Menopause and HRT Flashcards

Question

vaginal therapy

Answer 1

In the postmenopausal years oestrogen deficiency causes atrophic changes in the vaginal wall and a reduction in vaginal blood flow and secretions, leading to dryness and dyspareunia. Topical and intravaginal oestrogen can be used to alleviate these symptoms -see table below for range of products available. Vaginal oestrogens are only effective locally and therefore have no effect on vasomotor symptoms. Endometrial effects are not usual, so there is no need for a progestogen in women without hysterectomy. Topical oestrogens however should be used in the lowest effective dose to minimise systemic absorption. Tablets and creams should be used nightly for 2 weeks (3 weeks for pessary and gel) and then twice weekly thereafter.

Answer 2

* oestrogen-dependent cancer * history of breast cancer * active thrombophlebitis * active or recent arterial thromboembolic disease (e.g. angina or myocardial infarction) * venous thromboembolism, or history of recurrent venous thromboembolism (unless already on anticoagulant treatment) * thrombophilic disorder * liver disease (where liver function tests have failed to return to normal) * Dubin-Johnson and Rotor syndromes (or monitor closely) * untreated endometrial hyperplasia * undiagnosed vaginal bleeding Pregnancy

Answer 3

Potentially serious drug interactions with HRT include: * rifamycins – accelerate the metabolism of oestrogen and progestogen * phenindione – anticoagulant effect antagonised by oestrogen and progestogen * St. John’s Wort – avoid concomitant use with oestrogen and/or progestogen * antiepileptics – metabolism of oestrogen and progestogen accelerated by carbamazepine, phenobarbital, phenytoin and topiramate; dose of lamotrigine may need increased antivirals, aprepitant, bosentan, modafinil – accelerate the metabolism of oestrogen and progestogen

Answer 4

The effect of postmenopausal HRT on cardiovascular disease has been the subject of controversy over the years. Older studies highlighted only the risks of HRT, but this view is now regarded as out-dated, as it didn't account for the benefits of HRT as well as the risks. In addition the final follow-up results of the Women’s Health Initiative (2019), showed that the risk of CHD only increased when combined HRT is started in older women or >20 years since the menopause50. The first 10 years after the menopause is now regarded as the cardiovascular ‘window of opportunity'. HRT should not be prescribed for the prevention of heart disease alone. However, women who have a premature menopause and do not take HRT have a much higher incidence of CHD and osteoporosis. Experts now advise that all women with a premature menopause should use HRT until at least age 50/51 years for the treatment of vasomotor symptoms, bone preservation and reduced CHD risk

Answer 5

A woman’s risk of stroke increases with age and therefore older women are at a greater absolute risk of stroke. * The use of oral HRT started in older women (> 60 years), with oestradiol at either high or low doses is also associated with an increased risk of ischaemic stroke, compared with non-users However, transdermal preparations, containing low doses of oestrogen have not been shown to be associated with this risk

Answer 6

Women using oral HRT are at an increased risk of deep vein thrombosis (DVT) and pulmonary embolism. * this increased risk is 2-3 times background risk of 1.7 per 1,000 women aged over 50 years. The greatest risk is in the first 12 months of use * risk of VTE increases by about 50% in women using oestrogen plus synthetic progestogens, compared with oral oestrogen alone * this risk is not present with transdermal HRT (patch, gel or spray) thus transdermal HRT is recommended for menopausal women at increased risk of VTE, including those with a BMI >30 kg/m2. With respect to CVD prevention, lifestyle changes should be considered (including a balanced diet, moderate weight bearing exercise, maintaining a healthy body weight, avoiding smoking, moderate alcohol consumption) and attention of the GP to the individual woman’s risk factors, e.g. hypertension, hypercholesterolemia and diabetes. Counselling a woman about the menopause is an excellent opportunity to address the risk factors for CVD and intervene appropriately.

Answer 7

Whilst there is no strong evidence for an additive effect of HRT, upon the risk of diagnosis, in women at elevated personal risk of breast cancer, it is still recommended to avoid HRT in women at high risk (with the exception of BRCA-1 and BRCA-2 mutation carriers, with a prophylactic oophorectomy, up to age of 50 years)

Answer 8

Fluctuating estrogen levels are associated with increased migraine prevalence during the perimenopause. Successful management of vasomotor symptoms though, can also lead to improvements for women with migraine. Advice provided for prescribers include: * Using non-oral estrogen (such as transdermal patches or gel) * Use the lowest estrogen dose that effectively controls vasomotor symptoms * If progestogen is required, continuous delivery is recommended with a norethisterone & oestrogen (combined patch), a Levonorgestrol Intrauterine Device or micronised progesterone * Migraine aura does not contraindicate the use of HRT * Perimenopausal women with no history of migraine aura may benefit from continuous combined hormonal contraception until age 50 years Women in whom oestrogens are contraindicated, may benefit from use of the SSRIs Escitalopram or Venlafaxine