hormone replacement therapy

Question 1

when does progesterone need to be given with oestrogen

Answer 1

women that have a uterus

Question 2

why is progesterone given to women with a uterus

Answer 2

prevent endometrial hyperplasia and endometrial cancer secondary to unopposed oestrogen

Question 3

clonidine

Answer 3

agonist of alpha-2 andrenergic receptora and imidazoline receptors

helpful for vasomotor sympotms when there are contraindications to HRT

Question 4

indications for HRT

Answer 4

• replacing hormones in premature ovarian insufficiency even w/o symptoms
• reducing vasomotor symptoms
• improving low mood,, dec libido, sleep, joint pain
• reducing risk osteoporosis in women<60

Question 5

HRT in women <60

Answer 5

benefits generally outweigh the risk

Question 6

key benefits

Answer 6

improved vasomotor and other symptoms
improved QoL
reduce risk osteoporosis and fractures

Question 7

risks of HRT

Answer 7

breast cancer
endometrial cancer
VTE
stroke, CAD

Question 8

ways to reduce risk VTE

Answer 8

using patch rather than tablets

Question 9

contraindications to HRT

Answer 9

• undiagnosed abnormal bleeding
• endometrial hyperplasia/Ca
• breast cancer
• uncontrolled htn
• VTE
• liver disease
• active angina or MI
• pregnancy

Question 10

assessment before HRT

Answer 10

• full Hx to ensure no contraindications
• FHx to assess risk oestrogen dependent cancers and VTE
• check BMI and BP
• ensure breast and cervical screening up to date
• lifestyle changes

Question 11

3 steps to consider when choosing formualtion

Answer 11

1. local or systemic symptoms?
2. uterus present?
3. period in past 12mo?

Question 12

choosing formulation: do they have local or systemic symptoms

Answer 12

local = topical treatment e.g. oestrogen cream

systemic = systemic treatment , go to step 2

Question 13

choosing formulation: do they have a uterus

Answer 13

no = use continuous oestrogen only HRT

yes = add progesterone (combined HRT), go to step 3

Question 14

choosing formulation: have they had a period in the last 12mo

Answer 14

perimenopausal = cyclical combined HRT

postmenopausal = continuous combined HRT

Question 15

options for oestrogen delivery

Answer 15

oral - tablets
transdermal - patches, gels

patches more suitable if higher risk VTE, CVD, headaches

Question 16

cyclical progesterone

Answer 16

give for 10-14days per month

allows patients to have monthly breakthrough bleed during oestrogen only part of cycle

Question 17

continuous progesterone

Answer 17

used if women has not had period in the past

• 24mo if < 50yrs
• 12mo if >50yrs

Question 18

use of continuous combined HRT before postmenopause

Answer 18

can lead to irregular breakthrough bleeding

Question 19

switching from cyclical to continuous HRT

Answer 19

after 12mo of Rx in women >50 yrs

after 24mo of Rx in women < 50yrs

Question 20

options for progesterone delivery

Answer 20

oral - tablets
transdermal patches
mirena coil

Question 21

Progestogens

Answer 21

target and stimulate progesterone receptors

Question 22

progestins

Answer 22

synthetic progestogens

Question 23

best way of delivering oestrogen

Answer 23

patches due to decreased risk VTE

Question 24

tibolone

Answer 24

synthetic steroid that stimulates oestrogen and progesterone receptors

used as form of continuous combined HRT

Question 25

follow up

Answer 25

3mo after initiating HRT to review symptoms and side effect

Question 26

problematic or irregular bleeding

Answer 26

gynae referral

Question 27

woman on HRT due to have major surgery

Answer 27

stop oestrogen containing contraceptive or HRT 4wks before major surgery

Question 28

symptoms persisting despite HRT

Answer 28

consider other symptoms causes e.g. liver, thyroid, diabetes

Question 29

oestrogenic side effects

Answer 29

nausea + bloating
breast swelling, tenderness
headaches
leg cramps

Question 30

progestogenic side effects

Answer 30

mood swings
bloating 
fluid retention 
weight gain 
acne