2.11 Hormone Replacement Therapy Flashcards
What two patient characteristics largely shape HRT choice? How?
do they have a uterus?
Yes - need endometrial protection ie progesterone
No - can use oestrogen alone
are they postmenopaus?
Yes - continuous HRT
No - cyclical HRT with breakthrough bleeds
What are 6 non-hormonal treatments for menopause symptoms? (4 drugs)
- lifestyle changes (diet, smoking, alcohol, caffeine, stress)
- CBT
- clonidine (alpha adr and imidazoline receptor agonist)
- SSRI antidepressants (fluoxetine)
- venlafaxine (SNRI)
- gabapentin
How does clonidine work and what are some side effects?
agonist of alpha-2 ADR and imidazole receptors in brain: reduce BP and HR
helps the vasomotor Sx and hot flushes, also used in HTN and ADHD.
SE: dry mouth, headaches, dizziness, fatigue, sudden withdrawal gives increase BP and agitation.
Name 5 alternative remedies patients may try and their risks?
- black cohosh - can cause liver damage
- dong quai - can cause bleeding disorders
- red clover - oestrogenic effects that may be concerning in oestrogen sensitive cancer
- evening primrose oil - drug interactions, clotting and seizures
- ginseng - mood and sleep benefits
4 indications for HRT?
- replace hormones in premature ovarian failure even if symptoms are absent
- reduce vasomotor symptoms eg flushes and night sweats
- improves symptoms of low mood, decreased libido, sleep, joint pain
- reduce the risk of osteoporosis in women under 60
4 risks of HRT?
Increased risk of:
- breast cx (from progesterones)
- endometrial cx (reduced by progesterones)
- VTE (3x the usual risk)
- stroke and CVD in older women
How can you reduce the risks of HRT?
- give progesterones to reduce endometrial cx risk
- use patches to reduce VTE
- local progesterones (mirena) reduce breast cx risk and CVD risk
8 contraindications to HRT
- undiagnosed abnormal bleeding
- endometrial hyperplasia or cx
- breast cx
- uncontrolled HTN
- VTE
- liver disease
- angina or MI
- pregnancy
General history things to check before HRT prescription?
- FHx of oestrogen cx eg breast cancer
- FHx of VTE
- cervical smears up to date
- any contraindications
- BMI and BP
- encourage lifestyle changes
3 steps to choosing the right HRT for a woman?
- Local or systemic Sx? (local just use topical oestrogen) (Systemic then proceed to step 2)
- Do they have uterus? (no uterus use oestrogen-only) (has uterus, add progesterone and go to step 3)
- Period in the last 12 months? (perimenopausal: cyclical combined HRT) (postmenopausal: continuous combined HRT)
What are the two option for oestrogen delivery for HRT?
oral
patches / gels
better for VTE risk, CVD and headaches
Why do you give progesterone in HRT?
reduce endometrial hyperplasia and cx risk in a woman with a uterus.
What are the two option for oestrogen delivery for HRT?
cyclical (given 10-14 days per month for women who had a period in the last year/2years, allows breakthrough bleed)
continuous
When do you give continuous progesterone?
over 50 and no period for a year
under 50 and no period for 2 years
How can you administer the progesterone in HRT?
oral (can be combined pills that have a break in progesterone)
patches
mirena coil
