Hormone Replacement Therapy Flashcards
Why are natural oestrogens preferred and give some examples?
They have a more appropriate profile for hormone replacement therapy (HRT) than synthetic oestrogens
1) Estradiol
2) Estriol
3) Estrone
Give examples of synthetic oestrogens?
1) Ethinylestradiol
2) Menstranol
Which drug has oestrogenic, progestogenic and weak androgenic activity?
1) Tibolone
In women with a uterus, what must be added to oestrogen and why?
Progestogen - to reduce the risk of cystic hyperplasia of the endometrium which can lead to endometrial cancer.
Give examples of progestogens?
Dydrogesterone
Medroxyprogesterone
Norethisterone Levonorgestrel
Norgestrel
Drospirenone
Which progestogen is useful for women who have fluid retention during the progestogen phase?
Drospirenone
Which progestogen is useful for women who have hypertriglyceridaemia?
Micronized progesterone (Utrogestan) or dydrogesterone
What are menopausal symptoms?
No or infrequent periods (taking into account whether the women has a uterus)
Hot flushes
Night sweats
Mood changes
Memory and concentration loss
Vaginal dryness
Lack of interest in sex
Headaches
Joint and muscle stiffness
Vaginal atrophy - thinning, drying, inflammation
Vasomotor symptoms - hot flushes, night sweats
At what age is menopause common?
Over 45 years of age
What is the difference between perimenopause, and menopause?
Woman with a uterus with infrequent or irregular periods with vasomotor symptoms = perimenopause
Woman with a uterus with no periods in the last 12 months = menopause
Woman without a uterus with symptoms = menopause
What is premature ovarian insufficiency?
Menopause occurring before the age of 40 years
What tests do you need to diagnose menopause in a woman over 45 years of age?
None
Women over 45 years presenting with menopausal symptoms are diagnosed with perimenopause or menopause based on their symptoms alone, without confirmatory laboratory tests.
What tests do you need to diagnose menopause in a woman under 40 years of age?
Measure FSH
Persistently elevated FSH levels are needed to confirm the diagnosis in this age group
What is a patient going through menopause at an increased risk of?
CVD
Osteoporosis
Urinary incontinence
Sexual dysfunction
Weight gain
What is a patient taking HRT at an increased risk of?
1) Coronary heart disease (if started more than 10 years after menopause)
2) Stroke and thromboembolism
3) Endometrial cancer (reduced by progestogen)
4) Breast cancer (higher with combined)
5) Ovarian cancer
When is HRT contraindicated?
1) Current, past, or suspected breast cancer.
2) Known or suspected oestrogen-dependent cancer.
3) Undiagnosed vaginal bleeding.
4) Untreated endometrial hyperplasia.
5) Previous idiopathic or current venous thromboembolism (deep vein thrombosis or pulmonary embolism), unless the woman is already on anticoagulant treatment.
6) Active or recent arterial thromboembolic disease (for example angina or myocardial infarction).
7) Active liver disease with abnormal liver function tests.
8) Pregnancy
9) Thrombophilic disorder.
When is HRT cautioned?
1) Porphyria cutanea tarda
2) Diabetes mellitus (increased risk of heart disease)
3) Factors predisposing to venous thromboembolism
4) History of endometrial hyperplasia
5) Migraine and migraine-like headaches
6) Increased risk of breast cancer e.g. family history
When would a transdermal route of administration be more suitable than oral?
1) Persistent troublesome symptoms with oral treatment
2) Troublesome adverse effects with oral treatment
3) A history of, or increased risk of, venous thromboembolism
4) Cardiovascular risk factors, such as obesity, uncontrolled hypertension, or hypertriglyceridaemia
5) Concomitant hepatic enzyme-inducing drug treatment (for example carbamazepine)
6) A gastrointestinal disorder that may affect absorption of oral treatment
7) A history of migraine or gallbladder disease
8) Lactose sensitivity (most HRT oral preparations contain lactose)
Which progestogens are usually found in combined HRT patches?
Norethisterone or Levonorgestrel
When may the levonorgestrel-releasing intrauterine system (LNG-IUS, Mirena®) be useful?
1) Persistent progestogenic adverse effects from systemic HRT.
2) Troublesome or heavy withdrawal bleeds taking cyclical HRT.
3) Contraception is needed along with HRT.
What is the maximum use of Mirena® with oestrogen?
Up to 5 YEARS for endometrial protection, as part of an HRT regimen (licensed for 4 years but may be used for up to 5 years off-label).
Women using Mirena® for this purpose must have the device changed every 5 YEARS
Is a progestogen needed for endometrial protection when using vaginal oestrogens?
NO
Systemic absorption of vaginal oestrogen is minimal
When is vaginal oestrogen therapy regimens preferred?
Menopausal atrophic vaginitis
Local symptoms
No breast cancer risk
When are continuous combined preparations or tibolone not suitable?
Continuous combined preparations or tibolone are not suitable for use in the perimenopause or within 12 months of the last menstrual period
When may a progestogen be considered in women without a uterus?
If endometrial foci still remains post hysterectomy.
Which drug can be considered to reduce vasomotor symptoms in women unable to have oestrogen?
Clonidine Hydrochloride
In what conditions should HRT be stopped?
1) Sudden severe chest pain (even if not radiating to left arm);
2) Sudden breathlessness (or cough with blood-stained sputum);
3) Unexplained swelling or severe pain in calf of one leg;
4) Severe stomach pain;
5) Serious neurological effects including unusual severe, prolonged headache especially if first time or getting progressively worse or sudden partial or complete loss of vision or sudden disturbance of hearing or other perceptual disorders or dysphasia or bad fainting attack or collapse or first unexplained epileptic seizure or weakness, motor disturbances, very marked numbness suddenly affecting one side or one part of body;
6) Hepatitis, jaundice, liver enlargement;
7) Blood pressure above systolic 160 mmHg or diastolic 95 mmHg;
8) Prolonged immobility after surgery or leg injury;
9) Detection of a risk factor which contra-indicates treatment.
What can Raloxifene be used for?
Treatment and prevention of postmenopausal osteoporosis
What are the use cases for Ulipristal acetate?
To treat moderate to severe symptoms of uterine fibroids.
Emergency hormonal contraception
Which HRT regimens are preferred in post menopausal women?
1) Monthly or 3-monthly cyclical regimens
2) Continuous combined regimen (no withdrawal bleeding) - if bleeding occurs beyond 6 months or becomes heavier REFER
Which HRT regimens are preferred in perimenopausal women?
Monthly or 3-monthly cyclical regimens
(Monthly = bleed every month)(3 monthly = bleed every 3 months)
DO NOT USE CONTINUOUS COMBINED REGIMEN IN PERIMENOPAUSE OR WITHIN 12 MONTHS OF LAST BLEED.
Describe a monthly cyclical regimen?
Oestrogen is taken daily and progestogen is given at the end of the cycle for 10–14 days
Describe a 3-monthly cyclical regimen?
Oestrogen is taken daily and progestogen is given for 14 days every 13 weeks
When would a 3-monthly cyclical regimen be preferred?
Women with infrequent periods or who are intolerant to progestogens
How would you wear a HRT patch?
Put your patch on below your waist, for example buttock, thigh or lower abdomen.
Avoid places where tight clothing may rub it off.
Do not apply the patch over a skin fold or on hair. Your skin should be clean and dry.
Avoid exercise or sweating for 1 hour
Change the patch once or twice a week (depending on the brand you use). Try to do this on the same day or days every week. This may mean that 1 patch is on for 3 days and the next patch for 4 days. For example, if you put on a patch on a Monday, change it on Thursday, and again on the following Monday.
If your patch falls off or you need to replace it during the week, put the new patch in a different place.
If you have been using sequential combined HRT (taking your progestogen only on some days, and having a break), wait until the end of the cycle of your current medicine before using your new patches.
What HRT a patient have who suffers with migraine with aura?
Oestrogen only
combined contraindicated in migraine with aura
