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Table 1 Comparing contraindications of CHC and HRT4,5


Contraindications Ovarian or uterine cancer Undiagnosed vaginal bleeding Breast cancer Severe liver disease Myocardial infarction or stroke


CHC No No Yes Yes Yes


HRT Yes Yes Yes Yes


Only if active or recent, otherwise use transdermal route (TD)


Smoker >35 years BMI >35 Hypertension Complicated diabetes Migraine with aura Venous thromboembolism


Yes Yes Yes Yes Yes Yes


Table 2 Comparing benefits of CHC and HRT2,3


Benefits Control of perimenopausal symptoms Protection from osteoporosis Reduced risk of bowel cancer Contraception Control over timing of bleeds Lighter, less painful bleeds Improved PMS Improved acne


Reduced risk of fibroids, ovarian cysts and benign breast lumps


Reduced risk of ovarian and endometrial cancer Free when prescribed for contraception


cases of suspicious vaginal bleeding awaiting investigation, or gynaecological cancers. CHC has been shown to have a powerful protective effect against ovarian and uterine cancers, which continues for at least 15 years after the method is stopped.3


Prescribing CHC as an alternative to


HRT for healthy, non-smoking women under the age of 50 has been shown to provide a safe, effective management option and offers many additional benefits, including excellent control over bleeding that may decrease the unnecessary investigation rate. The many benefits of prescribing CHC rather than HRT are summarised in table 2 (right); not least of which is the fact that there is no prescription charge for contraception products when prescribed for contraception.


Q


Given the reassurance over HRT, will it find a use again in the


treatment of osteoporosis? Are there any trials comparing the benefits of intensive exercise against HRT in osteoporosis prevention?


1.5 CPD A


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The NICE guideline development group (GDG) concluded that there is robust evidence showing a lower risk of fracture associated with current HRT use, which may persist after HRT is stopped. The GDG advises, however, that HRT is not licensed in the UK for the treatment of osteoporosis.1 Osteoporosis treatment can be


targeted at the primary prevention of fractures in women who have not previously sustained a fragility fracture, or secondary fracture prevention in cases of fragility fracture, particularly for postmenopausal women. A number of therapies are licensed for the treatment of postmenopausal osteoporosis, including bisphosphonates, strontium ranelate, raloxifene, denosumab, teriparatide and calcium with vitamin D.6 With regards to recommending


intensive exercise instead of HRT for osteoporosis prevention: • The evidence is not available. • HRT has many other benefits in addition to osteoporosis prevention. • Persuading women to maintain the level of intensive weight-bearing exercise


CHC Yes Yes Yes Yes Yes Yes Yes Yes Yes


Yes Yes


HRT Yes Yes Yes No ? ? ? ?


No No No


required would possibly be even more difficult than convincing them to maintain an optimum weight. Any decision about prescribing HRT for the prevention or treatment of osteoporosis is outside of the latest NICE menopause guideline1, so will involve individual assessment, clinical judgment and negotiation with local expert colleagues. It is recommended that all women are given lifestyle advice about weight-bearing exercise and calcium intake as an integral part of the menopause consultation. Risk assessment can be undertaken to aid decision-making regarding initiating treatment as per the NICE guideline on osteoporosis.6


Q


Should I be cautious of using HRT if a woman has a family history of


breast cancer? What risk can I reliably quote, and does this increased risk potentially start straight away or only after five years of use?


Women with a family history of breast cancer are a heterogeneous group ranging from those with near


A ► Pulse February 2016 59


No Use TD route Use TD route Use TD route Use TD route Use TD route


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