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Hormone Replacement Therapy Flashcards

1
Q

What is the definition of menopause?

A

Permanent cessation of menstruation; diagnosis made in primary care when woman has not had a period for 12 months

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2
Q

What causes the menopause?

A

Loss of follicular activity

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3
Q

What proportion of postmenopausal women have menopausal symptoms?

A

75%

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4
Q

How long do symptoms of the menopause typically last for?

A

7 years; variable, may develop before sart of menopause, even years before

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5
Q

What are the three categories that the management of menopause can be split into?

A
  1. Lifestyle modifications
  2. Hormone replacement therapy (HRT)
  3. Non-hormone replacement therapy
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6
Q

What are 16 of the symptoms of the menopause?

A
  1. Hot flushes
  2. Night sweats
  3. Irregular periods
  4. Mood swings
  5. Vaginal dryness
  6. Decreased libido
  7. Headaches
  8. Breast soreness
  9. Joint pain
  10. Digestive problems: bloating, indigestion, constipation, diarrhoea, cramps
  11. Fatigue
  12. Disrupted sleep
  13. Weight gain
  14. Irritability
  15. Depression
  16. Osteoporosis
  17. Heart palpitations
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7
Q

What are 3 lifestyle modifications to treat hot flushes?

A
  1. Regular exercise
  2. Weight loss
  3. Reduce stress
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8
Q

What are 2 lifestyle modifications to treat sleep disturbance in the menopause?

A
  1. Avoiding late evening exercise
  2. Maintaining good sleep hygiene
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9
Q

What are 3 lifestyle modifications to treat mood changes in the menopause?

A
  1. Sleep
  2. Regular exercise
  3. Relaxation
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10
Q

What are 2 lifestyle modifications to treat the cognitive symptoms of the menopause e.g. memory problems?

A
  1. Regular exercise
  2. Good sleep hygiene
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11
Q

What are 4 contraindications to treatment of the menopause with HRT?

A
  1. Current or past breast cancer
  2. Any oestrogen-sensitive cancer
  3. Undiagnosed vaginal bleeding
  4. Untreated endometrial hyperplasia
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12
Q

What proportion of women will have some sort of HRT to treat their menopausal symptoms?

A

10% - undertreated due to worries about increased cancer risk

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13
Q

What form of HRT is given and why?

A

Oral or transdermal combined HRT given - mustn’t give unopposed oestrogens as this will increase risk of endometrial cancer

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14
Q

When is the only time oestrogen alone can be given as HRT?

A

If the woman doesn’t have a uterus

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15
Q

What are 5 of the risks of HRT to advise women about?

A
  1. Venous thromboemboslim: increase in risk with all forms of oral HRT, no increase with transdermal
  2. Stroke: slightly increased risk with oral oestrogen HRT
  3. Coronary heart disease: combined HRT may be associated with a slight increase in risk
  4. Breast cancer: increased risk with all combined HRT although risk of dying from breast cancer not raised (just increases rate it grows at/detection, no increased incidence or mortality)
  5. Ovarian cancer: increased risk with all HRT
  6. Endometrial cancer: due to oestrogen, addition of progestogen reduces risk but not eliminaed completely. BNF says completely eliminated if progestogen given continuously
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16
Q

What are 4 non-HRT treatment options to treat the vasomotor symptoms of menopause (hot flushes, sweating, palpitations)?

A
  1. Fluoxetine
  2. Citalopram
  3. Venlafaxine
  4. Clonidine
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17
Q

What are 4 symptoms of the menopause that can be treated with non-HRT?

A
  1. Vasomotor symptoms
  2. Vaginal dryness - lubricant or moisturiser
  3. Psychological symptoms - self-help groups, cognitive behaviour therapy or antidepressants
  4. Urogenital symptoms - treat vaginal dryness, use vaginal oestrogens for urogenital atrophy
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18
Q

What are 2 things that can be done to treat the urogenital symptoms of the menopause?

A
  1. If urogenital atrophy can treat with vaginal oestrogen; whether taking HRT or not
  2. Treat vaginal dryness with moisturisers and lubricants
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19
Q

How long may HRT be required for the vasomotor symptoms of menopause?

A

2-5 years of HRT

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20
Q

What should you advise women of when stopping HRT?

A

Tell women that gradually reducing HRT is effective at limiting recurrence only in the short term; in long-term, no difference in symptom control

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21
Q

How long might vaginal oestrogen be required to treat vaginal dryness in the menopause?

A

May be required long-term

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22
Q

What are 3 cases when a woman with menopausal symptoms should be referred to secondary care?

A
  1. Treatment has been ineffective
  2. Ongoing side effects
  3. Unexplained bleeding
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23
Q

What are 3 side effects of HRT?

A
  1. Nausea
  2. Breast tenderness
  3. Fluid retention and weight gain
24
Q

What part of HRT increases the risk of breast cancer and by how much?

A
  • increased by addition of progestogen
  • WHI (women’s health initiative) study said relative risk of developing breast cancer was 1.26 at 5 years
25
Q

With what does the HRT-associated risk of breast cancer increase and when does it go down?

A

Increased risk relates to duration of use; risk of breast cancer begins to decline when HR stopped and by 5 years reaches same level as in women who have never taken HRT

26
Q

What part of HRT increases the risk of VTE and in what form does HRT not increase this risk?

A

Progestogen; transdermal HRT doesn’t appear to increase risk

27
Q

What should be done if a woman has high risk for VTE and is planning to start HRT?

A

Refer to haematology before starting any treatment - even transdermal

28
Q

When does HRT increase the risk of ischaemic heart disease?

A

If taken more than 10 years after menopause

29
Q

What is the definition of postmenopausal bleeding?

A

Vaginal bleeding occurring after 12 months of amenorrhoea, in woman at the age where the menopause can be expected

30
Q

When can postmenopausal bleeding occur in women who are NOT at the age when menopause is expected?

A

Premature ovarian failure or premature menopause

31
Q

What is important to rule out in cases of postmenopausal bleeding?

A

Endometrial malignancy (but is usually benign)

32
Q

What is the commonest cause of postmenopausal bleeding?

A

Vaginal atrophy - thinning, drying and inflammation of walls of the vagina due to a reduction in oestrogen following the menopause

33
Q

What are 10 causes of postmenopausal bleeding?

A
  1. Vaginal atrophy
  2. HRT - periods or spotting, or endometrial hyperplasia due to long-term oestrogen therapy
  3. Endometrial hyperplasia - abnormal thickening of endometrium and precursor for endometrial carcinoma
  4. Endometrial cancer
  5. Cervical cancer
  6. Ovarian cancer- especially oestrogen-secreting (theca cell) tumours
  7. Vaginal cancer
  8. Trauma
  9. Vulval cancer
  10. Bleeding disorders
34
Q

What are 5 risk factors for endometrial hyperplasia, which may cause post-menopausal bleeding?

A
  1. Obesity
  2. Unopposed oestrogen use
  3. Tamoxifen use
  4. Polycystic ovary syndrome
  5. Diabetes
35
Q

What proportion of patients with postmenopausal bleeding have endometrial cancer, and what proportion of endometrial cancer presents with postmenopausal bleeding?

A
  • only 10% BUT
  • 90% present with this - must rule it out urgently
36
Q

What should be obtained when ruling out cervical cancer as a cause of postmenopausal bleeding?

A

Cervical cancer screening programme attendance

37
Q

Which type of ovarian cancer can most commonly present with postmenstrual bleeding?

A

Oestrogen secreting aka theca cell tumours

38
Q

Which women should be referred for a 2 week wait appointment with postmenstrual bleeding and what are they referred for?

A

Women over 55 with postmenopausal bleeding - ultrasound for endometrial cancer

39
Q

What are 8 things to ask about in the history in the case of postmenopausal bleeding?

A
  1. Timing of bleeding
  2. Consistency of blood
  3. Quantity of bleeding
  4. Full gynaecological and obstetric history
  5. Risk factors for endometrial cancer
  6. Establish menstrual timeline from menarche to menopause
  7. Full drug history including HRT
  8. Red flag symptoms for gynaecological cancer should be enquired about
40
Q

What examinations should be performed if a patient presents with postmenopausal bleeding?

A

Full abdominal and vaginal examination: looking for masses or abnormalities within abdomen or felt from within the vagina, as well as speculum visualisation of walls of vagina and cervix. May see blood or discharge

41
Q

What are 3 primary care investigations that can be performed in postmenopausal bleeding?

A
  1. Urine dispstick to look for haematuria or infection
  2. Full blood count - anaemia or bleeding disorder
  3. CA-125 levels (ovarian cancer)
42
Q

What is the investigation of choice for women referred to the 2 week wait pathway for those with postmenopausal bleeding? What is being assessed?

A

Transvaginal ultrasound - assessing endometrial lining thickness

43
Q

What is an acceptable depth of the endometrial lining in postmenopausal women?

A

<5mm

44
Q

Should assessment of endometrial thickness with transvaginal ultrasound be the only investigation for women referred to the 2ww pathway for postmenopausal bleeding?

A

No - may miss some pathology and if clinical suspicion is high, further testing required

45
Q

What is the test that gives a definitive diagnosis of endometrial cancer? What are the 2 ways of doing this?

A
  • Endometrial biopsy:
  1. Taking during hysteroscopy OR
  2. Aspiration (pipelle) biopsy, where a thin flexible tube is inserted into uterus via speculum to remove cells for testing
46
Q

What imaging in secondary care should be performed for women with postmenopausal bleeding?

A

CT or MRI of uterus, pelvis and abdomen

47
Q

Do women on HRT with postmenopausal bleeding still need to be investigated?

A

Yes - to rule out endometrial cancer

48
Q

What is the treatment for postmenopausal bleeding caused by vaginal atrophy?

A

Topical oestrogens and lifestyle changes such as lubrication can help reduce symptoms of vaginal atrophy, HRT can also be used

49
Q

What can be done if postmenopausal bleeding is due to HRT the patient is on?

A

Different HRT preparations can be used

50
Q

What is the usual treatment for endometrial hyperplasia?

A

Dilatation and curettage to remove excess endometrial tissue

51
Q

What is the average age of menopause?

A

51

52
Q

How long after amenorrhoea should contraception be stopped in women <50y?

A

2 years

53
Q

How long after amenorrhoea should contraception be stopped in women >50y?

A

1 year

54
Q

In what age group should you automatically offer HRT if there are symptoms of menopause?

A

>45 y

55
Q

What should be done if a woman <45y has symptoms of menopause?

A

Measure FSH, if >40 suggests menopause, give HRT

GP (43 decks)

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