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YR2 LCRS Endocrinology > 10. Menopause, HRT and oral contraceptives > Flashcards

10. Menopause, HRT and oral contraceptives Flashcards

1
Q

what are common symptoms of menopause?

A
  • sleep disturbance
  • urogenital atrophy (dryness) which results in dyspareunia (painful sex)
  • hot flushes
  • depression
  • reduced libido
  • joint pain
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2
Q

why are many women anxious about receiving HRT?

A

patients are aware that menopause can cause bone problems but they are worried that HRT may give them breast cancer, blood clots, strokes or heart attacks

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3
Q

what is menopause?

A

a permanent cessation of menstruation that occurs because of loss of ovarian follicular activity

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4
Q

what is the average age of menopause?

A

51 (range is 45-55)

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5
Q

what does the term ‘climacteric’ refer to?

A

the transition period a patient may go through where the body ‘gets a bit mad’

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6
Q

describe the normal hypothalamic-pituitary-gonadal (HPG) axis

A

the hypothalamus releases pulses of GnRH which acts on the pituitary and stimulates the production of LH and FSH. LH&FSH stimulate the ovaries to release oestradiol and inhibin B, which -vely feedbacks to the hypothalamus and pituitary to reduce the release of GnRH and LH&FSH respectively

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7
Q

what changes in the HPG axis during menopause?

A

during menopause follicular activity reduces which causes oestradiol levels to decrease and LH&FSH to increase as GnRH is still stimulating the pituitary but the ovaries are not releasing oestradiol and inhibin B in response to LH&FSH so the hypothalamus and pituitary receive no -ve feedback

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8
Q

what are the complications of menopause?

A
  • osteoporosis (loss of bone matrix)

- cardiovascular disease (CVD)

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9
Q

describe the effect of menopause on osteoporosis

A
  • oestrogen is an anabolic hormone

- oestrogen deficiency results in a loss of bone matrix which leads to a 10-fold increased risk of fracture

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10
Q

describe the effect of menopause on CVD

A
  • oestrogen protects women against heart disease
  • it has beneficial effects on lipid profile and endothelial function
  • after menopause women have the same risk of CVD as men by the age of 70 due to loss of oestrogen
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11
Q

what does hormone replacement therapy (HRT) involve and what does it do?

A
  • involves giving both oestrogen and progestogens

- it helps to control vasomotor symptoms (hot flushes)

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12
Q

why is oestrogen alone not given in HRT?

A
  • oestrogen causes endometrial proliferation

- giving someone unopposed oestrogen carries a risk of endometrial carcinoma

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13
Q

in which circumstance can oestrogen alone be given?

A

if the patient has had a hysterectomy as there is no risk of endometrial cancer

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14
Q

describe cyclical HRT

A

oestrogen given every day, progesterone given for the last 12-14 days

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15
Q

describe continuous combined HRT

A

continuous oestrogen and progestogens all the time

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16
Q

outline the oestrogen preparations

A
  • oral estradiol (1mg)
  • oral conjugated equine oestrogen (0.625mg)
  • transdermal (patch) oestradiol (50micrograms/day)
  • intravaginal (for dyspareunia)
17
Q

what are the pros and cons of estradiol administration?

A

PROS:
it is well absorbed

CONS:
it has a low bioavailability (1st pass metabolism)

18
Q

in what forms other than estradiol can oestrogen be given?

A
  • estrone sulphate (‘conjugated’ oestrogen)

- ethinyl estradiol (semi-synthetic oestrogen, the ethinyl group protects the molecule from 1st pass metabolism)

19
Q

what are the side effects of HRT?

A
  • Breast cancer
  • Coronary heart disease
  • Deep vein thrombosis
  • stroke
  • gallstones
20
Q

what do Women’s Health Initiative (WHI) trials show about HRT and coronary heart disease?

A

WHI trials show an increased risk but there is no excess risk in younger menopausal women (50-59)

21
Q

what is seen in women >60years taking HRT?

A

increased atherosclerosis because these patients are susceptible to pro-thrombotic and pro-inflammatory effects of oestrogen

22
Q

what is tibolone and what does it reduce and promote?

A
  • a synthetic prohormone with oestrogenic, progestogenic and weak androgenic actions
  • it reduces fracture risk
  • it promotes an increased risk of stroke and possibly an increased risk of breast cancer
23
Q

what is raloxifene (SERM)?

A
  • selective oestrogen receptor modulator (SERM - selective in different tissues)
  • oestrogenic in bone (reduces risk of vertebral fractures)
  • anti-oestrogenic in breast and uterus (reduces breast cancer risk)
  • it does not reduce vasomotor symptoms and it carries an increased risk of venous-thrombo embolism and fatal stroke
24
Q

what is tamoxifen?

A
  • anti-oestrogenic on breast tissue

- used to treat oestrogen-dependent breast tumours/metastatic breast tumours

25
Q

what is premature ovarian insufficiency?

A
  • menopause occurring before age 40

- can be autoimmune, caused by surgery, chemotherapy and radiation (iatrogenic)

26
Q

what is the combined contraceptive?

A

oestrogen (ethinyl oestradiol) + progestogens (levonorgestrel or norethisterone)

27
Q

how does the contraceptive pill work?

A

by suppressing ovulation:

  • oestrogen and progesterone cause negative feedback actions at hypothalamus/pituitary which reduces fertility
  • take the pill for 21 days then stop for 7 days (or take for 12 weeks)
28
Q

when is the progesterone only contraceptive given?

A
  • smoker
  • > 35 years old (oestrogen has adverse effects in older women involving CVD)
  • migraine with aura
29
Q

why must the pill be taken at the same time every day?

A
  • short half-life

- short duration of action

30
Q

what can be given to be more long-lasting and how can it be given?

A

long acting preparations like mirena may be given via an intra-uterine system

31
Q

what are the 2 types of emergency post-coital contraception?

A

copper IUD:

  • exclude pregnancy
  • affects sperm viability and function
  • levonorgestrel (within 72hrs)

Ulipristal:

  • anti-progestin activity
  • delay ovulation by as much as 5 days
  • impairs implantation
  • can be taken up to 120hrs after intercourse

YR2 LCRS Endocrinology (18 decks)

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