8. Sex hormone responsive conditions

Question 1

Menopause and symptoms

Answer 1

When oestrogen levels decline in women between 45 - 55 years

• vaginal atrophy: walls of vagina become dry, thin and inflammed.
  Treated with topical oestrogens such as creams, tablets or rings
• vasomotor instability: such as hot flushes
  Treated with systemic oestrogens or tibolone (tablets, transdermal patch which should be applied below the waistline as breast cancer is a side effect of oestrogens)

Question 2

Hormone replacement therapy mechanism of action

Answer 2

Replaces declining oestrogen levels

Question 3

Types of oestrogens

Answer 3

Natural oestrogens
* Estrone
* Estradiol
* Estriol

Synthetic oestrogens
* Ethinylestradiol
* Mestranol

Tibolone
* oestrogenic, progestogenic and weakly androgenic

Question 4

Rationale for HRT treatment

Answer 4

In women with a uterus, in addition to oestrogen, must also give a progesterone

As osteogren can cause thickening of the endothelial lining. Progesterone prevents it from overgrowing and becoming cancerous.

The progesterone can be given cyclically or continously to avoid withdrawal bleeding. If a woman has withdrawal bleeding with a continous progestogen, endometrial cancer can be rules out.

In women without a uterus, oestrogen-only HRT would be given continously

Question 5

HRT side effects/risks

Answer 5

• Breast cancer, cervical cancer, ovarian cancer
• Venous thromboembolism
• Cardiovascular disease, e,g coronary heart disease, stroke

Question 6

When to stop HRT

Answer 6

If a patient has unexplained swelling or severe pain in the calf of one leg = Deep vein thrombosis

If a patient has sudden or severe chest pain, breathlessness, coughing up blooding with blood-stained sputum - Pulmonary embolism

Numbness on one side of the body = stroke

HRT can also cause liver dysfunction and is contraindicated in liver disease

Question 7

HRT durng surgeries

Answer 7

For major procedures HRT must be stopped 4-6 weeks before and restarted when the patient is fully mobile, as it is a great risk factor for VTE

If HRT cannot be stopped, an oral anticoagulant can be offered with stockings

Question 8

HRT and contraception

Answer 8

A women under 50 is still considered fertile 2 years after her last period. If she is free from all risk factors for a DVT can be given a low-oestrogen combined oral contraceptive

A woman over 50 is still considered fertile 1 year after her last period. Non-hormonal contracpetives such as condoms can be offered

Question 9

Testosterone mechanism of action

Answer 9

Plays a role in masculine development and spertmatogenesis

Question 10

Testosterone mechanism of action and side effects

Answer 10

Testosterone is used if there is a testosterone or androgen deficiency

Side effects:
Masculinisation, acne, anxiety, male pattern baldness

Testostergone gels should be applied to shoulders, arms, abdomen BUT NOT genital area

Question 11

Anti-oestrogens mechanism of action + example

Answer 11

Clomifene stimulates ovulation by making your body think your oestrogen levels are lower than they actually after, by causing more FSH to be made. FSH stimulates an ovary to release an egg.

It is used to treat infertility

Question 12

Clomifene side effects

Answer 12

• Ovarian cancer, so can only be used for 6 cycles only
• Multiple pregnancies