Hormonal Replacement Therapy

Question 1

Menopause

Answer 1

• Natural process of aging
• 12 consecutive months of amenorrhoea
• Permanent cessation of menses
• The average of age of menopause is 51 years (40-60 years old)
• Genetics are associated with timing of menopause

Question 2

Pituitary & Ovarian Hormone Changes

Answer 2

1. Premenopausal Period
   - Estradiol is the major source of oestrogen produced in the ovaries
2. Menopause
   - Loss of ovarian function, decreases ovarian secretion of oestrogen & progesterone, which increases Gonadotropin
   - Oestrogen deficiency leads to Vasomotor Symptoms, Genitourinary Atrophy, Osteoporosis

Question 3

Vasomotor Symptoms

Answer 3

1. Oestrogen deficiency increases hypothalamic release of GnRH
2. GnRH nephrons are close to the temperature regulatory centre in the hypothalamus
3. Stimulation of the temperature regulates centre increases skin temperature and increases blood flow to the skin, leading to Hot Flashes (Anterior part of the body, especially face, neck, check, and lasts for a few minutes)
4. Oestrogen replacement therapy decreases GnRH production and decreases Hot Flashes

Question 4

Osteoporosis

Answer 4

1. Oestrogen Deficiency
   - Increased Ca2+ efflux from the bones, increased serum secretion leads to Vitamin D3 synthesis, which decreases Ca2+ absorption from the intestines
   - Decreased hormone calcitonin secretion, Calcitonin inhibits bone reabsorption
2. Bones become thin and weak
   - Increased risk of fractures in the vertebrae (Compression fractures and height loss), minimal - trauma fractures hip and wrist

Question 5

Genitourinary Atrophy

Answer 5

1. Genital Tract Changes
   - Vaginal: Epithelium thinning, decreased blood supply, dryness, changes of pH from acidic to alkaline, and predispose to infection. Vaginal discharge secondary to infection and Painful intercourse from dryness
   - Ovaries: Shrink
   - Uterus: Atrophy
2. Urinary Tract Changes
   - Bladder Atrophy
   - Urinary Frequency, Urgency, Incontinence, UTI

Question 6

Potential Consequences of Oestrogen Loss (Symptoms and Conditions)

Answer 6

1. Early Menopause
   - Mood disturbances
   - Depression
   - Irritability
   - Insomnia
   - Hot Flashes
   - Irregular Menstrual Cycles
   - Headaches
2. Midmenopause
   - Vaginal Atrophy
   - Increased infections
   - Painful intercourse
   - Stress Urinary Incontinence
   - Sexual Disinterest
3. Postmenopause
   - CVS Disease
   - Osteoporosis
   - Alzheimer’s-like Dementia, Colon Cancer

Question 7

Hormone Replacement Therapy (HRT)

Answer 7

1. Aims to alleviate menopausal symptoms
2. Low dose of oestrogen
   - Alone in women without a uterus (After total Hysterectomy)
   - Combination with progesterone in women without an intact uterus to protect endometrium
   - Reduce postmenopausal Osteoporosis

Question 8

Composition of HRT

Answer 8

1. Natural Oestrogen
   - More physiological effect and more appropriate for HRT
   - Conjugated oestrogen, Estradiol, Oestrone and Oestriol
2. Synthetic Oestrogen
   - Ethinylestradiol, Mestranol
3. Combined Preparation
   - With a variety of progesterones

Question 9

Recommendations of HRT

Answer 9

• Minimum effective dose for shortest duration
• Does not provide contraceptive cover

Question 10

Administration of HRT

Answer 10

1. Oral
   - Subject to first-pass metabolism
2. Transdermal route
   - More representative of endogenous hormone activity
3. Combined HRT
   - Cyclical Preparations: Facilitate regular withdrawal bleeding
   - Continuous Preparations: In postmenopausal women to prevent cyclical bleeding
4. Topical Oestrogen Locally
   - Vaginal pessaries, cream or rings to treat atrophic vaginitis

Question 11

Risks associated with HRT

Answer 11

1. Increased risk of Endometrial Cancer, Breast Cancer, Ovarian Cancer
   - Increased risk of endometrium is not opposed with progesterone
2. Cardiovascular Risk
   - No increased risk for women taking oestrogen alone
   - A small increase in risk for combined oestrogen and progesterone
3. Risk of Stroke
   - A small increase in risk in oral preparation
   - No risk with transdermal route
4. Venous Thrombotic Disease
   - Increase risk in oral preparation

Question 12

Adverse Effects of HRT

Answer 12

1. Postmenopausal Bleeding (More likely during withdrawal period if oestrogen is given cyclically with progestin)
2. Acne & Hirsutism with androgen-like progestins
3. Thrombophlebitis
4. Headache
5. Hypertension
6. Oedema
7. Weight gain
8. Nausea, Vomiting
9. Breast Tenderness

Question 13

Role of Nurse in HTN

Answer 13

1. Monitor patient closely for signs and symptoms of thrombus or embolus
2. Encourage patient to report signs of depression, decreased libido, headache, fatigue, weight gain
3. Controversy surrounds long-term use of these drugs, so teach women to be aware of current research