Hormone Replacement Therapy (HRT) Flashcards
What is hormone replacement therapy (HRT)?
Hormone replacement therapy (HRT) is used in perimenopausal and postmenopausal women to alleviate symptoms associated with menopause. These symptoms are associated with a declined in the level of oestrogen. Exogenous oestrogen is given to alleviate the symptom
Why does progesterone need to be given in women with a uterus?
Progesterone needs to be given (in addition to oestrogen) to women that have a uterus. The primary purpose of adding progesterone is to prevent endometrial hyperplasia and endometrial cancer secondary to “unopposed” oestrogen.
What are the non-hormonal treatments for menopause?
Non-hormonal treatments may be tried initially, or used when there are contraindications to HRT. Options include:
- Lifestyle changes such as improving the diet, exercise, weight loss, smoking cessation, reducing alcohol, reducing caffeine and reducing stress
- Cognitive behavioural therapy (CBT)
- Clonidine, which is an agonist of alpha-adrenergic and imidazoline receptors
- SSRI antidepressants (e.g. fluoxetine)
- Venlafaxine, which is a selective serotonin-norepinephrine reuptake inhibitor (SNRI)
- Gabapentin
What is the role of clonidine in treating menopause?
Clonidine act as an agonist of alpha-2 adrenergic receptors and imidazoline receptors in the brain. It lowers blood pressure and reduces the heart rate, and is also used as an antihypertensive medication. It can be helpful for vasomotor symptoms and hot flushes, particularly where there are contraindications to using HRT.
What are the side effects of clonidine?
Common side effects of clonidine are dry mouth, headaches, dizziness and fatigue. Sudden withdrawal can result in rapid increases in blood pressure and agitation.
What alternative remedies may women use to treat menopause?
Patients might try alternative remedies, although they are not generally recommended as the safety and efficacy is unclear. They can have significant side effects and interact with other medications. These alternative remedies are intended to manage the vasomotor symptoms, such as hot flushes:
- Black cohosh
- Which may be a cause of liver damage
- Dong quai
- Which may cause bleeding disorders
- Red clover
- Which may have oestrogenic effects that would be concerning with oestrogen sensitive cancers
- Evening primrose oil
- Which has significant drug interactions and is linked with clotting disorders and seizures
- Ginseng may be used for mood and sleep benefits
What are the indications for HRT?
The indication for HRT are:
- Replacing hormones in premature ovarian insufficiency, even without symptoms
- Reducing vasomotor symptoms such as hot flushes and night sweats
- Improving symptoms such as low mood, decreased libido, poor sleep and joint pain
- Reducing risk of osteoporosis in women under 60 years
What are the benefits of HRT?
In women under 60 years, the benefits of HRT generally outweigh the risks.
The key benefits to inform women of include:
- Improved vasomotor and other symptoms of menopause (including mood, urogenital and joint symptoms)
- Improved quality of life
- Reduced the risk of osteoporosis and fractures
What are the risks of HRT?
Women may be concerned about the risks of HRT. It is crucial to put these into perspective. In women under 60 years, the benefits generally outweigh the risks. Specific treatment regimes significantly reduce the risks associated with HRT.
The risks of HRT are more significant in older women and increase with a longer duration of treatment. The principal risks of HRT are:
- Increased risk of breast cancer (particularly combined HRT- oestrogen-only HRT has a lower risk)
- Increased risk of endometrial cancer
- Increased risk of venous thromboembolism (2-3 times the background risk)
- Increased risk of stroke and coronary artery disease with long term use in older women
- The evidence is inconclusive about ovarian cancer, and if there is an increase in risk, it is minimal
These risks do not apply to all women:
- The risks are not increased in women under 50 years compared with other women their age
- There is no risk of endometrial cancer in women without a uterus
- There is no increased risk of coronary artery disease with oestrogen-only HRT (the risk may even be lower with HRT)
How are the risks of HRT minimised?
Ways to reduce the risks:
- The risk of endometrial cancer is greatly 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 HRT?
There are some essential contraindications to consider in patients wanting to start HRT:
- Undiagnosed abnormal bleeding
- Endometrial hyperplasia or cancer
- Breast cancer
- Uncontrolled hypertension
- Venous thromboembolism
- Liver disease
- Active angina or myocardial infarction
- Pregnancy
What should be checked before starting HRT?
Before initiating HRT, there are a few things to check and consider:
- Take a full history to ensure there are no contraindications
- Take a family history to assess the risk of oestrogen dependent cancers (e.g. breast cancer) and VTE
- Check the body mass index (BMI) and blood pressure
- Ensure cervical and breast screening is up to date
- Encourage lifestyle changes that are likely to improve symptoms and reduce risks
What 3 steps need to be assessed when choosing the appropriate HRT regime?
Step 1: Do they have local or systemic symptoms?
- Local symptoms: use topical treatments such as topical oestrogen cream or tablets
- Systemic symptoms: use systemic treatment- go to step 2
Step 2: Does the woman have a uterus?
- No uterus: use continuous oestrogen-only HRT
- Has uterus: add progesterone (combined HRT)- go to step 3
Step 3: Have they had a period in the past 12 months?
- Perimenopausal: give cyclical combined HRT
- Postmenopausal (more than 12 months since last period): give continuous combined HRT
How can oestrogen be administered in HRT?
Oestrogen is the critical component of HRT for reducing the symptoms of menopause. There are two options for delivering systemic oestrogen:
- Oral (tablets)
- Transdermal (patches or gels)
When are oestrogen patches more appropriate in HRT?
Patches are more suitable for women with poor control on oral treatment, higher risk of venous thromboembolism, cardiovascular disease and headaches.