Hormone Replacement Therapy Flashcards
What is the purpose of HRT and how does it work?
- 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
How is HRT different in women who have a uterus?
- progesterone needs to be given in addition to oestrogen
- progesterone prevents endometrial hyperplasia + endometrial cancer secondary to “unopposed” oestrogen
What are the non-hormonal treatments for menopausal symptoms that may be trialled prior to HRT?
- lifestyle changes
- CBT
- clonidene
- SSRI antidepressants
- venlafaxine (SNRI)
- gabapentin
SNRI = selective serotonin-norepinephrine reuptake inhibitor
How does clonidene work?
- it is an agonist of alpha-2 adrenergic receptors + imidazoline receptors in the brain
- it lowers the BP + reduces HR
When is clonidene used?
- 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
What are the side effects associated with clomidene?
- dry mouth
- headaches
- dizziness
- fatigue
- sudden withdrawal can result in rapid increases in BP + agitation
What advice is given about alternative remedies for menopausal symptoms?
NOT RECOMMENDED
- their safety / efficacy is unclear
- many have significant adverse effects and interact with other medications
What are the 4 indications for HRT?
- 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
What is the advice given about the risks / benefits of HRT in younger women?
the benefits generally outweigh the risks in women < 60
What are the key benefits of HRT that should be highlighted to the patient?
- improvement of vasomotor symptoms + others (e.g. mood, joint pain, etc.)
- improved quality of life
- reduced risk of osteoporosis / fractures
What are the risks associated with HRT that it is important to make the patient aware of?
Who is more affected by these risks?
- 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
Which groups of individuals may not be affected by the risks of HRT?
- 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
How can the risk of endometrial cancer / VTE be reduced?
- 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
What are the contraindications to starting HRT?
- undiagnosed abnormal bleeding
- endometrial hyperplasia / cancer
- breast cancer
- uncontrolled hypertension
- VTE
- active angina / MI
- liver disease
- pregnancy
What 5 things must be assessed prior to starting HRT?
- 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
What are the 3 steps that must be considered when choosing the HRT formulation?
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
What are the 2 options for delivreing systemic oestrogen?
- oral through tablets
- transdermal through patches / gels
What are the 2 options for delivreing systemic oestrogen?
- oral through tablets
- transdermal through patches / gels
In which women may patches be a better alternative to pills?
- women with poor control over oral treatment
- women at higher risk of VTE, cardiovascular disease or headaches
What are the 2 options for progesterone delivery?
- cyclical progesterone
- continuous progesterone
progesterone is only required in women who have a uterus
How is cyclical progesterone given and who is this recommended for?
- 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
When is continuous progesterone used?
- 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
Why should continuous combined HRT not be used prior to the menopause?
- it can lead to irregular breakthrough bleeding
- this often leads to investigation for an underlying cause of the bleeding
When can a switch from cyclical to continuous HRT be made?
- 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
What is the purpose of switching from cyclical to continuous HRT?
continuous HRT has better endometrial protection than cyclical HRT
What are the 3 options for delivering progesterone for endometrial protection?
- oral through tablets
- transdermal through patches
- intrauterine system (Mirena coil)
For how long does the Mirena coil provide endometrial protection for?
4 years
- after this time it needs replacing
What are the added benefits of using the Mirena coil?
- it provides contraception
- it can treat heavy menstrual periods
What is important to tell women about the Mirena coil?
- it can cause irregular bleeding / spotting in the first few months after insertion
- this usually settles with time and most women become amenorrhoeic
What are the 2 progestogen classes used in HRT?
C19 and C21 progestogens
- this refers to the number of carbon atoms
- if a woman experiences side effects, consider switching progestogen classes
When are C19 progestogens usually chosen?
What are some examples?
- they are derived from testosterone and are more “male” in their effects
- helpful for women with reduced libido
- including norethisterone, levonorgestrel and desogestrel
When are C21 progestogens typically chosen?
What are some examples?
- 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
What are the “best” ways to deliver oestrogen and progesterone?
- 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
What is tibolone?
- 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
Who might tibolone be suitable for?
its weak stimulation of androgen receptors means it can be helpful for patients with reduced libido
What is the drawback of using tibolone?
it can cause irregular bleeding
this can result in further investigations to exclude other causes
When might testosterone be given?
- this is an androgen
- it can increase energy and improve libido
- given through a transdermal route
- initiated and monitored by a specialist
When should women be followed up following HRT being started?
How long does it take to have an effect?
- 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
When should a women taking HRT be referred to a specialist?
if there is problematic or irregular bleeding
What are the guidelines around surgery and HRT?
ALL HRT or oestrogen-containing contraceptives should be stopped 4 weeks prior to surgery
What discussion should be had with women about contraception when starting HRT?
- 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
What are the oestrogenic side effects associated with HRT?
- nausea
- bloating
- breast swelling
- breast tenderness
- headaches
- leg cramps
What are the progestogenic side effects associated with HRT?
- mood swings
- bloating
- weight gain
- fluid retention
- acne / greasy skin
What advice is given regarding stopping HRT?
- 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
