Menopause and HRT

Question 1

What is the menopause?

Answer 1

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

Question 2

Peri-menopause

Answer 2

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

Question 3

Clinical features of peri-menopause

Answer 3

Irregular menstrual cycles

Occasional heavy bleeding

Hot flushes

Nervousness irritability

Question 4

Primary symptoms of menopause

Answer 4

Menstrual cycle change

• oligomenorrhoea
• amenorrhoea

Vasomotor symptoms

• hot flushes
• night sweats

Vaginal dryness

Question 5

Secondary symptoms of menopause

Answer 5

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

Question 6

Hormone replacement therapy

Answer 6

Oestrogen required for symptoms

Progestogens required to prevent endometrial cancer

Question 7

Drugs for osteoporosis

Answer 7

Bisphosphonates

• alendronate
• risedronate

Question 8

Drugs for reducing vasomotor symptoms

Answer 8

Progesterone

SERMs- raloxifene

Beta-blocker

Clonidine

Question 9

Complementary and alternative therapies

Answer 9

Phyto-oestrogens

Herbalism

• black cohost
• st john’s wort
• gingseng
• oil of evening primrose

Progesterone cream

Homeopathy

Acupuncture

Reflexology

Question 10

How HRT is given when there is no uterus

Answer 10

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

Question 11

How HRT is given when there is a uterus

Answer 11

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

Question 12

Absolute contraindications to HRT

Answer 12

Pregnancy

Active venous thromboembolism

Severe active liver disease

Endometrial carcinoma with recurrence

Breast carcinoma with recurrence

Question 13

Relative contraindications to HRT

Answer 13

Abnormal bleeding

Breast lump (prior to investigation)

Previous endometrial cancer

Previous breast cancer

Strong family history of breast cancer

Family history of thromboembolism

Question 14

Side effects of HRT

Answer 14

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)

Question 15

Short term benefits of HRT

Answer 15

Reduces vasomotor symptoms (e.g. hot flushes)

Improves psychological symptoms (e.g. mood swings)

Question 16

Long term benefits of HRT

Answer 16

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

Question 17

Risks of HRT

Answer 17

Endometrial cancer (if unopposed oestrogen used)

Breast cancer

Cardiovascular disease (stroke and MI)

Venous thrombo-embolic disease

Question 18

Endometrial cancer

Answer 18

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

Question 19

Endometrial cancer risk factors

Answer 19

Obesity (endogenous oestrogens)

Unopposed HRT (oestrogens without progestogens)

Nulliparity

Late menopause

Diabetes

Family history of breast, colon and ovarian cancer

Question 20

COCP

Answer 20

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

Question 21

HRT

Answer 21

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

Question 22

Women’s health initiative summarises risks

Answer 22

Stroke

PE

Endometrial cancer

Colorectal cancer
Hip fracture

Death due to other causes