HRT Flashcards
What blood test levels are suggestive / diagnostic of menopause?
low oestradiol (<70 pmol/L) despite high LH and FSH
Why do we try to avoid the systemic use of HRT?
It causes endometrial hyperplasia → possibility of malignancy
*therefore, if needed (symptom assessment/impact on life), use minimal doses for short period of time
How do we divide (2) the women patients for the purpose of treatment with HRT?
- Those with uterus
- Those who had a hysterectomy
What HRT would be recommended in a woman with a uterus who have bled within last year (perimenopausal)?
Cyclical combined HRT
(progesterone on the last 12 out 28 days)
Result: regular post-progesterone withdrawal bleed → protective for endometrium
* given for max 5 years (as prolonged use increases the risk of endometrial cancer)
* once a patient has been amenorrhoeic for 1 year / or reaches 54 → transfer to continous combined therapy
When do we change cyclical combined HRT into continuous combined HRT?
Once a patient has been amenorrhoeic for 1 year / or reaches 54 (whichever is sooner)→ transfer to continuous combined therapy
What HRT to prescribe for a woman with uterus, who has not bled for 1 year (postmenopausal) ?
Continuous combined HRT
(continuous oestrogen and progesterone)
- endometrial atrophy is caused → women should not bleed on that
- progesterone protects the endometrium from hyperplasia (and reduces risk of endometrial cancer)
- unwanted SEs of progesterone: withdrawal bleeds, premenopausal-like symptoms
Do we expect a bleed in a woman on continuous combined HRT?
- endometrial atrophy is caused → women should not bleed on that
- progesterone protects the endometrium from hyperplasia (and reduces risk of endometrial cancer)
- unwanted SEs of progesterone: withdrawal bleeds, premenopausal
What HRT can we give in women who have had a hysterectomy?
Oestrogen only HRT
- doses can be titrated to their symptoms
- progesterone is not required → if hysterectomy, there is no risk of unopposed oestrogen-induced endometrial hyperplasia
(3) indications for HRT
- menopausal-related symptoms
- early menopause
- prevention of osteoporosis
- Contraindications (strong) for HRT (4)
- Relative contraindications for HRT
Strong:
- endometrial cancer
- liver disease (e.g. active hepatitis)
- suspected pregnancy
- inherited thrombophilias
Relative: (referral to specialist)
- hypertension
- previous personal or family Hx of thromboembolism
- breast cancer
(close consideration for risk-benefit analysis)
Indications for specialist referral in terms of starting/not HRT
Relative contraindications:
- hypertension
- previous personal or family Hx of thromboembolism
- breast cancer
Other:
- menopause before 40 yo
- confirmed risk of osteoporosis
- high risk of personal Hx of oestrogen-dependant ca (e.g. breast, endometrium)
- abnormal bleed before the start of HRT/while using cyclical HRT or more than 6 months after start of continous combined HRT
MoA and use of Bisphosphonates
- examples of drugs
MoA: inhibit the osteoclast-mediated bone resorption → prevent osteoporosis
Examples: Pamidronate and Alendronate
*oral calcium and vitamin D supplements often given in addition to bisphosphonates
What’s Tibolone?
Tibolone
- synthetic steroid
- agonist → oestrogenic, progestogenic and androgenic effects
- Use: to relieve post-menopausal symptoms and protect the bones
- it doesn’t cause endometrial proliferation (but may cause irregular bleeding within few months)
What’s Raloxifene?
Raloxifene
- new class of selective-oestrogen-receptor-modulators (SERMs)
- MoA: selective stimulation of oestrogen receptors → to prevent osteoporosis and have beneficial effect on lipid profile
- SERMs do not relieve menopausal symptoms
Benefits of HRT (3)
- relieve in menopausal symptoms
- 50% reduction in osteoporosis risk
- it may delay onset of Alzheimer’s (no effect on established disease)
