Q.7 Hormone Replacement Therapy (HRT): Counseling.
Introduction, then you may begin by saying: “I have heard that you are here to discuss HRT. You know every woman goes through the menopause. This occurs when a woman’s ovaries produce no more the female sex hormones, which are oestrogen and progesterone. Oestrogen has an effect on every cell in the body, whether it is in the skin, bone, blood vessels, womb and vagina. So when the level of oestrogen in the body fall, women get features of hot flushes, night sweats, mood changes, forgetfulness, sleep disturbances, and loss of concentration. In addition, lack of oestrogen causes a type of protein, called collagen, to be gradually lost from the skin, so the skin become thinner, drier, and easily bruised. Also the vagina becomes thinner, less flexible, drier leading to painful sexual intercourse, and less resistant to infections. But the most important effect of oestrogen lack, is on the bones causing what we call osteoporosis, which means that the bones loose mass so they become weak, brittle, and much more likely to break causing number of minor injury such as a fall. Another important effect is on the heart, where before menopause women rarely get heart diseases, while after menopause, the possibility of getting heart attack increases. And within 10 years they catch up with the heart attack incidence in men. Fortunately, there is an effective way of dealing with the problem that is the use of HRT, which consists of these lacking hormones, oestrogen and progesterone.
There are many ways of taking HRT; the first is tablets, which are taken by mouth every day, the second is patches that stick to the skin and should be changed twice weekly. Another way is implants that are inserted under the skin under local anesthesia and their effect lasts for 3-6 months. The fourth way is the gel, which is applied to the skin daily. But you should not bath after application for 1 hour. If vaginal dryness is the main problem, we could give you cream or pessary to place inside the vagina.
With HRT, hot flushes usually disappear within few weeks. It also helps dryness of vagina, improves mood, and sleep disturbances. And the most important effect of HRT is that it can dramatically decrease the risk of osteoporosis, hence fractures. And substantially decreases the risk of heart attacks.
There are very few reasons why a woman cannot take HRT, such as in liver disease, cancer of the womb, or cancer of the breast, and in case of abnormal bleeding from vagina that has no obvious cause. Like any other medication HRT has some side effects, most of them are minor and often disappear if you stop the treatment. Some women feel sick, that is with tablets. Some may put on weight, some may get breast pain and mood changes before periods, which will re-appear with HRT. Some may get skin irritation with the usage of patches. With the use of oestrogen hormone there is a slight increased risk of womb cancer and to decrease that risk we add progesterone, which has protective effect on the womb. Therefore, in women who have had their womb removed this combination of drug is not necessary. The most common reason people are worried about in HRT, is breast cancer, however if you use HRT for five years the risk still minimal. But once you get beyond that e.g. 10-15years then risk tends to increase bit more and we usually teach women how to do self-examination of the breast. Also, we tell them to report, immediately, any vaginal bleeding if happens. One more thing is that HRT is not a contraception method and the woman should continue to use her usual contraception method for one year after the last menstrual period.
Patches, implants, and gel can be taken with liver disease.
The benefits have to be balanced against the risks. You have to decide what is right for you, with advice from your doctor or nurse, depending on your circumstances. As a general rule:
For short-term treatment of menopausal symptoms
If you are troubled with menopausal symptoms, the balance of risks and benefits is probably in favour of taking HRT. You may be happy to accept the small risk of taking HRT for 1-3 years to be free of these symptoms. You should take the lowest dose which keeps symptoms away. Many women find that after 1-3 years the worst of the flushing-type symptoms have gone and they no longer need HRT to prevent them. If the genital symptoms such as vaginal dryness persist after stopping HRT, an option is to use an oestrogen cream or pessary in the vaginal area (see below).
To help prevent osteoporosis
HRT is not considered a 'first line' treatment to prevent osteoporosis. This is because you need to take HRT long-term (at least 5 to 10 years) to help to prevent osteoporosis. Also, there are other medicines and lifestyle measures which can help to prevent osteoporosis. (See separate leaflet called 'Osteoporosis'.) So, the balance of risks and benefits is usually not in favour of taking HRT to prevent osteoporosis. However, HRT may be an option if you are at increased risk of developing osteoporosis and you unable to take other osteoporosis prevention treatments, or if you have tried other treatments and they have not worked.
For healthy women without symptoms and a menopause at around 50 or over
HRT is usually not advised as there is little to be gained, and even the small risks of HRT are then unacceptable.
If you have an early menopause
Long-term HRT may be advised until you are aged 50 to prevent osteoporosis (and ease menopausal symptoms if they occur). You have an increased risk of developing osteoporosis if you have an early menopause. The health risks of taking HRT are not thought to apply, or be very small, until you reach the usual age of menopause (about aged 50).
If you just have genital symptoms such as a dry vagina
An option which may be advised by your doctor is to use a vaginal oestrogen cream or pessary. This gives the benefits of easing the symptoms, but with less risk than using HRT tablets, patches, etc, as less oestrogen gets into the bloodstream.
Some other points about HRT
The menopausal years may be difficult for all sorts of reasons other than hormone changes. HRT is not a 'cure all' for all symptoms and problems.
HRT does not act as a contraceptive. So, if you are still having periods when you start HRT, or have only recently stopped having periods, you should still use contraception. Your doctor will advise when you no longer need to use contraception.
You should not take HRT if you have severe liver disease, or cancer of the uterus or breast.
If you have had a previous blood clot in a vein, or have a family history of a blood clotting problem, you may be advised not to take HRT until certain blood tests are checked.
Other treatments are being studied to counter menopausal symptoms. See separate leaflet called 'Menopause - The Alternatives to HRT'.
Atrophic Vaginitis (Vaginal Dryness)
After the menopause many women develop a dry vagina, and other symptoms around the genital area. The symptoms can usually be eased with treatment. Treatment options include: hormone replacement therapy (HRT), oestrogen cream, and lubricating gels.
What is atrophic vaginitis and what causes it?
The vagina is kept supple and moist by fluids and mucus which are made by glands at the neck of the womb. Oestrogen (the female hormone) affects these glands and the tissues in and around the vagina.
After the menopause (the 'change') the ovaries make less oestrogen. The lack of oestrogen leads to a thinning of the tissues around the vaginal area, and number of the small glands that make mucus reduces. You also lose some fat tissue from around the genital area. This causes the vulva and vagina to look slightly different than before the menopause.
As a result the vagina can become shorter, less elastic, dryer with less lubricating mucus. The genital skin looks paler. These changes usually take months or years to develop, and vary between women. Atrophic vaginitis is the medical term for this condition.
How common is atrophic vaginitis?
After the menopause about 1 in 2 women have some symptoms related to atrophic vaginitis. About 7 in 10 women in their seventies have some symptoms.
What symptoms can occur?
The changes described above may occur, but without causing any symptoms or discomfort. However, some of the following symptoms may develop in some women. All of the following symptoms can be caused by other medical conditions, but atrophic vaginitis is a common (and usually treatable) cause of these symptoms.
Pain when you have sex. This may occur because the vagina is smaller, drier, and less likely to become lubricated during sex than before the menopause. Also, the skin around the vagina is more easily made sore, and this can make the problem worse.
Discomfort. If the vulva or vagina is sore and inflamed you may develop a persistent discomfort.
Infection and discharge. The vagina is less resistant to infection after the menopause and sometimes becomes infected. A smelly, unpleasant vaginal discharge may indicate that you have an infection.
Itch. The skin around the vulva is more sensitive and more likely to itch. This can make you prone to scratch, which then makes the skin more likely to itch. An itch/scratch cycle may develop which can be difficult to break, and can be quite distressing.
Urinary problems. These may be due to thinning and weakening of the tissues around the neck of the bladder, or around the urethra (opening for urine). A prolapse (dropping down) or weakening of part of the vaginal wall may also cause urinary symptoms. The urinary symptoms that may occur include:
Passing water too often (frequency).
Not being able to hold on (urgency).
Pain when passing urine (dysuria).
Leaking urine when you cough (stress incontinence).
Leaking on the way to the toilet (urge incontinence).
What are the treatments for atrophic vaginitis?
Not all women have all of the above symptoms. Treatment may depend on which symptoms are the most troublesome. Because the problem is mainly due to a lack of oestrogen, it can be helped by replacing the oestrogen in the tissues.
Hormone Replacement Therapy (HRT)
This means taking oestrogen in the form of a tablet, gel, implant or patches. This may be the best treatment, but some women don't like the idea of taking HRT. Another leaflet discusses the menopause and HRT in more detail.
Oestrogen creams
Sometimes a cream or pessary containing oestrogen is prescribed. This restores oestrogen to the vagina and surrounding tissues without giving oestrogen to the whole body. Usually the cream or pessary is used every day for 2 weeks, and then twice a week for a further month. This treatment usually works well. The treatment can be repeated if the problem recurs. It is important to follow the instructions about the amount of cream to use. Sometimes, if you use oestrogen cream for long periods, you may also need to take a hormone called progestogen for a few days each month.
Lubricating gels
If vaginal dryness is the only problem, or hormone creams are not recommended because of other medical problems, lubricating gels like KY jelly or Senselle may help. You can buy these from the pharmacy. There are also other gels which are specifically designed to help the problem of vaginal dryness by replacing moisture (for example, Replens).
Many women find freedom from periods and the risk of pregnancy quite liberating and actually enjoy sex more after the menopause. However, some problems may occur around the menopause which may affect your sex life. Often these can be helped, so it is worth discussing any problem with a doctor.
Two common problems are as follows
Discomfort during sex
In the years following the menopause the body produces much less of the female hormone (oestrogen). The lack of oestrogen tends to alter the tissues in and around the vagina. You may find that the vagina feels smaller and tighter. Less lubrication is produced from glands around the vagina. As a result of both these changes, it may be uncomfortable or even painful when you have sex. Ways this can be helped include:
Lubricants. You can buy KY Jelly or similar lubricants from pharmacies. These help if you apply to the vagina before sex.
Hormone creams which contain oestrogen. There are a various creams and pessaries which may be prescribed by your doctor. These are usually prescribed for courses which last a few months. They replace the oestrogen in the vaginal tissues which often eases the problem.
Hormone Replacement Therapy (HRT). This is more general hormone treatment that some women take after the menopause. After several months of use the tissues around the vagina often return to a state similar to before the menopause. However, long-term use of HRT is not generally advised unless symptoms are troublesome and the above treatments have not helped.
Reduced sex drive (Libido)
Many women say that they just don't feel like sex as often as they used to. A few women don't want to have sex at all. This may cause friction with your partner. Appetite for sex does reduce over the years, but may be made worse by depression or other problems of the menopause. These include: hot flushes, dry vagina, psychological problems, family problems, etc.
These are often temporary and being able to talk things through with an understanding partner is often all that is required. However, if symptoms of the menopause or of depression persist then it may be best to discuss this with a doctor. Both can usually be treated.
1--INTRODUCE
2--MAINTAIN EYE CONTACT AND AVOID MEDICAL JARGON,UR AIM IS TO REASSURE THE PT
3--ASk her what her understanding is of HRT and what r her concern
4--EXPLAIN WHAT HRT IS
6-EXPlAIN the short term risks
7--EXPLAIN the long term benefits of HRT
INFORM Her taking HRT is associated e 2%increase in bone density per year if taken for 5 years and consequently it will lessen her risk of osteoprosis by 50%
INFORM her that 1 in 2 women will suffer a osteoprosis related fracture in her 70,s and 1 in 4 women will suffer a osteoprosis related fracture in her 60,s
INFORM her that it has also been associated e a decrease in heart disease by upto 40% and a delay in onset of ALZHEMIER DISEASE
8--EXPLAIN the long term risks are a 2 fold increased risk of DVT in the 1st year of use and a 2 in 1000 absolute risk of breast cancer after 5 years of HRT and 6 per 1000 after 10 years of hrt
REASSURE that these risk r very small and that there is no change in outcome in patient e breast cancer on HRT and those who do not take HRT
9--EXPLAIN THE ROUTES OF ADMINISTRATION
oral tab
transdermal patch
percutaneous
subcutanous implant
vaginal (vagifem) or as a nasal spray
10 ASK IF SHE NEEDS FURTHER CLARIFICATION
11--SUGGEST that she go home and think about what hasbeen discussed to give her time to absorb this
12--SUGGEST that she make a follow up appointment at her convinenice if she would like to try HRT
|
Topic Tags: 
