Hormone replacement therapy Flashcards
When is HRT used?
Perimenopause
Post menopause
What is HRT used for?
To alleviate the symptoms of menopause
What are menopausal symptoms caused by?
Decline in oestrogen
Why is progesterone required in women with a uterus?
Unopposed oestrogen may increase risk of endometrial hyperplasia and cancer
List some non-hormonal treatments for menopausal symptoms
Lifestyle - improve diet, exercise, weight loss, smoking cessation, reduce alcohol, reduce caffeine, reduce stress
CBT
Clonidine
SSRI antidepressants - fluoxetine
Venlafaxine - SNRI
Gabapentin
Describe the mechanism of action of clonidine
Agonist of alpha-2 adrenergic receptors and imidazoline receptors in the brain
Reduces BP and HRT and can be helpful in reducing vasomotor symptoms
List some common side effects of clonidine
Dry mouth
Headaches
Dizziness
Fatigue
What can sudden withdrawal of clonidine cause?
Rapid increases in blood pressure and agitation
What might black cohosh cause?
Liver damage
What might dong quai cause?
Bleeding disorders
What might red clover cause?
Oestrogenic effects concerning with oestrogen sensitive cancer
What might evening primrose oil cause
Drug interactions
Clotting disorders
Seizures
What might ging seng be beneficial for?
Mood and sleep
What are the benefits of HRT
Improved vasomotor symptoms and other menopausal symptoms
Improved QoL
Reduced risk of oesteoporosis and fractures
What are the risks of HRT
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
When are the risks of HRT apparent?
Long duration of HRT
Woman aged >60yrs
List the indications for HRT
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
How can the risks of HRT be reduced?
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
List some contraindications to HRT
Undiagnosed abnormal bleeding Endometrial hyperplasia or cancer Breast cancer Uncontrolled hypertension Venous thromboembolism Liver disease Active angina or MI Pregnancy
What should be checked/considered before starting a woman on HRT
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
Describe the 3 steps to consider when choosing a HRT formulation
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
Who are oestrogen patches more suitable for than oral treatment
Poor control
Higher risk of VTE, CVD or headaches
Who is cyclical progesterone given to and how?
Progesterone given 10-14 days per month in women who have had a period in past 12 months
When is continuous progesterone used?
No period in past 24 months if <50 or past 12 months if >50
Can you switch from cyclical to continuous HRT?
After at least 12 months of treatment in >50 and >24 months in women <50
Switch during the withdrawal bleed
Name the 3 ways of delivering progesterone
Oral
Transdermal
IUS
Define progestogen
Any chemical that targets and stimulates progesterone receptors
What are progestins?
Synthetic progestogens
What are the two classes of progestogens? Describe them
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
What is tibolone
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
Describe how testosterone may be used in HRT
Transdermal application
Describe the follow up of HRT
3 months after initiating HRT to review symptoms and side effects
How long does it take to feel the full effects of HRT?
3-6 months
When should oestrogen containing contraceptives or HRT be stopped before surgery?
4 weeks before
What contraception options are there with HRT
Mirena coil
Progesterone only pill
What are the oestrogenic effects of HRT
Nausea Bloating Breast tenderness Headaches Leg cramps
What are the progestogenic effects of HRT
Mood swings Bloating Fluid retention Weight gain Acne and greasy skin
