HRT

Question 1

Oestrogens and progestrogens

Common indications

Answer 1

1. For hormonal contraception in women who require highly effective and reversible contraception, particularly if they may also benefit from its other effects, such as improved acne symptoms with oestrogens
2. For hormone replacement therapy (HRT) in women with early menopause (when it is given until 50 years of age) and those who have distressing menopausal symptoms

Question 2

Oestrogens and progestrogens

MOA

Answer 2

• Lutenising hormone (LH) and follicle-stimulating hormone (FSH) control ovulation and ovarian production of oestrogen and progesterone
• In turn, oestrogen and progesterone exert predominantly negative feedback on LH, FSH release
• In hormonal contraception, an oestrogen and or progesterone are given to suppress LH/FSH release and hence ovulation
• O&P also have many effects outside the ovary
• Some such as those on the cervix and endometrium may contribute to contraceptive effect
• Other effects include: Reduced menstral bleeding+pain, improved acne
• At the menopause, a fall in oestrogen and progesterone levels may generate a variety of symptoms, including vaginal dryness and vasomotor instability (hot flush)

Question 3

Oestrogens and progestogens

Adverse effects

Answer 3

• Irregular bleeding and mood change
• Increased risk of VTE prophylaxis but the risk is low
• Increased risk of CVD and stroke but only in women with other risk factors
• Increased risk of breast and cervical cancer
• In both cases the effect is small and for breast cancer, this reduces back when the pill is stopped
• HRT are similar adverse effects are CHC but risk is higher, the relative risks have more significant implications

Question 4

HRT

Warnings

Answer 4

• All forms of oestrogens and progestogens are contraindicated in patients with breast cancer
• Combined hormonal contraception should be avoided in patients at increased risk of VTA or CVD (>35yr, CV risk, migraine with aura, heavy smoker)

Question 5

HRT

Interactions

Answer 5

• CYP inducers (Rifamipicin) may reduce the efficacy of hormonal contraceptives, particularly progestogen only forms
• Most other antibiotics are safe to use with hormonal contraception

Question 6

HRT

Administration

Answer 6

• COC pills can be started on any day of the cycle; if this is within the first 6 days, no additional contraception is needed
• If it is beyond day 6, a barrier method should be used, or sex avoided for the first 7 days.
• Most Chc is designed to be taken for 21 days and stopped for 7
• Guidance is available for how to deal with missed pills; this is summarised in the BNF.
• In general, missing 1 CHC pill is okay, but missing 2 or more pulls necessitates the use of additional contraception for the 7 day

Question 7

HRT

Communication

Answer 7

• Hormonal contraception should be offered only after a discussion of the risks and benefits of the various contraceptive method available
• Explain that the usual method of taking the pill results in a bleed every month, although initially irregular bleeding can occur
  *

Question 8

HRT

Monitoring

Answer 8

• Baseline assessment should take place (history, BMI, BP)
• A woman starting CHC should be seen again at 3 months to check her BP and to discuss any issues.
• Thereafter she should be seen yearly to discuss health changes and to check her BP and BMI.