hot flushes and night sweats usually improve within 4 weeks of starting HRT. Many women report an improvement of psychological symptoms like sleep disturbance, loss of sexual interest, irritability ,mood swings. Vaginal dryness and urinary symptoms may take as long as a year to respond to oestrogen therapy. The long term oestrogen therapy significantly reduced osteoporotic fracture risk.The bone protection lasts as long as the regimen is taken and stops on cessation of treatment. Several epidemiological studies have suggested that oestrogen use may delay or prevent the onset of Alzheimer?s diseases.It may protect against colon cancer, periodontal disease and cataracts.

Most RCTs and observational studies have indicated that HRT increases the risk of breast cancer. The increased risk appears to be directly related to the duration of therapy. The evidence suggests that combined preparations increase the risk more than oestrogen alone. There is a theoretical risk of reactivation of dormant tumour cells(especially oestrogen receptor positive cell).Observational studies suggest that recurrence is no greater than expected if HRT given. Patient given a risk benefit analysis and consultation with her breast cancer specialist they will make the decision depending on ?quality of life?.
Women Health Initiative study showed early increase in clinical events of Coronary Heart Disease followed by a subsequent decline. It increase risk of stroke .HRT provokes increased risk of venous thromboembolism and pulmonary embolism. HRT should be avoided in women with multiple pre-existing risk factors for VTE. Long term use may increased risk of endometrial cancer.

Healthy life style habits such as sustained ,regular exercise, avoidance of smoking, reduction of intake of alcohol can reduce the severity and frequency of vasomotor symptoms. Progestogen may be avoided as it increased risk of breast cancer. .Transdermal Clonidine may reduce hot flush . Phytooestrogens (soy isofavin) and red clover may have benefits on symptom relief. Selective serotonin and noradrenalin reuptake inhibitor?s (fluoxetine, Paroxetin) may significantly effective for treatment of vasomotor symptoms. Other complementary therapies (acupressure, acupuncture) and vitamin E therapy on hot flushes need .further research.











































Posted by Shahla  K.
Thu Aug 23, 2007 08:55 am
A)i will tell her that HRT help in reducing menopausal symptoms,those are hot flush night sweat,and depression.this lead to psychological improvement.it also relieves vaginal dryness and urinary incontinence.By improving tissue quality it improve skin texture and hair.
HRT by its long term use prevent osteoporosis and fracture of hip bone .
Its beneficial effect seen in preventing Alzaheimer disease.It prevents tooth decay,cataract formation and macular degeneration .Also reduce incidence of colorectal cancer.
b)I will tell her that recent trial reveal risks associate with HRT use.There is increase risk of ischemic heart disease(myocardial infarction)in first year of use.there is also increase incidence of stroke.there is no difference in estrogen being used alone or in combination with progesterone.
Breast cancer is common cancer ,incidence is 45/1000 among women more then 50year.
When HRT being used the cumulative excess rate of breast cancer are 2 extra cases/1000 in 5 year,then 6/1000 in 10year,12/1000 after 15 year of use.after discontinuation of HRT excess risk fell back to nonuser in 5 year.
Risk of venousthromboembolism increase at age of 50 and menopause,but with use of HRT the risk of venous thromboembolism increase by 2-3 fold ,which is highest in first year of use ,VTE can be avoided by use of transdermal rout.
Endometrial cancar risk is also increase but more so with sequential use then continuous use of HRT.Gall bladder disease is also incease.
Fibroid may increase in size,endometriosis reactivated.
Risk of overian cancer is also increase in user as compare to non user.
Other risk might bother a women are fluid retention ,mood swing,leg cramps,and breast tenderness.
c)Alternative to conventional HRT depend on her symptom profile ,so that targeted approach can be offer.First of all I will motivate her to change her life style by quiting smoking, stopping alcohol, or enter in to a excersice programme,and try to reduce weight by appropriate dietery advice.
As she has history of breast cancer and hot flush bothering her , I will enquire about any history of thromboembolism,and make notice of her wishes and expectations,therefore I will inform her that menopausal symptoms are self limiting in 1-2 year. Use of conventional HRT for short period of time can relief her symptom without increasing risk of recurrence breast cancer.
She can use progesterone for short period of time it effectively reduce hot flush and night sweat Norethisterone 5mg,or medroxyprogestrone 5 mg are the dose.
Tibolone has no risk of breast cancer and VTE ,it is effective in eliminating hot flush and sweat,and prevent osteoporosis.
Fluxitene(SSRI) have shown efficacy for hot flush.
Transdermal conidine can effectively reduce vasomotor symptoms.
SERM although good in reducing osteoporosis and breast protective but it does not help her to reduce hot flush.
Phytoestrogen contain estrogen are not suitable in recaptor positive breast cancer,there role not fully understood.
St john wood ,and black kohosh can relief depression and hot flush but concern about safety.
Acupuncture is effective in reducing hot flush ,haemopathy also claim to be usefull
Verbal information supported by information leaflet given with follow up visit.


Posted by Paul T.
Thu Aug 23, 2007 02:41 pm
a-
I will tell her that HRT is effective in treatment of her hot flushes (1) .It also provides psychological improvement may be secondary to the relief of vasomotor symptoms.IT releives vaginal dryness (1) and it delays Alzehimer\'s disease but it is not a treatment in established cases.
It reduces osteoporosis if used for a long period but the risks of its use outweigh its benefits so, is not justifiable to use as a prophylactic of osteoporosis (1) .It also reduces the LDL and cholesterol and rises HDL so it may be of benefit in cases without history of previous coronary disease.


b-
HRT use is associated with increased risk of breast cancer by 2,6 &12 more cases after

3,5 &10 years of use respectively (1) .It can be associated with increase recurrence in brest

cancers (1) with estrogen receptors so the oncologist should be included in the decision of

starting HRT therapy to her ? effect of short term use and reduction in risk following cessation .
HRT therapy is associated with increased risk of endometial cancer if unopposed estrogen or

sequential combined regimens used (1) .If the patient is on tamoxifen therapy ,she is also at

incresed risk of endometial cancer.
There is increased risk of venous thrombo-embolism(3 fold as compared to non users) (1) .
There is increased risk of ischaemic heart disease in patients with previous attacks (1) .
? gall bladder disease, drug side-effects, abnormal vaginal bleeding requiring investigation, written information

c-
There are alternatives to conventional HRT therapy.Regular muscular excercises ,stop

smoking and reducing alchol&coffee intake (1) reduce postmenopausal symptoms.
Tibolone this should be considered as conventional HRT and is associated with increased risk of breast cancer ? has oestrogenic & progestogenic effects which is a weak estrogenic,progestogenic and androgenic drug is effective in

releiving vaso-motor symptoms and not asociated with increase risk of breast

cancer
this is incorrect (-1) .Selective nor-adrenaline re-uptake inhibtors(floxetine and paroxitine)and selective

serotonine re-uptake inhibtor (venlafaxine) reduces vasomtor symptoms .Clonidine subdermal

also reduces hot flushes (1) .St. John\'s wort reduces depression is depression a menopausal symptom / disease?? . Selective ESTROGEN RECEPTOR

MODULATORS (SEMS)as ralxiofene does not improve hot flushes , increase risk of venous

thrombo-embolism but reduces osteoporosis
are SSRMs a suitable alternative for this woman? .
progestogens alone can reduce vasomotor symptoms but reduces bone density ? evidence for reducing bone density?? .phytoestrogens

that present in soya beans,vitamin E &D are of not proved value.Acupuncture improves hot

flushes but associated with increased risk of hepatitis B ,C and HIV why should this be the case? The same would apply if you went to a hospital where needles were re-used and inadequately sterilised .
Providng written information (1) leaflets help teh patient to take an informed decision.

Some breast cancers have progestogen receptors. Phyto-oestrogens have oestrogenic activity. There is therefore a theoretical increase in recurrence risk with progestogens and phyto-oestrogens



Posted by Paul T.
Thu Aug 23, 2007 02:43 pm
HRT is very good at relieving hot flushes and night sweats (1) .It also protects against osteoporosis and fractures secondary to it requires life-long use .It improves vaginal dryness (1) and hence any associated dyspareunia.It may also protect against dementia there are several types of dementia and colorectal cancers (1) .

The main risk to be discussed is the increase in breast cancer incidence (1) . HRT is associated in bigger lesions and at a more advanced stage. In her especially, this may either cause a recurrence of her cancer or a new cancer may form (1) what is the increase in risk? More detail + figures required . Her risk of recurrence may be higher if her initial tumour was oestrogen receptor positive.

She should be informed about the increased risk of thromboembolism with HRT, including DVT and PE (1) .Her risk of cardiovascular disease and hypertension is risk of hypertension increased?? will also be increased.Her risk of getting stokes will be higher on HRT.HRT will also increase her risk of endometrial cancer especially if taken cyclically (1) risk of ovarian cancer, gall bladder disease, drug side effects, abnormal vaginal bleeding requiring investigation .

There is a variety of alternatives to HRT available and not all of them are proven to help with symptoms of menopause.

Maintaining an active lifestyle, optimum BMI, stopping smoking and alcohol and having a healthy diet may help her symptoms (1) and provide benefits such as osteoporosis prevention. Vitamin D supplements and bisphosphonates may be used and help prevent osteoporosis and fractures her complain is hot flushes .

Acupuncture, aromatherapy and reflexology (1) are available and may be tried safely without the risks of HRT. Acupuncture has been shown to be helpful in studies.

There are also herbal remedies such as black cohosh, red clover, ginseng, evening primerose oil and st johns wort. She should be cautious with them as they may interact with any other medications she takes especially st johns wort.These remedies have not been beneficial in studies but she may try them.
phyto-oestrogens have oestrogenic activity and therefore a theoretical breast cancer risk especially in a woman with a history of breast cancer.

SSRIs, clonidine, progestogens

Posted by Paul T.
Thu Aug 23, 2007 02:44 pm
I will inform her that HRT relieves the symptoms of hot flushes, relief of night sweats (1) start by 4 weeks and maximum effect is noticed at 3 months of use. HRT also helps in psychological wellbeing, due to placebo effect and due to relief of symptoms. There is improvement in vaginal lubrication (1) especially with topical estrogens. HRT prevents osteoporosis, but life long treatment is required to prevent age related osteoporotic fractures (1) . HRT also delays the onset of Alzheimer?s disease, but provides no benefit in already established disease. I will supplement the information with leaflets and websites

HRT increases the relative risk of coronary artery diease, stroke and pulmonary embolism what is the increase in risk of VTE? Why address this in the same sentence as coronary artery disease? You did not present sufficient detail on VTE and lost the mark according to the WHI trial. In women with established coronary artery disease, it increases coronary events in first year (1) . In healthy menopausal women, HRT has not been shown to be cardioprotective this has been called into question by subsequent studies . HRT increses the risk of development of breast cancer (1) in practice, you would address this first as it is the woman?s main concern. From a technique point of view, this is likely to carry more marks and should be addressed first in case you run out of time / space by 2, 6, 12 per 1000cases for 3,5 ,10 years of use respectively (1) , risk factor being the duration of oestrogen exposure. In this woman with history of treated breast cancer, there is high risk of relapse of the disease with HRT, especially if the tumour was hormone receptor positive (1) . HRT increases the risk of endometrial cancer , if unopposed estrogen or sequential combined regimen of less than 10 days preogesterone the risk is still increased per cycle is used in women with intact uterus. HRT also increases the risk of ovaraian cancer compared with nonusers (1) . Another important side effect is the increased risk of venous thromboembolism see first sentence ? is pulmonary embolism different from VTE? . Women on HRT have double the risk of VTE compared to nonusers (1) . Hence in women with additional risk factors should be advised against the use of hormonal HRT. In addition there are minor side effects of HRT ? estrogen related nausea, vomiting, headache, leg cramps and progesterone related acne, fluid retension, depression (1) . There is risk of enlargement of fibroids and reactivation of endometriosis with hormonal HRT. I would give her information leaflets and written information (1) what is the difference between information leaflets and written information?? about the risks and benefits of treatment so that she can make an informed choice at a later appointment.

Life style modification with regular moderate aerobic exercises improves menopausal symptoms. Avoiding alcohol and caffeine is also helpful (1) . She can use topical clinidine, which is proven to relieve hot flushes. Selective serotonin uptake inhibitors like fluoxetine, noradrenaline uptake inhibitor venlafaxine have been proven to be effective for hot flushes (1) . Herbal, homeopathic, acupuncture treatments are alternatives to HRT, but no definite studies have been undertaken to prove their benefit (1) . Similarly , multivitamins , soy, black cohosh have been tried but none have proven benefit contain phyto-oestrogens which have oestrogenic activity therefore pose theoretical breast cancer risk .
Posted by Paul T.
Thu Aug 23, 2007 02:45 pm
The benefits of HRT are relief from vasomotor symptoms, like night sweats, and hot flushes (1) within 4weeks of use and thus improving the quality of life. It relieves urogenital atrophy, reduces vaginal soreness and dryness (1) and thus improves the sexual function. It improves the quality of hair, reduces tooth loss, macular degeneration, but this effect can be achieved by long term use rather than short duration used to control menopausal symptoms. It reduces progression to alzeheimer\'s disease not been shown to alter course of established disease and protects against colon cancer. It reduces the risk of osteoporosis, by reducing the bone mineral density loss, but it does not reduce the risk of fractures unless taken for a long time (1) .

(b) The risk of HRT is increase in risk of VET within the first year of use, the risk increases from 11/100,000 in non users to 27/100,000 in current users (1) you should begin with breast cancer risk . Risk of breast cancer increases from 2/1000 in 5years to 8/1000 in 10years This is not correct ? the risk of breast cancer in a 50 year old woman is not 2/1000 after 5 years of use. It causes 2 extra breast cancers per 1000 women? . But the risk declines like to that of non users within 5years of discontinuation of the HRT (1) . It increases the risk of coronary arterial disease, and stroke in the first year of use (1) particularly in women with a previous event . It is no longer cardioprotective this has been called into question by more recent publications in younger women with no previous history . There is increase risk of gall bladder disease. The effect on ovarian cancer is uncertain increases risk ? see notes > key papers . There is a risk of endometrial cancer there is a risk of endometrial cancer in every woman with a uterus. You need to indicate that the risk is increased and by how much on those using sequential HRT only. Side effects due to oestrogenic and progestogenic effects are mood swings, depression, loss of libido ?? , breast tenderness and fluid retention. One of the other side effect is erratic bleeding (1) , which investigation. Patient should be told that the overall complications due to HRT remains small.

there are more marks for (b) than (c) yet you have dedicated more space / time to (c)
(c) the life style modification of reducing weight, weight bearing exercises, reduction in alcohol and smoking improves quality of life (1) reduce menopausal symptoms . Progestogens like norethisterone, megesterol are effective in relieving hot flushes some breast cancers have progesterone receptors. Progestogens should therefore not be considered risk-free in women with breast cancer . They are effective in those where oestrogen is contraindicated like in breast cancer and VET. Tibolone is less effective on the breast ?? what do you mean less effective on breast? Which breast condition is it supposed to treat? Tibolone is associated with increased risk of breast cancer and relieves vasomotor symptoms. Natural progesterone these are phyto-OESTROGENS creams extracted from soya and yam relieves vasomotor symptoms but not endometrial or bone protective. Vaginal lubricants , and topical creams are effective for vaginal dryness. Transdermal clonidine reduces vasomotor symptoms. Among SSRI, and SNRI , SNRI are found to be effective, but the compliance is reduced due to nausea (1) . SERMS like raloxifene are unsuitable as they donot relieve menopausal symptoms, but effective in reducing osteoporosis. Complementary therapy may be effective but needs more evaluation. Black cohosh controls vasomotor symptoms, has no effect on breast ,but limited due to hepatotoxicity. St.John\'s wart relives depression but no effect on vasomotor symptoms. Acupuncture relieves vasomotor symptoms (1) , it is effective in those on tamoxifen for breast cancer, and the effect remains for 3months after treatment. No difference between traditional chinese medicine and placebo. Homeeopathy is effective, and may be available in NHS. Biphosphonates can be offered for preventing osteoporosis the woman?s problems are hot flushes and a history of breast cancer, not osteoporosis . Patient has to be told that all alternative therapies are not as effective as HRT is HRT more effective than bisphosphonated in preventing osteoporosis? . Opinion of breast surgeon is vital in this patient. She will be given written information (1) and names of support groups do you know an example of a support group? provided.
Posted by Paul T.
Thu Aug 23, 2007 02:46 pm
The initiation of HRT in woman with history of breast carcinoma should be in consultation with oncologist and she should be referred to special menopause clinic. Not necessary ? you were asked about what you would tell her
Benefits of HRT are improvement in vasomotor symptoms such as hot flushes ,night sweats (1) and vaginal dryness.Topical estrogens may help to improve mild urogenital symptoms(not incontinence) (1) .Onset and progression of Alzheimers disease is delayed with long term use of HRT.There is decreased incidence of vertebral fractures and osteoporosis with long term use of HRT.There is association with reduced incidence of colorectal carcinoma (1) ..HRT is associated with improvement in quality of life ,libido and mood.There is increase in collagen of skin. The use of HRT is associated with reduction in macular degeneration ,cataract and tooth loss (1) .
(b) The risk of venous thromboembolism is increased 2-3 folds with use of HRT (1) .There is association with increased incidence of breast cancer (1) with long term HRT use but there are 2 extra cases of breast cancer per 1000 women after 5 years of HRT use (1) what about the issue of recurrence which would be of concern for this woman?. There is increased incidence of coronary heart disease and stroke during first year of HRT use(WHI trial) but risk increased in those with cardiovascular risk factors such as diabetes and hypertension (1) .Use of unopposed estrogen and sequential combined HRT is associated with increase risk of endometrial carcinoma (1) by how much? .There is increased risk of gall bladder disease.Systemic side effects of estrogen( fluid retention,headache and breast tenderness) and progestogens(acne ,mood swings and depression) and irregular vaginal bleeding may affect compliance (1) .The woman should be provided with written informations (1) .
(c) Alternative in form of life style modification by reducing alcohol,caffeine and smoking and motivation with weight bearing exercises may help to improve symptoms (1) .Role of herbal medicine such as soya ,ginseng,primrose oil and st john wort is unproven. Acupuncture and reflex therapy may improve symptoms (1) .In pharmacotherapy, Progestogens such as megestrol may help in relief of vasomotor symptoms but associated with risk of venous thromboembolism and breast cancer(as some breast cancers have progesterone receptor expression) (1) .Trandermal clonidine (not oral ) is effective in relief of vasomotor symptoms.Selective serotonoin reuptake inhibitor(SSRI) such as flouxetene helps in shot term relief of hot flushes (1) . SERMS(selective estrogen receptor modulators) such as Raloxifene has antiestrogenic effect on breast and endometrium (causing reduction in risk of breast cancer ) and estrogenic effect on bone (preventing osteoporosis) but no effect in relief of vasomotor symptoms is this an appropriate alternative for a woman with severe hot flushes? .They are associated with hot flushes and increase risk of venous thromboembolism.

good answer
Posted by Paul T.
Thu Aug 23, 2007 02:47 pm
A. Benefits of HRT are related to improvement in vasomotor symptoms (hot flushes) (1) in 80-90% of patients within 4 weeks of commencing the treatment. HRT has positive effect on psychological condition of women, it improves mood, libido and general well-being. Combined oestrogen-progesterone HRT decreases the risk of colorectal cancer. It also decreases the risk of osteoporotic fractures of hip, vertebra, and wrist. Bone mineral dencity improves within 2 years of starting HRT. Although HRT has to be taken for life to sustain prevention of osteoporosis (1) . HRT improves vaginal dryness, especially local oestrogen preparations (1) . It also improves skin condition, associated with decreased rate of cataract, and teeth problems (1) .

B. HRT increases risk of brest cancer (1) , which has been shown in large trials (for example, relative risk of breast cancer in WHI strial was 1.24 (1) ). Risk of breast cancer is increased with prolonged use of HRT (more than 5 years). Breast cancer was diagnosed at a more advanced stage, and had larger size in HRT users in comparion to non-users. Such findings can be related to mammogramic changes due to HRT, and , therefore, difficulties in mammogram interpretations in such women. HRT use was studied in women with postmenopausal symptoms and previous breast study in HABITS trial. This study (as well as several other sudies in this area) was stopped early due to findings of significant number (24 in HRT users vs 7 in non-users per approximately 200 women in each group) why quote statistics per 200 women?? Usually per 100 or per 1000 of recurrent breast cancer in HRT users (1) . Such effect of HRT on breast cancer is related to hormone oestrogen receptors sensitivity can also be due to progesterone ? some breast cancers have progesterone receptors of breast cancer. Therefore, HRT is contraindicated in women with history of breast cancer (1) .
HRT also associated with increased risk of cardiovascular disease in women with a history of cardiovascular disease (1) . It\'s also associated with increased risk of thromobotic episodes, (pulmonary embolsim, stroke, VTE (1) what is the increase in risk? ) and shoudl not be used for primary or secondary prevention of such conditions. HRT was thought be beneficial for congnitive function, but it does not have any role in women with already altered condition (Alzheimers disease). There is also an association between HRT use and risk of ovarian cancer. Mortality from ovarian cancer is also increased in HRT users (1) . Unopposed oestrogen HRT in women with intact uterus is associated with endometrial cancer risk also increased in women in sequential combined HRT . Most of the information obtained on HRT is from studies of women who did not have menopausal symptoms, were late in menopause (in their sixties and seventies), and had multiple risk factors (obesity, smoking, cardiovascular disease, previous use of HRT), which may differ to women who would contribute from HRT the most in easrly menopause with severe vasomotor symptoms and no contraindication to HRT use and no risk factors. drug side effects, gall bladder disease, abnormal vaginal bleeding requiring investigation, written information

C. Unfortunately alternatives to HRT are not as effective as HRT (50-60% relief of vasomotor symptoms by alternative preparations vs 80-90% by HRT). Life-style changes, e.g. aerobic exersice improve generall well-being and vasomotor symtoms. Avoiding consumption of caffeine and alcohol also improves vasomotos symptoms (1) . Progesterone preparations and phytoestrogens (red clover and soy) have some effecicy in treatment of vasomotor symptoms (1) , but should be avoided in women with oestrogen-progesterone dependant tumours (such as breast cancer) (1) . SNRIs (venlafaxine) and SSRIs (fluoxetine, paroxetine) have been shown to improve vasomotor symptoms (especially venlafaxine) as well as improve mood, sleep, and psychological well-being. Oral clonidine preparations are not effective intreatment of vasomotor symptoms, but dermal preparations are effective (1) . None of the herbal preparations (black cohosh, evening primrose oil, dong uie, St John\'s wort, ginseng) have been shown to effective in treatment of hot flushes, though some of them are useful in treatment of depression (St John\'s wort). Acupuncture has positive effect of treatment of vasomotor symptoms (1) , but it carries the risk of adverse effects (cardiac tamponade, pneumothorax, hepatitis). Reflexology, homeopathy and vitamin supplementation have not been shown to be effective in treatment of menopausal symptoms.

good answer
Posted by Paul T.
Thu Aug 23, 2007 02:48 pm
a) I would obtain a detailed history to assess her sympton\'s and the severity and the effect on her quality of life the question was about what you would tell her. History not necessary . I would inform her menopausal symptons are transient and only short term treatment is required( 1-2yrs).
The short term benefits of HRT includes relief of menopausal sympton\'s of hot flushes,night sweats (1) and vaginal dryness (1) .It also
help mood changes and it is associated with improvement in skin and hair texture. It also prevents peri-odontal disease. Long term use is associated with a reduction in the risk of urogenital atrophy and urinary symptoms. There is also reduction in the risk of colorectal cancer (1) . It prevents or delay the development of Alzheimer\'s disease and prevents hip fractures and osteoporosis requires long-term / life-long use .
b) The risks depends on the type of HRT, the duration of its use and the route of administration. The overall risk of complication from HRT is small.The WHI trial has shown there is an increased risk of VTE in the 1st year of use (1) what is the relative risk?? . There is also an increased risk of breast cancer after 5years of use (1) what is the relative risk? How many extra breast cancers after 5 years? . In patients with previous breast cancer there is the risk of reactivation of dormant tumour cells with the risk of recurrence (1) . There is an increased risk of IHD, angina and stroke this has to be qualified as the increase is mainly in women with a previous event and in older women .
There is also an increased risk of gall bladder disease. The risk of endometrial cancer increases after 5years especially if oestrogen alone preparation is used risk also increased with sequential combined . I would offer her information leaflet (1) and address of support group ? example . If she wishes to use HRT based on her risk benefit ratio, i would seek advice from the gynae oncologist gynae oncologists do not deal with breast cancer or HRT .
c) The alternatives include life style modification of regular exercise, stop smoking and alcohol and dietary modifications may be helpful (1) . Tibolone is effective against menopausal sympton\'s but associated with androgenic side effects of greasy skin, acne and irregular vaginal bleeding. It also increases the risk of breast cancer should be considered as conventional HRT as works through oestrogen receptors and carries similar breast cancer risk . The SERMS(raloxifene) are unsuitable because they do not relief menopausal symptons. Clonidine(alpa 2 agonist) transdermal is moderately effective in relieving menopausal symptons. The SSRI (paroxetine) and the SNRI( fenlafaxine) are effective in relieving hot flushes (1) .Complementary therapy like St. John\'s Wort, phyto-oetrogens and evening primprose oil have doubtful efficacy in the relief of menopausal symptoms phyto-oestrogens have oestrogenic activity and a theoretical breast cancer risk

Please see good answers above
.
Posted by Paul T.
Fri Aug 24, 2007 02:59 pm
a.I will tell her that menopausal symptoms are transient and that HRT can be used for 02 years for their relief. .
The benifits associated with HRT are improvement in menopausal symptoms like hot flushes, night sweats (1) . There is improvement in vaginal dryness (1) . HRT also prevents from hair loss. HRT also prevent from tooth loss .HRT also improves improves the skin of menopausal women. The long term benifits of HRT are prevention of osteoprosis has to be used long-term , Alzheimer\'s disease and maculopapular rash ?? . Writteninformation and hospital contact details are provided.
b. As patient is having had breast cancer so HRT will not be recommended (1) and furthur advice in collaboration with breast surgeon and gynaecologist is needed. I will tell her that there is an increased CVS risk after one year usage particularly in women with a previous event .There is increased risk of stroke when HRT is used for one year. Then I will tell her that there is increased risk of VTE with HRT (1) what does increased risk mean? 2 fold or 100 fold increase??. There is increased risk of endometrial cancer with sequential HRT. She will be told that since she had breast cancer 08 years back HRT is not advised in such individuals. She will be told that in those persons without breast cancer HRT increase risk from 32 per 1000 women to 38 per 1000 and 51 per 1000 women at 5 and 10years respectively (1) . After stoppage of HRT the risk of breast cancer is same as non users ? immediately after stopping?? What about recurrence risk? . She will be told that there is increased risk of gall bladder disease and bleeding per vaginal and hence may require investigations (1) . She will be told that overall risk is lower as compared to improving quality of life this is not true for this woman with a Hx of breast cancer . Written information (1) and hospital contact details are provided.
c. I will tell her that continued HRT is inappropiate . Other alternatives which can improve menopausal symptoms are general health measures, which include improvement of life style measures like stopping smoking and use of alcohol. She is advised for regular exercise and diet manipulation (1) . Complementary measures like reflexology, haemopathy will be advised if you are going to advise her to have these, do you have evidence that they are effective? . Primrose oil , phytoestrogen, black cohosh has not found poor English to be effective. SSRI such as paroxetene are found to be effective. Progestogen such as norethisterone or megesterol are effective some breast cancers have progesterone receptors therefore theoretical breast cancer risk . Tibolone can be used NO ? associated with increased risk of breast cancer .Raloxifene(SERMs)are unsuitable as they donot improve menopausal symptoms like hot flushes. Use of lubricant/topical treatment for vaginal symptoms is advised. Written information will be provided (1) .
Posted by Paul T.
Fri Aug 24, 2007 02:59 pm
a) HRT is beneficial in the symptomatic relief of menopausal symptoms that are affecting a woman\'s quality of life. The benefits of HRT can be divided into short term and long term. The short term benefits include the relief of hot flushes and night sweats (1) and mood swings. The long term benefits include a reduction in the risk of osteoporotic fractures but this benefit declines when the HRt is stopped. Benefits are also in the reduction in urogenital atrophy and vaginal dryness (1) is this long-term? ; reduced loss of tone in the pelvic floor muscles ? evidence?? and reduced incidence of colorectal cancer (1) .

b) There is a small but significant increase in the risk of breast cancer and should not be used in women with previous breast cancer (1) what is a small increase?? . Combined estrogen and progestogen preparations are associated with a greater risk then the estrogen only preparations. The increased risk of breast cancer is assocated with duration of use and not the dose of the HRT. Regular mammograms would need to be done. When the HRT is stopped the risk of breast cancer returns to that of women not taking HRT ? immediately?? .

The risks associated with HRT include a small increased risk of venous thromboembolism (1) what is small increase???. If she has had an episode of thromboembolism in the past she should avoid using HRt since there is a chance of recurrence of embolism. If she also has a thrombophilia, it is not recommended because of a significant risk of recurrence of thromboembolism. Deep Vein Thrombosis can present with leg or calf pain, swelling and redness. Pulmonary embolism may present with chest pain and shortness of breath. If she develops any of these she should go immediately to the hospital to be assessed.
There is an increased risk of coronary heart disease which was shown by the Women\'s health initiative study this is particularly in women with a previous event and more recent studies in younger healthy women have called this into question

Risk of ovarian / endometrial cancer, gall bladder disease, abnormal vaginal bleeding, drug side-effects
.

c) Alternatives to conventional HRT have been of interest to women who don\'t want to use HRT or have contraindications to HRT. They are not as effective as HRT and in some cases have side effects.

The alternatives include life style measures such as a reduction in the intake of alcohol and caffeine. Regular aerobic exercise such as swimming has also been shown to reduce the incidence of hot flushes and night sweats (1) .
Pharmacological alternatives include selective serotonin reuptake inhibitors such as fluoxetine and venflaxine. These have been shown to reduce hot flushes and night sweats; but have been limited in their use by the side effect of nausea. They may be a good alternative for her since they are not contraindicated in previous breast cancer. Clonidine, an alpha 2 agonist has not been effective trans-dermal clonidine is effective .
Vitamin C and E have been used in the past but studies have shown no effect on menopausal symptoms.
Complementary therapies include phytoestrogens such as soy and red clover. Studies have shown inconsistent findings on their efficacy oestrogenic activity poses theoretical breast cancer risk . Soy has also been associate dwith endometrial hyperplasia. Herbs such as black cohosh and evening primerose oil have also been used to treat menopausal symptoms. More studies need to be done to confirm efficacy of Black cohosh. Evening primerose oil has been shown to be ineffective in treating hot flushes. Complementary interventions such as acupuncture and reflexology (1) have been shown to be effective but not as effective as combined HRT.
Posted by Paul T.
Fri Aug 24, 2007 03:00 pm
ESSAY
A
I would tell her that HRT can treat vasomotor symptoms like hot flushes and night sweats (1) . It reduces urogenital atrophy and reduces vaginal dryness (1) . It causes improved sleep and improved mood which may be due to the improved sleep and reduced vasomotor symptoms. It maintains bone and reduces the risk of osteoporosis and fractures including hip fractures (30-40% reduction) needs to be taken long-term / life-long .
It reduces the risk of colorectal cancer and of Alzheimers. It reduces weight gain and fat accumulation ?? evidence ? potentially misleading to many women .

B
HRT is associated with an increased risk of breast cancer so if her disease was estrogen or progesterone receptor positive it may stimulate or activate her disease (1) . Combined estrogen and progesterone therapy (EPT) has a higher risk of causing breast cancer than (estrogen) E alone according to the Womens? Health Initiative WHI trial. WHI showed a 25% (1) increased risk while the Million Women Study MWS showed a doubled risk.
HRT causes an increased risk of endometrial cancer. If a uterus is present E alone as well as sequential or cyclic EPT is associated with an increased risk (6 times for estrogen and 3 times for cyclical EPT) (1) . Continuous combined is not associated with an increased risk and may even cause a decreased risk.
There is an increased risk of ovarian cancer (1) . Estrogen therapy causes this more than EPT and the risk is related to the length of use where the longer use causes greater increased risk.
Venousthromboembolism VTE and pulmonary embolism PE are increased. EPT (double risk WHI trail) (1) associated with a higher risk than E alone.
Stroke is also increased and these are mostly ischaemic strokes. Cardiovascular disease has also been shown to increased. This increased is higher with EPT than with E alone. The longer after the menopause the HRT is started the higher this increased risk and the longer it is used the higher the risk the risk is particularly high in the first year of use after which it declines . There is an increased risk in gallbladder disease abnormal vaginal bleeding, drug side-effects; written information .

C
For vasomotor symptoms progestogens cause a significant improvement (almost 90% reduction) in vasomotor symptoms some breast cancers are progesterone receptor positive therefore theoretical breast cancer risk . Other therapies include phytoestrogens like isoflavine and in soy products and black cohosh phyto-oestrogens have oestrogenic activity with potential breast cancer risk . These have been shown to reduce vasomotor symptoms. Ginko baloba has been shown to improve memory.
Venlafaxine and SSRIs like Paroxitine have been shown to produce around a 40% reduction in vasomotor symptoms. Transdermal clonidine has been found to be effective though not oral preparations (1) . Gabapentin has some reduction in vasomotor symptoms.
Alternatives for bone protection are Raloxitine and bisphosphonates.
Posted by Paul T.
Fri Aug 24, 2007 03:01 pm
a) HRT is an effective treatment ofmenopausal vasomotor symptoms.. It significantly improves night sweats, Mood swings, hot flushes (1) within 4 ? 6 weeks of use. Short term i e 1 year ( at the most 18 months ) of HRT is required for the treatment of such symptoms. HRT also helps in preventing bone loss, osteoporosis, tooth loss, macular degeneration. But to achieve such benefits, life long HRT is required (1) . HRT (long term) also prevents the onset of Alzheimer?s disease. Skin quality also improves with HRT use. Vaginal dryness (1) can be treated with estrogen component of HRT. Colorectal cancer risk is reduced with HRT (1) .
b) Since she has a previous history of breast cancer HRT is associated with an increased risk of recurrence of breast cancer (1) . The estrogen receptor status of her previous breast cancer should be known. Her breast cancer surgeon should be contacted & regular mammograms will be required. The interpretation of mammogram will be difficult due to increased breast tissue density with HRT. There is a risk that breast cancer if it recurs will be detected at an advanced stage. The risk is further increased in case she is a carrier of a genetic syndrome (BRCA- 1 or BRCA 2). Her cardiovascular risk will be increased; especially in the first year of use (MI, coronary artery desease) (1) . I will also inform her about the increased risk of stroke (CVA).
HRT, increases the risk of VTE,Pul.embolism three times (1) . In case she has
a personal or family of VTE , HRT is contraindicated, so also, in case she is affected with a major thrombophilia e.g antithrombin 111 deficiency.
The associated obesity & decreased mobility of post menopausal age,
increase these risks many fold.
Progestogen replacement results in side effects like bloating, breast tenderness, decreased libido. The estrogenic side effects are headache, nausea, vomiting, leg cramps (1) .
She may have to undergo investigations for intermittent PV bleeding, while on HRT, as there is an increased risk of endometrial cancer on sequential HRT due to the estrogenic component (1) . Her risk of Ca ovary is also increased (1) . GB disease risk is also increased with HRT. I will give her written information (1) to back up the discussion & enable her to make an informed choice.
c) Since she is a high-risk candidate for HRT (due to her previous history of breast cancer) alternatives to conventional HRT, should be offered to her. Life style modifications e.g cutting down on alcohol, coffee intake, regular sustained exercise e.g aerobics, or weight bearing exercise like walking are helpful (1) . Tibolone helps in preventing bone loss bone loss is not an issue. Tibolone associated with increased risk of breast cancer . SSRI (e.g fluoxetine, paroxitine) and SNRI (venlafaxine) are helpful in the relief of menopausal vasomotor symptoms (1) .
Vaginal gels (bioadhesive gels) or KY jelly may be helpful in vaginal dryness.
Since she has a history of breast cancer, progestogens are contraindicated. Phyto estrogens are also contra indicated for the same reason (1) what is the reason?? .
Acupuncture (1) could help, but is associated with the risk of pneumothorax, cardiactamponade & transmission of hepatitis.Blackcohosh may relieve vasomotor symptoms but hepatotoxicity is a risk.St Johns wort may help in mild depression .To enable her to make an informed choice written information (1) is also provided.

GOOD answer
Posted by Paul T.
Fri Aug 24, 2007 03:02 pm
Hot flushes and night sweats (1) usually improve within 4 weeks of starting HRT. Many women report an improvement of psychological symptoms like sleep disturbance, loss of sexual interest, irritability ,mood swings. Vaginal dryness (1) and urinary symptoms may take as long as a year to respond to oestrogen therapy. The long term oestrogen therapy significantly reduced osteoporotic fracture risk.The bone protection lasts as long as the regimen is taken and stops on cessation of treatment (1) . Several epidemiological studies have suggested that oestrogen use may delay or prevent the onset of Alzheimer?s diseases.It may protect against colon cancer, periodontal disease and cataracts (1) .

Most RCTs and observational studies have indicated that HRT increases the risk of breast cancer (1) ? by how much? . The increased risk appears to be directly related to the duration of therapy. The evidence suggests that combined preparations increase the risk more than oestrogen alone. There is a theoretical risk of reactivation of dormant tumour (1) cells(especially oestrogen receptor positive cell).Observational studies suggest that recurrence is no greater than expected if HRT given. Patient given a risk benefit analysis and consultation with her breast cancer specialist they will make the decision depending on ?quality of life?.
Women Health Initiative study showed early increase in clinical events of Coronary Heart Disease followed by a subsequent decline subsequent studies have questioned this in younger healthy women . It increase risk of stroke .HRT provokes increased risk of venous thromboembolism and pulmonary embolism (1) ? by how much???. HRT should be avoided in women with multiple pre-existing risk factors for VTE. Long term use may increased risk of endometrial cancer ? may?? The evidence is that it does (sequential HRT) .
Risk of ovarian cancer, gall bladder disease, drug side-effects, vaginal bleeding; written info

Healthy life style habits such as sustained ,regular exercise, avoidance of smoking, reduction of intake of alcohol can reduce the severity and frequency of vasomotor symptoms (1) . Progestogen should be may be avoided as it increased risk of breast cancer (1) . .Transdermal Clonidine may reduce hot flush . Phytooestrogens (soy isofavin) and red clover may have benefits on symptom relief oestrogenic activity therefore potential breast cancer risk . Selective serotonin and noradrenalin reuptake inhibitor?s (fluoxetine, Paroxetin) may significantly effective for treatment of vasomotor symptoms (1) . Other complementary therapies (acupressure, acupuncture (1) ) and vitamin E therapy on hot flushes need .further research.
Posted by Paul T.
Fri Aug 24, 2007 03:05 pm
A)i will tell her that HRT help in reducing menopausal symptoms,those are hot flush night sweat (1) ,and depression depression is not a menopausal symptom or disease .this lead to psychological improvement.it also relieves vaginal dryness and urinary incontinence there is no evidence that HRT is effective in treating stress or urge incontinence .By improving tissue quality it improve skin texture and hair.
HRT by its long term use prevent osteoporosis and fracture of hip bone .
Its beneficial effect seen in preventing Alzaheimer disease.It prevents tooth decay,cataract formation and macular degeneration .Also reduce incidence of colorectal cancer (1) .
b)I will tell her that recent trial reveal risks associate with HRT use.There is increase risk of ischemic heart disease(myocardial infarction)in first year of use (1) this is particularly the case in women with a previous event .there is also increase incidence of stroke.there is no difference in estrogen being used alone or in combination with progesterone.
Breast cancer is common cancer ,incidence is 45/1000 among women more then 50year.
When HRT being used the cumulative excess (1) rate of breast cancer are 2 extra cases/1000 in 5 year,then 6/1000 in 10year,12/1000 after 15 year of use (1) .after discontinuation of HRT excess risk fell back to nonuser in 5 year (1) what about risk of recurrence? .
Risk of venousthromboembolism increase at age of 50 and menopause,but with use of HRT the risk of venous thromboembolism increase by 2-3 fold (1) ,which is highest in first year of use ,VTE can be avoided by use of transdermal rout.
Endometrial cancar risk is also increase but more so with sequential use then continuous continuous combined use of HRT.Gall bladder disease is also incease.
Fibroid may increase in size,endometriosis reactivated.
Risk of overian cancer is also increase in user as compare to non user (1) .
Other risk might bother a women are fluid retention ,mood swing,leg cramps,and breast tenderness (1) ? written information .
c)Alternative to conventional HRT depend on her symptom profile you have been given this ? severe hot flushes ,so that targeted approach can be offer.First of all I will motivate her to change her life style by quiting smoking, stopping alcohol, or enter in to a excersice programme,and try to reduce weight by appropriate dietery advice (1) .
As she has history of breast cancer and hot flush bothering her , I will enquire about any history of thromboembolism,and make notice of her wishes and expectations,therefore I will inform her that menopausal symptoms are self limiting in 1-2 year. Use of conventional HRT for short period of time can relief her symptom without increasing risk of recurrence breast cancer what is the evidence for this statement? (-1) .
She can use progesterone some breast cancers have progesterone receptors and therefore there is a potential breast cancer risk for short period of time it effectively reduce hot flush and night sweat Norethisterone 5mg,or medroxyprogestrone 5 mg are the dose.
Tibolone has no risk of breast cancer this is incorrect (-1) and VTE ,it is effective in eliminating hot flush and sweat,and prevent osteoporosis.
Fluxitene(SSRI) have shown efficacy for hot flush.
Transdermal conidine can effectively reduce vasomotor symptoms (1) .
SERM although good in reducing osteoporosis and breast protective but it does not help her to reduce hot flush.
Phytoestrogen contain estrogen are not suitable in recaptor positive breast cancer (1) ,there role not fully understood.
St john wood ?? ,and black kohosh can relief depression and hot flush but concern about safety.
Acupuncture is effective in reducing hot flush ,haemopathy also claim to be usefull (1)
Verbal information supported by information leaflet (1) given with follow up visit.

Posted by Paul T.
Sun Aug 26, 2007 01:36 pm
A good candidate should

(a)

? Explain that the main benefit would be relief of hot flushes. Explain other menopausal symptoms that are improved including night sweats, vaginal dryness (2) .

? Explain potential additional benefits ? prevention of osteoporosis, colo-rectal carcinoma, possibly Alzheimer?s disease, macular degeneration, tooth loss. Stress that these may only be achieved with long term use and would not apply with short-term use to control menopausal symptoms (2)

(b)
? Explain the risk of breast cancer (4) :

? associated with long-term use of HRT (>5 years).

? In a 50 year old woman, (back ground risk 32 per 1000 over 15 years), oestrogen + progestogen HRT for 5 and 10 years increases risk to 38 and 51 per 1000 respectively.

? The risk of breast cancer in women who have discontinued HRT for 5 years is similar to that in never users.

? Risk of recurrence of breast cancer likely to be increased with long term use

? The effect of short-term HRT use on risk of breast cancer recurrence uncertain but HRT best avoided

? Discuss risk of thrombo-embolic disease ? risk is particularly increased in the first year of use (1)

? Explain increased risk of endometrial cancer (1)

? Explain increased risk of ovarian cancer (1)

? Explain risk of coronary artery disease and stroke especially in the first year of use in women with a previous event (1)

? Explain increased risk of gall bladder disease, abnormal vaginal bleeding requiring investigation and drug side-effects (1)

? Provide written information (1)

(c )

? Explain the value of life-style changes (1)

? Explain the value of alpha agonists like clonidine and SSRIs (1)

? Explain the value of complementary therapies like acupuncture, reflexology (1)

? Explain the value of phyto-oestrogens. These products have oestrogenic activity and the potential implications for breast cancer risk have not been investigated (1)

? Explain the value of progestogens. Some breast cancers have progesterone receptors and therefore potential breast cancer risk (1)

? Provide written information (1)