Hormonal Replacement Therapy (HRT) Flashcards
Indications for HRT
Used perimenopausal and postmenopausal to alleviate symptoms associated with the menopause
- decline in the level of oestrogen
(so oestrogen is given to alleviate)
exogenous oestrogen and progesterone
exogenous oestrogen and need to give progesterone to women that have a uterus.
progesterone is to prevent endometrial hyperplasia and endometrial cancer 2’ to unopposed oestrogen
(women without a uterus can have oestrogen-only HRT with cyclical progesterone and regular breakthrough bleeds)
postmenopausal with a uterus and more than 12 months without period should go on continuous combined HRT
non-hormonal treatment for menopausal symptoms
Lifestyle changes such as improving the diet, exercise, weight loss, smoking cessation, reducing alcohol, reducing caffeine and reducing stress
Cognitive behavioural therapy (CBT)
Clonidine, which is an agonist of alpha-adrenergic and imidazoline receptors
SSRI antidepressants (e.g. fluoxetine)
Venlafaxine, which is a selective serotonin-norepinephrine reuptake inhibitor (SNRI)
Gabapentin
clonidine
agonist of alpha-2 adrenergic receptors and imidazoline receptors in the brain.
lowers blood pressure and reduces the heart rate, and is also used as an antihypertensive medication.
can be helpful for vasomotor symptoms and hot flushes, particularly where there are contraindications to using HRT.
side effects: dry mouth, headaches, dizziness and fatigue. Sudden withdrawal can result in rapid increases in blood pressure and agitation.
alternative remedies for HRT
Black cohosh, which may be a cause of liver damage
Dong quai, which may cause bleeding disorders
Red clover, which may have oestrogenic effects that would be concerning with oestrogen sensitive cancers
Evening primrose oil, which has significant drug interactions and is linked with clotting disorders and seizures
Ginseng may be used for mood and sleep benefits
indications for HRT
Replacing hormones in premature ovarian insufficiency, even without symptoms
Reducing vasomotor symptoms such as hot flushes and night sweats
Improving symptoms such as low mood, decreased libido, poor sleep and joint pain
Reducing the risk of osteoporosis in women under 60 years
benefits and risk of HRT
Improved vasomotor and other symptoms of the menopause (including mood, urogenital and joint symptoms)
Improved quality of life
Reduced the risk of osteoporosis and fractures
in women <60, the benefit outweighs the risks
Increased risk of breast cancer
Increased risk of endometrial cancer
Increased risk of venous thromboembolism (2 – 3 times the background risk)
Increased risk of stroke and coronary artery disease with long term use in older women
The evidence is inconclusive about ovarian cancer, and if there is an increase in risk, it is minimal
risks HRT and to reduce risks
These risks do not apply to all women:
The risks are not increased in women under 50 years compared with other women their age
There is no risk of endometrial cancer in women without a uterus
There is no increased risk of breast cancer with oestrogen-only HRT (the risk may even be reduced on treatment)
There is no increased risk of cardiovascular disease with oestrogen-only HRT (the risk may even be lower with HRT)
Ways to reduce the risks:
The risk of endometrial cancer is greatly reduced by adding progesterone in women with a uterus
The risk of VTE is reduced by using patches rather than pills
The risk of breast cancer can be reduced by using local progestogens (i.e. Mirena coil) rather than systemic
The risk of cardiovascular disease can be reduced by using local progestogens (i.e. Mirena coil) rather than systemic
HRT contraindications
Undiagnosed abnormal bleeding Endometrial hyperplasia or cancer Breast cancer Uncontrolled hypertension Venous thromboembolism Liver disease Active angina or myocardial infarction Pregnancy
HRT assessment before HRT
Take a full history to ensure there are no contraindications
Take a family history to assess the risk of oestrogen dependent cancers (e.g. breast cancer) and VTE
Check the body mass index (BMI) and blood pressure
Ensure cervical and breast screening is up to date
Encourage lifestyle changes that are likely to improve symptoms and reduce risks
