69 - Use of HRT

Use of HRT

Drug treatment of psychiatric symptoms in the context of other conditions CHAPTER 10 Elderly care Genitourinary symptoms of menopause (GSM) may be a factor in agitation and aggression in elderly care. Consider vaginal atrophy and localised vaginal oestrogen or ospemifene use in women presenting with GSM symptoms, recurrent urinary tract infections, recurrent candida, urinary leakage and vaginal discomfort.20,21 Use of HRT For most women, HRT is a very safe and effective first-­line option for treatment of menopausal symptoms, reducing osteoporosis and cardiovascular disease risk,21–23 although there are some contraindications and precautions to its use (Table 10.22). Treatment options 1 Perimenopause: sequential combined HRT (oestrogen + progesterone cover in luteal phase for 12–14  days of cycle) ± localised vaginal oestrogen, and testosterone (Table 10.23). 2 Post menopause: continuous combined HRT (oestrogen + progesterone) ± local vaginal oestrogen, and testosterone (Table 10.23). Combined HRT – oestrogen and progesterone – is required in all women except those who have had a total hysterectomy who may have oestrogen-­only treatment. Oral oestrogen imposes a small increase in thrombus risk and therefore transdermal oestrogen is preferred when there is an increased risk of VTE or stroke.1,23 Table 10.22  Summary of the risks of using hormone replacement therapy (HRT). Contraindications to HRT use Precautions for HRT use Risks Oestrogen-­dependent malignant tumours Undiagnosed vaginal bleeding Pregnancy Active liver disease with abnormal LFTs Active or recent thromboembolic disorder (angina/MI) Active or idiopathic VTE untreated Untreated endometrial hyperplasia Symptomatic fibroids Untreated hypertension Migraine with aura – clot risk Epilepsy – lamotrigine interaction Endometriosis – choice of HRT important VTE/stroke – choice of HRT important Heart disease – choice of HRT important Endometrial hyperplasia and cancer Clot risk – dependent on type of HRT Breast cancer risk – small increased risk for women over 50 years. Use patient counselling aided by WHC Irregular bleeding – see Table 10.25 Adverse effects – see Table 10.25 MI, myocardial infarction; VTE, venous thromboembolism; WHC, Women’s Health Concern.

862 The Maudsley® Prescribing Guidelines in Psychiatry CHAPTER 10 Local treatment options with GSM Additional topical treatment options when GSM symptoms are prominent are given in Table 10.24. Table 10.23  Hormone replacement therapy (HRT) products and regimens. Estradiol Progesterone Sequential combined HRT – perimenopause (prescribe by brand name) Patch: 25–100mcg twice weekly Micronised progesterone 200mg on, days 15–28 of cycle Estradiol gel 0.6mg/g: 1–4 pumps daily Progesterone 200mg on, days 15–28 of cycle Estradiol gel sachets: 0.5–1.5mg daily Medroxyprogesterone acetate 10mg od, days 16–27 of cycle Estradiol 1.53mg/spray: 1–3 sprays daily Levonorgestrel 52mg IUD Estradiol hemihydrate/valerate tablets: 1–2mg daily Combined products: ■ ■Estradiol hemihydrate 50mcg/24h and norethisterone acetate 11.2mg combined patch, used for 14/28 days, and estradiol 50mcg patch used for 14/28 days. Applied twice weekly ■ ■Estradiol 1mg/2mg with dydrogesterone 10mg tablets – calendar pack one daily ■ ■Estradiol 1mg/2mg with norethisterone 1mg tablets – calendar pack one daily Continuous combined HRT – post menopause (prescribe by brand name) Estradiol patch: 25–100mcg twice weekly Micronised progesterone 100mg on Estradiol gel 0.6mg/g: 1–4 pumps daily Progesterone 100mg on Estradiol gel sachets: 0.5–1.5mg daily Medroxyprogesterone acetate 2.5–5mg od Estradiol 1.53mg/spray: 1–3 sprays daily Levonorgestrel 52mg IUD Estradiol hemihydrate/valerate tablets: 1–2mg daily Combined products: ■ ■Estradiol hemihydrate 50mcg/24h and norethisterone acetate 11.2mg combined patch, applied twice weekly ■ ■Estradiol 0.5/1mg with 2.5/5mg dydrogesterone tablets: 1 od ■ ■Estradiol 2mg with 1mg norethisterone tablets: 1 od IUD, intrauterine device; od, once a day; on, every night. Table 10.24  Topical vaginal oestrogen or GSM treatment. Drug Dose Estradiol 10mcg vaginal tablets One pv daily for 14 days and then twice weekly Estriol 0.03mg pessary One pv daily for 21 days and then twice weekly Estriol 1mg cream 1 applicator daily for 4 weeks and then twice weekly Prasterone 6.5mg pessary One daily Ospemifene 60mg oral One daily with food GSM, genitorurinary symptoms of menopause; pv, per vagina.