Menopausal Hormone Therapy

Question 1

Indications for HRT

Answer 1

Symptoms of menopause
- Sleep disturbance, hot flushes, lethargy, vulvovagina atrophy
- Prevention of osteoporosis
- Prevention of Cardiovascular disease in patients with early menopause or premature ovarian insufficiency

Question 2

Methods of systemic menopausal hormone therapy

Answer 2

Oestrogen-only - Continuous oestrogen. Only in patients with total hysterectomy
Cyclical combined - Continuous oestrogen with progestogen for 10-14 days of each cycle. - Perimenopausal women or Premature ovarian insufficiency
Continuous combined - Post-menopausal. Have migraines.
Other
- Tibolone - Postmenopausal individuals as alternative to combined HRT (Not associated with VTE risk increase)

Question 3

Contraindications to all systemic HRT

Answer 3

Age >= 60 yo
Previous VTE
Previous TIA
Uncontrolled HTN
Undiagnosed vaginal bleeding
HIgh risk of breast cancer
Endometrial or breast cancer
SLE
Significant liver disease

Question 4

Routine Screening for menopausal women

Answer 4

Exclude Thyroid, disorder, diabetes, iron deficiency
- Screen for metabolic syndrome

• FBC, EUC, LFT, Iron, TSH, Fasting BSL or HbA1C

Measure of sex hormones is not useful as they fluctuate daily.

Question 5

Examples of HRT

Answer 5

Intravaginal oestrogen therapy (No association with increased CVD or VTE risk)
- Oestriol (Ovestin) 1mg/g cream - 0.5mg intravaginally daily at bedtime for 2-3 weeks, then once or twice weekly
- Oestriol pessary 500microg intravaginally daily at bedtime for 2-3 weeks, then once or twice weekly

Per oral Oestrogen
- Oestradiol 1-2mg PO daily

Transdermal oestrogen
- Climara 25 - Oestradiol 25microg/24hour transdermal patch once weekly

Oral Progestogen
- Norethisterone 2.5mg PO for the same 10 - 14 days in. each calendar month
- Progesterone 100mg per oral for 25 out of 28 day cycle.

IUD Progetogen
- Levenorgestrel 20microg/24hrs intravaginally - replace every 5 years.

Question 6

Non-hormonal Menopausal treatments

Answer 6

SSRI - Escitalopram, Fluoxetine, Paroxetine
SNRI - Desvenlafaxine, venlafaxine
- Gabapentinoids (Pregabalin, gabapentin)
- Clonidine 25microg PO BD

Question 7

Bioidentical Hormone Therapy Discussion with patient

Answer 7

• Hormone treatments that are compounded products marketed as hormones that are identical to those produced in the body.
• Not subject to regulatory conditions of approved pharmaceutical products.
• Preparation as cream, troche (dissolvable under the tongue) or pessary.
• promoted as being ‘natural’ - All hormones including conventional MHT are synthesised in the laboratory from some precursor by enzymatic manipulation.
• Combination of hormones such as oestrogen, progesterone, testosterone and other hormones.
• Concerns
  
  • Unsure safety of production of product
• Hormones in compounding process modified either week-to-week or month-to-month based upon expensive salivary fluid tests.
• Can have risks including lack of endometrial protection (unopposed or inadequately opposed oestrogen in compound)