Hormone replacement therapy

Question 1

What is HRT?

Answer 1

Replacement of oestrogen and/or progesterone in an attempt to delay onset of the menopause

Question 2

What is important in establishing when considering HRT?

Answer 2

Presence of uterus:
No uterus - oestrogen alone
Uterus - combined HRT (oestrogen and progesterone, to prevent hyperplasia of endometrium - precancer)

Question 3

Why should unopposed oestrogen use be avoided?

Answer 3

Risk factor for endometrial cancer development

Question 4

What are the administration methods for HRT?

Answer 4

Systemic oestrogens - oral, transdermal (patch/gel), SC (implant)
Topical oestrogens - vaginally
Progesterones - oral, transdermal patch, direct into uterus (Mirena)

Question 5

What form of HRT should be used in peri-menopausal women?

Answer 5

Oestrogen and cyclical progesterone

Usually results in withdrawal bleeds

Question 6

What form of HRT should be used in post-menopausal women?

Answer 6

Continuous-combined HRT e.g.

Kliofem oestradiol 2mg and norethisterone 1mg

Question 7

Is a woman on HRT considered infertile?

Answer 7

No
Should be considered fertile for 
1y if >50
2y if <50
Non-hormonal contraception should be used e.g. condoms

Question 8

What are the contraindications to HRT?

Answer 8

Oestrogen-dependent cancer
Past PE (consider potential thrombophilia)
Undiagnosed PV bleeds
Raised LFTs
Pregnancy
Breastfeeding
Phlebitis
Avoid/monitor closely in Dubin-Johnson syndrome

Question 9

What are the side effects of HRT?

Answer 9

Fluid retention
Bloating
Breast tenderness
Nausea
Headaches
Leg cramps
Dyspepsia
Progesterone related side effects include:
-Mood swings
-Depression
-Acne
-Backache

If irregular breakthrough bleed - further investigation required

Question 10

What should be performed at an annual check up for HRT?

Answer 10

Breast symptoms/lumps
BP (stop if >160/100)
Weight
Any abnormal bleed

Question 11

What oestrogens are available?

Answer 11

Natural (oestradiol, oestrone, oestriol from soya beans/yams; also derived from equine sources)
Synthetic (e.g. ethinyloestradiol) not used in HRT, but are found in COCP

Question 12

What progestogens are used in HRT?

Answer 12

Levonorgestrel and norethisterone (from plants; think yams and soya beans)
Mirena coil uses levonorgestrel used for endometrial protection (contraceptive; also only definitive way of getting no bleed HRT)

Question 13

When might tibolone be used in HRT?

Answer 13

Used in post-menopausal who desire amenorrhoea

Also treats vasomotor, psychological and libido problems, while conserving bone mass/reducing vertebral fracture risk

Question 14

When might androgens be used in HRT?

Answer 14

Testosterone to improve libido

Limited success and no help to other issues of menopause

Question 15

What should be considered for women on HRT with a history of transcervical resection of endometrium?

Answer 15

Endometrial ablation may not remove all endometrium

Therefore, these women should be on combined HRT rather than oestrogen alone

Question 16

What would be the indication for topical oestrogens in HRT?

Answer 16

Urogenital symptoms (normally administered oestriol, by cream or pessary, or oestradiol by tablet/ring

Question 17

What are the benefits of HRT?

Answer 17

Reduction of vasomotor symptoms (usually within 1-3m)
Improvement of urogenital symptoms and sexual function
Osteoporotic fractures reduced (but only if HRT sustained)
Reduced risk of colorectal cancer by a third (prevention of CRC not indication for HRT)

Question 18

What are the risks of HRT?

Answer 18

• Breast cancer (2.3% increase/year, risk returns to normal 5y after cessation; greatest association with combined therapy)
• Endometrial cancer (unopposed oestrogens; risk remains even after stopping; hence addition of progesterone)
• VTE (doubled, but relatively still low; more likely in first year of therapy and risk increases with age)
• Gallbladder disease
• Uncertainties around CVS disease, dementia, ovarian cancer

Question 19

What recommendations should be given for the use of HRT?

Answer 19

Diet, exercise and local treatments tried first
Starting HRT around menopause safer than waiting 5-10y after menopause
Discuss risks vs benefits
Encourage breast awareness (e.g. breast screening attendance)
Use lowest effective dose for shortest time possible
Be wary in FHx of breast cancer

Question 20

For what duration should HRT be used?

Answer 20

For menopausal symptoms
-Continue for up to 5y, then evaluate
For premature menopause
-Continue until median age of natural menopause e.g. 51/52y
For osteoporosis
-effective protection before 60y/within 10y of menopause; BMD falls when HRT stopped, so many change to bisphosphonates (esp due to inc risk of breast cancer with HRT)