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PHA223 > menopause and HRT > Flashcards

menopause and HRT Flashcards

1
Q

What is peri-menopause?

A

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

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2
Q

What is 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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2
Q

What is 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

What is post-menopause?

A

the time after the last mensurtal period

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4
Q

What slows down during peri-menopause?

A

ovarian activity

oestrogen levels drop

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5
Q

Where does oestrogen have a protective effect on the body?

A

brain, skin, bones, heart, urinary functions, genital area

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6
Q

What happens when oestrogen levels decrease?

A 
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
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7
Q

menopause and estradiol production

A

estradiol production becomes insufficient to stimulate the endometrium and amenorrhoea occurs

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8
Q

Where is estradiol produced?

A

thecal cells surrounding the oocyte

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9
Q

hormone pattern during menopause

A

low oestrogen

persistently high FSH and LH

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10
Q

age for early menopause

A

before the age of 45 years

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11
Q

What is premature ovarian insufficiency?

A

menopause before the age of 40 years

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12
Q

causes of early menopause

A 
FH
premature ovarian failure
radiotherapy and chemotherapy
hysterectomy
infection (TB, mumps, malaria, varicella, shigella - very rare)
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13
Q

diagnosis of menopause

A

patients over 45yrs with irregular periods or changes to normal menstrual pattern
other menopausal symptoms
no tests required

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14
Q

diagnosis for patient under 45yrs

A

can test FSH

if it’s raised it is likely they are menopausal

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15
Q

menopause % symptoms

A

80% suffer from symptoms
45% distressed
70-80% get hot flushes (usually < 5yrs)
symptoms last 2-5yrs

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16
Q

symptoms of menopause

A
  • 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
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17
Q

most common symptoms

A

hot flushes
night sweats
poor memory and concentration - brain fog
insomnia

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18
Q

associated problems with menopause

A 
increased risk of
- CVD
- dementia
- cognitive decline
- parkinsonism
- osteoporosis (loss of bone density)
breast cancer risk decreases
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19
Q

Is HRT recommendedd for prevention of osteoporosis?

A

no

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20
Q

1st line treatment for menopause

A

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
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21
Q

non HRT treatment

A
  • 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)
22
Q

benefits of HRT

A

treating vasomotor symptoms (hot flushes, night sweats)
treating urogenital symptoms (vaginal dryness)
managing sleep
mood disturbances caused by hot flushes/night sweats
preventing osteoporosis

23
Q

When can you get risks with HRT?

A

risks associated with LT use

24
Q

Why are risks with HRT now lower?

A 
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
25
Q

risks with HRT

A 
depends on delivery method
combined oral HRT:
- small increased risk of breast/ovarian cancer
- coronary events
- VTE
- stroke
26
Q

advice for HRTs

A

minimum effective dose for the shortest duration

27
Q

oestrogen dose in HRT

A

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

28
Q

When is progestogen not needed?

A

hysterectomy

29
Q

disadvantages with combined products

A

less flexibility if alteration in oestrogen dose is needed

contain older progestogens

30
Q

considerations with oral oestrogens

A
  • 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)
31
Q

What is the optimal HRT regimen?

A

transdermal oestrogen with micronised progeserone

doesn’t increase CV risk

32
Q

problems with transdermal oestrogens/why they might not be used

A

some women can’t absorb it through their skin
patches come off
can’t tolerate adhesive

33
Q

2 options for oral oestrogen formulations

A
  1. oestrogen with continuous progestogen

2. oestrogen with cyclical progestogen

34
Q

best oestrogen formulation

A

17 betaestradiol

35
Q

How long should HRT be taken for?

A

for as long as the benefits outweigh the risks

annual review conducted

36
Q

clot risks with transdermal oestrogen

A

no clot risks

can be given to women who have Hx/risk of clot/stroke, migraines, hypertension, CVD

37
Q

When should cyclical progesterone be given?

A

give cyclical HRT for first 6-12 mths to women having periods (peri-menopause)

38
Q

Why is continuous progestogen better?

A

it’s better for endometrial protection

39
Q

Who can take continuous progestogen and s/e?

A

any age

can cause erratic bleeding if given too early

40
Q

What type of progestogen is given?

A

micronised progesterone - Utrogestan

41
Q

prescribing of micronised progestogen

A

cyclically - 200mg every evening for 2 out of 4 weeks

continuously - 100mg every evening

42
Q

What is a 3-monthly cyclical regimen?

A

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

43
Q

continuous regimen advantage and s/e

A

preferred because they don’t give a wiithdrawal bleed

may have irregular bleeding/spotting for the first 4-6mths

44
Q

Why is the combined form preferred?

A

because the adverse effects of progestogen can lead to poor compliance if given separately

45
Q

What counselling if giving separate oestrogen and progestogen?

A

counselling about the protective effect of progestogens to ensure compliance

46
Q

other HRT preparation

A

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
47
Q

vaginal oestrogen

A
  • 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
48
Q

types of vaginal oestrogen

A

ortho gynest
vagifem pessaries
Estring vaginal ring

49
Q

advantages of testosterone for menopause

A

can improve sexual function/libido
general wellbeing
improve mood/energy/stamina/concentration/ brain fog/memory

50
Q

disadvantages of testosterone

A
  • 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
51
Q

When should HRT be stopped in an emergency (oral oestrogen)?

A
  • 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
52
Q

When to stop HRT?

A
  • 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
53
Q

contraception and HRT

A

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

PHA223 (43 decks)

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