HRT

Question 1

Contraindications to HRT

Answer 1

Current or past breast cancer
Any oestrogen-sensitive cancer
Undiagnosed vaginal bleeding
Untreated endometrial hyperplasia

Question 2

Non-HRT management of Vasomotor symptoms

Answer 2

fluoxetine, citalopram or venlafaxine

or clonadine (agonist of alpha-2 adrenergic receptors and imidazoline receptors)

Question 3

Non-HRT management of vaginal dryness

Answer 3

vaginal lubricant or moisturiser

Question 4

HRT for women with a uterus

Answer 4

oestrogen plus progesterone

Question 5

HRT for women without a uterus

Answer 5

oestrogen only

Question 6

HRT for perimenopuase/still have periods

Answer 6

cyclical HRT, with cyclical progesterone and regular breakthrough bleeds.

Question 7

HRT for postmenopause/12 months since last period

Answer 7

continuous combined HRT

Question 8

How to decrease VTE risk HRT

Answer 8

use patches instead of pills

Question 9

Who are oestrogen patches better for

Answer 9

more suitable for women with poor control on oral treatment, higher risk of venous thromboembolism, cardiovascular disease and headaches.

Question 10

Switching from cyclical to continuous HRT

Answer 10

You can switch from cyclical to continuous HRT after at least 12 months of treatment in women over 50, and 24 months in women under 50. Switch from cyclical to continuous HRT during the withdrawal bleed. Continuous HRT has better endometrial protection than cyclical HRT.

Question 11

How long is the mirena coil licenced for endometrial protection

Answer 11

4 years

Question 12

Best way of delivering progesterone

Answer 12

The best way of providing progesterone is with an intrauterine device, for example, the Mirena coil. The coil has the added benefits of contraception and treating heavy menstrual periods. Additionally, women will not experience progestogenic side effects.

Question 13

What is tibolone

Answer 13

Tibolone is a synthetic steroid that stimulates oestrogen and progesterone receptors. It also weakly stimulates androgen receptors. The effects on androgen receptors mean tibolone can be helpful for patients with reduced libido.

Tibolone is used as a form of continuous combined HRT. Women need to be more than 12 months without a period (24 months if under 50 years). They would be expected not to have breakthrough bleeding. Tibolone can cause irregular bleeding, resulting in further investigations to exclude other causes.

Question 14

HRT and elective surgery?

Answer 14

Stop oestrogen-containing contraceptives or HRT 4 weeks before major surgery

Question 15

Oestrogen or progesterone SE?

Nausea and bloating
Breast swelling
Breast tenderness
Headaches
Leg cramps

Answer 15

oestrogen

Question 16

Oestrogen or progesterone SE?

Mood swings
Bloating
Fluid retention
Weight gain
Acne and greasy skin

Answer 16

progesterone

Question 17

Irregular bleeding HRT

Answer 17

Unscheduled bleeding can occur in the first 3 – 6 months of HRT (in women with a uterus). If unscheduled bleeding continues, consider referral for investigations, particularly regarding endometrial cancer.

Question 18

c19 vs c21 progesterone?

Answer 18

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.

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.

Question 19

What does adding progesterone do to breast cancer risk of HRT

Answer 19

increases risk