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delivering pharmaceutical care > Menopause and HRT > Flashcards

Menopause and HRT Flashcards

1
Q

Facts about ovarian function state the four things that happen when a woman is 40

A

In 40s prime oocytes declines steeply
Progesterone, oestradiol and testosterone decline
Fertility declines
FSH & LH ↑ to stimulate the failing ovary
Eventually all oocytes are exhausted

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2
Q

Ovarian function 2

A

no oestrogen production to stimulate the monthly build up of the womb lining (endometrium)
No build up → no shedding or menstruation
The menopause has begun
Oestrogen levels can fall to 7% of normal

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3
Q

Ovarian function 3

A

Oestrogen does not only drive the reproductive cycle and prepare the body for pregnancy and lactation
It is also a major player in bones, blood vessels, the brain, the gut and the immune system
So when the ovary fails to produce oestrogen
These other systems are affected

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4
Q

Define menopause

A

Greek menos = month
pausos = ending

Occurs between 40-60yrs
Av. age is 51.4yrs

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5
Q

Facts about menopause

A 
Determined after 12 months amenorrhoea
Retrospective diagnosis (FSH levels)
Average age is 51 years
Over 55 in ≈ 2-3%
Under 40 in ≈ 1%
Occurs 1-2 years earlier in smokers
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6
Q

Menopause is determined after…..

A

12 months amenorrhoea

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7
Q

Menopause occurs 1-2 years earlier in smokers. True or false?

A

True

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8
Q

Age of menopause is unrelated to….

A

-number of pregnancies
-use of oral contraception
-socio-economic factors
Age of menarche

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9
Q

General symptoms of menopause

A

Loss of fertility

Early stages - erratic menstrual cycle or perimenopause

End stage - Cessation of periods is the menopause

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10
Q

list the 7 stages of women

A

see table slide 12

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11
Q

What is perimenopause?

A 
Transition from cyclic menstruation to total cessation of menses
About 4 years
Menstrual irregularity and amenorrhoea
Declining P and O
Ends at 12 months ammenorrhoea
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12
Q

What is Post menopause?

A

Life span AFTER menopause is called post-menopause

early menopause- 40 onwards- between 1 and 4years of amenorrhoea
late meopause- 47-51years- no periods at all

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13
Q

State the Physical Vasomotor Symptoms

A 
Hot flushes
Night sweats
Vaginal dryness
Giddiness
Faintness
Headaches
Insomnia
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14
Q

State the most common side effect of menopause

A

Hot flush

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15
Q

Facts about menopausal symptoms

A 
All women effected, different experience
Hot flush most common side effect
Prevalence decreases with age:
60% 50-54yrs
15% 55-59yrs
6% 60-69yrs
3% >70yrs
Culture and dietary influences
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16
Q

Pathophysiology in Menopause

A

Declining oestradiol – urogenital atrophy in 40% post menopausal women
Vaginal epithelial thinning, decreased secretions, reduction in vaginal size.
Painful intercourse, vaginal infections and UTIs

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17
Q

State the psychological symptoms of menopause

A 
Irritability
Poor concentration
Poor short term memory
Depression
Tiredness
Anxiety
Mood swings
18
Q

State the Medium term consequences of oestrogen deficiency

A 
Genital atrophy (Sexual dysfunction)
Vaginal dryness, can lead to dyspareunia
Urinary symptoms
Stress incontinence
Loss of collagen from skin, muscle & bone
Myalgia – pain in the muscles
Hair loss
Brittle nails
Dry skin
19
Q

State the Long term consequences of oestrogen deficiency

A

Cardiovascular disease

Osteoporosis

20
Q

State one of the treatments of Menopause?

A

HRT- Hormonal replacement therapy

21
Q

What does HRT do?

A

Offers relief from symptoms of oestrogen deficiency
HRT NOT first-line preventative treatment for osteoporosis
Not used to reduce risk of long term complications (associated with osteoporosis and CVD )
Diet and exercise for peri and post menopause

22
Q

Use HRT in caution if patient has…..

A

Migraines
Unexplained vaginal bleeding
Had breast cancer or any lumps in your breast, or if a close family member has had breast cancer.
Has or a close family member have ever had a blood clot in the legs or lungs.
Has diabetes, epilepsy or asthma
Depression
Blood pressure or heart conditions

23
Q

Treatment options for Menopausal symptoms

A

If menopausal symptoms interfere with quality of life
Non-pharmacological (lifestyle and alternative)
Pharmacological (hormonal and non-hormonal)

24
Q

State the nonpharmacological treatment for relieving mild Vasomotor Symptoms of Menopause

A

Lifestyle changes
esp if opposed to HRT
Weight loss, if appropriate, and exercise
Benefit CV and wellbeing
Avoid spicy food, alcohol, hot drinks & warm environments
Cooling methods
Yoga – psychological symptoms benefit but no impact on VMS and urogenital

25
Q

State the alternative or herbal therapies for mild VMS

A

Alternative/herbal therapies
Acupuncture
Dietary soya isoflavones, red clover, black cohosh (CI with aspirin sensitivity, as contains salicylates)
Benefit hot flushes, mood changes, sleep disturbances, fatigue and vaginal dryness

26
Q

State the moderate to the severe treatment of VMS

A
  1. Intact uterus
    Must have BOTH Oestrogen and P
    Prevents hypertrophy of endothelial lining
    Minimises endometriosis
    Protects the endometrium
    Induces a monthly bleed to reduce the risk of developing abnormal cancerous cells
    Can be sequential or continuous combined
  2. No uterus (following hysterectomy)
    Only needs Oestrogen
27
Q

Treatment for intact uterus for moderate to severe VMS

A

Cyclic (sequential O and P)
O for 21 days, P days 7-21 and 7 days none
Withdrawal bleed days 22-30
O at lowest dose to minimise risks (see slide 29)
Note that P can also be every 3 mths

Eg Elleste duet

28
Q

Facts about Continuous combines O and P therapy in moderate to severe VMS

A

Protect endometrial hyperplasia and cancer.
Risks and benefits, history, symptoms and concerns.
Start O at lowest dose 0.3mg/day oral or 0.05mg patch
BC, S and thromboembolic and CV events
P may ↑ risk BC than O alone
O and P daily, easiest to follow, no menstruation and preferred by most (avoid in perimenopause if irreg bleeding)
If breakthrough bleed after first 9 mths switch to cyclic
eg Premique

29
Q

Treatment options for those without uterus

A

Transdermal or topical O
P not needed, O alone if tolerated
Transdermal may be preferred to oral if taking other meds, borderline triglyceride levels, gallstone risk or adherence issues
Could have less risk than oral O but no RCT so probably same for (BC, S,T and CV events)
VMS relief in 4-12 weeks
Topical vaginal O
Dryness

30
Q

other treatment for patients without a uterus

A 
Oral Oestrogen
Safe if no CIs for up to 7 years
No increase of CVD, S or BC if alone
Start low and increase slowly
If not tolerated – non-hormonal considered
Taper dose every 6 months
31
Q

State the risk and benefit of HRT

A

Risks of HRT diminish over time after stopping
Peri – screening tests e.g. mammography, smear, colonoscopy (50yrs), osteoporosis (65yrs), serum lipids (few months post start of O)
Well balanced diet and exercise

32
Q

Risk and benefits of HRT 2

A

More than 1 year = higher risk of breast cancer than women who never use HRT (except vaginal oestrogen)
If ages 40s and 50s and HRT for 5 years risk:
1 extra case for every 200 women taking oestrogen-only HR
1 extra case for every 70 women taking cyclical HRT
1 extra case for every 50 women taking continuous HRT
Extra cases double if take HRT for 10 years.
Increased risk of BC falls if stop HRT, but can remain for more than 10 years compared to women who have never used HRT.
If for less than 1 year, no increased risk of BC.
Important to attend breast cancer screening appointments if taking HRT.

33
Q

State when to stop taking HRT

A

Sudden chest pain.
Sudden breathlessness, or if you cough up blood.
Swelling or pain in a leg.
An unusually severe headache.
Yellowing of your skin or the whites of your eyes (jaundice).

34
Q

What to prescribe if HRT not tolerated

A
  1. Antidepressants
    SSRIs and SNRIs
    Escitalopram most effective
    Hot flushes with varying degrees
  2. Clonidine
    VMS
    Caution with high does - ↓ BP
  3. Gabapentine
    VMS but SE of drowsiness, dizziness and unsteadiness
    Taper dose as VMS subside
35
Q

State the treatment for Vulvovaginal symtoms

A
  1. Vaginal oestrogen
    Cream, pessaries or ring for local symptoms not VMS.
    Less systemic effect
    But long term use – endometrial proliferation
    Ring expensive but less messy
    Safe in BC sufferers
  2. Vaginal moisturiser
    Polycarbophil gel – for vaginal atrophy, dryness and dyspareunia
36
Q

Urinary stress incontinence only

A

Pelvic floor rehabilitation

May be useful for urinary stress incontinence

37
Q

compliance with HRT

A

Most women take it for:
vasomotor symptoms
Women stop because they dislike side effects, bleeding or have concerns about risks
>50% will stop within a year

38
Q

Points to note about HRT

A

HRT is not a contraceptive.

If still having periods, or have only recently stopped, still use contraception for one year after last period if older than 50, or for two years after last period if less than 50.

Regular check-ups to discuss risks and benefits of taking HRT.

39
Q

Overview of HRT, types, side effects, risks and alternatives to HRT.

A

SEE SLIDE 40 for more info

40
Q

State the side effects of HRT

A 
breast tenderness
headaches
feeling sick
indigestion
abdominal (tummy) pain
vaginal bleeding
41
Q

OTHER treatment of HRT

A
  1. Bioidentical or “natural” hormones
    Bioidentical hormones are hormone preparations made from plant sources that are promoted as being similar or identical to human hormones.

Practitioners claim these hormones are a “natural” and safer alternative to standard HRT medicines.

However, bioidentical preparations are not recommended because:

they are not regulated and it’s not clear how safe they are – there’s no good evidence to suggest they’re safer than standard HRT
it’s not known how effective they are in reducing menopausal symptoms
the balance of hormones used in bioidentical preparations is usually based on the hormone levels in your saliva, but there’s no evidence that these levels are related to your symptoms
Bioidentical hormones are not the same as body identical hormones. A body identical hormone, or micronised progesterone, can be prescribed to treat menopausal symptoms.

Many standard HRT hormones are made from natural sources, but unlike bioidentical hormones, they’re closely regulated and have been well researched to ensure they’re as effective and safe as possible.

  1. Complementary therapies
    Several products are sold in health shops for treating menopausal symptoms, including herbal remedies such as evening primrose oil, black cohosh, angelica, ginseng and St John’s wort.

There’s evidence to suggest that some of these remedies, including black cohosh and St John’s wort, may help reduce hot flushes, but many complementary therapies are not supported by scientific evidence.

Even when there is some supporting evidence, there’s uncertainty about the right doses to use and whether the health benefits last. Some of these remedies (especially St John’s wort) may also cause serious side effects if they’re taken with other medicines.

These products are often marketed as “natural”, but this does not necessarily mean they’re safe. The quality, purity and ingredients cannot always be guaranteed, and they may cause unpleasant side effects.

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