Menopause and HRT

Question 1

What is the menopause?

Answer 1

The time of waning fertility leading up to the last period

It is diagnosed when woman has gone 12 months after last period

Question 2

What is the average age in the UK?

Answer 2

51

Question 3

What causes the symptoms?

Answer 3

Lower levels of oestrogen and progesterone

Question 4

Why are there lower levels of oestrogen?

Answer 4

The ovaries are depleted of follicles

Question 5

What symptoms occur?

Answer 5

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

Question 6

What can vaginal dryness lead to?

Answer 6

Vaginal and urinary infection 
Dyspareunia 
Traumatic bleeding 
Stress incontinence 
Prolapse

Question 7

What phases are there?

Answer 7

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

Question 8

What is used to measure physiological menopause?

Answer 8

FSH
2 consecutive levels >30 IU/L is suggestive of menopause, but NICE does not recommend testing - levels vary and unreliable if taking hormones

Question 9

Why is oestrogen not used to measure menopausal change?

Answer 9

It is also produced by aromatase in adipose tissue

Question 10

It is recommended to use effective contraception until how long after the last period in women >50?

Answer 10

12 months

Question 11

Effective contraception should be used how long after the last period in women less than 50?

Answer 11

24 months

Question 12

Are menopausal symptoms common?

Answer 12

Yes, effect roughly 75%

Question 13

How long do the symptoms last for?

Answer 13

Typically 7 years but may resolve quicker and in some cases take much longer

Question 14

The management can be split into 3 categories:

Answer 14

Lifestyle modifications
Hormone replacement therapy
Non-hormone replacement therapy

Question 15

What lifestyle modifications can be made?

Answer 15

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

Question 16

How can HRT be given?

Answer 16

Systemically - tablets or patches

Locally - oestrogen creams

Question 17

If a woman has a uterus, what should she be given?

Answer 17

Combined HRT as unopposed oestrogen will increase her risk of endometrial cancer

Question 18

If a woman does not have a uterus, what can be given?

Answer 18

Oestrogen alone can be given orally or transdermal patch

Question 19

What contraindications are there to HRT?

Answer 19

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

Question 20

What risks are associated with HRT?

Answer 20

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

Question 21

What are the HRT treatment routines?

Answer 21

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

Question 22

How can progestogens be administered?

Answer 22

Orally, transdermally or via IUS

Question 23

What non-HRT management options are there?

Answer 23

Vasomotor symptoms - SSRIs
Vaginal dryness - lubricant or moisturiser
Osteoporosis- calcium and vitamin D, bisphosphonates or SERMs

Question 24

What can be done if suffering from urogenital atrophy?

Answer 24

Local vaginal oestrogen cream

Question 25

What side effects of HRT are there?

Answer 25

Fluid retention
Bloating, breast tenderness
Nausea
Headaches
Leg cramps
Dyspepsia 
Mood swings, depression, acne thought to be due to progestogens

Question 26

You should be wary of HRT in those with a FH of…

Answer 26

Breast cancer

Question 27

What is premature menopause?

Answer 27

Menstruation stopped before 40

Affects 1% of women

Question 28

Are tests required for diagnosis?

Answer 28

Not after 45, symptoms only

Could be done between 40-45 if irregular period or considering g pregnancy