HRT Flashcards
What are the most appropriate oestrogens to use in HRT
Natural oestrogens - estradiol, estrone and estriol
Name some synthetic oestrogens
Ethinylestradiol and mestranol
Tibolone
- How is it given?
Without cyclical progestogen -
Oestrogenic, progestrogenic and weak androgenic activity
What should also be given for long-term therapy in women with a uterus and why?
Progestrogen - to reduce risk of cystic hyperplasia of the endometrium and possible transformation of cancer
What are the two types of menopausal symptoms
Vaginal atrophy - Vaginal dryness
Vasomotor sx - hot flushes, night sweats
How long is HRT given for in early menopause?
Until the approximate age of natural menopause roughly 50 years
What can be used to reduce vasomotor sx in those women who cannot take oestrogen?
Clonidine
What does HRT increase the risk of?
VTE
Stroke
Endometrial cancer (reduced by progestogen, at least 10 days per cycle)
Breast cancer
Ovarian cancer
CHD in women who take combined hRT for more than 10 years after menopause
In what age is using HRT evidence limited?
> 65
What is the risk of developing breast cancer when on HRT
All systemic HRT (not vaginal) increase risk of breast cancer after 1 year use (risk higher with combined).
After stopping hRT, there risk still persists for more than 10 years after stopping
The effect of weight and risk of endometrial cancer
Without HRT - high BMI increases risk of endometrial cancer
O only HRT or tibolone increased risk of endometrial cancer more apparent in those women who are not overweight
Tibolone increases the risk of what ? (2)
Endometrial cancer
Stroke (absolute risk increases with age)
Risk of ovarian cancer
Long term use of combined and HRT and O only hRT associated with small increased risk of ovarian cancer - disappears within a few years of stopping
Risk of VTE
Combined and O only HRT increase risk of DVT and PE especially in the first year of use.
Choice of HRT for women with a uterus
Oestrogen with cyclical progestogen for the last 12-14 days of cycle or a preparation which involves continuous administration of an oestrogen and a progestogen
When are combined preparations or tibolone not suitable?
Perimeonopause or within 12 months of the last menstrual period - may bleed irregularly in the early stages of tx - if bleeding continues endometrial abnormality should be ruled out and consideration given to changing to cyclical HRT
Choice of HRT for women without a uterus
Continuous Oestrogen only
Choice for endometriosis
In endometriosis, endometrial foci may remain despite hysterectomy and the addition of a progestrogen should be considered)
Surgery and HRT
Major surgery under general anaesthesia, including orthopaedic and vascular leg surgery - increased risk of VTE
Stop HRT 4-6 weeks before surgery and only restarted after full mobilisation
If HRT is continued or if discontinuation is not possible, prophylaxis with unfractionated or LMWH and graduated compression stockings is advised
Reasons to STOP HRT
Sudden severe chest pain (even if not radiating to left arm);
sudden breathlessness (or cough with blood-stained sputum);
unexplained swelling or severe pain in calf of one leg;
severe stomach pain;
serious neurological effects including unusual severe, prolonged headache especially if first time or getting progressively worse or sudden partial or complete loss of vision or sudden disturbance of hearing or other perceptual disorders or dysphasia or bad fainting attack or collapse or first unexplained epileptic seizure or weakness, motor disturbances, very marked numbness suddenly affecting one side or one part of body;
hepatitis, jaundice, liver enlargement;
blood pressure above systolic 160 mmHg or diastolic 95 mmHg;
prolonged immobility after surgery or leg injury;
detection of a risk factor which CI treatment
What is ethinylestradiol licensed for?
short term tx of sx of oestrogen deficiency, for osteoporosis prophylaxis if other drugs cannot be used and tx of female hypogonadism and menstrual disorders, palliative tx of prostate cancer,
specialist - hereditary haemorrhagic telangiectasia
What is raloxifene licenced for?
tx and prevention of postmenopausal osteoporosis
Can raloxifene be used to reduce menopausal vasomotor sx?
Nope
What are the two main groups of progestogen
Progesterone and its analogues (dydrogesterone and medroxyprogesterone acetate) - Testosterone analogues (noresthisterone and norgestrel)
Examples of newer progestogens
Desogestrel, norgestimate and gestodene
Which progestogens are less androgenic
progesterone and derivatives
which progestogens cause less virilization
progesterone and dydrogesterone
