HRT Flashcards
Early menopause is the cessation of ovarian function occurring between the ages of 40 and 45 years, in the absence of other causes of secondary amenorrhoea
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Premature menopause describes definitive loss of ovarian function before the age of 40 years, for example following bilateral oophorectomy
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Premature ovarian insufficiency (POI, also known as premature ovarian failure) is a clinical syndrome defined as the transient or permanent loss of ovarian function before the age of 40 years, characterized by menstrual disturbance (amenorrhoea or oligomenorrhoea), and potential spontaneous resumption of ovulation, menstruation, and spontaneous pregnancy
complications 1-Osteoporosis and fracture. 2-Cardiovascular disease. 3-Stroke disease. 4-Genitourinary syndrome of menopause, due to oestrogen depletion as well as natural ageing processes. =========== Premature or early menopause 1-All-cause mortality. 2-Cardiovascular disease. 3-Type 2 diabetes mellitus. 4-Depression. 4-Osteoporosis and fracture.
SYMPTOMS
1-Hot flushes/night sweats
A sudden feeling of heat in the upper body (face, neck, and chest) that spreads upwards and downwards. In some cases, this becomes generalized, typically lasting 2–4 minutes, and can be associated with excessive sweating, palpitations, or anxiety.
They can be embarrassing and distressing, and triggers may include spicy food and alcohol.
2-Cognitive impairment and mood disorders
There may be anxiety, mood swings, irritability, sleep disturbance, and reduced quality of life.
There may be poor concentration and memory, and difficulties in multi-tasking, causing social embarrassment.
3-Urogenital symptoms
These may include vulvovaginal irritation, discomfort, burning, itching, and/or dryness; dyspareunia; reduced libido; dysuria, urinary frequency and urgency, and recurrent lower urinary tract infections. See the CKS topic on Urinary tract infection (lower) - women for more information.
Symptoms of urogenital atrophy may appear for the first time more than 10 years after the last menstrual period.
Vaginal dryness tends to increase in severity with time since menopause.
4-Altered sexual function
5-Sleep disturbance
6-Other
Joint and muscle pains, headaches, and fatigue are often reported
Consider using serum FSH measurements to diagnose menopause in a woman, provided she is not taking combined hormonal contraception HRT
1-<40 years with suspected premature ovarian insufcencey
2-40 to 45 years old with menpause symptoms
3- .45 years with a tyrpical symptoms
4->50 years on progesterone only contraception
If the FSH level is in the premenopausal range, the woman should continue contraception and the FSH level
should be rechecked in 1 year.
Suspect a diagnosis of POI in a woman younger than 40 years, provided she is not taking combined hormonal contraception, if she has:
1-Menopausal symptoms, including no or infrequent periods
2-Elevated serum follicle-stimulating hormone (FSH) levels (more than 30 IU/L) on two blood samples taken 4–6 weeks apart.
Note: additional testing of serum luteinizing hormone (LH), oestradiol, prolactin, testosterone, and thyroid-stimulating hormone (TSH) levels may be helpful for the diagnostic work-up.
Note: do not routinely use anti-Müllerian hormone (AMH) testing to diagnose suspected POI.
assessment
1-symptoms
2-life style (smoking -alcohol excercise -nutrition )
3-smears status cervical and bowel also breast screening
4-Family history including premature menopause or POI, venous thromboembolism, or hormone-dependent cancer
5-PMH DVT CVD HTN stroke breast cancer endpmetrial or overian cancer and
6-other comorbid condition like migraine , radiotherapy ,chemotherapy , hystrectomy and bilateral opharectomy
7-her treatment goals any previous treatmnt tried
8- current medications
exams
BP
BMI
MANAGMENT
A-LIFE STYLE
Hot flushes and night sweats —
*regular exercise,
*weight loss (if applicable),
* wearing lighter clothing/layers of clothing, turning down central heating, sleeping in a cooler room, using fans, *reducing stress,
* avoiding possible triggers (such as spicy foods, caffeine, smoking, and alcohol).NON MEDIUCAL
NON HORMONAL
*VASOMOTOR
1-SSRI AND SNRI
* fluoxetine 20 mg *citalopram 20 mg *paroxetine 10 mg or venlafaxine modified-release (37.5 mg daily for 1 week then increased to 75 mg once daily if needed).
2-clonidine 50mic can be increased to 75mic BID if needed
3-papentine
4-CBT
*MOOD SSRI CBT
*UROGENITAL 1-Vaginal moisturizers, such as Replens +_ vaginal osterogen
*COMPLEMETARY THERAPY
There is some evidence that isoflavones and black cohosh may relieve vasomotor symptoms, but the quality, purity, constituents, and safety of these products may be
HRT
arrange follow up in 3 months
**For vasomotor symptoms:
1-UTERUS oral or transdermal combined
2-NO UTERUS oral or transdermal oestrogen-only
3-In eligible women under 50 years of age, offer a choice of HRT or a combined hormonal contraceptive
**mood disorders, offer a choice of oral or transdermal HRT preparations.
**urogenital symptoms
1-Offer low-dose vaginal oestrogen first-line as long as needed
2- some pt on HRT might benifit from it
3-If oestrogen is not tolerated or contraindicated, consider a trial of oral ospemifene if there are moderate-to-
severe symptoms and no contraindications
4-If a low-dose preparation does not relieve symptoms sufficiently, consider seeking specialist advice about
increasing the dose
**For altered sexual function, seek specialist advise
BENEFITS
1-reduces risk of fragility fracture while taking HRT and seases after stopping
2-might be benificial for BP
3-if continued until the natural age of menopause it protects against chronic diseases like CHD
risks
1- VTE is greater for oral than transdermal preparations. transdermal HRT given at standard therapeutic doses is no greater than baseline risk.
2- CHD oestrogen alone is associated with no, or reduced, comined with little increase
3-STROKE HRT does not increase CVD risk when started in women younger than 60 years.
Oral (but not transdermal) oestrogen is associated with a small increase in the risk of stroke.
4-BREAST CANCER
*oestrogen alone is associated with little or no increase in the risk of breast cancer.
*Combined with an increased risk of breast cancer that is dependent on duration which reduces after stopping
*HRT does not affect the risk of dying from breast cancer.
4-diabetes doesnt increase the risk
5- dementia unknown
COMORBIDITIES
* BREAST CANCER
1- dont offer and stop systemic HRT in patient diagnosed with breast cancer
2-Seek specialist advice if a woman wishes to consider the use of hormonal therapy, such as treatment with
low-dose vaginal oestrogen.
3- not to use fluoxetine or paroxetine, as they may inhibit the effect of tamoxifen.
4-Do not recommend the use of isoflavones, red clover, black cohosh, vitamin E, or magnetic devices to treat
menopausal symptoms in women with breast cancer.
5-Advise that the herbal preparation St John’s wort may interact with other drugs such as tamoxifen,
anticoagulants, and anticonvulsants
*VTE
1- transdermal rather than oral HRT including women with a BMI over 30 kg/m2.
2-Consider referring women at high risk of VTE (for example, with a strong family history of VTE or a hereditary
thrombophilia) to a haematologist for assessment before considering the use of HRT.
COMORBIDTIES
3-CVD
1-Be aware that the presence of cardiovascular risk factors is not a contraindication to taking HRT as long as they
are optimally managed.
2-Consider the use of transdermal rather than oral HRT for women at increased risk of CVD.
4-hypothyroidisim
Advise that thyroid-stimulating hormone (TSH) levels 6–12 weeks after starting oral HRT), to ensure that levels
remain in the acceptable range, as the dose of levothyroxine (LT4) medication may need to be increased
SPECIALITY REFERRAL
1- remains symptomatic inspite maximum treatment
2-persistant reduced sexual drive
3- difficult to decide on suitable treatment because of comorbidties
4-The woman has persistent, troublesome adverse effects from treatment.
5-There is uncertainty about diagnosing premature ovarian insufficiency, or specialist advice is needed to manage the condition.
CONTRA INDICATION
Current, past, or suspected breast cancer.
Known or suspected oestrogen-dependent cancer.
Undiagnosed vaginal bleeding.
Untreated endometrial hyperplasia.
Previous idiopathic or current venous thromboembolism (deep vein thrombosis or pulmonary embolism), unless the woman is already on anticoagulant treatment.
Active or recent arterial thromboembolic disease (for example angina or myocardial infarction).
Active liver disease with abnormal liver function tests.
Pregnancy.
Thrombophilic disorder.
