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Year 2 - ENDO > 10 - Oral contraceptives, Menopause and HRT > Flashcards

10 - Oral contraceptives, Menopause and HRT Flashcards

1
Q

What is menopause?

What is the average age for menopause?

A

Permanent cessation of menstruation (loss of ovarian follicular activity) - amenorrhoea for more than 12 months

NOTE: usually happens between 45-55 yrs. average = 51

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2
Q

What is the term given to the period of transition just before menopause? Describe this period of transition.

A

Climacteric period
You go from having normal regular cycles and then it becomes a little irregular (oligomenorrhoea) and then it progresses to amenorrhoea.

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3
Q

State some symptoms of menopause.

A
  • Hot flushes
  • Urogenital Atrophy (leads to dyspareunia – difficult or painful sexual intercourse)
  • Sleep disturbance
  • Decreased libido
  • Depression
  • Joint pain
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4
Q

Briefly describe the hypothalamic-pituitary-gonadal axis

A
  • GnRH from the hypothalamus stimulates the anterior pituitary to produce LH and FSH
  • these stimulate the ovaries to produce oestrodiol and inhibin B
  • oestrodiol and inhibin B inhibit FSH and LH secretion (negative feedback at the level of the hypothalamus and pituitary)
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5
Q

What do the ovaries produce that feeds back on the HPG axis?

A

Oestradiol and Inhibin B

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6
Q

What are the changes in feedback and the HPG axis in menopause?

A

There is a loss of ovarian follicular activity so you get a decreased production of oestradiol and inhibin
This means that there is less negative feedback on the HPG axis

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7
Q

What would you expect the LH and FSH levels of a menopausal woman to be?

A

High – because of the loss of oestrogen and inhibin production

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8
Q

What are the main complications of menopause?

A 
Osteoporosis (the protective effect of oestrogen on bone is lost)
Cardiovascular disease (women are protected against cardiovascular disease before menopause)
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9
Q

Why is HRT not just given to all post-menopausal women? What is it used for?

A

controls vasomotor symptoms (disabling hot flushes)

not used for the treatment of osteoporosis

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10
Q

When would HRT NOT be given to a post-menopausal woman?

A

to someone with ischaemic heart disease or DVT

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11
Q

What are the risks of giving (only) oestrogen as part of HRT?

A

Endometrial hyperplasia/proliferation, which increases the risk of endometrial carcinoma

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12
Q

How is the risk of endometrial hyperplasia from HRT prevented?

A

You give progesterone as well as oestrogen

The progesterone blocks this effect of oestrogen on the endometrium and, hence, prevents endometrial hyperplasia

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13
Q

In which subset of patients would you give oestrogen-only HRT?

A

Patients who have had a hysterectomy

There is no uterus so there is no endometrium to stimulate with oestrogen

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14
Q

Describe the 2 different formulations of HRT.

A

Cyclical – take oestradiol every day and then for the last 12-14 days you take progesterone
Combined continuous – take a little oestrogen and progesterone every day

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15
Q

State 4 different types of oestrogen preparations.

A

Oral oestradiol (1 mg)
Oral conjugated equine oestradiol (0.625 mg)
Transdermal oestradiol (50 mcg/day)
Intravaginal

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16
Q

Describe the absorption and metabolism of oestradiol.

A

Oestradiol is absorbed well but it is heavily metabolised in the liver (first pass) so the bioavailability is very low.
This means that in oral preparations, you must give a high dose of oestradiol.

17
Q

Name a semi-synthetic oestrogen that’s used in oral contraceptives.

A

Ethinyl oestradiol

The ethinyl group protects the drug from hepatic first pass metabolism.

18
Q

State some side-effect/risks of HRT.

A 
Breast cancer 
Coronary Heart Disease
Deep Vein thrombosis
(BCD)
Stroke 
Gallstones
19
Q

Describe the counteracting effects of oestrogens and progesterones

A

oestrogen - beneficial effect on lipid profile and endothelial function
synthetic progesterone negates these effects

20
Q

How does HRT affect cardiovascular disease risk?

A

increased risk of CHD

The timing of exposure is important in terms of cardiovascular disease risk – older patients starting on HRT have an increased risk of CHD but in younger women there’s no increased risk

Older women are more susceptible to the pro-thrombotic and pro-inflammatory effects of oestrogen

21
Q

Name a synthetic prohormone that has oestrogenic, progestogenic and weak androgenic effects.

A

Tibolone

22
Q

What is tibolone used for and what are the risks?

A

It reduces the risk of fracture

It increases the risk of stroke

23
Q

What is raloxifene and how does it work?

A
  • It is a selective oestrogen receptor modulator (SERM)
  • In bone it has oestrogenic effects and reduces the risk of fracture (used if other treatments fail in menopausal women with osteoporosis)
  • In breast and uterus it has anti-oestrogenic effects and reduces the risk of breast cancer
24
Q

What are the problems with raloxifene?

A

It is associated with an increased risk of fatal stroke and VTE

25
Q

What is tamoxifen?

A

Anti-oestrogenic on breast tissue

26
Q

What is tamoxifen used for?

A

Treatment of oestrogen-dependent breast tumours and metastatic breast cancers

27
Q

What is the term given for menopause before the age of 40?

A

Premature Ovarian Insufficiency

28
Q

Name the possible causes of Premature Ovarian Insufficiency

A

Autoimmune
Surgery
Chemotherapy
Radiotherapy

29
Q

What is the treatment for Premature Ovarian Insufficiency?

A

HRT to protect their bones

30
Q

What type of oestrogen is in the combined oral contraceptive pill?

A

Ethinyl oestradiol

31
Q

What types of progestogen is used in the combined oral contraceptive pill?

A

Levonorgestral

Norethistrone

32
Q

What other effect do progestogens have that reduces the chance of conception?

A

It thickens cervical mucus meaning that it is more difficult for sperm to penetrate it

33
Q

When would you use the progesterone only pill?

A

If oestrogen is contraindicated – this is if there is an increased risk of thrombosis (oestrogen has pro-coagulant effects)
e.g. smokers, older women, migraine with aura

34
Q

What is an important point to remember about when to take the progesterone only pill?

A

It must be taken at the same time every day

35
Q

What is the name given to the long-acting intra-uterine progesterone(-only) device?

A

Mirena

36
Q

What 3 things can you use for emergency (post-coital) contraception?

A
  • Copper IUD (affects sperm viability and inhibits fertilisation)
  • Levonorgestral (within 72 hours – high dose progesterone)
  • Ulipristal (within 120 hours)
    • Anti-progestin activity
    • Delays ovulation by as much as 5 days
    • Impairs implantation

Year 2 - ENDO (20 decks)

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