Menopause and HRT

Question 1

When is the menopause ‘diagnosed’

Answer 1

1 year after last menstrual period

Question 2

What is the average age of menopause

Answer 2

52

Question 3

What happens to FSH level around the time of the menopause

Answer 3

they peak

Serum FSH more than 30 on 2 occasions = ovarian failure = menopause

Question 4

What happens in the menopause

Answer 4

Loss of ovarian function –> oestrogen depletion (oestradiol)–> lack of endometrial stimulation = amenorrhoea

Question 5

Which oestrogen is predominant in premenopausal women and where is it produced

Answer 5

Oestradiol (E2)- produced by ovaries

Question 6

What is the main oestrogen in postmenopausal women

Answer 6

oestrone( E1)- produced by peripheral conversion of andrgoens in apidose tissue

Question 7

Which oestrogen is more biologically active

Answer 7

Oestradiol (E2)

Question 8

What is the third type of oestrogen

Answer 8

Oestriol

Question 9

What is the averaged duration of climacteric symptoms

Answer 9

1-5 years

but can last for 5+ years in many women

Question 10

What are the acute symptoms of menopause

Answer 10

Vasomotor - hot flushers, night sweats
Headache
Fatigue 
Insommnia
Arthralgia
Dizziness
Psychological - poor memory, loss of concentration, irritable, low mood, anxiety 
Reduced libido

Question 11

Medium term affects of the menopause

Answer 11

Urinary tract:
Urinary frequency/nocturia
Urgency
Stress/urge incontinence
Recurrent UTI

Vaginal:
Dryness/itch/burning
Dyspareunia
Sexual dysfunction
Prolapse

General:
Dry skin
Hair thinning

Question 12

What are the three main long term consequences of the menopause

Answer 12

Cardiovascular disease
Cerebrovascular disease
Osteoporosis

Question 13

Why is there an increased risk of CVD/stroke in post menopausal women

Answer 13

Oestorgen reduces LDL and increases HDL. It reduced cholesterol deposition and fat distribution.
After menopause this protective affect of oestrogen is lost.

Question 14

What preparations of HRT are available

Answer 14

Oestrogen Only HRT (tablet, patch, gel, implant)

Combined HRT - sequential or continuous (tablets/patch)

Question 15

When is sequential combined HRT used

Answer 15

perimenopausal women

Question 16

Why do women with a uterus need progesterone

Answer 16

For endometrial protection

Question 17

Why cant the COCP just be used as HRT

Answer 17

it contains higher doses of synthetic oetrogens than HRT but similar progesterones

Question 18

When is oestrogen only HRT used

Answer 18

Only in woman who have had a TOTAL hysterectomy

Question 19

What happens in sequenctial combined HRT

Answer 19

Oestrogen for the entire 28 days
Progesterone for last 10-14 days
Will have a normal ‘bleed’ as this mimics the normal menstrual cycle

Question 20

What is continuous conbined HRT

Answer 20

Oestrogen and Progesterone given throughout the whole ‘cycle’
No bleed after 1st 6 months
POST MENOPAUSAL WOMEN

Question 21

When is the mirena used in HRT

Answer 21

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.

Question 22

What is the main risk associated with sequential HRT

Answer 22

prolonged use increased risk of endometrial cancer

Question 23

What is the max duration of use of sequential HRT

Answer 23

five years

Question 24

When should continuous combined HRT be started

Answer 24

Should not be started until 1 year after LMP or before aged 54.
Unless under 54 but have been on sequential for two years.

Question 25

What is tibolone

Answer 25

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

Question 26

What are the downsides to tibolone

Answer 26

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)

Question 27

When is testosterone used in menopause

Answer 27

Help improve libido.

Question 28

In what estrogen therapies is progestrogen protection not required

Answer 28

Topical/ local oestrogens eg vaginal creams

Question 29

How often is a patient on HRT followed up

Answer 29

Initially after three months, then every 6 months annually

Question 30

What are the benefits of HRT

Answer 30

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)

Question 31

What is the risks of breast cancer and HRT

Answer 31

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

Question 32

What is the risks of VTE in HRT

Answer 32

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

Question 33

What things are women at an increased risk of on HRT

Answer 33

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

Question 34

Name alternatives to HRT which may help control symptoms in some women

Answer 34

Clonidinde, SSRI eg fluoxetine, SNRI eg venlafaxine - all for hot flushes
Gabapentin

Question 35

Which foods contain phytoestrogens which may have similar effects to oetrogen (and therefore some women find them benefical)

Answer 35

Isoflavones eg red clover, soy beans, soy, legumes

Lignans eg whole cereals, oilseeds, cereals, berries

Question 36

Define premature ovarian failure

Answer 36

Cessation of menses and complete/partial loss ovarian activity before the age of 45