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“I want to start HRT please”

“I want to start HRT please”. Samadhi Reid NPT VTS. History taking. Age (52 year old) Why does she think she wants HRT? What are her expectation? Symptoms; Hysterectomy or not? Menstrual hx; check for IMB, PCB and Smear hx Flushing or sweating Urinary symptoms and loss of libido

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“I want to start HRT please”

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  1. “I want to start HRT please” Samadhi Reid NPT VTS

  2. History taking Age (52 year old) • Why does she think she wants HRT? • What are her expectation? Symptoms; • Hysterectomy or not? • Menstrual hx; check for IMB, PCB and Smear hx • Flushing or sweating • Urinary symptoms and loss of libido • (Tiredness, anxiety, irritability, poor sleep etc.)

  3. History taking cont….. • PMH Breast Ca (do you examine your breasts?) DVT risk factors for CVD (inc smoking) • FH of above • DH Previous experience of HRT Anti epileptics If on thyroxine, check TFT as dose may need to be  Contraception

  4. Management • Check BP, Weight/ BMI • Explain what menopause/ peri-menopausal period is • Reassurance; short lived symptoms • Complementary medicines - ? Red clover ? Soy • Clonidine - placebo • Simple measures - cotton wear, fans, avoiding triggers, exercise, relaxation techniques

  5. HRT Contraindications • Ca breast/ endometrial • Thromboembolic disease (inc AF) • Liver disease (raised LFT) Indications • Early menopause - cont until 50 yrs • Hysterectomy - 1:4 have early menopause • Relief of symptoms of oestrogen deficiency

  6. Choice of HRT • Tablets, patches, implants, vaginal pessary/ gels/ creams/ rings Topical preparations • For vaginal dryness and atrophic vaginitis • No progesterone is needed, but limit use to 3-6/12 if intact uterus • HRT + Androgen implants for loss of libido

  7. No uterus Oestrogen only Add progesterone, if there is a hx of endometriosis Intact uterus Peri menopausal or first 12/12 since last period • Withdrawal bleed essential • Progesterone for the last 2/52 • Check FSH/LH if on cyclical HRT (start of pack)/ pill (end of pill free week) or • Stop HRT for 6/52 and check levels

  8. After the first 12/12 of menopause • Can have a continuous combined preparation or Tibolone (Livial) Side Effects • Oestrogen HRT - fluid retention, breast symptoms, nausea, headaches • Progesterone HRT - headache, bloating, weight gain, depression

  9. Follow up • Review in 3/12 • Review SE, Check BP and weight • Increase dose if still symptomatic • Erratic bleeding common in the first 3/12 • CC preparations - spotting for 12/12 common, Ix if > 12/12 • Review 6 - 12 monthly after

  10. Stopping HRT • Ideally < 5yrs • Warn re withdrawal flushes • Stop in cold weather, halve the dose for 1/12 • Need to discuss pros and cons of HRT

  11. Risk and Benefits of HRTOxford General Practice Library; Women’s health; Oxford Press

  12. Thank you!

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