I have read in the paper about a new drug called raloxifene -what advantage does this have?

Taloxifene is one of a class of drugs called Selective Estrogen (American spelling) Receptor Modulators, or SERMS. Tamoxifen is the one we already have but tamoxifen can sometimes, as a side effect, cause the uterus (womb) lining to overgrow and become troublesome. Raloxifene acts the same as tamoxifen in benefiting the heart and bones, avoids breast cancer risks and does not affect the womb. It is an important drug but like tamoxifen does not reduce hot flushes. It may be an important advance in HRT for women because it looks to have the major benefits without the major risks. A lot of research is taking place to determine how valuable it will be to the heart - proof is not yet available, but early results do not show any harm.

Does HRT have any side effects?

All medication can give side effects and HRT is no exception. You may feel nauseous but it usually goes after 2 weeks or so - taking tablets after a meal can help this. Breast tenderness and swelling may occur and, again, wear off. If they are persistent, you may be given a different form of HRT to try.

Women worry about gaining weight whilst on HRT. The many research trials do not report weight gain but you should remember that everyone is an individual and if you gain weight, it is you that matters, not the statistics. It is probably due to eating more as you feel better on HRT! Watching your weight is important anyway, so at this time take note of what you are eating and make sure that you take plenty of exercise.

On average, women take 3 months to settle into their HRT therapy.

Does HRT raise blood pressure?

Very rarely. Your doctor or nurse will always check your blood pressure when HRT is prescribed. If you have high blood pressure, you can still take HRT because the chances of your control being upset are so small.

I have breast cancer which is now controlled, and I have also had a heart attack - will HRT help me?

t will not obviously help the heart and it could make the breast cancer worse, so it is not recommended. HRT is not an alternative to proven heart attack treatments.

What sort of HRT therapy is available?

The choice of therapy is best discussed with your doctor. There are two sorts: the first is oestrogen only and this type is for women who have had a hysterectomy (removal of the womb) - this is known as 'unopposed oestrogen'. The second type is 'combined' HRT (containing oestrogen and progesterone) for women who still have a womb, because oestrogen alone in these women will cause excess stimulation of the lining of the womb.

I have been advised to go on HRT but I am resisting as I have read that it doubles your chances of getting blood clots in the legs - is this true?

Yes, this is true. Your normal risk of getting a dangerous blood clot is 1 in 10 000 and it increases to 2 in 10 000 on HRT. So the risk is very small and remains very small on HRT. The risk is higher in those over 60 years of age, but HRT is rarely started in this age group. Smoking and being overweight increase the risk. Talk to your doctor about this, if you think that you may be at risk.

I'm fit and active with no risk factors for heart disease - will I benefit from HRT?

If you have no risks for heart disease, HRT will not improve this as your risk is very low anyway, but you may benefit from HRT by avoiding osteoporosis (thin bones). This is more common in slim women. HRT also helps to relieve hot flushes. Check with your doctor about the possibility of having a bone density scan if you think you may be at risk for osteoporosis.

From the point of view of heart health, who will benefit most from taking HRT? I have been taking HRT for 7 years and I think that it is wonderful -1 now feel a new woman! However, my doctor says that I should stop it soon. How long should I continue taking HRT?

HRT is usually taken for hot flushes for up to 5 years. Bone benefits continue on beyond 10 years, but the breast cancer risk increases. So, at present, we recommend HRT is stopped.

I'm on HRT at the moment. Do I need regular check-ups?

It is very important that you attend for regular check-ups at first every 3 months and then 6-monthly, and follow your doctor's instructions. For these check-ups, make a note of any queries or concerns that you might have and discuss them with your doctor.

I have been on oral HRT for some months and my doctor has arranged for me to have a lipid test. Why?

The doctor is checking to make sure that you are not at risk of heart disease, which is good medical practice. Up to the menopause, women usually have a raised high density lipoprotein level (HDL) (greater than 1.3) which helps protect them from coronary disease. This HDL gradually falls after the menopause unless HRT is taken. It is important that women should always have a 'full lipid profile' taken (HDL as well as LDL) because a high total cholesterol may reflect good (HDL) rather than bad (LDL) cholesterol levels. Reducing your total cholesterol in this situation might reduce the protective HDL and be counter-productive.

A full lipid profile will also tell you about your triglycerides. Oral HRT can raise triglycerides, but HRT patches have no effect on triglyceride levels. A high triglyceride level is more of a risk in women than in men; the best means of lowering it is by weight loss and regular exercise, along with a low saturated fat diet. An underactive thyroid and too much alcohol can also be a cause.

I do find the advice on HRT confusing - can you clarify it for me?

All try, but doctors find it confusing too!

• HRT definitely helps menopausal symptoms, e.g. hot flushes.

• It definitely helps prevent thin bones (osteoporosis).

• It does not protect against heart disease developing.

- In those with coronary disease, it does not benefit them, so it is not a treatment for heart disease.

• In those with heart disease, it still helps menopausal symptoms and osteoporosis.

• HRT increases the risk of breast cancer.

• Overall, HRT is indicated only if menopausal symptoms are severe and intolerable. It is then given for as short a time as possible and at as low a dose as possible.

I'm concerned that my wife is at risk of heart disease and I want her to take it seriously; she smokes and is rather well padded! However, her doctor does not seem to be bothering either. What should I tell her?

You should point out that women are just as vulnerable to coronary disease as men. Some women don't recognise this and play down any symptoms of chest discomfort. They usually put their family first. Sometimes they might hide things from the doctor, which makes diagnosis difficult for both angina and a heart attack.

Your wife and every other woman should take heart disease seriously and her doctor, like all doctors, should recognise that women with a mixture of symptoms need taking seriously. Women may be reassured too easily because most women believe themselves to be less likely to have heart disease than men.

Post-menopausal women are at more risk and, even when the symptoms are not typical, these should be discussed and heart disease ruled in or out.

Women are just as likely as men to develop coronary disease if they smoke and just as likely to benefit if they stop. Keeping to a sensible weight and taking regular exercise are also important preventative measures. Tell her that heart disease is an equal opportunity killer and that she should do her best to avoid it for her sake and that of her family.

Send for the British Heart Foundation's booklet Women and heart disease and present it to her!

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