Climacteric and Menopause - Hormonal Replacement Therapy (HRT)

Question 1

Indication of HRT.

Answer 1

1. Perimenopausal/Postmenopausal Women : Alleviate Symptoms of Menopause (Exogenous Oestrogen).
2. Reduce Osteoporosis Risk in Below 60 Women.
3. Replace Hormones in Premature Ovarian Insufficiency.

Question 2

Why does Progesterone have to be given in HRT?

Answer 2

Women with a uterus : Prevent endometrial hyperplasia and endometrial cancer secondary to ‘unopposed’ Oestrogen.

Question 3

When can HRT be used continuously and when can it not be used continuously? (2)

Answer 3

1. Continuous : Postmenopausal + Uterus + 12 Months Without Periods.
2. Cyclical : Still Have Periods (cyclical Progesterone and regular breakthrough bleeds).

Question 4

HRT Benefits vs. Risks.

Answer 4

Benefits outweigh risks in women below 60.

Question 5

Benefits of HRT (3).

Answer 5

1. Improved Vasomotor and Other Symptoms of Menopause.
2. Improved Quality of Life.
3. Reduced Risk of Osteoporosis and Fractures.

Question 6

Risks of HRT (5).

Answer 6

Increased Risk (BEVS) :-

1. Breast Cancer (Oestrogen-Only HRT < Combined HRT).
2. Endometrial Cancer (Oestrogen-Only HRT).
3. Venous Thromboembolism (2-3x) - use patches; not pills.
4. Stroke and Coronary Artery Disease (Combined HRT).

Question 7

Contraindications to HRT (8).

Answer 7

1. Undiagnosed Abnormal Bleeding.
2. Endometrial Hyperplasia/Cnacer.
3. Breast Cancer.
4. Uncontrolled Hypertension.
5. VTE.
6. Liver Disease.
7. Active Angina or MI.
8. Pregnancy.

Question 8

HRT Formulation (2).

Answer 8

1. Do they have local or systemic symptoms? (STOP : Local - Topical).
2. Does the woman have a uterus? (Oestrogen-Only vs. Combined).
3. Any periods in last 12 months? (Cyclical if Perimenopausal - Continuous if Postmenopausal).

Question 9

How can Oestrogen be delivered systemically? (2)

Answer 9

1. Oral - Tablets.

2. Transdermal - Patches/Gels (lower risk of complications) : better.

Question 10

How can Progesterone be delivered for endometrial protection? (3)

Answer 10

1. Oral - Tablets.
2. Transdermal - Patches.
3. IUS - Mirena (4 years) : best.

Question 11

Cyclical Progesterone in HRT.

Answer 11

10-14 days per month - allows breakthrough bleed.

Question 12

When can Continuous Progesterone be used in HRT?

Answer 12

If a woman does not have a period in the past :

1. 24 months if below 50.
2. 12 months if above 50.

Question 13

When can you switch from Cyclical HRT to Continuous HRT?

Answer 13

After at least 12 months of treatment over 50 and 24 months under 50, DURING WITHDRAWAL BLEED.

Question 14

What are Progestogens?
What is Progesterone?
What are Progestins?

Answer 14

Progestogens - any chemicals that target and stimulate Progesterone receptors.
Progesterone - endogenous hormone.
Progestin - synthetic Progestogens.

Question 15

What Progestogens can be used in HRT? (2)

Answer 15

1. C19 - Derived from Testosterone e.g. Norethisterone, Levonorgestrel, Desogestreol : helpful against reduced libido.
2. C21 - Derived from Progesterone e.g. Progesterone, Dydrogesterone, Medroxyprogesterone : helpful against depression and acne.

Question 16

What is Tibolone?

Answer 16

A synthetic steroid that stimulates both Oestrogen and Progesterone receptors (and weakly Androgen receptors) - form of continuous combined HRT.

Question 17

How can Testosterone be administered?

Answer 17

Transdermal application (gel or cream).

Question 18

Important Considerations with HRT (5).

Answer 18

1. Follow-up 3 months after starting.
2. Side effects persist for at least 3 months.
3. Up to 3-6 months for full useful effects.
4. Referral : Problematic/Irregular Bleeding.
5. Stop HRT 4 weeks before major surgery.

Question 19

Oestrogen Side Effects (4).

Answer 19

1. Nausea and Bloating.
2. Breast Swelling and Tenderness.
3. Headaches.
4. Leg Cramps.

Question 20

Progestogenic Side Effects (4).

Answer 20

1. Mood Swings.
2. Bloating.
3. Fluid Retention & Weight Gain.
4. Acne and Greasy Skin.

Question 21

Composition of Hormones in HRT.

Answer 21

1. Natural Oestrogens (not Ethinylestradiol like COCP).
2. Synthetic Progestogens/IUS.
3. Tibolone.