Hormone Replacement Therapy

Question 1

Why are natural oestrogens preferred and give some examples?

Answer 1

They have a more appropriate profile for hormone replacement therapy (HRT) than synthetic oestrogens

1) Estradiol
2) Estriol
3) Estrone

Question 2

Give examples of synthetic oestrogens?

Answer 2

1) Ethinylestradiol
2) Menstranol

Question 3

Which drug has oestrogenic, progestogenic and weak androgenic activity?

Answer 3

1) Tibolone

Question 4

In women with a uterus, what must be added to oestrogen and why?

Answer 4

Progestogen - to reduce the risk of cystic hyperplasia of the endometrium which can lead to endometrial cancer.

Question 5

Give examples of progestogens?

Answer 5

Dydrogesterone
Medroxyprogesterone
Norethisterone Levonorgestrel
Norgestrel
Drospirenone

Question 6

Which progestogen is useful for women who have fluid retention during the progestogen phase?

Answer 6

Drospirenone

Question 7

Which progestogen is useful for women who have hypertriglyceridaemia?

Answer 7

Micronized progesterone (Utrogestan) or dydrogesterone

Question 8

What are menopausal symptoms?

Answer 8

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

Question 9

At what age is menopause common?

Answer 9

Over 45 years of age

Question 10

What is the difference between perimenopause, and menopause?

Answer 10

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

Question 11

What is premature ovarian insufficiency?

Answer 11

Menopause occurring before the age of 40 years

Question 12

What tests do you need to diagnose menopause in a woman over 45 years of age?

Answer 12

None

Women over 45 years presenting with menopausal symptoms are diagnosed with perimenopause or menopause based on their symptoms alone, without confirmatory laboratory tests.

Question 13

What tests do you need to diagnose menopause in a woman under 40 years of age?

Answer 13

Measure FSH

Persistently elevated FSH levels are needed to confirm the diagnosis in this age group

Question 14

What is a patient going through menopause at an increased risk of?

Answer 14

CVD
Osteoporosis
Urinary incontinence
Sexual dysfunction
Weight gain

Question 15

What is a patient taking HRT at an increased risk of?

Answer 15

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

Question 16

When is HRT contraindicated?

Answer 16

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.

Question 17

When is HRT cautioned?

Answer 17

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

Question 18

When would a transdermal route of administration be more suitable than oral?

Answer 18

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)

Question 19

Which progestogens are usually found in combined HRT patches?

Answer 19

Norethisterone or Levonorgestrel

Question 20

When may the levonorgestrel-releasing intrauterine system (LNG-IUS, Mirena®) be useful?

Answer 20

1) Persistent progestogenic adverse effects from systemic HRT.
2) Troublesome or heavy withdrawal bleeds taking cyclical HRT.
3) Contraception is needed along with HRT.

Question 21

What is the maximum use of Mirena® with oestrogen?

Answer 21

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

Question 22

Is a progestogen needed for endometrial protection when using vaginal oestrogens?

Answer 22

NO

Systemic absorption of vaginal oestrogen is minimal

Question 23

When is vaginal oestrogen therapy regimens preferred?

Answer 23

Menopausal atrophic vaginitis

Local symptoms

No breast cancer risk

Question 24

When are continuous combined preparations or tibolone not suitable?

Answer 24

Continuous combined preparations or tibolone are not suitable for use in the perimenopause or within 12 months of the last menstrual period

Question 25

When may a progestogen be considered in women without a uterus?

Answer 25

If endometrial foci still remains post hysterectomy.

Question 26

Which drug can be considered to reduce vasomotor symptoms in women unable to have oestrogen?

Answer 26

Clonidine Hydrochloride

Question 27

In what conditions should HRT be stopped?

Answer 27

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.

Question 28

What can Raloxifene be used for?

Answer 28

Treatment and prevention of postmenopausal osteoporosis

Question 29

What are the use cases for Ulipristal acetate?

Answer 29

To treat moderate to severe symptoms of uterine fibroids.
Emergency hormonal contraception

Question 30

Which HRT regimens are preferred in post menopausal women?

Answer 30

1) Monthly or 3-monthly cyclical regimens
2) Continuous combined regimen (no withdrawal bleeding) - if bleeding occurs beyond 6 months or becomes heavier REFER

Question 31

Which HRT regimens are preferred in perimenopausal women?

Answer 31

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.

Question 32

Describe a monthly cyclical regimen?

Answer 32

Oestrogen is taken daily and progestogen is given at the end of the cycle for 10–14 days

Question 33

Describe a 3-monthly cyclical regimen?

Answer 33

Oestrogen is taken daily and progestogen is given for 14 days every 13 weeks

Question 34

When would a 3-monthly cyclical regimen be preferred?

Answer 34

Women with infrequent periods or who are intolerant to progestogens

Question 35

How would you wear a HRT patch?

Answer 35

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.

Question 36

What HRT a patient have who suffers with migraine with aura?

Answer 36

Oestrogen only

combined contraindicated in migraine with aura