Menopause management seminar


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  • An increase in body weight and a shift in body fat distribution typically occur in the years following menopause. In one study,* over the course of a year, early postmenopausal women gained an average of 2.1 kg, even though caloric and macronutrient intake did not change. Accompanying this increased weight is a shift from gynoid to android fat distribution with a concomitant increased waist/hip ratio. This pattern of fat disposition is especially concerning given the association between abdominal obesity and cardiovascular disease risk. Espeland MA, Stefanick ML, Kritz-Silverstein D, Fineberg SE, Waclawiw MA, James MK. Effect of postmenopausal hormone therapy on body weight and waist and hip girths. Postmenopausal Estrogen-Progestin Interventions Study Investigators. J Clin Endocrinol Metab 1997;82:1549-1556. Gambacciani M, Ciaponi M, Cappagli B, Piaggesi L, de Simone L, Orlandi R, Genazzani AR. Body weight, body fat distribution, and hormonal replacement therapy in early postmenopausal women. J Clin Endocrinol Metab 1997;82:414-417. *Reubinoff BE, Wurtman J, Rojansky N, Adler D, Stein P, Schenker JG, Brzezinski A. Effects of hormone replacement therapy on weight, body composition, fat distribution, and food intake in early postmenopausal women: a prospective study. Fertil Steril 1995;64:963-968 .
  • Hänggi W, Lippuner K, Jaeger MH, Birkhäuser MH, Horber FF. Differential impact of conventional oral or transdermal hormone replacement therapy or tibolone on body composition in postmenopausal women. Clin Endocrinol 1998;48:691-699. OBJECTIVE: To compare the effects on body composition and body weight of tibolone vs two different sequential oral or transdermal oestrogen-progestogen hormone replacement therapies versus no therapy. PATIENTS AND METHODS: One hundred postmenopausal women were assigned to a control group (n = 26), or randomized to 1) tibolone (TIB) 2.5 mg/day (n = 28), 2) oral oestradiol 2 mg/day (PO) plus sequential dydrogesterone 10 mg/day for 14 of 28 days per cycle (n = 26), or 3) transdermal oestradiol patch (TTS) releasing 50 micrograms/day plus oral sequential dydrogesterone 10 mg/day for 14 of 28 days per cycle (n = 20). Body composition was measured at the base-line and every 6 months for 2 years by DXA (Hologic QDR 1000 W). RESULTS: Total body fat mass increased (P < 0.05) in controls (+3.6 +/- 1.5%) and in TTS treated (+4.7 +/- 2.2%), but not in PO (-1.2 +/- 2.4%) and TIB (-1.6 +/- 2.2%) treated subjects. This increase in total fat mass in controls and TTS treated women was mostly due to an increase in fat mass of the trunk (P < 0.05), but not legs. As a result, a redistribution of body fat to the trunk occurred in controls, TTS and TIB, but not in PO treated women (P < 0.05). Total lean body mass decreased (P < 0.02) in controls (-1.7 +/- 0.7%) and PO (-1.4 +/- 0.6%) but not in TTS (+0.3 +/- 0.8%) and TIB (+0.4 +/- 0.5%) treated subjects. CONCLUSIONS: The menopause is associated with an increase in total body fat and a decline in lean body mass. Oral oestradiol/dydrogesterone and tibolone prevent total body fat changes, whereas transdermal oestradiol/oral dydrogesterone and tibolone prevent the lean mass changes. Furthermore, oral oestradiol/dydrogesterone prevents the shift to a central, android fat distribution .
  • Highly effective in relieving vasomotor symptoms improvement usually seen within 4 weeks with
  • Amy JJ. Femoston®: effects on bone and quality-of-life. Eur Menop J 1995;2 (Suppl.):16-22. In a study in 186 postmenopausal women receiving femoston ® (2 mg 17ß-estradiol and 10 mg dydrogesterone) for one year, a clear reduction of menopausal symptoms such as hot flushes or night sweats was observed after 6 weeks and throughout the remaining observation period.
  • Stevenson JC, Teter P, Lees B . 17beta-estradiol (1 mg/day) continuously combined with dydrogesterone (5, 10 or 20 mg/day) increases bone mineral density in postmenopausal women. Maturitas 2001;38:197-203 Although the minimal dose of 17beta-estradiol in hormone replacement regimens was originally considered to be 2 mg/day, it is now increasingly accepted that a lower dose of 1 mg/day is effective in protecting women from the detrimental effects of the menopause. A 1-year, multicentre, double-blind, randomised study was conducted in 214 healthy postmenopausal women in order to assess the effect of 17beta-estradiol (1 mg/day) continuously combined with dydrogesterone (5, 10 or 20 mg/day) in preventing bone loss. Bone mineral density (BMD) was evaluable in 177 women who completed the study. In all women, a statistically significant increase from baseline in lumbar vertebrae (L2-L4) BMD was seen after 6 months ( + 2.4%; p < 0.01); this increase was somewhat greater after 12 months ( + 3.6%; p < 0.01). Similar effects were seen in the hip. After 6 months, BMD in the femoral neck, Ward's triangle and trochanter had increased by 0.20% (not significant [n.s.]), 0.32% (n.s.) and 1.08% (p < 0.01), respectively, compared with baseline. Greater increases were again seen after 12 months ( + 1.16%, + 1.62% and + 2.83%, respectively), all of which were statistically significant (p < 0.01) compared with baseline. The change in BMD from baseline did not differ significantly between the three dydrogesterone dosages for either L2-L4 or hip. All dosages were well-tolerated and amenorrhoea was achieved in over 70%. In conclusion, 17beta-estradiol (1 mg/day) continuously combined with dydrogesterone (5, 10 or 20 mg/day) results in a significant increase in lumbar vertebrae and hip BMD in postmenopausal women. The lower dose of oestrogen and the avoidance of cyclical bleeding make this a particularly suitable regimen for the prevention and treatment of osteoporosis in older women.
  • Menopause management seminar

    1. 1. Management ofManagement of MenopauseMenopause Dr Yusmadi Abdullah
    2. 2. Life After MenopauseLife After Menopause  Age at menopause : 51.7 (average)  1900 : life expectancy at 40 years old  1950 : life expectancy at 65 years old  2000 : life expectancy at 83 years old (Malaysian women - 75.4 years)
    3. 3. “Women now live a third of their lives after menopause” 8th International Congress on Menopause, Sydney 1996
    4. 4. MenopauseMenopause  MenopauseMenopause is the permanentis the permanent cessation of menstruation thatcessation of menstruation that results from loss of ovarian follicularresults from loss of ovarian follicular activity.activity.  Menopausal age :Menopausal age : 45 – 55 years45 – 55 years  Mean age ( M )Mean age ( M ) :: 50.7 years50.7 years  Premature menopausePremature menopause < 45< 45 yearsyears  Late menopauseLate menopause > 55 years> 55 years
    5. 5.  is the cessation of menstruationis the cessation of menstruation that follows surgical removal ofthat follows surgical removal of both ovaries orboth ovaries or iatrogenic ablationiatrogenic ablation of ovarian functionof ovarian function byby chemotherapy, radiotherapy orchemotherapy, radiotherapy or treatment with GnRH analogues.treatment with GnRH analogues. Induced /surgical menopauseInduced /surgical menopause
    6. 6. PerimenopausePerimenopause  Is the period beginnning with the first clinical, biological and endocrinological features of the approaching menopause such as vasomotor symptoms and menstrual irregularity  Can be 1 or 2 years and for some as long as 7 to 10 year
    7. 7. DiagnosisDiagnosis  For those 50 years and above :For those 50 years and above : 12 consecutive month of12 consecutive month of amenorrhoea is diagnostic.amenorrhoea is diagnostic.  For those below 50 years :For those below 50 years : ** FSHFSH > 30 IU/l> 30 IU/l
    8. 8. Consequences of menapauseConsequences of menapause  Vasomotor symptoms  Psychological symptoms  Sexual dysfunction  Osteoporosis  Cardiovascular Disease  Urogenital Atrophy
    9. 9. Vasomotor SymptomsVasomotor Symptoms  Hot flushes and night sweats are experienced by as many as 85% of women around the menopause.  Most would experience these symptoms for < 5 years, however about 25% would experience it for more than 5 years.
    10. 10. Sexual DysfunctionSexual Dysfunction  The underlying problem for female sexual dysfunction are usually multifactorial.  Oestrogen deficiency can lead vaginal dryness and dyspareunia,  Non hormonal factors such as conflict between partners, insomnia, inadequate stimulation, life stresses can also lead to sexual dysfunction.
    11. 11.  Depressed mood, anxiety, irritability, mood swings, lethargy and lack of energy have been associated with the menopause.  General population studies suggest that most women do not experience major mood changes during the menopause. Psychological SymptomsPsychological Symptoms
    12. 12. Prospective epidemiologicalProspective epidemiological studiesstudies ‘ psychological problems experienced during the menopause are likely to be associated with past problem and current life stresses’
    13. 13. OsteoporosisOsteoporosis  Affects 1:3 women.  Risk factors include family history of fracture, low BMI, early menopause, cigarette smoking, alcohol abuse, sedentary lifestyle, corticosteroids, hyperthyroidism.  Common sites for osteoporotic fracture are lower end of radius (wrist/Colles’ fracture), proximal femur (hip) and vertebrae.
    14. 14. Cardiovascular DiseaseCardiovascular Disease  common cause of death in women after the age of 60 years.  Risk factors for myocardial infarction are abnormal FLP, smoking, depression and stress.  Incidence of stroke increases with age.  Risk factors are hypertension, smoking, diabetes, hyperlipidaemia, obesity.
    15. 15. Urogenital AtrophyUrogenital Atrophy  Oestrogen and progestrone receptors are present in the vagina, urethra, bladder and pelvic floor musculature.  Oestrogen deficiency after menopause cause atrophic changes in the urogenital tract and is associated with urinary symptoms which may co-exist with symptoms of vaginal atrophy.
    16. 16. Treatment OptionTreatment Option Making lifestyle changes - healthy diet, exercise and stress reduction. Hormone replacement therapy. Complementary and alternative therapies.
    17. 17. Hormone ReplacementHormone Replacement TherapyTherapy
    18. 18. How to approach?How to approach? Counseling Health screening – history , examination and investigation Knowledge??
    19. 19. Hormone ReplacementHormone Replacement TherapyTherapy  combine regime- estrogen and progestogen in women with uterus  Oestrogen /ERT only – women with no uterus
    20. 20. OestrogensOestrogens  Natural : oestradiol, oestrone and oestriol which are chemically synthesised from soya beans or yams; conjugated equine oestrogen (CEE) consisting primarily of estrone sulphate and equilin sulphate,obtained from urine of pregnant horses,  Synthetic : ethinyl oestradiol and mestranol (less suitable for HRT)
    21. 21. ProgestogensProgestogens  High androgenic potency  marked adverse effects on lipoproteins!  negates beneficial effects of estrogen  eg. 19-nor progestogens, norgestrel, norethisterone  Moderate androgenic potency  some effects on plasma lipids  eg. Medroxyprogesterone acetate (MPA)
    22. 22. No androgenic potency  no effect on blood lipids  Eg dydrogesterone (Duphaston) Eg - Femaston
    23. 23. Routes of AdministrationRoutes of Administration  Oral -most widely used -well tolerated -highly effective -rapid onset -‘first-pass’ effect (beneficial changes in HDL:LDL)  Transdermal -patches or gels -messy, time consuming -redness/itchiness -need of oral progestogen: low compliance  Intravaginal -vaginal rings, pessaries, cream -no effects on vasomotor symptoms, osteoporosis or CVD -creams or tablets:messy -need oral progestogen: poor compliance  Subcutaneous -surgically inserted pellets -hormone release varies -treatment can’t be reversed -estrogen effects persist
    24. 24. Prescribing RegimensPrescribing Regimens  Estrogen therapy may be  cyclical :administered for first 21 days of the cycle)  continuous :administered throughout the cycle)  Progestogens therapy may be  sequentially :added for last 10 - 14 days of the cycle (induces a withdraw bleed)  continuously (to eliminate withdrawal bleed)
    25. 25. HRT CHARTHRT CHART link
    26. 26. Weight Gain and Android Fat Distribution in Menopause
    27. 27. % change from baseline after 24 months (n=26, n=28, n=26) Hänggi W et al. Endocrinology 1998;48:691-699. Effect of HRT on Body Weight and Fat Distribution -2 0 2 4 6 Total Body Fat Mass Trunk Fat mass Total Body Weight Controls Tibolone femoston 2/10 * *p<0.05 vs. baseline * * %changefrombaseline
    28. 28. Sequential TherapySequential Therapy  Mimics the menstrual cycle.  Regular, monthly periods.  Periods often lighter.  Appropriate for perimenopausal women with irregular bleed.
    29. 29. Continuous Combined RegimeContinuous Combined Regime  A continuous-combined regime is to eliminate wihdrawal bleeding.  Use should be avoided within the first 12 months after the last menstrual bleed.  Spottings may occur during the first 3 - 4 months in most women.  Appropriate for postmenopausal women who do not wish for any regular withdrawal bleed.
    30. 30. Duration of SystemicDuration of Systemic TreatmentTreatment  Vasomotor symptoms - up to 5 years and then evaluate as some women do experience symptoms for more than 5 years.  Prevention or treatment of osteoporosis - needs to be continued for life as BMD falls when treatment is stopped. However other option should be discussed as long term HRT is associated with other risk.
    31. 31.  Premature menopause - usually advised to continue until the natural age of menopause ~ 51 years. There after need to reevaluate what is the endpoint of treatment.
    32. 32. Treatment of LocalTreatment of Local SymptomsSymptoms Treatment is usually long term if not life long as symptom return on cessation of treatment. Synthetic oestrogens or CEE should be avoided as they are well absorbed from the vagina. The options available are low dose natural oestrogen e.g vaginal oestriol by cream or pessary or oestradiol by tablet or ring. With the recommended dose regimen, progestogen need not be added for endometrial protection.
    33. 33. - effective in treating hot flushes and improvement is usually seen within 4 weeks with maximum effect achieved by 3 months. - treatment should be continued for at least 1 year. Vasomotor symptomsVasomotor symptoms
    34. 34. Percentage of menopausal symptoms in 186 women during a 52 week period of femoston® 2/10 treatment Baseline 6 weeks 52 weeks 0 10 20 30 40 50 60 70 80 Hot flushes Night sweats Sweating attacks Vaginal dryness Painful intercourse Percentageofwomen Amy JJ. Eur Menop J 1995;2 (Suppl.):16-22 Relief of Menopause Symptoms with femoston® 2/10
    35. 35. Urogenital symptoms and sexualityUrogenital symptoms and sexuality - vaginal dryness, superficial dyspareunia, urinary frequency and urgency respond well to oestrogens - urinary incontinence, however, is not improved
    36. 36. - reduces the risk of spine, hip and other osteoporotic fracture. - need lifelong treatment to be effective in preventing fracture. - not recommended as a first-line treatment as risks outweigh benefits. - standard dose for bone protection are CEE 0.625mg, oestradiol 1-2mg and transdermal 25-50µg. OsteoporosisOsteoporosis
    37. 37. Bone Mineral Density % Change Stevenson JC et al. Maturitas 2001;38:197-203. Significant increase in BMD of the lumbar vertebrae and hips 1 mg estradiol plus 5, 10 or 20 mg continuous dydrogesterone, N=177, 1 year treatment duration * p<0.01 vs. baseline 0.0% 1.0% 2.0% 3.0% 4.0% L2-4 Vertebrae Femoral Neck Ward's Triangle Trochanter 3.6%* 1.16%* 1.62%* 2.83%* %increasefrombaseline
    38. 38. Prevention and Treatment ofPrevention and Treatment of OsteoporosisOsteoporosis  Biphosphonates - shown to reduce both vertebral and non- vertebral fractures - principal side-effect : irritation of upper GIT so given weekly/monthly to reduce this. Eg - alandroanate  SERMs (Raloxifene) - shown to reduce vertebral fracture. - does not treat vasomotor symptoms, cause transient side effects such as hot flushes and leg cramps. - Has an equal propensity with HRT to cause VTE
    39. 39. Prevention and TreatmentPrevention and Treatment of Osteoporosisof Osteoporosis  Calcitriol - active metabolite of vitamin D and facilitates the intestinal absorption of calcium.  Calcium - in postmenopausal women not on HRT 1.5 gram/day and in those on HRT 1.0 gram/day of elemental calcium is needed to preserve bone health.  Vitamin D - oral supplementation of 700-800IU/day seem to reduce risk of vertebral and non-vertebral fractures in ambulatory or institutionalized elderly people.
    40. 40. Colorectal cancerColorectal cancer - reduces risk of colorectal cancer by about one-third
    41. 41. HRT AND Breast cancerHRT AND Breast cancer - risk of breast cancer is dependent on the regimen prescribed, greatest with combined oestrogen-progestrogen replacement. - Risk of breast cancer minimal after 5 years of usage - The WHI found : risk in the oestrogen- alone group was 23% lower than in the placebo group.
    42. 42. Nurses' Health Study (January 2006Nurses' Health Study (January 2006))  Data suggest that timing of hormone initiation in relation to age of onset of menopause might influence coronary risk; women beginning HT/ET near onset of menopause had a significantly reduced risk (30% less) of CHD;  no significant correlation between HT/ET and CHD risk was observed among women who initiated therapy 10 years or more after menopause. Grodstein F, Manson JE, Stampfer MJ. Hormone therapy and coronary heart disease: the role of time since menopause and age at hormone initiation.
    43. 43. Effects of unopposed estrogen and risk of invasiveEffects of unopposed estrogen and risk of invasive breast cancer (Nurses' Health Study, May 2006)breast cancer (Nurses' Health Study, May 2006)  Data indicate that use of estrogen alone did not increase the risk of invasive breast cancer until 20 years of use and beyond, and risk was increased at 15 years for estrogen receptor and progesterone receptor- positive cancers. Chen WY, Manson JE, Hankinson SE, et al. Unopposed estrogen therapy and the risk of invasive breast cancer. Arch Intern Med. 2006;166:1027-1032.
    44. 44. Breast DisorderBreast Disorder  Benign breast disease - no convincing evidence to show that the risk of breast cancer is increased in patients with benign breast disease  Previous breast cancer - studies on systemic HRT showed contradictory results with some showing adverse outcome and some showed no further increase risk. However, low dose vaginal oestrogen are not contraindicated for vaginal symptoms.
    45. 45. HRT AND Endometrial cancerHRT AND Endometrial cancer - unopposed oestrogen therapy increased the risk of endometrial cancer and risk is still increased for 5 years or more after discontinuation of therapy. - addition of progestogen reduces this risk but not completely with sequential progestogens especially if used for more than 5 years. - no increase risk is found with combined continuous regimen.
    46. 46. HRT andHRT and VenousVenous thromboembolic diseasethromboembolic disease - highest risk occurs in the first year of use. - however, absolute risk is small as VTE occurs in 1.7 per 1000 in women older than 50 years who are not taking HRT and mortality is low (1-2%). - limited data suggest that transdermal HRT is associated with a lower risk than the oral route.
    47. 47. HRT and CANCERHRT and CANCER Cervical and ovarian cancer - not contraindicated except for endometrioid ovarian cancer where some doubt exist and progestogen addition is recommended. Endometrial cancer - need to be given with progestogen.
    48. 48. Cardiovascular DiseaseCardiovascular Disease  Hypertension - no evidence shows that oestradiol- based HRT increases blood pressure or has an adverse effect in women with hypertension. Rarely CEE may cause severe hypertension which returns to normal upon stopping treatment.  Hyperlipidaemia - depends on type of HRT used.  Venous thromboembolism - relative contraindication. If still need to give as benefits outweighed risks then the transdermal route might be safer (limited evidence)  HRT and surgery - to stop 4 weeks prior to elective surgery or to continue HRT with thromboprophylaxis.
    49. 49. Endocrine DiseaseEndocrine Disease  Diabetes Mellitus - HRT seems to improve the glycaemic control with varying results depending on the type and route of administion.  Thyroid disease - dose of thyroxine may need to be increased as oestrogen can can increase the concentration of thyroxine-binding globulin.
    50. 50. Non-oestrogen Based TreatmentNon-oestrogen Based Treatment  Menopausal symptoms - progestogens such as NET 5mg/day or megestrol acetate 40mg/day - Clonidine - 50-75mg bd, of limited value and effectiveness - SSRI, gabapentin  Vaginal atrophy - lubricants, moisturisers
    51. 51. What are other options?What are other options? Exercise – yoga, Taichi, meditations Healthy food – increase fruits and vegetable intake Alternative – black cohosh, red clovers, etc
    52. 52. Case StudiesCase Studies
    53. 53. Case Study 1Case Study 1  45 year old woman, para 3, complains of:  irregular bleeding (not heavy)  vasomotor symptoms (hot flushes, night sweats) What would you advise her ?What would you advise her ?
    54. 54. Case Study 1Case Study 1 1.1. Health ScreenHealth Screen • Detailed history of general health status including family history • Physical examination: BP, Anemia, Thyroid, CVS, Lung, Breasts, Pelvic examination including Pap Smear. • Blood Examination: Hb, Lipid profiles, FBS, Others if indicated. • Other investigations: Mammography, BMD (Dexa) 2. Treatment … If all tests are normal the choices are: • Combined Cyclical HRT (regular-bleed)
    55. 55. Case Study 1Case Study 1 2. …Treatment Combined Cyclical HRT (regular-bleed) • Short-term • Pregnancy? Rees M, Purdie DW (2002), Management of the Menopause. Pg 112
    56. 56. Case Study 2Case Study 2 50 year old woman, posthysterectomy 3 years (ovaries not removed), has menopausal symptoms. She wants to know what are her options for:  hot flushes  night sweats  Dryness of vagina  Dyspareunia What would you advise her ?What would you advise her ?
    57. 57. Case Study 2Case Study 2 1.1.Health ScreenHealth Screen • Baseline workup as is case 1 2. Treatment • If normal mammogram and no contraindication, estrogen only therapy can be started • For fast relieve of vaginal symptoms, local application of vaginal cream can be used for short term
    58. 58. Case Study 2Case Study 2 3. Weigh the benefits and risks What are my risks ? • Cardiovascular disease − no protection − If coronary artery disease present, higher risk of mortality in the first year • Breast Cancer − Increased risk (MW study) − No increase in risk (WHI Study) − Increase mortality from breast cancer (MW Study)
    59. 59. Case Study 2Case Study 2 4. Alternative therapy if there are other risk factors What are my options? • Prozac/Effexor • Antihypertensives (Aldomet) • Unproven therapy − Black Cohosh − Phytoestrogens − Advise on spritual exercise yoga, taichi etc
    60. 60. Case Study 3Case Study 3 60 year old woman, has taken HRT for 10 years is seeking your advice whether she should stop or continue taking HRT ? What would you advise her ?What would you advise her ?
    61. 61. Counseling risk outweigh benefit Health screening Offer non pharmacological treatment now consider HT rather than HRT?
    62. 62.  Nonpharmacological treatment of postmenopausal symptoms  Article first published online: 11 JAN 2013  © 2013 Royal College of Obstetricians and Gynaecologists Issue  The Obstetrician & Gynaecologist Volume 15, Issue 1, pages 19–25, January 2013
    63. 63. Where are we now?Where are we now?
    64. 64. ACOG: State-of-the-Art Guide to HormoneACOG: State-of-the-Art Guide to Hormone TherapyTherapy  Combined hormone therapy should not be used for prevention of diseases such as cardiovascular disease, due to the small but significant increased risk of conditions such as breast cancer, heart attack, stroke, and blood clots;  Estrogen-alone therapy, used for women who have had a hysterectomy, should also not be used for prevention of diseases, due to increased risks of blood clots and stroke. Although ET carries fewer risks than combined HT, women with a uterus should not use estrogen alone due to their increased risk of uterine cancer;
    65. 65. ACOG: State-of-the-Art Guide toACOG: State-of-the-Art Guide to Hormone TherapyHormone Therapy  Hormone therapies are appropriate for the relief of vasomotor symptoms, so long as a woman has weighed the risks and benefits with her doctor; and  Women on combined HT or ET should take the smallest effective dose for the shortest possible time and annually review the decision to take hormones.
    66. 66. NAMS (North American Menopause Society –NAMS (North American Menopause Society – Sept 2003)Sept 2003)  The primary indication for systemic hormone therapy is moderate and severe menopausal symptoms: Hot flashes, night sweats/insomnia, mood swings  When treating moderate and severe urogenital atrophy (vaginal dryness, dyspareunia, urinary frequency, and incontinence), local estrogen preparations are preferred.
    67. 67.  2. HRT for treating menopausal symptoms  Treatment is justified since the benefits outweigh the risks.  4. HRT for managing osteoporosis  Consider alternative therapies such as calcium, biphosponates and the selective estrogen receptor modulators. (SERMs)
    68. 68.  3. HRT for preventing cardiovascular diseases  3.1 Conventional HRT should not to be used for primary prevention however a low dose HRT and transdermal therapy can be considered to be used.  3.2 HRT should not be used for secondary prevention against heart disease.  3.3 Women at risk of cardiovascular disease who wish to discontinue HRT should consider dietary and lifestyle changes (weight loss, regular exercise, stop smoking) as well as the use of drugs to lower cholesterol and blood pressure.