BMS-Menopause

Question 1

Talking about women age 50-59-how many extra cases of breast cancer will there be per 1000 women over 5 years in women taking combined HRT?

Answer 1

4

Question 2

Talking about women age 50-59-how many extra cases of breast cancer will there be per 1000 women over 5 years in women with a BMI >30?

Answer 2

24

Question 3

Talking about women age 50-59-how many fewer cases of breast cancer will there be per 1000 women over 5 years in women who take 2.5hrs moderate exercise a week?

Answer 3

7

Question 4

Talking about women age 50-59-how many extra cases of breast cancer will there be per 1000 women over 5 years in women who drink 2+ units?

Answer 4

5

Question 5

What’s the point in all those stats?

Answer 5

Consider HRT in context of other modifiable risk factors

Question 6

In women with HIV what 2 things do you need to consider re HRT?

Answer 6

1. Drug interactions with ART
2. Use transdermal due to increased clot risk
   Otherwise just treat as per guidelines

Question 7

Can women with migraine with aura have HRT?

Answer 7

Yes-use transdermal and continuous (eg LNG-IUD) if possible to avoid fluctuating levels

Question 8

How do you approach HRT post hysterectomy & BSO in people with endometriosis?

Answer 8

Give E and P-at least to start-little evidence but prevent theoretical risk of E alone activating any extrauterine deposits of endo/stimulating malignant transformation

Question 9

Is CBT effective for hot sweats in menopause?

Answer 9

Yes

Question 10

What should you tell women about applying Testosterone gel?

Answer 10

Lower abdo/thighs, let it dry, wash hands after (don’t touch kids etc), don’t wash off for 2-3 hours

Question 11

What bloods/how often for T?

Answer 11

Total testosterone always:
Prior to starting
Approx 3-6 weeks after starting
At least annually

Rarely do SHBG (If high eg with oral E may explain lack of effect of T…if low may explain androgenic SE’s)

Question 12

In women with low libido on oral HRT what should you do?

Answer 12

Consider transdermal (to decrease SHBG)

Question 13

Women with breast cancer on tamoxifen what are the non hormonal alternatives to hrt to avoid?

Answer 13

Sertraline, paroxetine and fluoxetine-they render it less effective
Better is Citalopram.
Best is Venlafaxine (in terms metabolism of tamoxifen)

Question 14

Apart from SSRI/SNRI what other non hormonal medications are there for hot sweats?

Answer 14

Gabapentin (900mg effective in 50 % hot flushes)
Pregabalin (50-300mg) better tolerated same effect as above
Clonidine (start 25-50mcg bd) only licensed option-poor sleep

Question 15

How many days of progestogen are needed in a sequential HRT regime for endometrial protection?

Answer 15

12-14 (at least same as natural luteal phase)

Question 16

What is the risk that favours switch to continuous HRT after 5+ years of sequential HRT?

Answer 16

Possible increased risk of endometrial hyperplasia and cancer with sequential > 5 years (but not before)

Question 17

In who should you start sequential HRT?

Answer 17

Women with a uterus who have had a period in last year (or in POI in last 2 years)

Question 18

What do you need to remember about HRT and subtotal hysterectomy?

Answer 18

trial sequential combined to start with -switch to E only if no bleeding ie no residual endometrium in stump

Question 19

What are the usual doses of micronised progesterone? Uterogestan

Answer 19

Sequential 200mg 12-14 days
Conti 100mg daily

Can increase both by 100mg eg if taking high dose E or if unscheduled bleeding a problem

Question 20

When do you worry about unscheduled bleeding on HRT?

Answer 20

After 4-6 months and tried changing progestogen if persists then investigate (or ‘if concerned’ before then)

Question 21

What % of women are menopausal by 54?

Answer 21

80%

Question 22

What are the 3 potential benefits of HRT?

Answer 22

Symptom control
Bone health
If < 60/< 10 years after LMP cardiac benefits too

Question 23

In who do you diagnose POI?

Answer 23

under 40
FSH x2 > 30 4-6 weeks apart
ammen/oligo >3/12

Question 25

Who cannot have paroextine or fluoxetine?

Answer 25

Prescribed tamoxifen-reduces efficacy

Question 26

When do you use clonidine?

Answer 26

Vasomotor can’t have hrt
50-75mcg BD
Dry mouth sedation dizziness nausea