HRT Flashcards
TOM TIP: Hormone replacement therapy is a massive topic. If you remember one thing about HRT for your exams, remember the basics of choosing the HRT regime. Women with a uterus require endometrial protection with progesterone, whereas women without a uterus can have oestrogen-only HRT. Women that still have periods should go on cyclical HRT, with cyclical progesterone and regular breakthrough bleeds. Postmenopausal women with a uterus and more than 12 months without periods should go on continuous combined HRT.
Describe the stepwise approach should use to determine what HRT should prescribe [3]
Step 1: Do they have local or systemic symptoms?
* Local symptoms: use topical treatments such as topical oestrogen cream or tablets
* Systemic symptoms: use systemic treatment – go to step 2
Step 2: Does the woman have a uterus?
* No uterus: use continuous oestrogen-only HRT
* Has uterus: add progesterone (combined HRT) – go to step 3
Step 3: Have they had a period in the past 12 months?
* Perimenopausal: give cyclical combined HRT
* Postmenopausal (more than 12 months since last period): give continuous combined HRT
Clonidine can be used as a non-hormonal treatment for menopausal symptoms.
Which receptors does it work on? [2]
What is the MoA? [1]
Which symptoms is it particularly indicated for in menopause? [2]
Clonidine:
- act as an agonist of alpha-2 adrenergic receptors and imidazoline receptors in the brain
- It lowers blood pressure and reduces the heart rate
It can be helpful for vasomotor symptoms and hot flushes, particularly where there are contraindications to using HRT.
What is considered the most immportant factor in choosing whether to start HRT? [3]
vasomotor symptoms such as flushing, insomnia and headaches
What is the most important reason in giving HRT to younger women? [1]
To prevent osteoporosis
What are the indications for HRT? [4]
- Replacing hormones in premature ovarian insufficiency, even without symptoms
- Reducing vasomotor symptoms such as hot flushes and night sweats
- Improving symptoms such as low mood, decreased libido, poor sleep and joint pain
- Reducing risk of osteoporosis in women under 60 years
Describe the risks of HRT [4]
- Increased risk of breast cancer (particularly combined HRT – oestrogen-only HRT has a lower risk)
- Increased risk of endometrial cancer unless the women has no uterus
- Increased risk of venous thromboembolism (2 – 3 times the background risk)
- Increased risk of stroke and coronary artery disease with long term use in older women in COMBINED HRT (not oestrogen only)
NB The evidence is inconclusive about ovarian cancer, and if there is an increase in risk, it is minimal
Describe the relationships between HRT and breast cancer [2]
Combined HRT:
- Increases the risk
Oestrogen only:
- Decreases the risk
Why are women under 50 with a uterus offered combined HRT? [1]
The risk of endometrial cancer is greatly reduced by adding progesterone in women with a uterus
How do you reduce the risk of VTE when giving HRT? [1]
The risk of VTE is reduced by using patches rather than pills
There are some essential contraindications to consider in patients wanting to start HRT:
What are they? [7]
- Undiagnosed abnormal bleeding
- Endometrial hyperplasia or cancer
- Breast cancer
- Uncontrolled hypertension
- Venous thromboembolism
- Liver disease
- Active angina or myocardial infarction
- Pregnancy
What are key factors need to ask when assessing if a patient is suitable for HRT? [6]
Take a family history to assess the risk of oestrogen dependent cancers (e.g. breast cancer) and VTE
Check the body mass index (BMI) and blood pressure
Ensure cervical and breast screening is up to date
Continuous progesterone is used when the woman has not had a period in the past:
[] months if under 50 years
[] months if over 50 years
Continuous progesterone is used when the woman has not had a period in the past:
24 months if under 50 years
12 months if over 50 years
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.
There are three options for delivering progesterone for endometrial protection.
What are they? [3]
Oral (tablets)
Transdermal (patches)
Intrauterine system (e.g. Mirena coil)
The Mirena coil is licensed for [] years for endometrial protection, after which time it needs replacing
The Mirena coil is licensed for four years for endometrial protection, after which time it needs replacing
TOM TIP: The key to HRT is to remember the principles, so that you can counsel women and look up the specific regimes when required.
The best way of delivering oestrogen is with [], due to the reduced risk of venous-thromboembolism.
The best way of providing progesterone is with an []
TOM TIP: The key to HRT is to remember the principles, so that you can counsel women and look up the specific regimes when required.
The best way of delivering oestrogen is with patches, due to the reduced risk of venous-thromboembolism.
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.
You’ve been asked to counsel someone about HRT.
Explain the risks vs benefits of HRT
