Menopause and HRT

Question 1

What is menopause? Average age? Hormonal changes?

Answer 1

Waning fertility leading up to the last period
Said to have occurred 12 months after the last period

52

Falling oestrogen levels

Question 2

What are problems relating to falling oestrogen levels?

Answer 2

Menstrual irregularity as cycles become anovulatory before sotpping

Vasomotor disturbance (sweating, palpitation, flushes)

Atrophy of oestrogen dependent tissues (genitalia, breasts) and skin

Vaginal dryness can lead to vaginal and urinary infection, dyspareunia, traumatic bleeding, stress incontinence and prolapse

Osteoporosis - menopause accelerates bone loss - fracture of femur neck, radius and vertebrae

Question 3

What should you consider for management of menopause?

Answer 3

Diet and exercise

Mirena could for menorrhagia

Endometrial biopsy if irregular bleeding is very heavy

Contraception until 1y amenorrhoea if >50, 2y if < 50

Vaginal dryness responds to topical oestrogen PV every night for 2 weeks and twice per week as required afterwards

Question 4

What consideration must be made for HRT? Why?

Answer 4

Is there a uterus:
Those with uterus should be given combined HRT
Those without should be given oestrogen-only

Unopposed oestrogen is a risk factor for endometrial cancer

Question 5

Who doe you use oestrogen only HRT in?

Answer 5

Women without uterus (post-hysteretomy) as no risk of endometrial cancer

Question 6

Who should you use oestrogen and cyclical progestogen in - cyclical combined HRT?

Answer 6

Women who are still having periods or who are within 12 months of a period

IF LMP < 1 YEAR

Results in regular withdrawal bleeding

Question 7

Who is continuous combined HRT used in?

Answer 7

Post-menopausal women - oestradiol and norethisterone

IF LMP > 1 YEAR
It has been 2 years since their LMP if they had premature menopause (<40yo)
Taken cyclical combined for at least 1 year

Question 8

How are oestrogens and progestogens administered

Answer 8

Oestrogen can be administered orally, transdermal, subcutaneous or PV
Progestogens can be administered orally, transdermally and via intrauterine system - Mirena

Question 9

Does HRT provide contraception? How long are women considered fertile?

Answer 9

HRT does not provide contraception
Women are considered fertile until 2y after LMP if < 50 and for 1 yr if >50
Potentially fertile women should use barrier contraception if on HRT

Question 10

What are contraindications to HRT?

Answer 10

Oestrogen dependent cancer
Past pulmonary embolus
Undiagnosed PV bleeding
LFT raised
Pregnancy
Breastfeeding
Phlebiits

Question 11

What are side effects of HRT?

Answer 11

Fluid retention
Bloating breast tenderness
Nausea
Headaches
Leg cramps

Progestagens:
Mood swings
Depression
Acne
Backache

Question 12

What should you check at annual check up of HRT?

Answer 12

Breasts
BP - stop if > 160/100
Weight
Abnormal bleeding?

Question 13

What can help treat vasomotor symptoms? Alternative to HRT

Answer 13

SSRI

Sertraline is not useful in treating hot flushes

Question 14

What can treat osteoporosis? Alternative to HRT?

Answer 14

Calcium and vitamin D
Bisphosphonates or strontium
Selective oestrogen receptor modulators

• HRT should not be used first line for osteoporosis unless menopause symptoms need to be treated

Question 15

What can treat vaginal dryness?

Answer 15

Local treatment with vaginal oestrogen does not require systemic progestogens

If CI or woman wants to avoid (possibly due to breast cancer history) use a lubricant

Question 16

What are benefits of HRT?

Answer 16

Reduction of vasomotor symptoms is brought about by oestrogen and improvement is evident by 4 weeks and max effect by 3 months
HRT should be continued for at least 1 year to minimise symptoms recurrence

Improvement in urogenital symptoms and systemic function via systemic or vaginal oestrogens may take several months

Osteoporotic fractures are reduced but treatment needs to be lifelong and sustained for HRT to be effective method

Reduced risk of colorectal cancer (but this is not an indication)

Question 17

What are risks of HRT?

Answer 17

Breast cancer risk is increased 2.3% per year and risk is dependent on duration of HRT
5 years after stopping, risk returns to normal women
Greatest risk with combined therapy

Unopposed oestrogen increase risk of endometrial cancer - remains for 5 or more years after stopping

HRT more than doubles risk of VTE
Most likely to occur in the first year of taking HRT
risk is lower with transdermal preparations compared with oral

Gallbladder disease appears to be increased but risk also increases with age an obesity

It is uncertain what effect HRT has on CVD risk, dementia and ovarian cancer

Question 18

What considerations should you have in prescribing HRT?

Answer 18

Consider diet, exercise and local treatments first
Starting HRT closer to menopause may be safer than waiting 5 or 10 years
Discuss benefits and risks
Encourage breast awareness and to report breast changes
Attend breast screening
Use lowest effective dose for shortest time possible
Be wary about HRT in those with FHx of breast cancer

Question 19

What is premature ovarian failure? Causes?

Answer 19

Premature ovarian failure is defined as the onset of menopausal symptoms and elevated gonadotrophin levels before the age of 40 years.

Idiopathic
Chemotherapy
Autoimmune
Radiation

Question 20

What are features of premature ovarian failure?

Answer 20

Hot flushes
Night sweats
Infertility
Secondary amenorrhoea
Raised FSH and LH