menopause and HRT Flashcards
What is peri-menopause?
the time before the last menstrual period when ovarian activity slows and oestrogen levels start to fall
can last several years
What is menopause?
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
What is menopause?
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
What is post-menopause?
the time after the last mensurtal period
What slows down during peri-menopause?
ovarian activity
oestrogen levels drop
Where does oestrogen have a protective effect on the body?
brain, skin, bones, heart, urinary functions, genital area
What happens when oestrogen levels decrease?
reduced negative feedback to the pituitary FSH and LH levels rise FSH levels fluctulate on a daily basis the menstrual cycle is disrupted causes menopausal symptoms
menopause and estradiol production
estradiol production becomes insufficient to stimulate the endometrium and amenorrhoea occurs
Where is estradiol produced?
thecal cells surrounding the oocyte
hormone pattern during menopause
low oestrogen
persistently high FSH and LH
age for early menopause
before the age of 45 years
What is premature ovarian insufficiency?
menopause before the age of 40 years
causes of early menopause
FH premature ovarian failure radiotherapy and chemotherapy hysterectomy infection (TB, mumps, malaria, varicella, shigella - very rare)
diagnosis of menopause
patients over 45yrs with irregular periods or changes to normal menstrual pattern
other menopausal symptoms
no tests required
diagnosis for patient under 45yrs
can test FSH
if it’s raised it is likely they are menopausal
menopause % symptoms
80% suffer from symptoms
45% distressed
70-80% get hot flushes (usually < 5yrs)
symptoms last 2-5yrs
symptoms of menopause
- hot flushes and night sweats
- anxiety and depression
- irritability
- poor memory/concentration
- insomnia
- sexual changes
- urinary porblems
- headache
- joint/muscle pains
- vaginal symptoms - dryness, discomfort, itching, dyspareunia (pain during SI), worse with age
- thinning of skin and hair
- bone mass is lost and bones more liable to breaking
- dryness of eyes/mouth/throat
- atrophy of breasts/endometrium/vagina/ vulva/pelvic muscles
most common symptoms
hot flushes
night sweats
poor memory and concentration - brain fog
insomnia
associated problems with menopause
increased risk of - CVD - dementia - cognitive decline - parkinsonism - osteoporosis (loss of bone density) breast cancer risk decreases
Is HRT recommendedd for prevention of osteoporosis?
no
1st line treatment for menopause
lifestyle changes
- weight management and exercise
- smoking and BMI > 30 increases hot flushes
- wear lighter/cooler clothes
- avoid triggers for hot flushes (caffeine/spicy foods)
- sleep hygeine
- sleep in a cooler room
- relaxation techniques
- reduce stress
non HRT treatment
- antidepressants (often not needed when hormones corrected)
- vaginal moisturiser (Replens)
- clonidine 50-75mcg BD (antihypertensive, for flushing, if can’t take oestrogens, not 1st line)
- self-help groups
- psychotherapy
- counselling
- supplements/homeopathy (poor evidence)
benefits of HRT
treating vasomotor symptoms (hot flushes, night sweats)
treating urogenital symptoms (vaginal dryness)
managing sleep
mood disturbances caused by hot flushes/night sweats
preventing osteoporosis
When can you get risks with HRT?
risks associated with LT use
Why are risks with HRT now lower?
not taken orally transdermal preparations used now bypass absorption from GIT can use lower doses straight to blood stream therefore, the risks are much lower
risks with HRT
depends on delivery method combined oral HRT: - small increased risk of breast/ovarian cancer - coronary events - VTE - stroke
advice for HRTs
minimum effective dose for the shortest duration
oestrogen dose in HRT
oestrogen would cause the lining of the uterus to proliferate
this increases the risk of uterine cancer
therefore, combined with progestogen
- progestogen opposes the overproliferation of the uterus
can be combined or both taken separetely
When is progestogen not needed?
hysterectomy
disadvantages with combined products
less flexibility if alteration in oestrogen dose is needed
contain older progestogens
considerations with oral oestrogens
- VTE risk with oral oestrogen
- oral oestrogen increases SHBG so reducing free androgen, lowers libido
- less reliable absorption
- more contraindications (obesity, diabetes, gallbladder disease, migraine)
What is the optimal HRT regimen?
transdermal oestrogen with micronised progeserone
doesn’t increase CV risk
problems with transdermal oestrogens/why they might not be used
some women can’t absorb it through their skin
patches come off
can’t tolerate adhesive
2 options for oral oestrogen formulations
- oestrogen with continuous progestogen
2. oestrogen with cyclical progestogen
best oestrogen formulation
17 betaestradiol
How long should HRT be taken for?
for as long as the benefits outweigh the risks
annual review conducted
clot risks with transdermal oestrogen
no clot risks
can be given to women who have Hx/risk of clot/stroke, migraines, hypertension, CVD
When should cyclical progesterone be given?
give cyclical HRT for first 6-12 mths to women having periods (peri-menopause)
Why is continuous progestogen better?
it’s better for endometrial protection
Who can take continuous progestogen and s/e?
any age
can cause erratic bleeding if given too early
What type of progestogen is given?
micronised progesterone - Utrogestan
prescribing of micronised progestogen
cyclically - 200mg every evening for 2 out of 4 weeks
continuously - 100mg every evening
What is a 3-monthly cyclical regimen?
oestrogen given every day
progestogen given for 14 days every 13 weeks (bleed every 3 mths)
more suitable for women with infrequent periods/intolernt to progestogens
continuous regimen advantage and s/e
preferred because they don’t give a wiithdrawal bleed
may have irregular bleeding/spotting for the first 4-6mths
Why is the combined form preferred?
because the adverse effects of progestogen can lead to poor compliance if given separately
What counselling if giving separate oestrogen and progestogen?
counselling about the protective effect of progestogens to ensure compliance
other HRT preparation
IUD Mirena
- contains levonorgestrel
- LNG delivered locally to the uterus
- much lower daily dose needed
- delivers progestogen to protect the endometrium
- aslo a contraceptive
- low bleed risk
- safe for up to 5 years
- irregular bleeding/spotting
vaginal oestrogen
- not HRT
- applied to the vagina for vaginal atrophy
- systemic absorption of low-dose vaginal oestrogen is very low and doesn’t relieve other symptoms (hot flushes)
- can be used with HRT or for post-menopausal women who have vaginal symptoms after stopping HRT
types of vaginal oestrogen
ortho gynest
vagifem pessaries
Estring vaginal ring
advantages of testosterone for menopause
can improve sexual function/libido
general wellbeing
improve mood/energy/stamina/concentration/ brain fog/memory
disadvantages of testosterone
- no available licenced preparations in UK (off licence)
- need to make sure oestrogen levels are well controlled before adding testosterone (no vasomotor symptoms)
- can take weeks/months for beneficial effects
When should HRT be stopped in an emergency (oral oestrogen)?
- stop 4-6 weeks before surgery
- severe chest pain
- breathlessness
- severe pain the calf of one leg
- severe stomach pain
- severe neurological effects
- hepatitis, jaundice, liver enlargement
- BP > 160/100
- prolonged immobility (DVT risk)
- detection of a risk factor
When to stop HRT?
- symptom control - trial withdrawal after 1-2yrs if symptom free
- early menopause - take HRT unitl the age of natural menopause
- gradual dose reduction, not abrupt withdrawal
- severe symptoms for months after stopping, consider restarting
contraception and HRT
HRT doesn’t provide contraception
U50 considered fertile for 2 yrs after last period
O50 considered fertile for 1 yr after last period
no risk factors can use low-oestrogen combined contraceptive pill if required/usually POP/barrier/IUD
