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PHA 332 > HRT in practice > Flashcards

HRT in practice Flashcards

1
Q

define peri menopause

A

time before last menstrual period when ovarian activity slows and oestrogen levels start to fall –this time can last several years

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2
Q

define menopause

A

the time when menstruation ceases permanently due to the loss of ovarian follicular activity. It occurs with the final menstrual period -diagnosed clinically after 12 months of amenorrhoea

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3
Q

define post menopause

A

time after last menstrual period

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4
Q

what is the menopause?

A

Ovaries have a finite number of oocytes
•Decrease till about 50 years old then have none left•
During the peri-menopause ovarian activity slows
•Oestrogen levels drop
•Oestrogen is protective in a number of different body systems: brain, skin, bones, heart, urinary functions and the genital area –low levels of oestrogen can affect all these body areas
•This disrupts the menstrual cycle and causes menopausal symptoms

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5
Q

what does a decrease in oestrogen levels do during menopause?

A

causing reduced negative feedback to the pituitary… FSH and LH levels rise
it begins to disrupt the menstrual cycle and may cause other menopausal symptoms such as hot flushes and night sweats

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6
Q

what happens to estradiol during the menopause?

A

Estradiolproduction, which occurs in the granulosa and the cal cells surrounding the oocyte, becomes insufficient to stimulate the endometrium, and amenorrhoea occurs.

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7
Q

what is early /premature ovaruarian insufficiency menopause defined as?

A
  • Early menopause = before the age of 45 years

* Premature Ovarian Insufficiency = menopause before the age of 40 year

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8
Q

what are the causes of early menopause?

A
  • Family history
  • Premature ovarian failure
  • Radiotherapy and chemotherapy
  • Hysterectomy
  • Infection (TB, mumps, malaria, varicella, shigella. Very rare!)
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9
Q

how do you diagnose early menopause?

A

•For patients 45 years + with irregular periods and other menopausal symptoms no tests required.
can use apps to track
if u45 may need FSH test

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10
Q

what are the symptoms of menopause?

A
  • 45% get distressed•70-80% get hot flushes -usually present for less than 5years
  • Vaginal symptoms (including dryness, discomfort, itching, and dyspareunia) generally persist or worsen with ageing
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11
Q

how long do menopause symptoms last?

A

2-5 years

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12
Q

what are the long term physical effects of menopause?

A
  • Thinningof skin and hair.
  • Bone mass is lost and bones more liable to breaking.
  • Dryness of eyes mouth and throat.
  • Atrophy of breasts; endometrium; vagina; vulva; pelvic muscles.
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13
Q

what are the symptoms of menopause?

A
  • Hot flushes and night sweats.
  • Anxiety and depression.
  • Irritability.
  • Poor memory and concentration…Brain fog•Insomnia.
  • Sexual changes.
  • Urinary problems.
  • Headaches, joint and muscle pains.
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14
Q

what are the assoicated problems with menopause?

A
  • Increased risk of osteoporosis, CVD (especially in smokers), dementia, cognitive decline, and parkinsonism
  • Breast cancer risk decreases
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15
Q

is HRT recommended for prevention of osteoporosis in menopausal women?

A

no

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16
Q

what are the treatment options for menopausal women?

A
  • Weight management and exercise
  • There is evidence that smoking cigarettes and having a BMI >30 kg/m2increases the likelihood of flushing.
  • Discuss risks and benefits when deciding to introduce HRT
17
Q

what management is there for menopause without HRT?

A 
•Lifestyle advice
•Exercise
•Wear lighter/cooler clothes
•Avoid triggers to hot flushes –caffeine, spicy foods etc
•Sleep hygiene
•Sleep in a cooler room
•Relaxation techniques
•Reduce stress
•Antidepressants?
•Vaginal moisturiser
e.g. Replens®
•Clonidine 50-75mcg bd
•Self-help groups
•Psychotherapy
•Counseling
•Supplements/homeopathy etc 
–evidence base for any of these is very poor
18
Q

what are the benefits of HRT?

A

Treating vasomotor symptoms eg. hot flushes and night sweats
•Treating urogenital symptoms eg. vaginal dryness etc
•Managing sleep or mood disturbances caused by hot flushes and night sweats
•Preventing osteoporosis…..risks associated with long term use

19
Q

what are the risks for HRT orally?

A
  • There is a small increased risk of breast cancer, coronary events, VTE, and stroke
  • There is some evidence suggesting that combined HRT may be associated with an increased risk of ovarian cancer
20
Q

how does hrt work/ differ in preperation?

A
  • All types deliver a set dose of oestrogen into the bloodstream.
  • However, oestrogen alone would cause the lining of the uterus to proliferate….
  • This increases the risk of uterine cancer therefore -usually combined with a progestogen
21
Q

when is progestogen not required in an HRT?

A

Hysterectomy

22
Q

what considerations are there when prescribing? combined

A

considerations with combined products
- less flexibility if alteration in oestrogen dose is needed
they all contain older porgestogens

23
Q

what considerations are there when prescribing oral oestrogens?

A
  • There is VTE risk with oral oestrogen.
  • Oral oestrogen increases sex hormone binding globulin (SHBG) so reducing free androgen index (lowers libido even more)
  • There is less reliable absorption.
  • More contraindications (for example obesity, diabetes, gallbladder disease, migraine etc).
24
Q

what effect does transdermal oestroegn have?

A

•There is robust evidence demonstrating that transdermal oestrogenin association with micronised progesterone represents the optimal HRT regimen, particularly in women at risk of cardiovascular events

25
Q

what is oestrogen best as?

A

best as 17 betaestradiol.
optimal dose to improve symptoms and also to optimise bone and heart health
not about lower dose and shortest length of time

26
Q

what are the risks/ benefits to transfermal oestrogen?

A

Transdermal oestrogen has no clot risk. It can be given to women with a history or risk of clot or stroke including women with migraines, and to women with hypertension and cardiovascular disease.

27
Q

what are the tips for giving progestogen?

A
  • Give cyclical HRT for first 6 -12 months to women having periods
  • Continuous progestogens are better for endometrial protection
  • Any age woman can take continuous HRT but it may cause erratic bleeding if given too early
28
Q

what does your choice of progestogen depend on?

A
  • Evidence supports the use of micronised progesterone (Utrogestan)
  • Can be prescribed cyclically, 200mg each evening, for 2 out of 4 weeks •OR continuously, 100mg each evening:
29
Q

what is the difference between continuous or cyclical regimens?

A
  • Monthly cyclical regimens —oestrogen is taken daily and progestogen is given at the end of the cycle for 10–14 days –produces monthly bleed
  • Three-monthly cyclical regimens —oestrogen is taken every day and progestogen is given for 14 days every 13 weeks (bleed every 3 months) -may be more suitable for women with infrequent periods or who are intolerant to progestogens
  • Continuous combined regimens —oestrogen and progestogen are taken every day
30
Q

what regimes are best for postmenopausal women?

A
  • Continuous combined regimens may be preferred because they do not produce withdrawal bleeding
  • May produce irregular bleeding or spotting for the first 4–6months of treatment.
31
Q

what is a perfered option for post menopausal women?

A

.preferable for combined form to be used (eg. in one patch/tablet), because the adverse effects of the progestogen may lead to poor compliance if given separately. •If given separately, counselre the endometrial protective effect of progestogens to ensure compliance.

32
Q

what about IUD mirena?

A

contains levonorgestrel) is an alternative route of delivery of progestogen to protect the endometrium. •Levonorgestrel is delivered locally to the uterus –therefore much lower daily dose is used!
•Is also a contraceptive
•Low bleed risk and safe for up to 5 years

33
Q

is vaginal oestrogen HRT? how does it work?

A
  • NOT HRT•Applied to the vagina for vaginal atrophy •E.g.ortho gynest, vagifem pessaries, Estring vaginal ring
  • Systemic absorption of low-dose vaginal oestrogen is very low and does not relieve other menopausal symptoms, such as hot flushes.
34
Q

how can testosterone benefit menopausal women?

A

Adding to HRT can improve sexual function and general wellbeing and can improve libido.
•Testosterone can improve mood, energy, stamina and concentration. Many women notice that their brain fog and memory improve.
unlicnesed

35
Q

when should you stop HRT in an emergency?

A
  • Stop 4-6 weeks before surgery
  • Severe chest pain
  • Breathlessness
  • Severe pain in the calf of one leg
  • Severe stomach pain
  • Severe neurological effects
  • Hepatitis, jaundice or liver enlargement
  • BP >160/100
  • Prolonged immobility –DVT risk
  • Detection of a risk factor
36
Q

how do you stop HRT?

A
  • If used for symptom control-trial withdrawal after 1-2 years if symptom free….note there is no reason to stop HRT in women who wish to continue taking it.
  • Women with early menopausetake HRT toat least the age of natural menopause
  • Gradual reduction of dose rather than stopping abruptly
  • If symptoms are severe for several months after stopping consider restarting
37
Q

when are you protected for contraception durinh menopause?

A
  • HRT does not provide contraception!•Under 50 years woman is considered potentially fertile for 2 years after her last menstrual period•Free from risk factors can use low-oestrogen combined contraceptive pill if required
  • Over 50 years woman is considered potentially fertile for 1 year after her last menstrual period

PHA 332 (42 decks)

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