Hormone Replacement Therapy (HRT)

Question 1

What are the indications of HRT?

Answer 1

• relief of menopausal symptoms, eg hot flushes, night sweats (short-term treatment)
• prevention of postmenopausal osteoporosis when there is a high risk of fractures and alternative tx is inappropriate

Question 2

What are the common AEs of HRT?

Answer 2

Oestrogen: breast tenderness, nausea
Progestogen: PMS symptoms, uterine bleeding on withdrawal

Question 3

Do women who had a hysterectomy need a HRT combination of estrogen and progestogen? Why or why not?

Answer 3

• No, because has no intact uterus
• for women with an intact uterus, there is an increased endometrial cancer risk with oestrogen alone
• addition of progestogen (10-14 days each month or continuously) eliminates risk
• therefore for women with an intact uterus, they always need to use a combination of oestrogen and progestogen

Question 4

Discuss the various regiments available.

Answer 4

Oestrogen-only HRT

• recommended in women post-hysterectomy
• oestrogen is taken continuously

Vaginal oestrogen

• 1st choice for urogenital symptoms
• use lowest effective dose to control symptoms. Stop treatment at least annually to see if it is still required
• progestogen is not usually necessary for endometrial protection - investigate if irregular/atypical bleeding occurs as it may indicate endometrial pathology

Combined HRT (cyclical or continuous)
- recommended in women with a uterus because of the increased risk of endometrial cancer associated with oestrogen-only HRT

> Cyclical

• continuous oestrogen plus progestogen for 10–14 days of each month, or for 14 days every 3 months
• expect withdrawal bleed after stopping progestogen
• suitable for women in the perimenopause or early post menopause
• low-dose COC is a suitable alternative in selected perimenopausal women Continuous
• continuous oestrogen plus continuous progestogen (generally half or quarter of the cyclical dose)
• suitable for postmenopausal women (at least 12 months since last menstrual period); 50% have irregular bleeding in the first 6 months of treatment; 90% are amenorrhoeic after 12 months.

Question 5

What non pharmacological advice would you give?

Answer 5

• regular light exercise
• light clothing
• keeping bedroom cool and lighter bedclothes
• sleep hygiene
• relaxation therapy
• avoid triggers eg. caffeine, smoking, alcohol

Question 6

What is the brand name of the transdermal patch of HRT? Discuss.

Answer 6

Estalis Sequi 50/140: oestradiol 50 mcg/24 hours, oestradiol 50 mcg/24 hours, norethisterone 140 mcg/24 hours

Estalis Sequi 50/250: oestradiol 50 mcg/24 hours, oestradiol 50 mcg/24 hours, norethisterone 250 mcg/24 hours

AEs: Common - skin irritation
Rare - allergic contact dermatitis

Counseling:

• apply oestradiol patches for 2 weeks, then combined patches for 2 weeks (change patch every 3–4 days)
• apply to clean, dry skin on your lower abdomen or buttocks.
• when changing the patch, remove the old patch and apply a new one to a different place

Question 7

What are the estrogen deficiency symptoms?

Answer 7

• hot flushes/night sweats
• anxiety/depression
• arthralgia (joint pain)
• loss of libido
• dry vagina
• uncomfortable intercourse
• urinary frequency

Question 8

List the drugs used for HRT.

Answer 8

• Tibolone

Oestrogens:

• conjugated equine oestrogens
• oestradiol
• oestriol

Progestogens:

• levonorgestrel IUD
• medroxyprogesterone
• norethisterone

Question 9

Discuss Tibolone (Livial®).

Answer 9

Class: HRT

MOA:

• acts as an oestrogen on vagina, bone and thermoregulatory centres in brain
• has progestogenic and anti-oestrogenic effects on breast and endometrium
• androgenic effects include decrease in HDL, triglycerides and lipoprotein(a)

Indications:

• relief of menopausal symptoms, eg hot flushes (short-term treatment)
• prevention of postmenopausal osteoporosis when there is a high risk of fractures and alternative treatment is inappropriate

AEs:
Common
- abdominal pain, bloating
- weight increase
- vaginal bleeding or spotting
- vaginal discharge and itching, vaginitis
- breast pain, increased aminotransferases

Infrequent
stroke

Dose: 2.5 mg d

Question 10

What is Vagifem® and what is it’s route of administration?

Answer 10

> Vagifem® is a HRT which contains 25mcg of oestradiol and it is a pessary
1 pessary is inserted into the vagina once each day for 2 weeks, then reduce to twice a week
tell your doctor immediately if you develop:
- symptoms of a blood clot (red, swollen or painful leg, difficulty in breathing or chest pain)
- changes in your breasts (eg skin or nipple changes or a lump)
- changes in vaginal bleeding a few months after starting HRT (heavy or irregular bleeding, or bleeding after sex)

Question 17

Discuss Angeliq®.

Answer 17

Angeliq® = oestradiol 1 mg, drospirenone 2 mg

Indication: HRT

Dose: 1 tablet d

Counseling:
Tell your doctor immediately if you develop:
- symptoms of a blood clot (red, swollen or painful leg, difficulty in breathing or chest pain)
- changes in your breasts (eg skin or nipple changes or a lump)
- changes in vaginal bleeding a few months after starting HRT (heavy or irregular bleeding, or bleeding after sex).