This page contains a Flash digital edition of a book.
FEATURE


HRT RISK Risk


Age range (years)


Background incidence per 1000 women


Breast cancer Endometrial Cancer Ovarian Cancer


50-59 60-69


50-59 60-69


50-59 60-69


Over 5 yrs Over 10 yrs 10


15 2


3 2


3


20 30


4 6


4 6


Additional cases per in Europe not using HRT only HRT (estimated)


For 5 yrs For 10 yrs 2


3 4


6


<1 <1


6 9


32 48


1 2


Additional cases per 1000 women using oestrogen 1000 women using combined


(oestrogen and progestogen) HRT (estimated)


For 5 yrs For 10 yrs 6


9


24 36


Not Significant Not Significant


<1 <1


Venous thromboembolism 50-59 52 7 60-69 82 10


Stroke Coronary Heart Disease


50-59 41 1 60-69 93 3


70-79 29-44 Table 2: The risks associated with HRT as per MHRA7


> It is recommended that patients are reviewed often, with regular attempts at discontinuing therapy.


The minimum effective dose of HRT should be used for the shortest duration possible. Table 2 details the risks associated with HRT.


A number of factors increase the risk of breast cancer development, including early menarche and/or late menopause, postmenopausal obesity, lack of exercise, high alcohol intake, shift work with increased exposure to light at night and positive family history.


Tibolone is licensed for both the treatment of menopausal symptoms and also as second line therapy for the prevention of osteoporosis in postmenopausal women at risk of fracture.


The benefits and risks of tibolone were re-assessed following a LIFT (Long- term intervention on fractures with tibolone) randomised placebo controlled trial.


The result was that the increased risk of stroke associated with tibolone administration outweighed the benefit in women over the age of sixty years.


Additionally, the Million Women Study found an increased risk of breast cancer rate with tibolone administration in comparison to non-users.


LIBERATE (Livial® Intervention following Breast cancer, Efficacy, Recurrence And Tolerability Endpoints) began a study on the efficacy of tibolone in breast cancer patients, however the study was stopped prior to completion of the study due to an increase in the recurrence of breast cancer rates in patients taking tibolone.


Despite the risk of breast cancer not being as high with tibolone as for other forms of HRT, current advice is that tibolone should not be used in


42 pharmacyinfocus.co.uk


patients with diagnosed or suspected breast cancer, nor those with a history of breast cancer.


Alternative treatments and other management strategies Lifestyle alterations can help to reduce menopausal symptoms. There is some evidence supporting aerobic exercise as a means of reducing symptoms.


The evidence indicates that exercise improves quality of life and psychological help. Losing weight (if appropriate) can also decrease the frequency and intensity of vasomotor symptoms9


.


Advising patients to wear light clothing, sleep in a cool room, avoid trigger factors (such as caffeine and spicy foods) and reduce stress can help to alleviate symptoms.


The alpha-2 agonist clonidine, although now considered as a medicine less suitable for prescribing, has been licensed for quite some time for the treatment of vasomotor symptoms.


Evidence supporting its efficacy is conflicting, but many women benefit from its use.


One theory behind the existence of vasomotor effects is an overloading of serotonin sites in the hypothalamus; hence antidepressants such as SSRIs and SNRIs are thought to help reduce such symptoms.


Some evidence supports the use of citalopram, venlafaxine, fluoxetine and paroxetine although they are unlicensed for this indication. They may be of benefit to women who do not want to take HRT.


Gabapentin is another medicine used off-license for the treatment of vasomotor effects. Its use is currently limited to specialist menopause clinics.


One study found that doses of 900mg per day are associated with reduced vasomotor symptoms by up to 45%


and a 54% reduction in symptom severity10


.


Phytoestrogens are naturally occurring plant chemicals which bind to oestrogen receptor sites, mimicking their action.


Of the various types, isoflavones have been the most studied. Isoflavones are found in soy beans, chickpeas and red clover, and are also possibly found in other legumes.


Phytoestrogens have stimulated interest since populations such as the Japanese, who tend to have a diet rich in isoflavones, seem to have lower incidences of menopause vasomotor effects, osteoporosis, cardiovascular disease as well as breast, colon, endometrial and ovarian cancers10


.


The effectiveness of black cohosh is inconclusive and long term safety has yet to be studied. Despite this, it may show anti-inflammatory, serotenergic or oestrogenic effects.


Liver toxicity has been reported and so caution is required if used alongside medicines such as isoniazid, carbamazepine, amiodarone and methotrexate.


Limited data supports the use of Agnus Castus, a herbal product made up of a combination of chaste tree, black cohosh, dong quai, red clover and American ginseng, for menopause.


One randomised controlled trial found that it reduced vasomotor symptoms, but further research is needed in this area.


Vitamin E has limited evidence to support its role in the treatment of menopausal symptoms. One study investigated its use in women with breast cancer.


The conclusion was a statistically significant reduction in hot flush frequency at a dose of 800IU/ day compared with placebo. 


Not significant 15


1 2


“For the majority of women under the age of sixty years, the benefits of short-term HRT outweigh the risks”


References 1. NI Centre for Pharmacy Learning and Development, 2015. Womens Health: Menopause. Available at: http://www.nicpld.org/online/menopause/#m 1-definitions-menopause [Accessed 10/8/15]


2. National Institute for Health and Care Excellence, 2015. Clinical Knowledge Summaries- Menopause. Available at: http://cks.nice.org.uk/menopause#!backgrou ndsub [Accessed 10/8/15]


3. NI Centre for Pharmacy Learning and Development, 2015. Womens Health: Menopause. Available at http://www.nicpld.org/online/menopause/#m 1-symptoms-hot_flushes [Accessed 10/8/15]


4. NI Centre for Pharmacy Learning and Development, 2015. Womens Health: Menopause. Available at http://www.nicpld.org/online/menopause/#m 1-symptoms-urinary_and_vaginal_symptoms [Accessed 10/8/15]


5. National Institute for Health and Care Excellence, 2015. Clinical Knowledge Summaries- Menopause. Available at: http://cks.nice.org.uk/menopause#!diagnosis sub:4 [Accessed 10/8/15]


6. NI Centre for Pharmacy Learning and Development, 2015. Womens Health: Menopause. Available at: http://www.nicpld.org/online/menopause/#m 1-hrt-types-sequential_combined_therapy [Accessed 10/8/15]


7. MHRA/CHM, 2007. Hormone- replacement therapy- updated advice. Drug safety update. Available at: https://www.gov.uk/drug-safety- update/hormone-replacement-therapy-updat ed-advice [Accessed 10/8/15]


8. NI Centre for Pharmacy Learning and Development, 2015. Womens Health: Menopause. Available at: http://www.nicpld.org/online/menopause/#m 1-hrt_breast_cancer_risk [Accessed 10/8/15]


9. National Institute for Health and Care Excellence, 2015. Clinical Knowledge Summaries- Menopause. Available at: http://cks.nice.org.uk/menopause#!scenarior ecommendation:1 [Accessed 10/8/15]


10. Royal College of Obstetricians and Gynaecologists. Scientific Impact Paper No.6.2010. Alternatives to HRT for the management of Symptoms of the Menopause. Available at: https://www.rcog.org.uk/globalassets/docum ents/guidelines/sip_no_6.pdf [Accessed 10/8/15]


Page 1  |  Page 2  |  Page 3  |  Page 4  |  Page 5  |  Page 6  |  Page 7  |  Page 8  |  Page 9  |  Page 10  |  Page 11  |  Page 12  |  Page 13  |  Page 14  |  Page 15  |  Page 16  |  Page 17  |  Page 18  |  Page 19  |  Page 20  |  Page 21  |  Page 22  |  Page 23  |  Page 24  |  Page 25  |  Page 26  |  Page 27  |  Page 28  |  Page 29  |  Page 30  |  Page 31  |  Page 32  |  Page 33  |  Page 34  |  Page 35  |  Page 36  |  Page 37  |  Page 38  |  Page 39  |  Page 40  |  Page 41  |  Page 42  |  Page 43  |  Page 44  |  Page 45  |  Page 46  |  Page 47  |  Page 48