Hormone Replacement Therapy Flashcards
When giving oestrogen as HRT, what else needs to be given to women that have a uterus? Why?
Progesterone
To prevent endometrial hyperplasia and endometrial cancer secondary to “unopposed” oestrogen.
What non-hormonal treatments can be used for menopausal symptoms?
- Lifestyle changes
- CBT
- Clonidine (agonist of alpha-2 adrenergic receptors and imidazoline receptors)
- SSRI antidepressants
- Venlafaxine (SNRI)
- Gabapentin
How can clonidine be helpful in the management of menopausal symptoms?
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.
What are common side effects of clonidine?
- Dry mouth
- Headaches
- Dizziness
- Fatigue
What can sudden withdrawal of clonidine result in?
Rapid increases in blood pressure and agitation.
What is a potential side effect of black cohosh?
Liver damage
What is a potential side effect of dong quai?
Bleeding disorders
What is a potential side effect of red clover?
Oestrogenic effects that would be concerning with oestrogen sensitive cancers.
What is a potential side effect of evening primrose oil?
Significant drug interactions and is linked with clotting disorders and seizures.
What is ginseng used for?
Mood and sleep benefits
Name 4 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 risk of osteoporosis in women under 60 years
In what age group does HRT benefits generally outweigh the risks?
Women under 60
List 5 risks of HRT.
- Increased risk of breast cancer
- Increased risk of endometrial cancer
- Increased risk of VTE (2-3x)
- Increased risk of stroke and CAD with long term use in older women
- Inconclusive evidence r.e. ovarian cancer (if any, minimal risk)
What type of HRT increases the risk of breast cancer the most?
Combined HRT - oestrogen-only HRT has lower risk
In what groups do the risk of HRT not apply?
- Risks are not increased in women under 50 compared with other women of their age
- No risk of endometrial cancer in women without a uterus
- No increased risk of CAD with oestrogen-only HRT
How can the risk of endometrial cancer due to HRT be reduced?
Adding progesterone
How can the risk of VTE be reduced?
Using patches instead of pills
List 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 MI
- Pregnancy
Describe what needs to be checked and considered before starting HRT.
- Take full history to ensure no contraindications
- Take family history to assess risk of oestrogen dependent cancers and VTE
- Check BMI and BP
- Ensure cervical and breast screening up to date
- Encourage lifestyle changes that are likely to improve symptoms and reduce risks
How can menopause symptoms be split into two groups?
- Local symptoms
2. Systemic symptoms
What type of HRT is best for a women with no uterus?
Use continuous oestrogen-only HRT
What type of HRT is best for a women with a uterus?
Combined HRT
What type of HRT is best for a women with a uterus who is perimenopausal?
Cyclical combined HRT
What type of HRT is best for a women with a uterus who is postmenopausal (>12 months since last period)?
Continuous combined HRT
What are two options for delivering systemic oestrogen?
- Orally (tablets)
2. Transdermally (patches or gels)
For what women are patches more suitable than oral treatment?
- Poor control on oral treatment
- Those at higher risk of VTE
- Cardiovascular disease
- Headaches
When and how is cyclical progesterone given?
Given for 10-14 days per month.
Used for women that have had a period within the past 12 months.
Cycling progesterone allows patients to have monthly breakthrough bleeding during the oestrogen-only part of the cycle, similar to a period.
When and how is continuous progesterone given?
Used when women has not had period in past:
24 months if under 50
or
12 months if over 50
Why should continuous combined HRT before postmenopause be avoided?
Can lead to irregular breakthrough bleeding and investigation for other underlying causes of bleeding.
When can HRT be swtiched from cyclical to continuous HRT?
When exactly in the cycle should it be switched?
After at least 12 months of treatment in women over 50, and 24 months in women under 50.
Switch from cyclical to continuous HRT during the withdrawal bleed.
Does continuous or cyclical HRT provide better endometrial protection?
Continuous.
What are free options for delivering progesterone for endometrial protection?
- Tablets
- Patches
- Intrauterine system (e.g. mirena coil)
How long is the mirena coil licensed for for endometrial protection?
Four years
What are progestogens?
Refers to any chemicals that target and stimulate progesterone receptors
What is progesterone?
The hormone produced naturally in the body
What are progestins?
Synthetic progestogens
What are the two main progestogen classes?
- C19
2. C21
What should you consider if a women has side effects from a progestogen?
Consider switching progestogen class.
What are C19 progestogens derived from?
Testosterone
Name three examples of C19 progestogens.
- Norethisterone
- Levonorgestrel
- Desogestrel
What are C21 progestogens derived from?
Progesterone
Name three examples of C21 progestogens.
- Progesterone
- Dydrogesterone
- Medroxyprogesterone
What class of progestogen is more helpful in women with reduced libido?
C19 progestogens (testosterone-derived)
What class of progestogen is more helpful in women with side effects e.g. depressed mood or acne?
C21 progestogens (progesteron-derived)
What is the best way of delivering oestrogen? Why?
With patches due to reduced risk of venous-thromboembolism.
What is the best way of providing progesterone?
IUD e.g. mirena coil - benefits of contraception, treating heavy periods and no progestogenic side effects
What is tibolone?
Form of continuous combined HRT - synthetic steroid that stimulates oestrogen and progesterone receptors. Also weakly stimulates androgen receptors.
What is the significance of tibolone stimulating androgen receptors?
Can be helpful for patients with reduced libido.
What women are suitable for tibolone?
More than 12 months without a period (24 months if under 50).
When might testosterone be used?
For women with low energy and reduced libido.
How is testosterone given?
Transdermally (gel or cream)
When should a patient be followed up after initiating HRT?
After 3 months
What should patients be advised r.e. early side effects of HRT?
Often settle with time, so worth persisting for at least 3 months with each regime.
How long does it take to gain the full effect of HRT?
3-6 months
How should women on HRT with problematic or irregular bleeding be managed?
Unscheduled bleeding can occur in the first 3 – 6 months of HRT (in women with a uterus). If unscheduled bleeding continues, consider referral for investigations, particularly regarding endometrial cancer.
Why is oestrogen-containing contraceptives or HRT relevant to major surgery?
Should be stoped 4 weeks before major surgery.
What are two contraception options commonly used alongside HRT?
- Mirena coil
2. Progesterone only pill
List oestrogenic side effects.
- Nausea and bloating
- Breast swelling
- Breast tenderness
- Headaches
- Leg cramps
List progestogenic side effects.
- Mood swings
- Bloating
- Fluid retention
- Weight gain
- Acne and greasy skin
How should HRT be stopped?
There is no specific regime for stopping HRT. It can be reduced gradually or stopped abruptly, depending on the preference of the woman. This choice does not affect long term symptoms. Gradually reducing the HRT may be preferable to reduce the risk of symptoms recurring suddenly.
