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Tailoring HRT to the patient Dr Bruce Davies www.bradfordvts.co.uk Confusion! • There are loads of preparations • There are lots of forms • There are lots of brands Aims To bring order to the chaos To develop personal prescribing guidelines To enable rational selection To enable rational changes in treatment Forms of HRT – Implants – Tablets – Patches – Creams – Local effect Short term effects of the menopause physical – Hot flushes – Night sweats – Headaches – Feeling dizzy – Feeling tired – Urinary symptoms – Crawling sensation under the skin – Palpitations Short term effects of the menopause - Mental – Irritability – Mood swings – Anxiety – Insomnia – Loss of concentration – Lack of confidence – Memory disturbance – Loss of libido – Panic attacks Medium term effects of menopause – Vaginal dryness – Dyspareunia – Urinary problems – Bladder and vaginal infections – Thinning hair – Aches and pains – Skin thinning Long term effects of the menopause – Osteoporosis – Increased CHD Which effects ? –Choice of initial preparation depends on effects that: 1Concerns patient 2 Concerns doctor Patient Concerns – Breast cancer – Weight Gain – “Artificiality” – Periods – Duration Types • Oestrogen only • Topical oestrogen for local effects • Partial agonists • Opposed oestrogen – Sequential, Monthly or quarterly bleed – Continuous combined Oestrogen only • Implants • Skin Creams • Patches • Tablets 17 beta oestradiol, oestrone, conjugated equine, oestriol, Dienoestrol Topical oestrogen for local effects • • • • Oestriol pessaries Oestradiol vaginal tablets Dienoestrol vaginal cream Oestradiol vaginal ring Partial agonists • Tibolone • ? Raloxifene Opposed oestrogen • Sequential, Monthly or quarterly bleed • Continuous combined • Tablets • Patches • Tablets and patches • Creams and tablets Side effects or why change Rx • ? Route related • ? Avoidance of first pass metabolism • ? Oestrogen effect - so change oestrogen or dose or route • ? Progestogen effect - so change progestogen or dose or route Quackery? • ”Natural” progestogen cream • Foods rich in phytooestrogens • Mineral and vitamin supplements Benefits Viz Risks • Not as clear as some would make out • Undoubtedly help short term symptoms • Benefits clearer for unapposed oestrogens • Breast cancer risks? • CHD prevention?
