Menopause and HRT Flashcards
What is the menopause?
The time of waning fertility leading up to the last period
It is diagnosed when woman has gone 12 months after last period
What is the average age in the UK?
51
What causes the symptoms?
Lower levels of oestrogen and progesterone
Why are there lower levels of oestrogen?
The ovaries are depleted of follicles
What symptoms occur?
Menstrual irregularity as cycles become anovulatory
Dysfunctional uterine bleeding may occur
Vasomotor disturbance - sweating, palpitations, hot flushes, night sweats - need to change bed sheets
Atrophy of oestrogen dependent tissues - genitalia, skin and breasts
Psychological - anxiety and depression, short term memory impairment
Osteoporosis- the menopause accelerates bone loss
Increased risk of ischaemic heart disease
What can vaginal dryness lead to?
Vaginal and urinary infection Dyspareunia Traumatic bleeding Stress incontinence Prolapse
What phases are there?
Pre menopause - changes to menstrual cycle, follicular phase shortens, ovulation early/absent, less oestrogen secreted, LH and FSH rise (FSH more so)
Peri menopause - transition, physiological change
Menopause - permanent cessation
Post menopause - after 12 months cessation
What is used to measure physiological menopause?
FSH
2 consecutive levels >30 IU/L is suggestive of menopause, but NICE does not recommend testing - levels vary and unreliable if taking hormones
Why is oestrogen not used to measure menopausal change?
It is also produced by aromatase in adipose tissue
It is recommended to use effective contraception until how long after the last period in women >50?
12 months
Effective contraception should be used how long after the last period in women less than 50?
24 months
Are menopausal symptoms common?
Yes, effect roughly 75%
How long do the symptoms last for?
Typically 7 years but may resolve quicker and in some cases take much longer
The management can be split into 3 categories:
Lifestyle modifications
Hormone replacement therapy
Non-hormone replacement therapy
What lifestyle modifications can be made?
Hot flushes - regular exercise, weight loss, reduced stress
Sleep disturbance - avoid late night exercise and maintain good sleep hygiene
Mood - sleep, regular exercise, relaxation
Cognitive symptoms - regular exercise, good sleep hygiene
Reducing alcohol and coffee can help with hot flushes and night sweats
Smoking cessation
How can HRT be given?
Systemically - tablets or patches
Locally - oestrogen creams
If a woman has a uterus, what should she be given?
Combined HRT as unopposed oestrogen will increase her risk of endometrial cancer
If a woman does not have a uterus, what can be given?
Oestrogen alone can be given orally or transdermal patch
What contraindications are there to HRT?
Current, past or suspected breast cancer Any oestrogen sensitive cancer Undiagnosed vaginal bleeding Untreated endometrial hyperplasia Previous idiopathic/current DVT or PE unless already on anticoagulant treatment Active liver disease Untreated HTN Active or recent angina/MI
What risks are associated with HRT?
VTE - increased risk with all forms, greater for oral than transdermal
Breast cancer - increase 2.3% per year and dependent on duration of use, 5 years after stopping returns to that of a woman who has never had HRT, HRT with oestrogen alone is associated with little/no increased risk
Coronary heart disease - combined HRT slight increased risk, no increased risk when started in women under 60
Stroke - slight increased risk with oral oestrogen HRT
Ovarian cancer - increased risk with all HRT
What are the HRT treatment routines?
Cyclical - for women still having periods, results in regular withdrawal bleeding usually e.g monthly (oestrogen daily and progesterone given at end of cycle for 10-14 days) or three monthly (oestrogen taken daily and progesterone given for 14 days every 13 weeks)
Continuous combined - usually recommended for women who are post menopausal
How can progestogens be administered?
Orally, transdermally or via IUS
What non-HRT management options are there?
Vasomotor symptoms - SSRIs
Vaginal dryness - lubricant or moisturiser
Osteoporosis- calcium and vitamin D, bisphosphonates or SERMs
What can be done if suffering from urogenital atrophy?
Local vaginal oestrogen cream
