Menopause and HRT Flashcards
What is the menopause?
Permanent cessation of menses (periods) following loss of ovarian activity
Loss of oestrogen significantly impacts on women in this time of life
Proportion of average female lifespan spent in menopause years: 1/3 to 1/2
Peri-menopause
Transition from reproductive cycles to post menopause
Typical age start 45-50 years, median age 47.5 years
Mean duration 3.8 years
Few ova remain- less responsive to hormones
Clinical features of peri-menopause
Irregular menstrual cycles
Occasional heavy bleeding
Hot flushes
Nervousness irritability
Primary symptoms of menopause
Menstrual cycle change
- oligomenorrhoea
- amenorrhoea
Vasomotor symptoms
- hot flushes
- night sweats
Vaginal dryness
Secondary symptoms of menopause
Urinary stress/ urge incontinence
Cystitis like symptoms
Depression/ irritability changes
Musculoskeletal pains (join aches and osteoporosis)
Dry skin, hair thinning, nail changes
Decreased concentration
Decreased libido
Hormone replacement therapy
Oestrogen required for symptoms
Progestogens required to prevent endometrial cancer
Drugs for osteoporosis
Bisphosphonates
- alendronate
- risedronate
Drugs for reducing vasomotor symptoms
Progesterone
SERMs- raloxifene
Beta-blocker
Clonidine
Complementary and alternative therapies
Phyto-oestrogens
Herbalism
- black cohost
- st john’s wort
- gingseng
- oil of evening primrose
Progesterone cream
Homeopathy
Acupuncture
Reflexology
How HRT is given when there is no uterus
Only oestrogen
Oestradiol 1mg
Too low a dose of oestrogen to act as a contraception
Taken continuously as symptoms would return if not taking the oestrogen
How HRT is given when there is a uterus
Oestradiol every day (white tablets)
Oestrogen plus progestogen (norgestrol) for 11 days (brown tablets)
Packet taken one after the other or 7 days break
Withdrawal bleeding during the brown tablets
Absolute contraindications to HRT
Pregnancy
Active venous thromboembolism
Severe active liver disease
Endometrial carcinoma with recurrence
Breast carcinoma with recurrence
Relative contraindications to HRT
Abnormal bleeding
Breast lump (prior to investigation)
Previous endometrial cancer
Previous breast cancer
Strong family history of breast cancer
Family history of thromboembolism
Side effects of HRT
Tender of painful breasts
Fluid retention causing bloating and weight gain
Nausea
Headaches
Leg cramps
Mood swings/ low mood
Acne
Backache
Lower abdominal ache
Bleeding
Stomach upset (indigestion)
Short term benefits of HRT
Reduces vasomotor symptoms (e.g. hot flushes)
Improves psychological symptoms (e.g. mood swings)
Long term benefits of HRT
Maintains bone mass and reduces the risk of fracture
Reduces urogenital problems (e.g. dry vagina)
Improves skin
Reduces the risk of bowel cancer
May improve balance and reduce falls
May reduce tooth loss
May protect against arthritis
Risks of HRT
Endometrial cancer (if unopposed oestrogen used)
Breast cancer
Cardiovascular disease (stroke and MI)
Venous thrombo-embolic disease
Endometrial cancer
Rare under the age of 45
Presents as post-menopausal bleeding
NHS fast track clinics
Investigations- trans vaginal USS- measure the endometrial thickness
Diagnosis- endometrial sample/ biopsy
Treatment- hysterectomy and oophorectomy and possible radiotherapy
Endometrial cancer risk factors
Obesity (endogenous oestrogens)
Unopposed HRT (oestrogens without progestogens)
Nulliparity
Late menopause
Diabetes
Family history of breast, colon and ovarian cancer
COCP
Ethinyl oestradiol
Massive first pass metabolism by the liver
Increased clotting factors
High dose oestrogen suppressing GnRH/ FSH/ LH
Stops ovulation
Progestogen given to prevent hyperplasia of endometrium not really to add to contraception
HRT
Oestradiol
Lower dose to the body
Some increased clotting factors
Doesn’t suppress the FSH and LH to the same degree as the COCP
Doesn’t stop ovulation
Progestogen given to prevent hyperplasia of endometrium
Women’s health initiative summarises risks
Stroke
PE
Endometrial cancer
Colorectal cancer
Hip fracture
Death due to other causes
