Menopause and HRT Flashcards
What is menopause? Average age? Hormonal changes?
Waning fertility leading up to the last period
Said to have occurred 12 months after the last period
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Falling oestrogen levels
What are problems relating to falling oestrogen levels?
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
What should you consider for management of menopause?
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
What consideration must be made for HRT? Why?
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
Who doe you use oestrogen only HRT in?
Women without uterus (post-hysteretomy) as no risk of endometrial cancer
Who should you use oestrogen and cyclical progestogen in - cyclical combined HRT?
Women who are still having periods or who are within 12 months of a period
IF LMP < 1 YEAR
Results in regular withdrawal bleeding
Who is continuous combined HRT used in?
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
How are oestrogens and progestogens administered
Oestrogen can be administered orally, transdermal, subcutaneous or PV
Progestogens can be administered orally, transdermally and via intrauterine system - Mirena
Does HRT provide contraception? How long are women considered fertile?
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
What are contraindications to HRT?
Oestrogen dependent cancer Past pulmonary embolus Undiagnosed PV bleeding LFT raised Pregnancy Breastfeeding Phlebiits
What are side effects of HRT?
Fluid retention Bloating breast tenderness Nausea Headaches Leg cramps
Progestagens: Mood swings Depression Acne Backache
What should you check at annual check up of HRT?
Breasts
BP - stop if > 160/100
Weight
Abnormal bleeding?
What can help treat vasomotor symptoms? Alternative to HRT
SSRI
Sertraline is not useful in treating hot flushes
What can treat osteoporosis? Alternative to HRT?
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
What can treat vaginal dryness?
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
What are benefits of HRT?
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)
What are risks of HRT?
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
What considerations should you have in prescribing HRT?
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
What is premature ovarian failure? Causes?
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
What are features of premature ovarian failure?
Hot flushes Night sweats Infertility Secondary amenorrhoea Raised FSH and LH
