Menopause and HRT Flashcards
When is the menopause ‘diagnosed’
1 year after last menstrual period
What is the average age of menopause
52
What happens to FSH level around the time of the menopause
they peak
Serum FSH more than 30 on 2 occasions = ovarian failure = menopause
What happens in the menopause
Loss of ovarian function –> oestrogen depletion (oestradiol)–> lack of endometrial stimulation = amenorrhoea
Which oestrogen is predominant in premenopausal women and where is it produced
Oestradiol (E2)- produced by ovaries
What is the main oestrogen in postmenopausal women
oestrone( E1)- produced by peripheral conversion of andrgoens in apidose tissue
Which oestrogen is more biologically active
Oestradiol (E2)
What is the third type of oestrogen
Oestriol
What is the averaged duration of climacteric symptoms
1-5 years
but can last for 5+ years in many women
What are the acute symptoms of menopause
Vasomotor - hot flushers, night sweats Headache Fatigue Insommnia Arthralgia Dizziness Psychological - poor memory, loss of concentration, irritable, low mood, anxiety Reduced libido
Medium term affects of the menopause
Urinary tract: Urinary frequency/nocturia Urgency Stress/urge incontinence Recurrent UTI
Vaginal: Dryness/itch/burning Dyspareunia Sexual dysfunction Prolapse
General:
Dry skin
Hair thinning
What are the three main long term consequences of the menopause
Cardiovascular disease
Cerebrovascular disease
Osteoporosis
Why is there an increased risk of CVD/stroke in post menopausal women
Oestorgen reduces LDL and increases HDL. It reduced cholesterol deposition and fat distribution.
After menopause this protective affect of oestrogen is lost.
What preparations of HRT are available
Oestrogen Only HRT (tablet, patch, gel, implant)
Combined HRT - sequential or continuous (tablets/patch)
When is sequential combined HRT used
perimenopausal women
Why do women with a uterus need progesterone
For endometrial protection
Why cant the COCP just be used as HRT
it contains higher doses of synthetic oetrogens than HRT but similar progesterones
When is oestrogen only HRT used
Only in woman who have had a TOTAL hysterectomy
What happens in sequenctial combined HRT
Oestrogen for the entire 28 days
Progesterone for last 10-14 days
Will have a normal ‘bleed’ as this mimics the normal menstrual cycle
What is continuous conbined HRT
Oestrogen and Progesterone given throughout the whole ‘cycle’
No bleed after 1st 6 months
POST MENOPAUSAL WOMEN
When is the mirena used in HRT
The Mirena is now licensed for use with Oestrogen only HRT for 4 years. This effectively gives a continous combined HRT affect. The advantage is that it can be used in younger women to induce a no-bleed regime.
What is the main risk associated with sequential HRT
prolonged use increased risk of endometrial cancer
What is the max duration of use of sequential HRT
five years
When should continuous combined HRT be started
Should not be started until 1 year after LMP or before aged 54.
Unless under 54 but have been on sequential for two years.
What is tibolone
A synthetic steroid used as an alternative to CC HRT to help combat vasomotor, psychological and libido problems in menopause
Also conserves bone mass and reduced fracture risk
What are the downsides to tibolone
after age 60 there is an increased risk of stroke compared to HRT
Slight increased risk of endometrial cancer
(but less risk of breast cancer compared to HRT)
When is testosterone used in menopause
Help improve libido.
In what estrogen therapies is progestrogen protection not required
Topical/ local oestrogens eg vaginal creams
How often is a patient on HRT followed up
Initially after three months, then every 6 months annually
What are the benefits of HRT
reduces risk of colon cancer
very effective at relieving vasomotor symptoms
often less than 5 years therapy is sufficient
prevents osteoporosis (but used bisphosphonates for treatment usually)
What is the risks of breast cancer and HRT
The risk is increased in women who take HRT for several years (cf. Alcohol, nulliparity, high BMI)
Combined HRT has the highest risk
For oestrogen-only HRT the risk is lower/absent
Risk increases with duration of use and returns to normal within ~5 years of stopping
What is the risks of VTE in HRT
Oral HRT has been associated with an increased risk of VTE in RCT’s and observational studies.
Higher with combined HRT than oestrogen-only
More common in the first year of use
Risk may be lowered by transdermal route/changing progestogen
What things are women at an increased risk of on HRT
Stroke
Breast cancer
VTE
Ovarian (small)
CVD (uncertain) - older women, may be protective in younger women
Alzheimers - in older, again may be protective in younger women
Name alternatives to HRT which may help control symptoms in some women
Clonidinde, SSRI eg fluoxetine, SNRI eg venlafaxine - all for hot flushes
Gabapentin
Which foods contain phytoestrogens which may have similar effects to oetrogen (and therefore some women find them benefical)
Isoflavones eg red clover, soy beans, soy, legumes
Lignans eg whole cereals, oilseeds, cereals, berries
Define premature ovarian failure
Cessation of menses and complete/partial loss ovarian activity before the age of 45
