HRT

Question 1

What are the most appropriate oestrogens to use in HRT

Answer 1

Natural oestrogens - estradiol, estrone and estriol

Question 2

Name some synthetic oestrogens

Answer 2

Ethinylestradiol and mestranol

Question 3

Tibolone

- How is it given?

Answer 3

Without cyclical progestogen -

Oestrogenic, progestrogenic and weak androgenic activity

Question 4

What should also be given for long-term therapy in women with a uterus and why?

Answer 4

Progestrogen - to reduce risk of cystic hyperplasia of the endometrium and possible transformation of cancer

Question 5

What are the two types of menopausal symptoms

Answer 5

Vaginal atrophy - Vaginal dryness

Vasomotor sx - hot flushes, night sweats

Question 6

How long is HRT given for in early menopause?

Answer 6

Until the approximate age of natural menopause roughly 50 years

Question 7

What can be used to reduce vasomotor sx in those women who cannot take oestrogen?

Answer 7

Clonidine

Question 8

What does HRT increase the risk of?

Answer 8

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

Question 9

In what age is using HRT evidence limited?

Answer 9

> 65

Question 10

What is the risk of developing breast cancer when on HRT

Answer 10

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

Question 11

The effect of weight and risk of endometrial cancer

Answer 11

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

Question 12

Tibolone increases the risk of what ? (2)

Answer 12

Endometrial cancer

Stroke (absolute risk increases with age)

Question 13

Risk of ovarian cancer

Answer 13

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

Question 14

Risk of VTE

Answer 14

Combined and O only HRT increase risk of DVT and PE especially in the first year of use.

Question 15

Choice of HRT for women with a uterus

Answer 15

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

Question 16

When are combined preparations or tibolone not suitable?

Answer 16

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

Question 17

Choice of HRT for women without a uterus

Answer 17

Continuous Oestrogen only

Question 18

Choice for endometriosis

Answer 18

In endometriosis, endometrial foci may remain despite hysterectomy and the addition of a progestrogen should be considered)

Question 19

Surgery and HRT

Answer 19

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

Question 20

Reasons to STOP HRT

Answer 20

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

Question 21

What is ethinylestradiol licensed for?

Answer 21

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

Question 22

What is raloxifene licenced for?

Answer 22

tx and prevention of postmenopausal osteoporosis

Question 23

Can raloxifene be used to reduce menopausal vasomotor sx?

Answer 23

Nope

Question 24

What are the two main groups of progestogen

Answer 24

Progesterone and its analogues (dydrogesterone and medroxyprogesterone acetate) -
Testosterone analogues (noresthisterone and norgestrel)

Question 25

Examples of newer progestogens

Answer 25

Desogestrel, norgestimate and gestodene

Question 26

Which progestogens are less androgenic

Answer 26

progesterone and derivatives

Question 27

which progestogens cause less virilization

Answer 27

progesterone and dydrogesterone