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KEY QUESTIONS CLINICAL


population risk to those with a greater than 8% risk of developing breast cancer between the age of 40 and 50 years; the latter includes those with a BRCA mutation (see table 3 right).5 It is interesting to note that CHC can be prescribed to those with BRCA mutation with expert advice, and any other family history does not restrict use at all.4 HRT is also not contraindicated by any specific defined family history, and although caution is advised no specific proviso is made regarding BRCA genes. The recently published NICE menopause guideline1 summarises the up-to-date evidence we now have regarding any additional risk that HRT may confer (see table 4 right). It concludes that oestrogen-only HRT


is not associated with an increased risk of breast cancer. Combined HRT may be associated with an increased risk of breast cancer, but any increased risk reduces after stopping HRT.1 The 2013 NICE guidance on familial breast cancer recommends that advice on the use of HRT for these women should vary according to the individual clinical circumstances, such as severity of menopausal symptoms or osteoporosis.


It also recommends that HRT should


be restricted to as short a duration and as low a dose as possible; oestrogen-only HRT preferred where possible; and that generally HRT should be confined to women younger than 50 if at moderate or high risk.7 It is important, therefore, to establish her risk category in order to be able to advise her accurately. Local family history clinics or genetics


services may be able to help if she fits the referral criteria. Where appropriate, if she is older or at higher risk, alternatives to HRT may need to be explored for specific management scenarios such as osteoporosis or menopausal symptoms. HRT may also on occasion need to be considered for use in conjunction with risk-reducing gynaecological surgery for women at high risk, and this may be require joint working with the tertiary services and the woman herself.7


Table 3 Breast cancer risk category7


Breast cancer risk


Lifetime risk from age 20 Age 40-50


Near population (%) <17 <3


Table 4 HRT-related breast cancer risk1


HRT


Oestrogen-only HRT RCT estimate* Observational** estimate Combined HRT RCT estimate* Observational** estimate


Additional cases/1,000 women (baseline risk = 22.5/ 1,000/ 7.5 years) Current HRT


<5 years HRT


-4 +6


+5 +17


No data +4


No data +12


5-10 years HRT


No data +5


No data +21


-5 -5


+8 -9


*Data from trials where women were aged 50-59 years on entry to RCT. ** Observational estimates considered imprecise and implausible by NICE guideline.


Q


If a woman has cardiovascular disease I would use a transdermal


preparation, and optimise her risk factors. What should I tell women without risk factors who may still be concerned about the increased risk of stroke with oral HRT?


HRT does not increase cardiovascular risk when started under the age of 60, and does not affect the risk of dying from cardiovascular disease. Even better, we can explain that oestrogen-only HRT actually decreases the risk of coronary heart disease (see table 5 below). When counselling our patients about


A


HRT and stroke risk, although it is true that the transdermal route has shown to be safest, the most important message to emphasise is that the baseline population risk of stroke in women aged under 60 years is extremely low. Combined HRT


Table 5 HRT-related coronary heart disease risk1


HRT


Additional cases/1,000 women (baseline risk = 26/ 1,000/ 7.5 years) Current HRT


<5 years HRT


-6 -6


No data No data


No data No data


5-10 years HRT


No data No data


No data No data


>5 years after HRT


Oestrogen-only HRT RCT estimate* Observational estimate Combined HRT RCT estimate* Observational estimate *Data from trials where women were aged 50-59 years on entry to RCT. ** Data range crosses zero – i.e. includes reduced numbers.


-6 No data


+5** No data


+4** No data


60 February 2016 Pulse


We are now in the position to be able to reassure our patients that


may perhaps increase the risk to 15-17 cases per 1,000 over 7.5 years.


Q A


More questions online Full reference list plus questions on when to investigate irregular bleeding on the urgent pathway and alternatives to HRT pulse-learning. co.uk


Should I start with a lower-dose preparation in perimenopausal


women, and increase the dose gradually every three months to aim for the lowest effective dose?


Recommended best practice would usually be for the initiating dose to


be judged according to severity of symptoms, the age of the patient and the individual circumstances. A young woman who has recently suffered an abrupt surgical menopause at the age of 40, for example, is likely to require a higher initiating dose than a woman presenting with natural menopause in her 50s. Women often present after being distressed and overwrought with sleep deprivation for quite some time, so to prolong this suffering by under dosing may not be the best approach. As HRT has been shown to be safest when started closest to the natural age of menopause, perimenopausal women stand to gain the most with the lowest risk, so the younger they are the less reason there would be to start with a lower-dose preparation. Once her symptoms have been brought under control, and she is feeling able to cope again, there will be scope for discussing a gradual reduction in dose with age. Such decisions will need to be made in partnership with the patient, and may coincide with changing from sequential to continuous combined HRT.1


Dr Jenny Brotherston is a GPSI in sexual health and gynaecology in Hull. Dr Sara Ritchie is a GP in Stoke Newington, north London


>5 years after HRT


Moderate (%) 17-30 3-8


High (inc. BRCA mutations) (%)


≥30 >8


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