Hormone replacement therapy (HRT) Flashcards
What is the use of HRT?
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 symptoms.
For HRT, why is progesterone given in addition to oestrogen for women who have a uterus?
Purpose of adding progesterone is to prevent endometrial hyperplasia and endometrial cancer secondary to “unopposed” oestrogen.
Women with a uterus require endometrial protection with progesterone. True/false?
True
This is due to unopposed oestrogen causing risk of endometrial cancer.
Whereas women without a uterus can have oestrogen-only HRT.
What is the difference in HRT regime for women that still have periods compared to postmenopausal?
Women that still have periods should go on cyclical HRT, with cyclical progesterone and regular breakthrough bleeds.
Postmenopausal women with a uterus and more than 12 months without periods should go on continuous combined HRT.
What are non-hormonal treatments for menopausal symptoms?
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 clonidine?
An agonist of alpha-2 adrenergic receptors and imidazoline receptors in the brain.
Uses for clonidine?
Lowers blood pressure and reduces the heart rate, and is also used as an antihypertensive medication.
Can be helpful for vasomotor symptoms and hot flushes, particularly where there are contraindications to using HRT.
What are common side-effects of clonidine?
Dry mouth, headaches, dizziness and fatigue.
What are the effects of sudden withdrawal from clonidine?
Can result in rapid increases in blood pressure and agitation.
What are the indications for HRT use?
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
In women under 60 years old, the benefits of HRT generally outweigh the risks. True/false?
True
What are the main benefits of HRT?
Improved vasomotor and other symptoms of menopause (including mood, urogenital and joint symptoms)
Improved quality of life
Reduced the risk of osteoporosis and fractures
The risks of HRT are less significant in older women and decrease with a longer duration of treatment. True/false?
False
HRT risks are more significant in older women and increase with longer duration of treatment.
What are the main risks of HRT?
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
Do the main risks of HRT apply to all women?
No
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 can the main risks of endometrial cancer and VTE be avoided in HRT?
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 some major contraindications to HRT?
- Undiagnosed abnormal bleeding
- Endometrial hyperplasia or cancer
- Breast cancer
- Uncontrolled hypertension
- Venous thromboembolism
- Liver disease
- Active angina or myocardial infarction
- Pregnancy
Before initiating HRT, what is important to check?
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
When choosing the correct HRT formulation, what steps are checked through?
3 main things are checked:
Step 1: Do they have local or systemic symptoms?
Step 2: Does the woman have a uterus?
Step 3: Have they had a period in the past 12 months (perimenopause or postmenopause)?
Step 1 HRT formulation for local and 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 HRT formulation for women with and without uterus?
No uterus: use continuous oestrogen-only HRT
Has uterus: add progesterone (combined HRT) – go to step 3
Step 3 HRT formation for if woman has or hasn’t had period in last 12 months?
Perimenopausal: give cyclical combined HRT
Postmenopausal (more than 12 months since last period): give continuous combined HRT
2 main methods for delivering systemic oestrogen in HRT?
Oral (tablets)
Transdermal (patches or gels)
When are patches more suitable than tablets for systemic oestrogen delivery?
More suitable for women with poor control on oral treatment, higher risk of venous thromboembolism, cardiovascular disease and headaches.
In what cases is cyclical progesterone given in HRT and what is the pattern?
Given to perimenopausal women (had period in last 12 months)
Given for 10 – 14 days per month. Cycling the progesterone allows patients to have a monthly breakthrough bleed during the oestrogen-only part of the cycle, similar to a period.
When is continuous progesterone given in HRT?
Continuous progesterone is used when the woman has not had a period in the past:
24 months if under 50 years
12 months if over 50 years
Continuous HRT has better endometrial protection than cyclical HRT. True/false?
True
What are the 3 methods of administering progesterone for endometrial protection in HRT?
Oral (tablets)
Transdermal (patches)
Intrauterine system (e.g. Mirena coil)
How long can mirena coil be used for endometrial protection before being replaced?
4 years
What are progestogens?
Refer to any chemicals that target and stimulate progesterone receptors
What is progesterone?
Hormone produced naturally in the body
What are progestins?
Synthetic progestogens
2 main types of progestogens?
C19 and C21 progestogens
What are C19 progestogens?
C19 progestogens are derived from testosterone, and are more “male” in their effects.
Examples are norethisterone, levonorgestrel and desogestrel. These may be helpful for women with reduced libido.
What are C21 progestogens?
C21 progestogens are derived from progesterone, and are more “female” in their effects.
Examples are progesterone, dydrogesterone and medroxyprogesterone. These may be helpful for women with side effects such as depressed mood or acne.
In menopause, there is an increase in the male hormone known as testosterone. True/false?
False
Testosterone is naturally low in females.
In menopause, there can be reduced testosterone, resulting in low energy and reduced libido (sex drive).
Treatment with testosterone is usually initiated and monitored by a specialist.
What are the side-effects of the oestrogen components of HRT?
- Nausea and bloating
- Breast swelling
- Breast tenderness
- Headaches
- Leg cramps
What are the side-effects of the progesterone components of HRT?
- Mood swings
- Bloating
- Fluid retention
- Weight gain
- Acne and greasy skin
