Hormone replacement therapy

Question 1

When is HRT used?

Answer 1

Perimenopause

Post menopause

Question 2

What is HRT used for?

Answer 2

To alleviate the symptoms of menopause

Question 3

What are menopausal symptoms caused by?

Answer 3

Decline in oestrogen

Question 4

Why is progesterone required in women with a uterus?

Answer 4

Unopposed oestrogen may increase risk of endometrial hyperplasia and cancer

Question 5

List some non-hormonal treatments for menopausal symptoms

Answer 5

Lifestyle - improve diet, exercise, weight loss, smoking cessation, reduce alcohol, reduce caffeine, reduce stress

CBT

Clonidine

SSRI antidepressants - fluoxetine

Venlafaxine - SNRI

Gabapentin

Question 6

Describe the mechanism of action of clonidine

Answer 6

Agonist of alpha-2 adrenergic receptors and imidazoline receptors in the brain

Reduces BP and HRT and can be helpful in reducing vasomotor symptoms

Question 7

List some common side effects of clonidine

Answer 7

Dry mouth
Headaches
Dizziness
Fatigue

Question 8

What can sudden withdrawal of clonidine cause?

Answer 8

Rapid increases in blood pressure and agitation

Question 9

What might black cohosh cause?

Answer 9

Liver damage

Question 10

What might dong quai cause?

Answer 10

Bleeding disorders

Question 11

What might red clover cause?

Answer 11

Oestrogenic effects concerning with oestrogen sensitive cancer

Question 12

What might evening primrose oil cause

Answer 12

Drug interactions
Clotting disorders
Seizures

Question 13

What might ging seng be beneficial for?

Answer 13

Mood and sleep

Question 14

What are the benefits of HRT

Answer 14

Improved vasomotor symptoms and other menopausal symptoms
Improved QoL
Reduced risk of oesteoporosis and fractures

Question 15

What are the risks of HRT

Answer 15

Increased risk of breast cancer with combined HRT
Increased risk of endometrial cancer
Increased risk of VTE
Increased risk of stroke and CAD
Minimal increase in ovarian cancer risk - unknown

Question 16

When are the risks of HRT apparent?

Answer 16

Long duration of HRT

Woman aged >60yrs

Question 17

List the indications for HRT

Answer 17

Replacing hormones in premature ovarian insufficiency
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 <60yrs

Question 18

How can the risks of HRT be reduced?

Answer 18

Add progesterone in women with a uterus to reduce risk of endometrial cancer

Use patches rather than pills to reduce risk of VTE, CVD and breast cancer

Question 19

List some contraindications to HRT

Answer 19

Undiagnosed abnormal bleeding
Endometrial hyperplasia or cancer
Breast cancer
Uncontrolled hypertension 
Venous thromboembolism 
Liver disease
Active angina or MI
Pregnancy

Question 20

What should be checked/considered before starting a woman on HRT

Answer 20

Full history - ensure no CI

Family history to assess the risk of oestrogen dependent cancers and VTE

Check BMI and BP
Ensure cervical and breast screening is up to date

Encourage lifestyle changes to reduce symptoms and risks

Question 21

Describe the 3 steps to consider when choosing a HRT formulation

Answer 21

Do they have local or systemic symptoms?

• Local - topical treatments (oestrogen cream/tablet)
• Systemic - systemic treatment

Does the woman have a uterus?

• No - Continous oestrogen only HRT
• Yes - combined HRT (add progesterone)

Have they had a period in the past 12months?

• Yes - cyclical combined HRT
• No - Continuous combined HRT

Question 22

Who are oestrogen patches more suitable for than oral treatment

Answer 22

Poor control

Higher risk of VTE, CVD or headaches

Question 23

Who is cyclical progesterone given to and how?

Answer 23

Progesterone given 10-14 days per month in women who have had a period in past 12 months

Question 24

When is continuous progesterone used?

Answer 24

No period in past 24 months if <50 or past 12 months if >50

Question 25

Can you switch from cyclical to continuous HRT?

Answer 25

After at least 12 months of treatment in >50 and >24 months in women <50 Switch during the withdrawal bleed

Question 26

Name the 3 ways of delivering progesterone

Answer 26

Oral Transdermal IUS

Question 27

Define progestogen

Answer 27

Any chemical that targets and stimulates progesterone receptors

Question 28

What are progestins?

Answer 28

Synthetic progestogens

Question 29

What are the two classes of progestogens? Describe them

Answer 29

C19 - testosterone, more male in their effects, norethisterone, levonorgestrel, desogestrel, helpful for women with reduced libido C21 - Progesterone, more female in their effects, progesterone, Dydrogesterone and medroxyprogesterone. Helpful for women with acne or depressed mood

Question 30

What is tibolone

Answer 30

Synthetic steroid that stimulates oestrogen and progesterone receptors and weakly stimulates androgen receptors. Useful in women with reduced libido Used as a continuous form of HRT

Question 31

Describe how testosterone may be used in HRT

Answer 31

Transdermal application

Question 32

Describe the follow up of HRT

Answer 32

3 months after initiating HRT to review symptoms and side effects

Question 33

How long does it take to feel the full effects of HRT?

Answer 33

3-6 months

Question 34

When should oestrogen containing contraceptives or HRT be stopped before surgery?

Answer 34

4 weeks before

Question 35

What contraception options are there with HRT

Answer 35

Mirena coil | Progesterone only pill

Question 36

What are the oestrogenic effects of HRT

Answer 36

``` Nausea Bloating Breast tenderness Headaches Leg cramps ```

Question 37

What are the progestogenic effects of HRT

Answer 37

``` Mood swings Bloating Fluid retention Weight gain Acne and greasy skin ```