Hormone replacement therapy Flashcards
What is HRT used for?
Hormone replacement therapy (HRT) is used in perimenopausal and postmenopausal women to alleviate symptoms associated with menopause.
Which hormones are in HRT?
Menopausal symptoms are associated with a decline in the level of oestrogen. Exogenous oestrogen is given to alleviate the symptoms.
Progesterone needs to be given (in addition to oestrogen) to women that have a uterus. The primary purpose of adding progesterone is to prevent endometrial hyperplasia and endometrial cancer secondary to “unopposed” oestrogen.
Do all menopausal women need HRT?
Not all menopausal women require hormone replacement therapy. Women have often tried non-hormonal methods of controlling their symptoms before seeking help from their GP. HRT can offer very effective relief from symptoms, and in the majority of women the benefits will outweigh the risks.
TOM TIP HRT?
TOM TIP: Hormone replacement therapy is a massive topic. If you remember one thing about HRT for your exams, remember the basics of choosing the HRT regime. Women with a uterus require endometrial protection with progesterone, whereas women without a uterus can have oestrogen-only HRT. Women that still have periods should go on cyclical HRT, with cyclical progesterone and regular breakthrough bleeds. Postmenopausal women with a uterus and more than 12 months without periods should go on continuous combined HRT.
What are some non-hormonal treatments for menopausal symptoms?
Non-hormonal treatments may be tried initially, or used when there are contraindications to HRT. Options include:
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
What is clonidine?
Side effects?
Clonidine act as an agonist of alpha-2 adrenergic receptors and imidazoline receptors in the brain. It lowers blood pressure and reduces the heart rate, and is also used as an antihypertensive medication. It can be helpful for vasomotor symptoms and hot flushes, particularly where there are contraindications to using HRT.
Common side effects of clonidine are dry mouth, headaches, dizziness and fatigue. Sudden withdrawal can result in rapid increases in blood pressure and agitation.
What are some alternative remedies patients may try themselves for menopause?
Patients might try alternative remedies, although they are not generally recommended as the safety and efficacy is unclear. They can have significant side effects and interact with other medications. These alternative remedies are intended to manage the vasomotor symptoms, such as hot flushes:
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
What are the indications for HRT?
The indications for HRT are:
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 risk of osteoporosis in women under 60 years
What are the benefits of HRT?
In women under 60 years, the benefits of HRT generally outweigh the risks.
The key benefits to inform women of include:
Improved vasomotor and other symptoms of menopause (including mood, urogenital and joint symptoms)
Improved quality of life
Reduced the risk of osteoporosis and fractures
What risks are associated with HRT?
Do they apply to all women?
In women under 60 years, the benefits generally outweigh the risks.
The risks of HRT are more significant in older women and increase with a longer duration of treatment. The principal risks of HRT are:
Increased risk of breast cancer (particularly combined HRT – oestrogen-only HRT has a lower risk)
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
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 coronary artery disease with oestrogen-only HRT (the risk may even be lower with HRT)
How are the risks associated with HRT reduced?
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
What are the contraindications to HRT?
There are some essential contraindications to consider in patients wanting to start HRT:
Undiagnosed abnormal bleeding Endometrial hyperplasia or cancer Breast cancer Uncontrolled hypertension Venous thromboembolism Liver disease Active angina or myocardial infarction Pregnancy
What assessments have to be carried out before beginning HRT?
Before initiating HRT, there are a few things to check and consider:
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 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
What factors influence the choice of HRT formulation?
There are three steps to consider when choosing the HRT formulation:
Step 1: Do they have local or systemic symptoms?
Local symptoms: use topical treatments such as topical oestrogen cream or tablets
Systemic symptoms: use systemic treatment – go to step 2
Step 2: Does the woman have a uterus?
No uterus: use continuous oestrogen-only HRT
Has uterus: add progesterone (combined HRT) – go to step 3
Step 3: Have they had a period in the past 12 months?
Perimenopausal: give cyclical combined HRT
Postmenopausal (more than 12 months since last period): give continuous combined HRT
What are the options for oestrogen delivery in HRT?
Oestrogen is the critical component of HRT for reducing the symptoms of menopause. There are two options for delivering systemic oestrogen:
Oral (tablets)
Transdermal (patches or gels)
Patches are more suitable for women with poor control on oral treatment, higher risk of venous thromboembolism, cardiovascular disease and headaches.