Menopause And HRT

Question 1

What is menopause?

Answer 1

It is the time of waning fertility leading up to the last period. It is a retrospective diagnosis and is said to have occurred 12 months after the last period.

Question 2

What is the average age of menopause?

Answer 2

52

Question 3

What are the problems associated with falling levels of oestrogen during menopause?

Answer 3

Mental irregularity (cycles become anovulatory before stopping)
Vasomotor disturbance (sweats, palpitations, hot flushes)
Atrophy of genitalia, breasts and skin
Vaginal dryness - leads to vaginal/urinary infection, dyspareunia, traumatic bleeding, stress incontinence, prolapse
Osteoporosis (due to acceleration of bone loss) — predisposes to fracture of femur neck, radius and vertebrae later in life.

Question 4

How can menopause be diagnosed and what are the differentials to rule out?

Answer 4

Thyroid and psychiatric problems may present similarly so rule those out.
2 consecutive FSH levels >30 is suggestive of menopause, but not accurate as levels vary and unreliable if taking hormones

Question 5

Outline the management options for menopause.

Answer 5

Diet and exercise may relieve symptoms.
Menorrhagia responds to mirena coil (rule out endometrial cancer if irregular bleeding is very heavy/could be post-menopausal)
Use contraception until amenorrhoeic for 1 year (2 years if <50)
HRT
- vaginal dryness responds to oestrogen

Question 6

How does the presence or absence of a uterus affect type of HRT given? Why?

Answer 6

Those with a uterus should be given combined HRT
- unopposed oestrogen is a risk factor for endometrial cancer
Those without can have oestrogen only

Question 7

In women with a uterus, how would you decide whether to give them continuous or cyclical HRT?

Answer 7

Oestrogen and cyclical progestogen is given to women still having periods/within 12 months of a period. This results in regular withdrawal bleeding.
Continuous-combined HRT is given to postmenopausal women

Question 8

What are the different modes of administration for oestrogen in HRT?

Answer 8

Oral
Transdermal patch/gel
Subcutaneously
Vaginally

Question 9

How can progestogens be administered in HRT?

Answer 9

Orally
Transdermal
Via IUS e.g. Mirena

Question 10

Is a woman still fertile if she is on HRT?

Answer 10

Yes, if she is <50 and had her LMP in the last 2 year/>50 and had her LMP in the last year.
Need to use non-hormonal contraception e.g. condoms

Question 11

What are the contraindications for HRT?

Answer 11

Oestrogen-dependent cancer
Past PE
Undiagnosed PV bleeding
Raised LFTs
Pregnancy
Breastfeeding
Phlebitis

Question 12

What are the side effects of HRT?

Answer 12

Fluid retention, bloating, breast tenderness, nausea, headaches, leg cramps, dyspepsia, mood swings, depression, acne, backache.
Irregular breakthrough bleeding may need investigation.

Question 13

Describe the follow-up for those on HRT.

Answer 13

Annual check-up.
Breasts
BP (stop if >160/100)
Weight
Abnormal bleeding

Question 14

What are the alternatives to HRT?

Answer 14

SSRIs may help with vasomotor symptoms
Osteoporosis- calcium + vit D/bisphosphonates/strontium/SERM (HRT should not be first-line for osteoporosis unless symptoms of menopause also need treating)
Vaginal dryness - topical oestrogen/lubricants

Question 15

What are the benefits of HRT?

Answer 15

Reduction of vasomotor symptoms usually evident in 4 weeks
Improvement in urogenital and sexual function (may take several months)
Osteoporotic fractures reduced
Reduction of colorectal cancer by ~1/3

Question 16

What are the risks of HRT?

Answer 16

Breast cancer
Endometrial cancer (unopposed oestrogen)
VTE risk (doubles)
Gallbladder disease