HRT_Adverse_Effects_Flashcards

Question 1

What is Hormone Replacement Therapy (HRT)?

Answer 1

HRT involves the use of a small dose of oestrogen (combined with a progestogen in women with a uterus) to help alleviate menopausal symptoms.

Question 2

What are the common side-effects of HRT?

Answer 2

Common side-effects of HRT include nausea, breast tenderness, and fluid retention with weight gain.

Question 3

What are the potential complications of HRT?

Answer 3

Potential complications of HRT include increased risks of breast cancer, endometrial cancer, venous thromboembolism (VTE), stroke, and ischaemic heart disease.

Question 4

What is the increased risk of breast cancer associated with HRT?

Answer 4

The Women’s Health Initiative (WHI) study found a relative risk of 1.26 at 5 years of developing breast cancer with HRT. The risk is increased by the addition of a progestogen.

Question 5

How does the duration of HRT use relate to breast cancer risk?

Answer 5

The increased risk of breast cancer with HRT relates to the duration of use. The longer the duration, the higher the risk.

Question 6

What happens to the risk of breast cancer when HRT is stopped?

Answer 6

The risk of breast cancer begins to decline when HRT is stopped, reaching the same level as in women who have never taken HRT by 5 years.

Question 7

What is the increased risk of endometrial cancer with HRT?

Answer 7

HRT is associated with an increased risk of endometrial cancer, especially when oestrogen is given alone.

Question 8

Why should oestrogen not be given alone as HRT to women with a womb?

Answer 8

Oestrogen alone should not be given as HRT to women with a womb because it increases the risk of endometrial cancer.

Question 9

How can the risk of endometrial cancer be reduced in HRT?

Answer 9

The risk of endometrial cancer can be reduced by adding a progestogen to HRT, though the risk is not completely eliminated. Continuous progestogen use eliminates the additional risk according to the BNF.

Question 10

What is the increased risk of venous thromboembolism (VTE) with HRT?

Answer 10

HRT increases the risk of venous thromboembolism (VTE), with a higher risk when a progestogen is added.

Question 11

Does transdermal HRT increase the risk of VTE?

Answer 11

Transdermal HRT does not appear to increase the risk of VTE.

Question 12

What should be done for women at high risk for VTE who request HRT?

Answer 12

NICE states that women requesting HRT who are at high risk for VTE should be referred to haematology before starting any treatment, including transdermal HRT.

Question 13

What is the increased risk of stroke with HRT?

Answer 13

HRT increases the risk of stroke.

Question 14

What is the increased risk of ischaemic heart disease with HRT?

Answer 14

HRT increases the risk of ischaemic heart disease if taken more than 10 years after menopause.

Question 15

summarise HRT adverse effects

Answer 15

Hormone replacement therapy: adverse effects

Hormone replacement therapy (HRT) involves the use of a small dose of oestrogen (combined with a progestogen in women with a uterus) to help alleviate menopausal symptoms.

Side-effects
nausea
breast tenderness
fluid retention and weight gain

Potential complications
increased risk of breast cancer
increased by the addition of a progestogen
in the Women’s Health Initiative (WHI) study there was a relative risk of 1.26 at 5 years of developing breast cancer
the increased risk relates to the duration of use
the risk of breast cancer begins to decline when HRT is stopped and by 5 years it reaches the same level as in women who have never taken HRT
increased risk of endometrial cancer
oestrogen by itself should not be given as HRT to women with a womb
reduced by the addition of a progestogen but not eliminated completely
the BNF states that the additional risk is eliminated if a progestogen is given continuously
increased risk of venous thromboembolism
increased by the addition of a progestogen
transdermal HRT does not appear to increase the risk of VTE
NICE state women requesting HRT who are at high risk for VTE should be referred to haematology before starting any treatment (even transdermal)
increased risk of stroke
increased risk of ischaemic heart disease if taken more than 10 years after menopause

Question 16

A 52-year-old female presents to primary care complaining of a three-week history of reduced libido and vasomotor symptoms. She has suffered with vaginal dryness for the past 12 months and currently uses topical oestrogen to control this symptom. After discussion with the general practitioner, the decision is made to stop her topical oestrogen and commence an oral preparation of oestrogen-progestogen hormone replacement therapy (HRT).

What is the patient at increased risk of due to the addition of progestogen?

Breast cancer
Cervical cancer
Endometrial cancer
Hyponatraemia
Postural hypotension

Answer 16

Breast cancer

HRT: adding a progestogen increases the risk of breast cancer

Adding a progestogen to HRT increases the risk of breast cancer, making this the correct answer.

Cervical cancer is incorrect, this is most commonly associated with HPV serotypes 16, 18 and 33 and the combined oral contraceptive pill.

Endometrial cancer is incorrect as this is caused by unopposed oestrogen, so would be a risk associated with oestrogen only HRT.

Hyponatraemia is wrong as this is a side-effect of paroxetine, which is an SSRI used for vasomotor symptoms.

Postural hypotension is incorrect as this is a side-effect of clonidine, which is an α2 agonist, also used in the treatment of vasomotor symptoms.

Question 17

A 56-year-old woman presents to her general practitioner with several months of hot flashes, irritability and fatigue. She thinks she may be post-menopausal as she has not experienced any periods for 3 years. She has no significant past medical history.

After discussing options, she wishes to trial hormone replacement therapy. As she has a uterus, it is explained to her that a second drug, a progestogen, will need to be added to the oestrogen replacement.

What does the addition of this second drug most increase the risk of?

Breast cancer
Cervical cancer
Colorectal cancer
Endometrial cancer
Ovarian cancer

Answer 17

Breast cancer

HRT: adding a progestogen increases the risk of breast cancer

Hormone replacement therapy (HRT) alters the risk of numerous conditions to varying degrees. This is also partly determined by whether the HRT used is oestrogen-only or combined. Oestrogen use increases the risk of breast cancer. The addition of a progestogen further increases the risk of breast cancer, so this is the correct answer.

Cervical cancer is incorrect. The use of HRT is not thought to significantly alter the risk of cervical cancer.

Colorectal cancer is incorrect. Combined HRT is thought to have a protective effect against colorectal cancer, conferring a reduced risk. Oestrogen-only HRT provides a more modest risk reduction.

Endometrial cancer is incorrect. Oestrogen-only HRT increases the risk of endometrial cancer. However, the addition of a progestogen mitigates this risk.

Ovarian cancer is incorrect. Both oestrogen-only and combined HRT are thought to slightly increase the risk of ovarian cancer similarly. The addition of a progestogen, compared to oestrogen-only HRT, is not thought to be significant.

Question 18

A 53-year-old woman presents to her GP complaining of hot flushes, low mood and anxiety. She has been having erratic periods for years; her last period was 5 months ago. Her symptoms are affecting her ability to work and she would like something to help. However, she is very concerned about breast cancer as her friend was recently diagnosed, and does not want anything that could increase her risk. She has no significant medical or surgical history.
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What potential treatment would be most associated with her concern?
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Clonidine
Combined hormone replacement therapy
Oestrogen-only hormone replacement therapy
St John’s wort
Venlafaxine

Answer 18

Combined hormone replacement therapy

HRT: adding a progestogen increases the risk of breast cancer

Combined hormone replacement therapy (HRT) is correct. This consists of an oestrogen and a progestogen being administered either continuously or cyclically. Whilst oestrogen-only HRT slightly increases breast cancer risk, the progestogens are the component of HRT most associated with increased breast cancer risk. The risk can be lowered by using micronised progesterone instead of other progestogens such as norethisterone. In a woman with a uterus, it is important to give oestrogen AND progestogen to reduce the risk of endometrial cancer. This is because the risk of endometrial cancer in unopposed oestrogen therapy is greater than the risk of breast cancer from the added progestogens.

Clonidine is incorrect. This can be used in menopause to manage symptoms of hot flushes but is not associated with breast cancer risk.

Oestrogen-only hormone replacement therapy is incorrect. Many believe that oestrogen is the main HRT component that can drive breast cancer risk. However, it’s the progesterone, not oestrogen, that increases the risk for breast cancer the most. However, despite this, for anyone with a uterus, it is important to prescribe a combined HRT regimen to reduce the risk of endometrial cancer, despite the slightly increased risk of breast cancer.

St John’s wort is incorrect. This can be used in menopause to manage symptoms but is not associated with breast cancer risk. It is known to interact with many medications and should be used with caution.

Venlafaxine is incorrect. This is a non-hormonal option for managing hot flushes in menopause and does not carry a risk of breast cancer. It is an SNRI, and can be very useful in managing menopausal women who wish to avoid hormones either by preference or because of a medical contraindication such as current or past breast cancer.