7. Menopause and HRT Flashcards
What is the menopause?
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
Peri-menopause
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
Primary symptoms of menopause
Menstrual cycle changes - oligomenorrhea, amenorrhea
Vasomotor symptoms - hot flushes, night sweats
Vaginal dryness
Secondary symptoms of menopause
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
What are the components of HRT and what do they do?
Oestrogen required for symptoms
Progestagens required to prevent endometrial cancer
Alternatives to HRT to reduce osteoperosis?
biphosphonates
• Aldronate
• Risedronate
Alternatives to HRT to reduce vasomotor symptoms
- Progesterone
- SERMS - raloxifene
- Beta-blocker
- Clonidine
Complementary and alternative therapies to HRT
• Phyto-oestrogens (soya bean) • Herbalism ○ Black cohost ○ St John's Wort ○ Ginseng ○ Oil of Evening Primrose • Progesterone cream • Homeopathy • Acupuncture • Reflexology
Options in HRT
Choice of route:
- oral
- patches
- implants
- vaginal rings
- transdermal gel
- nasal
Choice of dose and type of drug
Choice of regimen
How is HRT given?
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
No uterus HRT
Only oestrogen
Oestradiol 1 mg
Has to be taken continuously as symptoms return once treatment is stopped
HRT with a uterus
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
Absolute contraindications to HRT
Pregnancy Active venous thromboembolism Severe active liver disease Endometrial carcinoma with recurrence Breast cancer with recurrence
Relative contraindications to HRT
Abnormal bleeding Breast lump (prior to investigation) Previous endometrial cancer Previous breast cancer Strong family history breast cancer Family history of thromboembolism
Side effects of HRT
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)
Benefits of HRT
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
Risk of HRT
Endometrial cancer (if unopposed oestrogen used)
Breast cancer
Cardiovascular disease (stroke and MI)
Venous thrombo-embolic disease (VTE)
Endometrial cancer
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
Endometrial cancer risk factors
Obesity (endogenous oestrogens)
Unopposed HRT (oestrogens without progestagens)
Nulliparity
Late menopause
Diabetes
Family history of breast, colon and ovary Ca (genetic)
Why is progestagen given in both COCP and HRT?
To prevent hyperplasia of the endometrium by allowing it to shed
COCP
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
HRT
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
What was the first HRT study for heart disease?
the HERS study, no significant effect of HRT on heart disease
WHI study
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
Outcomes of WHI HRT study
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
RCOG guidance 2015
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
