7. Menopause and HRT Flashcards

1
Q

What is the menopause?

A

permanent cessation of menses (no periods) following loss of ovarian activity

loss of oestrogen significantly impacts on women in this time of life

proportion of average female lifespan spent in menopause years: 1/3 to 1/2

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2
Q

Peri-menopause

A

transition from reproductive cycles to post menopause

typical age at start 45-50 y, median 47.5 y
mean duration: 3.8 y

few ova remain – less responsive to hormones

irregular menstrual cycles
occasional heavy bleeding
hot flushes
nervousness, irritability

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3
Q

Primary symptoms of menopause

A

Menstrual cycle changes - oligomenorrhea, amenorrhea

Vasomotor symptoms - hot flushes, night sweats

Vaginal dryness

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4
Q

Secondary symptoms of menopause

A
urinary stress/urge incontinence
cystitis-like symptoms
depression/irritability changes
musculoskeletal pains (joint aches & osteoporosis)
dry skin, hair thinning, nail changes
decreased concentration
decreased libido
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5
Q

What are the components of HRT and what do they do?

A

Oestrogen required for symptoms

Progestagens required to prevent endometrial cancer

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6
Q

Alternatives to HRT to reduce osteoperosis?

A

biphosphonates
• Aldronate
• Risedronate

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7
Q

Alternatives to HRT to reduce vasomotor symptoms

A
  • Progesterone
    • SERMS - raloxifene
    • Beta-blocker
    • Clonidine
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8
Q

Complementary and alternative therapies to HRT

A
• Phyto-oestrogens (soya bean)
	• Herbalism
		○ Black cohost
		○ St John's Wort
		○ Ginseng
		○ Oil of Evening Primrose
	• Progesterone cream
	• Homeopathy
	• Acupuncture
	• Reflexology
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9
Q

Options in HRT

A

Choice of route:

  • oral
  • patches
  • implants
  • vaginal rings
  • transdermal gel
  • nasal

Choice of dose and type of drug
Choice of regimen

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10
Q

How is HRT given?

A

Continous oestrogen:
no tablet break
No bleeding as no uterus

Continuous sequential HRT:
Oestrogen then progestogen on day 14. Sequential therapy without a tablet break. Regular bleeding at end of cycle (there is a uterus).

Continuous combined HRT:
Oestrogen and progestogen combined and given continuously, without bleeding at the end of cycle

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11
Q

No uterus HRT

A

Only oestrogen
Oestradiol 1 mg
Has to be taken continuously as symptoms return once treatment is stopped

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12
Q

HRT with a uterus

A

Oestradiol every day (white tablets)
Oestrogen plus progestagen (norgestrol) for 11 days (brown tablets)
Packet taken one after the other or with a 7 day break
Withdrawal bleeding during the brown tablets

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13
Q

Absolute contraindications to HRT

A
Pregnancy
Active venous thromboembolism
Severe active liver disease
Endometrial carcinoma with recurrence
Breast cancer with recurrence
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14
Q

Relative contraindications to HRT

A
Abnormal bleeding
Breast lump (prior to investigation)
Previous endometrial cancer
Previous breast cancer
Strong family history breast cancer
Family history of thromboembolism
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15
Q

Side effects of HRT

A
Tender or painful breasts
Fluid retention causing bloating and weight gain
Nausea
Headaches
Leg cramps
Mood swings/low mood
Acne
Backache
Lower abdominal ache
Bleeding
Stomach upset (indigestion)
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16
Q

Benefits of HRT

A

Short Term Benefits
Reduces vasomotor symptoms (eg hot flushes)
Improves psychological symptoms (eg mood swings)

Long Term Benefits
Maintains bone mass and reduces the risk of fracture
Reduces urogenital problems (eg dry vagina)
Improves skin (cosmetic)
Reduces the risk of bowel cancer
May improve balance and reduce falls – less fractures
May reduce tooth loss
May protect against arthritis

17
Q

Risk of HRT

A

Endometrial cancer (if unopposed oestrogen used)
Breast cancer
Cardiovascular disease (stroke and MI)
Venous thrombo-embolic disease (VTE)

18
Q

Endometrial cancer

A

Rare under the age of 45
Presents as post-menopausal bleeding (useful for early detection)
NHS fast track clinics
Investigation - transvaginal USS - measure the endometrial thickness - if over 5mm
Diagnosis - endometrial sample/biopsy
Treatment - hysterectomy, oophorectomy and possible radiotherapy

19
Q

Endometrial cancer risk factors

A

Obesity (endogenous oestrogens)
Unopposed HRT (oestrogens without progestagens)
Nulliparity
Late menopause
Diabetes
Family history of breast, colon and ovary Ca (genetic)

20
Q

Why is progestagen given in both COCP and HRT?

A

To prevent hyperplasia of the endometrium by allowing it to shed

21
Q

COCP

A

Ethinyl oestradiol (not natural)
Massive first pass metabolism by the liver
Increased clotting factors
High dose oestrogen suppressing GnRH/ FSH/LH
Stops ovulation
Progestagen given to prevent hyperplasia of endometrium not really to add to contraception

22
Q

HRT

A

Oestradiol (natural)
Lower dose to the body
Some increased clotting factors
Doesn’t suppress the FSH and LH to the same degree as the COCP
Doesn’t stop ovulation
Progestagen given to prevent hyperplasia of endometrium

23
Q

What was the first HRT study for heart disease?

A

the HERS study, no significant effect of HRT on heart disease

24
Q

WHI study

A

15 year programme launched in 1991 in 161,808 healthy postmenopausal women

Main outcome wanted to measure CHD and invasive breast cancer

Also measured other things: stroke, PE, endometrial cancer, colorectal cancer, hip fracture, death due to other causes

25
Q

Outcomes of WHI HRT study

A

Risks: breast cancer, VTE, coronary artery disease, stroke

Benefits: osteoperosis treatment, colon cancer, overall mortality

but: most were rather overweight and aging North American women taking one type of drug (premarin), don’t know about other drugs or populations

26
Q

RCOG guidance 2015

A

RCOG guidance 2015:

Little or no of risk of CVD with HRT under the age of 60
Risk of thrombosis with oral HRT – use gel/implants
Breast cancer risk with combined HRT – little or no risk with oestrogen alone HRT