Controversies in Primary Care Pros and Cons of HRT on patients with CHD Claire Bellone MSc Clinical Nurse Specialist Menopause Nottingham
Declaration Honorariums & Sponsorship from Bayer, Novonortis, Wyeth
Women s Perceptions of Their Greatest Health Problems Cardiovascular Disease Don t Know/ No Answer 16% 7% 34% Breast Cancer Other Problems 16% 27% Cancer Adapted from Mosca L, et al. Arch Fam Med. 2000;9:506-15.
Cardiovascular Disease ~ 46% of all female deaths - the biggest killer in UK and most Western Countries* Chronic Lower Respiratory Disease Other Cancers Breast Cancer 15% 4% 34% Diabetes 3% 6% Heart Disease Other 28% 10% Cerebrovascular Disease * Percentage of total deaths in 1999 among women aged 65 years and older. Anderson RN. Natl Vital Stat Rep. 2001;49:1-13.
CV Risk Factors: 90% of cardiovascular disease is Preventable Non-Modifiable Gender Age Family history Ethnicity Modifiable Hypertension Diabetes Mellitus Cigarette smoking Abnormal lipid profile Menopause Sedentary lifestyle Obesity
Controversies x 4 A B C HRT should be stopped after 5 years use? VTE/CHD is a contraindication for HRT? All HRT increases VTE risk? F HRT can not be initiated after the age of 60? 1=YES 2=NO
Case Study 86 Post menopausal Symptomatic Intact uterus x4 MI in 2 years Controlled hypertensive Continuous combined HRT Under shared care with the Royal Brompton Hospital
HRT and Regulatory guidance MHRA, BMS (NICE - 2015) No age limit, No time limit Licensed for symptomatic menopausal women & osteoporosis prophylaxis INDIVIDUALISE LOWEST EFFECTIVE DOSE RISKS Versus BENEFITS
WHI discredited by the authors themselves Years after the menopause increases population risk of CHD WHI study average age 63.5 and unhealthy American population Probable class effect of E+P VTE risk +3/1000 in 5 years (Population risk 6) WINDOW OF OPPORTUNITY Titrate dose with transdermal patch or gel
HRT: CHD and VTE HRT is cardio-protective: but not a licenced indication Oral estrogen Pro-thrombotic: first pass effect on liver Increases triglycerides Increases BP +/- Transdermal estrogen No effect on clotting Preferred option in high risk patients
Percent of population Prevalence of hypertension in UK 2002 90 80 Women Men 70 60 >30-50 % Hypertensive 50 40 30 20 10 0 16-24 25-34 35-44 45-54 55-64 65-74 >75 Age British Heart Foundation Statistics database www.heartstats.org 2004 Page 157 Data derived from: Health survey for England 2002Department of Health, UK Systolic BP>140; Diastolic BP>90mmHg
5 Year Risk (%) Association of hypertension with absolute and relative risk of stroke and MI 20 Normotensives Hypertensives 15 10 Stroke Myocardial Infarction 5 0 0 20 40 60 80 100 120 140 160 180 200 220 240 260 280 300 Systolic Blood Pressure (mmhg) Brown, M.J. Lancet 2000; 355: 653-654
Diastolic BP 5-6 mmhg Systolic BP 9-10 mmhg Stroke 40% CAD 25% Collins R. Lancet 1990; 335:827
HRT: Bioidentical v Synthetic All HRT Estradiol is BIOIDENTCAL Plant based Exception Equine Estrogens (WHI study) Class effect exists with Progestogens MPA (WHI study): increased breast cancer NET: androgenic side effects Dydrogesterone: none significant breast cancer risk BIOIDENTICAL progesterone: no significant VTE or breast cancer risk
Stroke Effects of Combined HRT (50-59 yrs) Additional 1 incidence In a group of 1,000 women aged 50-59 years who have never taken HRT, 3 women would be at risk of stroke. If all were using combined HRT for 5 years, then 1 more woman would be at risk. Adapted from: CSM Vol 30 October 2004
Recommended prescriptions 1 st choice: Transdermal bioidentical Estradiol Evorel 50mcg BiWkly Sandrena Gel 1mg OD Oestrogel 2-4/day Progesterone Utrogestan 100mg nocte CCHRT Utrogestan 2x100mg nocte SCHRT 2 nd Choice Femoston combined oral pill (Estradiol + Dydrogesterone) Femoston Conti PO Femoston Conti 0.5/2.5mg PO Femoston 1/10 or 2/10 PO Evorel combined patch (Estradiol + Norethisterone) Evorel Conti BiWkly Evorel Sequi BiWkly
Relative Risk Coronary Heart Disease Effect of Body Mass Index BMI RR relates to risk of nonfatal myocardial infarction and fatal CHD combined, (adjusted for age and smoking). HRT RR relates to risk of CHD. 3.5 3.3 3 2.5 2 Ideal BMI 18.5-25 1.8 1.5 1 1 1.3 1.23 0.5 0 BMI <21 1 BMI 21<25 1 BMI 25<29 1 BMI >29 1 HRT User 2 Risk Factor Taken from: 1. Manson JE. NEJM. 1990;322:882-889. 2. Rossouw et al.jama. 2007;297:1465-1477
Controversies Q x 4 A B C HRT should be stopped after 5 years use? VTE/CHD is a contraindication for HRT? All HRT increases VTE risk? F HRT can not be initiated after the age of 60? 1=YES 2=NO
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