HRT and the Menopause Flashcards
Why would you expect during menopause for there to be an increase in the number of UTIs?
There are two possible reasons for an increase in UTIs:
1) The vaginal tissue thins, making it more prone to infection (reduce in the natural barrier defence)
2) Women may experience difficulty emptying their bladder, which again increases risk of infection
Aside from recurrent UTIs, what are some of the other urinary symptoms associated with menopause?
Dysuria
Increase in the frequency and urgency of passing urine
Urinary incontience
What is the mean age of menopause occuring in the UK?
51
When can menopause actually be determined?
Following 12 months of spontaneous amenorrhea (absence of menstrual periods for a year) as a result of loss of follicle activity.
Describe the hormone changes that occur during the menopause.
By the age of menopause the number of eggs within the ovaries has significantly decreased meaning that the overall follicular activity begins to decline, stimulating a decrease in estrogen level. Due to the drop in estrogen there is then no negative feedback cycle acting on the pituitary to regulate FSH and LH levels and therefore they continue to rise.
The decline in which hormone is responsible for the symptoms associated with the menopause?
Decline in estrogen
How can some women still conceive during the menopause?
Despite levels of estrogen dropping during the menopause meaning that the negative feedback cycle is no longer established and FSH and LH are able to rise, often the LH level can remain relatively stabilised for some time and meaning that conception is possible.
What are the three stages of the menopause and what is the average associated with each stage?
Perimenopausal - usually lasts about 4 years starting at the age of around 47.5 years
Menopause - mean age is 51 years
Postmenopausal - 80% of women by the age of 54
What is the defining symptom that determines whether a women is in the perimenopause or menopause?
The symptoms associated with the perimenopause and menopause are generally the same (due to the drop in estrogen) however during perimenopause the women usually first has menstrual abnormalities such as periods being more irregular (longer or shorter cycles), and usually heavier cycles. Menopause is the time in which periods cease and then postmenopausal is the time period after which a women has not had a period for 12 months.
What is the percentage of women that do not undergo a perimenopausal transition?
About 10% of women their periods, instead of becoming more irregular, just stop abruptly
What age is classed as a premature menopause?
If a women’s periods stop before the age of 40
What types of risks are associated when a women undergoes a premature menopause?
Increased risk of osteoporosis
Increased risk of cardiovascular disease (heart attack, stroke etc).
What percentage of post-menopausal women seek help for their symptoms?
50%
What are some of the short term symptoms associated with the menopause, aside from changes in the menstrual cycle?
Sexual dysfunction (dyspareunia, vaginal dryness, reduced libido)
Depression
Sleep disturbances
Mood changes
Irritability
Joint and muscle pain
Vasomotor symptoms (night sweats, hot flushes, palpitations)
Recurrent UTIs
Urinary incontinence
What percentage of women during menopause experience vasomotor symptoms?
80%
What can urinary incontience during the menopause lead to?
Utheral syndrome which is defined by the symptoms:
Dysuria (pain on passing urine)
Increase in the frequency and urgency of passing urine
What are some of the positive effects of associated with estrogen?
Estrogen has positive effects on:
Increasing and protecting bone density
Positive effect on blood lipid profile
Positive effect of coagulation and fibrinolytic pathway
Briefly describe the role of estrogen in bone metabolism?
Estrogen increases bone density by promoting the activity of osteoblasts (bone forming cells) and reduces the number and activity of osteoclasts (bone degrading cells).
What age does peak bone mass occur?
Between the ages of 30 and 35
What age in women does the rapid deterioration of bone density occur?
In the five years after menopause as the protective effects of estrogen is no longer present (due to the decline in menopause) in maintaining/ increasing bone density.
What is meant by the blood lipid profile?
A blood lipid profile simple means the level of lipids in your blood. There are two types of lipids cholesterol and triglycerides.
What are some of the exerted cardio protective effects of estrogen in pre-menopausal women?
Estrogen specifically E2 mediates a range of cardioprotective effects such as reducing reactive oxygen species (ROS), oxidative stress and fibrosis whilst increasing angiogenesis and vasodilation all of which reduces the cardiovascular risk in premenopause.
What is estrogen’s role in the coagulation and fibrinolytic pathway?
Estrogen increases fibrinogen and the activity of coagulation factors whilst decreasing the concentration and activity of anti-coagulant proteins.
Which demographics often experience the complications associated with estrogen and why?
Those taking combined hormonal contraceptives.
Estrogen promotes coagulation and this can result in the clinical complication and side effect of the combined hormonal contraceptive, venous thromboembolism.
By understanding the protective effects of estrogen, what are some of the clinical complications that arise alongside menopause?
Osteoporosis (loss of calcium from the bones, increasing risk of fractures), resulting in fractured neck of the femur.
Myocardial infarction
Cerebrovascular accident
Why are strokes more commonly seen in the post-menopausal era in comparison to the pre-menopausal era?
Menopause is associated with an increase in multiple stroke risk factors.
These risk factors include:
Increase in abdominal obesity
Increase in triglycerides
Increase in total cholesterol and LDL cholesterol
Decrease in HDL cholesterol
Increased fasting glucose and other measures of insulin resistance
Increased BMI
Increase in blood pressure
What is the mnemonic for the remebering symptoms associated with menopause?
Amenorrhea
Blood pressure
Cholesterol
Depression
Emily’s UTIs
Fractures
Gain in weight
Hot flushes
Insulin resistance
Joint muscle pain
Which women are indicated HRT estrogen and progesterone and why?
Women with an intact uterus, progesterone prevents the over-stimulation of the endometrium associated with estrogen due to the increase risk of endometrial cancer.
Which HRT is indicated for a woman after a hysterectomy?
Estrogen only, there is no endometrium to over stimulate
What are some examples of naturally occuring estrogens used in HRT?
Estradiol
Estrone
Conjugated oestrogens (equine)
What is the main aim of oestrogen therapy?
To restore the natural estrogen levels pre-menopausal and therefore continue the negative feedback cycle with FSH and LH.
Why are naturally occuring estrogens used in HRT rather than synthetic HRTs?
Synthetic HRTs are x200 more potent, and therefore the risk of using them would outweigh the potential benefits (raised blood pressure, blood lipid profile etc). Remember use in HRT is just for the relief of symptoms, in contraception it is to prevent pregnancy, so the benefit is greater than the risk.
Also the generation that would potentially be using these HRTs are 10-30 years older and so the cardiovascular risk increases with age.
Can HRT protect against pregnancy?
Natural estrogens used in HRTs are x200 times less potent than the synthetic estrogens used in treatment of HRT. These estrogens are simply for relieving symptoms associated with estrogen defiency and restoring natural levels and do not provide protection aganist pregnancy.
When are women still considered potentially fertile?
For two years after their last period if they are aged under 50 (I think if they went through menopause under the age of 50 / menopause started under 50) or
For one year after their last period if they are aged over the age of 50
How would you advice and recommendations differ if a 48 year old women presented to the Pharmacy wanting some medication for menopause relief but also a contraceptive to if a 55 year old woman made the same request and why?
Women under the age of 50 can be given a low dose combined oral contraceptive which provides relief of menopausal symptoms and also effective contraception.
However women over the age of 50 have to be recommended separate non-hormonal contraception and HRT due to the risk associated with using combined oral contraceptives in over 50s.
What are the specific risks of using combined oral contraceptives in the over 50s (3)?
Raised blood pressure
Adverse lipid profile
Abnormal blood clotting
What is the minimum requirement of progesterone use in HRT?
At least every 10 days in every 28 days cycle
Which progesterones are used in treatment of HRT?
Artifically occuring progesterones as the oral absorption of natural progesterones are very low.
Normally see the less androgenic progesterones used in the treatment such as:
Dydrogesterone
Medroxyprogesterone acetate
