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Y4 - GOSH > Hormone Replacement Therapy > Flashcards

Hormone Replacement Therapy Flashcards

1
Q

What is the purpose of HRT and how does it work?

A
  • it is given to perimenopausal / menopausal women to alleviate their symptoms
  • their symptoms are caused by a decline in oestrogen
  • exogenous oestrogen is given to alleviate the symptoms
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2
Q

How is HRT different in women who have a uterus?

A
  • progesterone needs to be given in addition to oestrogen
  • progesterone prevents endometrial hyperplasia + endometrial cancer secondary to “unopposed” oestrogen
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3
Q

What are the non-hormonal treatments for menopausal symptoms that may be trialled prior to HRT?

A
  • lifestyle changes
  • CBT
  • clonidene
  • SSRI antidepressants
  • venlafaxine (SNRI)
  • gabapentin

SNRI = selective serotonin-norepinephrine reuptake inhibitor

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4
Q

How does clonidene work?

A
  • it is an agonist of alpha-2 adrenergic receptors + imidazoline receptors in the brain
  • it lowers the BP + reduces HR
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5
Q

When is clonidene used?

A
  • it can be used to relieve the vasomotor symptoms + hot flushes associated with menopause
  • particularly where there are contraindications to HRT
  • it is also used as an antihypertensive medication
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6
Q

What are the side effects associated with clomidene?

A
  • dry mouth
  • headaches
  • dizziness
  • fatigue
  • sudden withdrawal can result in rapid increases in BP + agitation
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7
Q

What advice is given about alternative remedies for menopausal symptoms?

A

NOT RECOMMENDED

  • their safety / efficacy is unclear
  • many have significant adverse effects and interact with other medications
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8
Q

What are the 4 indications for HRT?

A
  • replacing hormones in premature ovarian insufficiency (even without symptoms)
  • reducing vasomotor symptoms
  • improving symptoms such as low mood, poor sleep, decreased libido + joint pain
  • reducing the risk of osteoporosis in women < 60
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9
Q

What is the advice given about the risks / benefits of HRT in younger women?

A

the benefits generally outweigh the risks in women < 60

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10
Q

What are the key benefits of HRT that should be highlighted to the patient?

A
  • improvement of vasomotor symptoms + others (e.g. mood, joint pain, etc.)
  • improved quality of life
  • reduced risk of osteoporosis / fractures
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11
Q

What are the risks associated with HRT that it is important to make the patient aware of?

Who is more affected by these risks?

A
  • increased risk of breast cancer (particularly with combined HRT)
  • increased risk of endometrial cancer
  • increased risk of VTE by 2-3x
  • increased risk of stroke / coronary artery disease in older women with long-term use

  • the risks are more significant in older women
  • the risk increases with a longer duration of treatment
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12
Q

Which groups of individuals may not be affected by the risks of HRT?

A
  • the risks are NOT increased in women < 50 compared with other women their age
  • there is no risk of endometrial cancer if the woman does not have a uterus
  • there is no increased risk of coronary artery disease with oestrogen-only HRT
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13
Q

How can the risk of endometrial cancer / VTE be reduced?

A
  • the risk of endometrial cancer is reduced by adding progesterone in women with a uterus
  • the risk of VTE is reduced by using patches rather than pills
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14
Q

What are the contraindications to starting HRT?

A
  • undiagnosed abnormal bleeding
  • endometrial hyperplasia / cancer
  • breast cancer
  • uncontrolled hypertension
  • VTE
  • active angina / MI
  • liver disease
  • pregnancy
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15
Q

What 5 things must be assessed prior to starting HRT?

A
  • take a full history to identify any contraindications
  • assess family history of oestrogen-dependent cancers + VTE
  • BMI and BP
  • ensure cervical + breast screening is up to date
  • encourage lifestyle changes that will improve symptoms / reduce risks
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16
Q

What are the 3 steps that must be considered when choosing the HRT formulation?

A

1 - Do they have local or systemic symptoms?

  • local - consider topical treatments
  • systemic - move to step 2

2 - Do they have a uterus?

  • no - use continuous oestrogen only HRT
  • yes - use combined HRT (with progesterone) + move to step 3

3 - Have they had a period in the last 12 months?

  • yes - use cyclical combined HRT
  • no - use continuous combined HRT
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17
Q

What are the 2 options for delivreing systemic oestrogen?

A
  • oral through tablets
  • transdermal through patches / gels
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18
Q

What are the 2 options for delivreing systemic oestrogen?

A
  • oral through tablets
  • transdermal through patches / gels
19
Q

In which women may patches be a better alternative to pills?

A
  • women with poor control over oral treatment
  • women at higher risk of VTE, cardiovascular disease or headaches
20
Q

What are the 2 options for progesterone delivery?

A
  • cyclical progesterone
  • continuous progesterone

progesterone is only required in women who have a uterus

21
Q

How is cyclical progesterone given and who is this recommended for?

A
  • given for 10-14 days each month
  • used for women who are perimenopausal (have had a period in the last 12 months)
  • cycling the progesterone allows patients to have a monthly breakthrough bleed during the oestrogen-only part of the cycle
22
Q

When is continuous progesterone used?

A
  • if a woman < 50 has not had a period in the last 24 months
  • if a woman > 50 has not had a period in the last 12 months
23
Q

Why should continuous combined HRT not be used prior to the menopause?

A
  • it can lead to irregular breakthrough bleeding
  • this often leads to investigation for an underlying cause of the bleeding
24
Q

When can a switch from cyclical to continuous HRT be made?

A
  • after at least 12 months of treatment in women > 50

OR

  • after at least 24 months of treatment in women < 50
  • the switch needs to be made during the withdrawal bleed
25
Q

What is the purpose of switching from cyclical to continuous HRT?

A

continuous HRT has better endometrial protection than cyclical HRT

26
Q

What are the 3 options for delivering progesterone for endometrial protection?

A
  • oral through tablets
  • transdermal through patches
  • intrauterine system (Mirena coil)
27
Q

For how long does the Mirena coil provide endometrial protection for?

A

4 years

  • after this time it needs replacing
28
Q

What are the added benefits of using the Mirena coil?

A
  • it provides contraception
  • it can treat heavy menstrual periods
29
Q

What is important to tell women about the Mirena coil?

A
  • it can cause irregular bleeding / spotting in the first few months after insertion
  • this usually settles with time and most women become amenorrhoeic
30
Q

What are the 2 progestogen classes used in HRT?

A

C19 and C21 progestogens

  • this refers to the number of carbon atoms
  • if a woman experiences side effects, consider switching progestogen classes
31
Q

When are C19 progestogens usually chosen?

What are some examples?

A
  • they are derived from testosterone and are more “male” in their effects
  • helpful for women with reduced libido
  • including norethisterone, levonorgestrel and desogestrel
32
Q

When are C21 progestogens typically chosen?

What are some examples?

A
  • they are derived from progesterone and are more “female” in their effects
  • useful for side effects such as acne or low mood
  • includes dydrogesterone and medroxyprogesterone
33
Q

What are the “best” ways to deliver oestrogen and progesterone?

A
  • it is best to deliver oestrogen through a patch due to the decreased risk of VTE
  • it is best to deliver progesterone via the Mirena coil as it does not produce progestogenic side effects
34
Q

What is tibolone?

A
  • a synthetic steroid that stimulates oestrogen + progesterone receptors
  • it also stimulates androgen receptors
  • it is a form of continuous combined HRT

women must be 12 months without a period ( or 24 months if < 50) before considering this

35
Q

Who might tibolone be suitable for?

A

its weak stimulation of androgen receptors means it can be helpful for patients with reduced libido

36
Q

What is the drawback of using tibolone?

A

it can cause irregular bleeding

this can result in further investigations to exclude other causes

37
Q

When might testosterone be given?

A
  • this is an androgen
  • it can increase energy and improve libido
  • given through a transdermal route
  • initiated and monitored by a specialist
38
Q

When should women be followed up following HRT being started?

How long does it take to have an effect?

A
  • it can take 3-6 months to gain the full effects
  • women should be followed up 3 months after starting HRT to review symptoms / SEs
  • side effects settle with time so it is worth persisting for 3 months with each regime
39
Q

When should a women taking HRT be referred to a specialist?

A

if there is problematic or irregular bleeding

40
Q

What are the guidelines around surgery and HRT?

A

ALL HRT or oestrogen-containing contraceptives should be stopped 4 weeks prior to surgery

41
Q

What discussion should be had with women about contraception when starting HRT?

A
  • HRT does NOT provide contraception
  • perimenopausal women need to have adequate contraception with the Mirena coil or POP
  • the POP is given in addition to HRT
42
Q

What are the oestrogenic side effects associated with HRT?

A
  • nausea
  • bloating
  • breast swelling
  • breast tenderness
  • headaches
  • leg cramps
43
Q

What are the progestogenic side effects associated with HRT?

A
  • mood swings
  • bloating
  • weight gain
  • fluid retention
  • acne / greasy skin
44
Q

What advice is given regarding stopping HRT?

A
  • there is no regime for stopping HRT
  • it can be stopped gradually or abruptly
  • it is recommended to gradually reduce HRT to minimise the risk of symptoms recurring suddenly

Y4 - GOSH (62 decks)

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