The video version of this podcast can be found here:

·       https://youtu.be/lgHKxBVz6kE

This episode makes reference to guidelines produced by the "National Institute for Health and Care Excellence" in the UK, also referred to as "NICE". The content on this channel reflects my professional interpretation/summary of the guidance and I am in no way affiliated with, employed by or funded/sponsored by NICE.

NICE stands for "National Institute for Health and Care Excellence" and is an independent organization within the UK healthcare system that produces evidence-based guidelines and recommendations to help healthcare professionals deliver the best possible care to patients, particularly within the NHS (National Health Service) by assessing new health technologies and treatments and determining their cost-effectiveness; essentially guiding best practices for patient care across the country.

My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this episode I review a section of the NICE guideline on Hypertension in adults, always focusing on what is relevant in Primary Care only.

I am not giving medical advice; this video is intended for health care professionals, it is only my summary and my interpretation of the guidelines and you must use your clinical judgement.  

Disclaimer:

The Video Content on this channel is for educational purposes and not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read or seen on this YouTube channel. The statements made throughout this video are not to be used or relied on to diagnose, treat, cure or prevent health conditions.

In addition, transmission of this Content is not intended to create, and receipt by you does not constitute, a physician-patient relationship with Dr Fernando Florido, his employees, agents, independent contractors, or anyone acting on behalf of Dr Fernando Florido.

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There is a podcast version of this and other videos that you can access here:

Primary Care guidelines podcast:

·       Redcircle: https://redcircle.com/shows/primary-care-guidelines

·       Spotify: https://open.spotify.com/show/5BmqS0Ol16oQ7Kr1WYzupK

·       Apple podcasts: https://podcasts.apple.com/gb/podcast/primary-care-guidelines/id1608821148

There is a YouTube version of this and other videos that you can access here: 

• The Practical GP YouTube Channel: 

https://youtube.com/@practicalgp?si=ecJGF5QCuMLQ6hrk

The NICE clinical guideline on Menopause: identification and management

[NG23] can be found here:

·       https://www.nice.org.uk/guidance/NG23

The link to the visual aid on HRT and the likelihood of some medical conditions can be found here:

·       https://www.nice.org.uk/guidance/ng23/resources/incidence-of-medical-conditions-with-and-without-hrt-a-discussion-aid-pdf-13553199901

The FSRH Guideline: Contraception for Women Aged Over 40 Years can be found here:

·       https://www.cosrh.org/Common/Uploaded%20files/documents/fsrh-guideline-contraception-for-women-aged-over-40-years.pdf

The recommendations by the British Menopause Society on the management of unscheduled bleeding on hormone replacement therapy (HRT) can be found here:

·       https://thebms.org.uk/publications/bms-guidelines/management-of-unscheduled-bleeding-on-hormone-replacement-therapy-hrt/

Transcript

If you are listening to this podcast on YouTube, for a better experience, switch to the video version. The link is in the episode description.

Hello and welcome, I’m Fernando, a GP in the UK. Today we are reviewing the NICE guideline on the menopause, always focusing on what is relevant in Primary Care only.

Today we will focus on HRT risks and benefits in people aged 45 and over.

In the next episode, we’ll cover early menopause, meaning people aged 40 to 44, and premature ovarian insufficiency, which refers to those aged under 40. In the previous two episodes, we covered diagnosis, treatment choices, and symptom management.

Right, let’s jump into it.

So let’s start by looking at the effects of HRT on specific health outcomes.

When discussing the risk of individual medical conditions, NICE recommends using its HRT discussion aid to explain risks and benefits more clearly. The link to this aid is in the episode description. It presents the information as the number of cases per 1,000 people over a 5- or 10-year period. So, in practice, the message is more nuanced than simply saying that HRT is safe or unsafe.

Let’s first look at the effects that are similar with combined and oestrogen-only HRT.

For people aged 45 or over, we will explain that neither combined HRT or oestrogen-only HRT is likely to affect life expectancy.

Equally, for people without coronary heart disease, the risk of developing it or mortality from it does not increase with either combined HRT or oestrogen-only HRT.

For osteoporosis, fragility fracture risk is reduced while on either combined HRT or oestrogen-only HRT and the benefit is maintained during treatment, but decreases once HRT stops. It may continue for longer in people who take HRT for longer. There is also limited evidence that HRT improves muscle mass and strength.

Neither combined HRT or oestrogen-only HRT increases the risk of developing type 2 diabetes and it has no adverse effect on blood glucose.

And finally, for venous thromboembolism, route matters. The risk is not increased with transdermal HRT, but it is increased with oral HRT, both combined and oestrogen-only.

And now let’s review the specific effects of combined HRT, which is given to people with a uterus.

And we will start looking at the Breast cancer risk first, which varies depending on the person’s risk factors.

With combined HRT, breast cancer risk increases, and this increase rises with duration of use.

In addition, the risk is higher while taking HRT compared to having taken it in the past and, after stopping HRT, the risk goes down, but it can persist for at least 10 years.

NICE says there is a very small increase in the risk of death from breast cancer too.

The type of combined HRT also matters.

Breast cancer risk is lower with sequential combined HRT than with continuous combined HRT, but it is still higher than without HRT.

There is not enough evidence that any specific progestogen carries a higher risk of breast cancer.

Contrary to what happens with breast cancer, for endometrial cancer, continuous combined HRT reduces risk whereas sequential combined HRT may slightly increase it, and this increases with the duration of use, fewer days of progestogen per cycle, or a higher dose of oestrogen.

For ovarian cancer there is a very slight increase in risk with combined HRT, but we should explain that the baseline population risk in women under 60 is very low.

For dementia, the risk might increase if it is started at the age of 65 or over.

For stroke, we should explain that the baseline population risk in women under 60 is very low.

Stroke risk is unlikely to increase with combined HRT that includes transdermal oestrogen, but it increases with combined HRT containing oral oestrogen.

This increase rises with higher oestrogen dose and longer duration of treatment, for example if used for more than 5 years.

The risk is also higher when HRT is started at a later age, and may be higher in Black people.

So, in summary, combined HRT is used in people with a uterus, breast cancer risk is increased and rises with duration of use, continuous combined HRT reduces endometrial cancer risk, and transdermal treatment has a more favourable profile for stroke and VTE risk than oral treatment.

Let’s now move to oestrogen only HRT, remembering that this is the option recommended for people who have had a total hysterectomy.

Starting with breast cancer, the discussion is different from combined HRT.

Oestrogen-only HRT causes very little or no increase in breast cancer risk or breast cancer mortality.

For endometrial cancer, the key point is that oestrogen-only HRT should not be used in people with a uterus precisely because it increases the risk of endometrial malignancy.

Ovarian cancer risk increases very slightly after 5 years of oestrogen-only HRT, and rises with longer use, regardless of the route. However, the baseline risk in women under 60 is very low.

For dementia, NICE says that the risk is unlikely to increase.

For stroke, the route of oestrogen matters.

Stroke risk increases with oral oestrogen-only HRT, and this increase rises with the dose of oestrogen and if started after the age of 60.

However, stroke risk is unlikely to increase with transdermal oestrogen-only HRT.

So, in summary, oestrogen-only HRT is generally used after total hysterectomy, breast cancer risk is very little or not increased, and transdermal treatment has a more favourable profile for stroke and VTE risk than oral treatment.

So that is it, a review of a section of the NICE guideline on the menopause.

We have come to the end of this episode. Remember that this is not medical advice but only my summary and my interpretation of the guidelines. You must always use your clinical judgement.

Thank you for listening and goodbye.