Hormone Replacement Therapy (HRT) Flashcards
What is the definition of Menopause?
Menopause is the permanent cessation (stop) of menstruation resulting from loss of activity of the ovarian follicles
When can Menopause be determined?
After 12 months of spontaneous amenorrhoea (absence of menstrual period)
What is the mean age for menopause
51
What happens during menopause?
- Number of eggs decreases until none are left
- Follicular activity fails
- Oestrogen levels fall -> leading to symptoms
- Negative feedback loop on pituitary starts to fail
- Levels of FSH and LH rise
- Low oestrogen - High FSH - High LH
What is perimenopause?
Perimenopause is when you have symptoms before your periods have stopped.
What happens during perimenopause?
Gradual onset of endocrine changes as ovaries start to fail
How long does perimenopause last?
Last approximately 4 years starting on average at 47.5 years
What percentage of women will not experience perimenopause and will cease menstruation abruptly?
10%
What is premature menopause ?
- Menopause occurs before the age of 40 years
- Lead to increased risk of developing osteoporosis and cardiovascular disease
What is postmenopause?
- The time after the menopause
- Occurs after 12 months of spontaneous amenorrhoea
- Difficulty to identify, especially in women who have started HRT
By what age are 80% of women postmenopausal?
54 years
What are the short term symptoms of menopause?
- Menstrual cycle shortens or lengthens
- Menstrual blood loss alters
- Vasomotor symptoms (Hot flushes/Night sweats/Palpitations)
- Psychological problems (Mood changes/Irritability/Sleep disturbance/ Depression/ Decreased libido)
- Musculoskeletal symptoms (Joint & muscle pain)
- Vaginal symptoms (Vaginal dryness/Dyspareunia (pain during sex))
- Urinary symptoms (UTIs/Urinary incontinence/Urethral syndrome)
What are the long term symptoms of menopause?
- Significant loss of calcium fro bones giving an increased risk of fractured due to osteoporosis
- Change in blood lipid profile giving an increased risk of cardiovascular disease
First signs of problems:
- Fractured neck of femur (broken hip)
- Myocardial infarction
- Stroke
What protective functions does oestrogen have in a pre-menopausal woman?
- Positive effect of bone mass
- Positive effect of blood lipid profile
- Positive effect on coagulation (formation of blood clots) and fibrinolytic activity (prevention of blood clots)
What is hormone replacement therapy (HRT)?
Hormone Replacement Therapy (HRT) is a treatment used to relieve symptoms of the menopause.
What kind of HRT is given to a woman with an intact uterus and why?
- Oestrogen + Progestogen
- Because to stop over-stimulation of the endometrium (layer of tissue lining the uterus) by unopposed oestrogen
What kind of HRT is given to a women without an intact uterus?
- Oestrogen alone
- Because if the uterus has been removed there is no endometrium to stimulate
What is the aim of oestrogen therapy?
- Aims to restore and maintain near normal plasma oestrogen levels
- Reinstates the negative feedback loop on LH and FSH so levels fall
What are the 3 nature;;y occurring oestrogens?
- Estradiol
- Estrone
- Conjugated oestrogens (equine)
Why are natural oestrogens used in HRT over synthetic oestrogen?
In HRT the risk of using synthetic oestrogen outweighs the benefits because of potentially serious side effects:
- Adverse lipid profile
- Raised BP
- Increased risk of abnormal blood clotting
Synthetic oestrogen used in oral contraceptives are up to 200 time more potent (powerful) than natural oestrogens. True or False
True
HRT is not as effective as contraceptive. True or False
True
- HRT is less potent therefore not as effective
For how long are women considered potentially fertile if they are under 50 years and menopause?
For 2 years after last period
For how long are women considered potentially fertile if they are over 50 years and menopause?
For 1 year after last period
What can women under 50 use as contraception?
Combined oral contraceptive pill (COC) for contraception and relief of menopausal symptoms
What can women over 50 use as contraception?
Non-hormonal contraception and HRT for menopausal symptoms if required
What is progestogen therapy used for?
- Progestogen is added to HRT for women with an intact uterus to protect from overgrowth and possible cancer
- Progestogen needed for a minimum of 10 days per 28 day cycle to protect against overgrowth.
Name 2 less androgenic progestogen
- Dydrogesterone
- Medroxyprogesterone acetate
Name 2 more androgenic progestogen
- Norethisterone
- Levonorgestrel
What are the 2 types of HRT?
- Combined HRT
- Oestrogen only HRT
What are the routes of administration available for HRT?
- Oral
- Transdermal (patch/gel/spray)
- Vaginal (cream/vaginal ring)
- Implant
What are the advantages of using transdermal route of HRT?
- Gives less day to day variation in blood level
- Produces a more natural physiological oeastradiol:oestrone ration
- Bypasses first-pass metabolism and has less effect on the clotting factors produced by the liver
- Smaller dose
Results in: Lower rate of venous thromboembolism
What forms of vaginal oestrogen are available?
- Vaginal tablets
- Vaginal ring
- Vaginal creams of gel
- Pessaries
When is vaginal oestrogen used as monotherapy for HRT?
When vaginal and/or bladder symptoms predominate
What vaginal oestrogen is available over the counter and what is it used for?
- Gina: Estradiol 10mg vaginal tablets - 1 tablet daily for 2 weeks then twice weekly
- For vaginal atrophy due to oestrogen deficiency in postmenopausal women over 50 years who have not had a period for at least 1 year
What forms of systemic HRT are available?
- Tablets
- Patches
- Gel
- Spray
- Implants
- For vasomotor symptoms and other symptoms control
- Prevention and treatment of osteoporosis
How long is HRT used for vasomotor symptoms?
2-3 years (initial review at 3 months to assess efficacy & tolerability)
Why is an annual review recommended when using HRT?
Due to increased risk of side effects such as
- Stroke
- Breast cancer
- Endometrial cancer
- Venous thromboembolism
HRT prescribed before the age of 60 has a favourable benefit/risk profile in healthy women. True or False
True
How should HRT be prescribed for women over 60 years of age?
- Should be started on lower doses
- Preferably a transdermal route of estradiol administration
What should women be assessed for when getting HRT?
Risks vs Benefits
What side effects does Oestrogen HRT give?
- Nausea and vomiting
- Abdominal cramps and bloating
- Weight changes (gain)
- Breast tenderness and enlargement
- Premenstrual-like syndrome
- Sodium and fluid retention
What side effects does Progestogen HRT give?
More androgenic drug (norethisterone, levonorgestrel)
- Cause greasy skin + hair
- Tend to off-set some of the protective effect of oestrogen’s on lipid profile
Less androgenic drugs (dydrogesterone, medroxyprogesterone) cause progesterone-like side effects:
- Abdominal bloating
- Mood changes such as irritability , depression
- Breast tenderness
Why do women stop taking HRT?
- Side effects of the progestogen
- Regular monthly bleed induced by combination therapy when periods had been in the process of stopping
- Weight gain
