Hormone Replacement Therapy (HRT)

Question 1

What are the signs and symptoms for menopause?

Answer 1

‘7 menopausal dwarfs’:
* Itchy
* Sweaty
* Bloaty
* Forgetful
* Psycho
* Bitchy
* Sleepy

Question 2

What is menopause?

Answer 2

• The time when menstruation stops permanently due to the loss of ovarian follicular activity.
• It occurs with the final menstrual period - diagnosed clinically after 12 months of amenorrhoea.

Question 3

What is perimenopause?

Answer 3

• Time before last menstrual period when ovarian activity slows and oestrogen levels start to fall.
• This time can last several years.

Question 4

What is post-menopause?

Answer 4

Time after last menstrual period

Question 5

Explain what happens during menopause.

Answer 5

• Ovaries have a finite number of oocytes.
• Decrease till around 50 years old then have none left
• During the peri-menopause ovarian activity slows
• Oestrogen levels drop
• Oestrogen is protective in a number of different body systems such as: brain, skin, bones, heart, urinary functions and the genital area – low levels of oestrogen can affect all these body areas
• This disrupts the menstrual cycle and causes menopausal symptoms.

Question 6

Explain what happens to FSH & LH levels during Menopause.

Answer 6

• Oestrogen levels decrease, causing reduced negative feedback to the pituitary ……..FSH and LH levels rise.
• Levels of FSH fluctuate on an almost daily basis during the transition to menopause.
• Decreasing oestrogen levels begin to disrupt the menstrual cycle and may cause other menopausal symptoms such as hot flushes and night sweats.
• Cycles tend to become anovulatory (not occur)
• Estradiol production, which occurs in the granulosa and thecal cells surrounding the oocyte, becomes insufficient to stimulate the endometrium, and amenorrhoea occurs.
• Eventually, the menopausal pattern of low oestrogen and persistently high FSH and LH levels is established.

Question 7

What is early menopause?

Answer 7

Occurs before the age of 45 years.

Question 8

What is premature ovarian insufficiency?

Answer 8

Menopause before the age of 40 years

Question 9

What are the causes of early menopause?

Answer 9

• Family history
• Premature ovarian failure
• Radiotherapy and chemotherapy (Cancer treatment)
• Hysterectomy
• Infection (TB, mumps, malaria, varicella, shigella. Very rare!)

Question 10

Explain the diagnostic process for menopause.

Answer 10

• For patients 45 years + with irregular periods and other menopausal symptoms no diagnostic tests required.
• It is useful for patients to track symptoms using an app such as ‘balance’ menopause support, or fill in the Greene Climacteric Scale questionnaire.
• < 45 years of age - may test FSH. If raised then it is very likely the patient is menopausal.

Question 11

What are the long-term physical effects for menopause?

Answer 11

• Thinning of skin and hair.
• Bone mass is lost and bones more liable to breaking.
• Dryness of eyes mouth and throat.
• Atrophy of breasts; endometrium; vagina; vulva; pelvic muscles.

Question 12

What are the possible complications relating to menopause?

Answer 12

• Increased risk of osteoporosis, CVD (especially in smokers), dementia, cognitive decline, and parkinsonism
• Breast cancer risk decreases
• Osteoporosis - Women lose bone mass quickly after the menopause
• HRT is not a stand alone recommended treatment for prevention of osteoporosis in menopausal women.

Question 13

What treatment options are available for menopause?

Answer 13

• 1st line lifestyle changes –
• Weight management and exercise
• There is evidence that smoking cigarettes and having a BMI >30 kg/m2 increases the likelihood of flushing.
• Discuss risks and benefits when deciding to introduce HRT

Question 14

What lifestyle advice does NICE guidelines recommend for managing menopause without HRT?

Answer 14

• Lifestyle advice as per NICE:
• Exercise
• Wear lighter/cooler clothes
• Avoid triggers to hot flushes – caffeine, spicy foods etc
• Sleep hygiene
• Sleep in a cooler room
• Relaxation techniques
• Reduce stress
  *Antidepressants???
• Vaginal moisturiser e.g. Replens®
• Clonidine 50-75mcg bd
• Self-help groups
• Psychotherapy
• Counseling
• Supplements/homeopathy etc – evidence base for any of these is very poor

Question 15

What are the benefits of HRT?

Answer 15

• Treating vasomotor symptoms eg. hot flushes and night sweats
• Treating urogenital symptoms eg. vaginal dryness etc
• Managing sleep or mood disturbances caused by hot
  flushes and night sweats
• Preventing osteoporosis - short-term treatment but if used for long-term, the risks of developing osteoporosis increase.
• HRT not used as first line treatment for long-term prevention of osteoporosis in women 50 yrs and older.

Question 16

What are the risks associated with HRT?

Answer 16

Risk is dependant on delivery method!!!:
For combined HRT given orally:
* There is a small increased risk of breast cancer,
coronary events, VTE, and stroke
* Combined HRT may be associated with an increased risk of ovarian cancer.
* CSM advises the minimum effective dose should be used for the shortest duration
* The benefits of HRT outweigh the risks for most women.

Question 17

Explain the process of choosing HRT.

Answer 17

• All types deliver a set dose of oestrogen into the
  bloodstream.
• However,oestrogen alone would cause the uterine lining to proliferate….
• Thus, increases the risk of uterine cancer.
• Usually combined with a progestogen.
• In some HRT products, the oestrogen and progestogen are combined in the same formulation, but they can also be given separately which helps to personalise the dose.
• Hysterectomy – progestogen NOT required

Question 18

What do you need to consider when prescribing combined products?

Answer 18

• Less flexibility if alteration in oestrogen dose is needed.
• They all contain ‘older’ progestogens.

Question 19

What do you need to consider when prescribing oral oestrogens?

Answer 19

• There is VTE risk with oral oestrogen.
• Oral oestrogen increases sex hormone binding globulin (SHBG) so reducing free androgen index (lowers libido even more)
• There is less reliable absorption.
• More contraindications (for example obesity, diabetes,
  gallbladder disease, migraine etc).

Question 20

When would it be appropriate to give transdermal oestrogen? What is the evidence behind its use?

Answer 20

When used alongside with micronised progesterone, optimises HRT regimen, particularly in women at risk of cardiovascular events.

Not always suitable for all women. Oral agents are used.
- Oestrogen + Continuous Progestogen
- Oestrogen + Cyclical Progestogen = first line for patients with regular bleeding.

Women with an intact uterus also needs progestogen,

Question 21

Name the most important hormone in HRT.

Answer 21

Oestrogen - Best as 17 betaestradiol.

Question 22

Explain the initiating treatment for Oestrogen.

Answer 22

• Give the optimal dose to improve symptoms and also to optimise bone and heart health.
• Women can continue taking HRT for as long as the benefits outweigh any risks….an annual review should be conducted.
• It is NOT about lower dose and shortest length of time anymore!

Question 23

What form of Oestrogen has no clotting risk?

Answer 23

Transdermal

Question 24

What risk does Transdermal oestrogen not have?

Answer 24

Clotting risk

Question 25

Explain how Transdermal Oestrogen is given.

Answer 25

It can be given to women with:
- A history or risk of clot or stroke
- including women with migraines
- women with hypertension and cardiovascular disease.

Question 26

What tips do you give to a woman with a uterus that needs progestogen?

Answer 26

• Give cyclical HRT for first 6-12 months to women having periods
• Continuous progestogens are better for endometrial protection
• Any age woman can take continuous HRT but it may cause erratic bleeding if given too early.

Question 27

Explain the process of choosing a progestogen.

Answer 27

• Evidence supports the use of micronised progesterone (Utrogestan)
• Can be prescribed cyclically, 200mg each evening, for 2 out of 4 weeks
• OR continuously, 100mg each evening.

Question 28

Explain the process of choosing between continuous or cyclical preparations.

Answer 28

• Postmenopausal women:
• Continuous combined regimens may be preferred because they do not produce withdrawal bleeding.
• May produce irregular bleeding or spotting for the first 4–6 months of treatment.

In Practice:
- Combined form is used (1 patch/tablet) due to progestogen s/e causing poor compliance if given in separate forms.
- If given separately, counsel progestogen’s endometrial effect to ensure compliance.

Question 29

Explain how IUD Mirena is used as an HRT.

Answer 29

• IUD Mirena has levonorgestrel.
• An alternative route of progestogen delivery to protect the endometrium (uterine lining)
• Levonorgestrel is delivered locally to the uterus – therefore much lower daily dose is used!
• Also a contraceptive
• Low bleed risk and safe for up to 5 years.

Question 30

What are the benefits of using micronized progesterone?

Answer 30

• Protective - lining of the womb
• Improves sleep and anxiety

Question 31

What is are the side effects of using micronised progesterone?

Answer 31

4 B’s:
- Bloating
- Breast tenderness
- Bleeding
- Blues

Question 32

What is vaginal oestrogen?

Answer 32

• Not HRT
• Applied to the vagina for vaginal atrophy
• E.g. ortho gynest, vagifem pessaries, Estring vaginal ring
• Systemic absorption of low-dose vaginal oestrogen = very low
• Does not relieve other menopausal symptoms, such as hot flushes.
• Can be used alongside HRT or for post-menopausal women who still have vaginal symptoms after stopping HRT.

Question 33

Explain how testosterone is used as adjunct therapy for HRT.

Answer 33

• Adding to HRT can improve sexual function and general wellbeing and can improve libido.
• Testosterone can improve mood, energy, stamina and concentration. Many women notice that their brain fog and memory improve.
• However - currently no available licensed preparations for women in the UK.
• It is important to ensure that women are adequately oestrogenised before adding in testosterone; ie - no longer experiencing vasomotor symptoms.

Question 34

Explain the reasons why stopping HRT is appropriate for emergency.

Answer 34

• Stop 4-6 weeks before surgery
• Severe chest pain
• Breathlessness
• Severe pain in the calf of one leg
• Severe stomach pain
• Severe neurological effects
• Hepatitis, jaundice or liver enlargement
• BP>160/100
• Prolonged immobility –DVTr isk
• Detection of a risk factor

Question 35

Explain the process of stopping HRT.

Answer 35

• If used for symptom control- trial withdrawal after 1- 2 years if symptom free….note there is no reason to stop HRT in women who wish to continue taking it.
• Women with early menopause take HRT to at least the age of natural menopause
• Gradual reduction of dose rather than stopping abruptly
• If symptoms are severe for several months after stopping consider restarting

Question 36

Explain the general relationship between HRT and contraception effect.

Answer 36

• If used for symptom control- trial withdrawal after 1- 2 years if symptom free. Note there is no reason to stop HRT in women who wish to continue taking it.
• Women with early menopause take HRT to at least the age of natural menopause
• Gradual reduction of dose rather than stopping abruptly
• If symptoms are severe for several months after stopping consider restarting

Question 37

What does HRT not provide?

Answer 37

Contraception

Question 38

At what ages are women considered to be potentially fertile after her last menstrual period?

Answer 38

< 50 yrs: 2 years
> 50 yrs: 1 year

Question 39

Explain how HRT is used for gender dysphoria.

Answer 39

Refer to this website for further details:
https://sunderlandccg.nhs.uk/wp-content/uploads/2016/03/SCCG-Gender-Dysphoria-Feminising-Hormones-Dec-2015.pdf?UNLID=186170263201831532222