Menopause/HRT Flashcards
A 49 year-old woman complains of hot flushes which have been causing her uncomfortable situations at work. She has had irregular periods for the last six months and finished treatment for breast Cancer 18 momths ago and is currently on Tamoxifen. Choose the single best next management option for her symptoms:
a) Paroxetine
b) Transdermal HRT
c) Clonidine
d) Cognitive-behavioral therapy
e) Venlafaxine
- 1st line treatment for vasomotor symptoms is HRT. in women who do not wish to start, have contra-indications or symptoms persist despite HRT, consider CBT
- SSRI, SNRIs or clonidine should not routinely be offered
- If women need antidepressants but are on Tamoxifen, they should have SNRI (Venlafaxin) rather than SSRI (paroxetine would be the first-line SSRI).
D (CBT)
A 58-year-old woman with a history of head injury resulting in reduced mobility and significant care needs has attended with vulvovaginal discomfort. Carers have reported bleeding on wiping. Pelvic ultrasound show a normal endometrial thickness. On examination, significant vulvovaginal atrophy is noted. Topical oestrogens have been suggested, but both the woman and the carer consider it to be impractical. What is the best management option for her symptoms?
a) Start on oral continuous combined HRT
b) Start on transdermal continuous combined HRT
c) vaginal prasterone
d) Ospemifene
e) water-based lubricants
NICE: Consider ospemifene (SERM) as oral treatment if locally applied is impractical (e.g., disability)
D (ospemifene)
A 55 year-old woman is currently taking aromatase inhibitors due to a history of breast cancer. She complains of vaginal discomfort during intercourse, which is significantly impacting her life. Her GP has recommended non-hormonal moisturisers and lubricants, with no effect. On examination, vulvovaginal atrophy is noted. What is the nest best management option:
a) Start on transdermal continuous combined HRT
b) Start on vaginal oestrogen, after discussing risks and benefits
c) ospemifene
d) vaginal prasterone
e) referral to breast cancer specialist
- HRT is contra-indicated with her history of breast Ca
- Vaginal prasterone is indicated for women with no hisory of breast Ca, when vaginal oestrogens and other options have not worked
- Ospemifene is recommended for women with no history of breast Ca, when vaginal therapies are impractical (for example, disabilities)
- NICE: For people currently having aromatase inhibitors as adjuvant treatment for breast
cancer, work with a breast cancer specialist to identify treatment options for
genitourinary symptoms that have continued despite trying non-hormonal
E - referral to breast cancer specialist
A 55 year-old woman with a histor of oestrogen receptor negative breast cancer complains of vaginal discomfort during intercourse, which is significantly impacting her life. Her GP has recommended non-hormonal moisturisers and lubricants, with no effect. On examination, vulvovaginal atrophy is noted. What is the nest best management option:
a) Start on transdermal continuous combined HRT
b) Start on vaginal oestrogen, after discussing risks and benefits
c) ospemifene
d) vaginal prasterone
e) referral to breast cancer specialist
NICE: Consider vaginal oestrogen with persistent symptoms despite trying non-hormonal treatments (off-label use).
- The amount aborbed is minimal in comparison to systemic HRT, therefore it is likely to be safe (NICE 2024)
- In oestrogen receptor positive cancer, the risk of recurrence is unknown therefore not generally recommended
B - vaginal oestrogen
A 49 year-old woman has been experiencing irregular and infrequent periods for the last 10 months. At the same time, she started experiencing hot flushes and often awakens in the middle of the night, which impacts her performance at work the following day. She does not wish to be started on HRT, as she believes it triggered a pulmonary embolism in her mother. What is the next best management option:
a) SSRI
b) SNRI
c) CBT
d) Gabapentin
e) transdermal HRT
NICE: Consider menopause-specific CBT as an option for people who have sleep
problems (such as night-time awakening) in association with vasomotor
symptoms:
* in addition to other management options (including HRT) or
* for people for whom other options are contraindicated or
* for people who prefer not to try other options. [2024]
C - CBT
A 60-year-old woman who has been on continuous combined HRT for 7 years is concerned about her risk of breast cancer. She has no family history of cancer and underwent a hysterectomy for heavy menstrual bleeding in her 40s. What is the most appropriate next step?
a) Discontinue HRT immediately
b) Switch to estrogen-only HRT
c) Continue the current HRT regimen
d) Reduce HRT dose
e) Offer non-hormonal alternatives
- Combined HRT: increases the risk of Breast Cancer
- This risk if longer use
- Higher risk with current use than those that have taken before
- Declines after stopping but persists 10 years after use
- Small increased risk of death from breast Ca
- Risk lower if sequential compared to continuous
- unknown if progesterone rather than progestogesns make a difference
- oestrogen-only HRT: little or no increase
B - switch to oestrogen only
A 60-year-old woman who has been on continuous combined HRT for 7 years is concerned about her risk of breast cancer. She has no family history of cancer. Which of the followin options would you advise her?
a) continuous combined HRT poses a higher risk of breast cancer when compared to sequential
b) the risk is unrelated to duration of HRT use
c) if HRT has been taken at any point in life, the risk is increased indefinitely
d) progesterones rather than progestogens slightly decrease the risk, but it is still higher than in the general population
e) if a woman develops breast cancer on HRT, it does not increase mortality
a) True - continuous as higher risk (continuous exposure to both hormones)
b) the risk is higher the higher the duration of use
c) the risk is higher during treatment rather than with a history of treament. It declines after stopping, but can persist for 10 years
d) there is not enough evidence comparing the two
e) there is a slight increase in death
A - continuous combined has a higher risk than sequential
A 58-year-old woman with a BMI of 34 kg/m² presents with bothersome symptoms of vaginal dryness and dyspareunia. She has a history of deep vein thrombosis (DVT) and is concerned about her options for managing menopausal symptoms. Which is the most appropriate treatment?
a) Oral combined HRT
b) Transdermal estrogen with micronized progesterone
c) Vaginal estrogen
d) Tibolone
e) Non-hormonal therapy (e.g., SSRIs or SNRIs)
vaginal oestrogen does not increase risk of DVT. Oral does
C - vaginal oestrogen
A 50-year-old woman presents with worsening vasomotor symptoms and reduced quality of life. She has a family history of breast cancer (mother diagnosed at age 65). Her BMI is 23 kg/m², and she is otherwise healthy. She seeks advice regarding HRT. What is the most appropriate advice?
a) HRT is contraindicated due to her family history
b) HRT is safe, but the risks and benefits must be discussed
c) Non-hormonal options should be first-line due to her family history
d) Only transdermal HRT is safe in her case
e) Tibolone is safer than standard HRT in her case
Family history is not a contra-indication to HRT
B
Which of the following statements about HRT and cardiovascular disease (CVD) is correct?
a) HRT should be initiated in all women with pre-existing CVD to improve symptoms
b) The risk of CVD is reduced if HRT is started within 10 years of menopause
c) Oral HRT is associated with a lower risk of venous thromboembolism compared to transdermal HRT
d) HRT increases the risk of stroke regardless of the formulation
e) HRT has no effect on lipid profiles
the “window of opportunity” is 10 years
B
Choose the most appropriate treatment for each scenario
Theme: Indications for Non-Hormonal Treatments
Options:
a) Venlafaxine
b) Gabapentin
c) Clonidine
d) Vaginal lubricants and moisturizers
e) SSRIs
f) SNRIs
g) CBT
h) vaginal oestrogens
Scenarios:
- A 56-year-old woman with a history of breast cancer and severe vasomotor symptoms.
- A 60-year-old woman with hot flushes and sleep disturbances but prefers to avoid hormones. She has been doing CBT for 4 months with no effect
- A 58-year-old woman with severe vaginal dryness but no vasomotor symptoms.
- A 50-year-old woman has been experiencing low mood since her menopausal symptoms started. She has a history of oestrogen receptor positive breast cancer.
- A 50-year old woman has been experiencing low mood, reduced appetite and apathy and lack of interest in her usual activities since her menopausal symptoms started. CBT has not had an effect. She has a history of breast cancer and is currently on Tamoxifen.
- F -> when HRT contra-indicated or not desired, consider menopause-specific CBT. do not routinely offer SSRI, SNRIs or Clonidine
- B –> gabapentin can be an option for sleep
- G
- F
- F
A 54-year-old woman with premature ovarian insufficiency (POI) was started on HRT at age 35. She asks when she can safely stop HRT. What is the most appropriate advice?
a) Stop HRT at age 50
b) Stop HRT after 5 years of treatment
c) Continue HRT until the average age of menopause
d) Stop HRT at age 60
e) Continue HRT for life if she has no contraindications
C
A 49-year-old woman is currently on remission for breast cancer. She has not had a period for 6 months and has been experiencing insomnia, which is responding well to cognitive-behavioral therapy. Her older sister has recently had a vertebral fracture, which made her concerned about osteoporosis. Her t score is 2.1. What is the best management option for prevention of osteoporosis in this case?
a) Alendronate
b) Raloxifen
c) Prasterone
d) Teriparatide
e) low dose transdermal HRT
In history of breast or endometrial Ca or strong family history of Breast Ca with no vasomotor symptoms: consider raloxifen. If vasomotor symptoms, may worsen it.
- reduces risk of breast Ca and at the same time osteoporosis
- however, slight increase in DVT and PE
B
- Breast cancer: yes, combined (continuous more than sequential)
- CHD: no. Protective if started within 10 yearas
- Dementia: no
- Stroke: yes, if oral oestrogen
- DVT: yes, if oral oestrogen
- Colorectal disease: false.
- Hip fracture: false
- Gall bladder disease: true. oestrogen increases
- Colorectal carcinoma: true
- Ovarian cancer: controversial. Choose false slight increase with combined HRT
-?
- F: 3-4 extra cases of breast CA if used for 5 years. If used for 10 years, 6 extra cases. If for 15 years, 12 extra cases
- T
- T
- T
- T
- T: 2-3 times increase
- T
- T
- T
- F - recommended if started within 10 years
- True - not contra-indication after MI, but advise to see specialist
- T
- T
- T
- F
- F
- F
- T
- F –> improves frequency and urgency, but not incontinence
- T
- T
- T
- T
- T
-A, B, C, D, E, J, K
- Acupuncture evidence, especially electric
- Clonidine not in low blood pressure, not good for sleep. In America, Paroxetine licensed. In UK, clonidine, but the worse and disturbance in sleep.
- SNRI
- SSRI
- St John’s Wart controversial
- Black Cohosh these last two are plant oestrogens. Difficult to know how much is in them. In breast CA, we cannot recommend it. If between the two, go for Black Cohosh!!!
- Mood disturbance rather than depression, therefore CBT not SSRI
- Clonidine could potentially be an option, but no improvement in mood
H
- already has osteoporosis. No contra-indication
- Also, 61 so avoid HRT
H
B
- answer without testosterone would be better, as no mention about libido. because ovaries removed though, considered a good idea
F
- Endometriosis:
o needs to add progesterone to avoid recurrence of endometriosis
o not for sequential as wants to keep endometriosis suppressed
o Needs continuous combined, as needs progesterone to reduce recurrence
D
- BMI and smoker –> prefer transdermal
A
- Although NICE says testosterone if HRT not working, for exam, treat loss of libido there and then
- ## Don’t give testosterone alone
E
- depression, not low mood
- if breast ca on tamoxifen, needs SNRI
I
- Strong FHx of breast Ca and osteoporosis.
- When they mention breast Ca and someone is scared, the one that reduces the risk of breast Ca and the risk of osteoporosis is SERM
- However, SERM cannot be used if hot flushes as it would make them even worse
B
- for prevention, not treatment
- smoker –> consider transdermal
- If we were to start treatment, we would not give Bisphosphonate and we would prefer Denosumab due to gastritis
- If she was closer to 60, A would be a good option as we would want to start low dose
D
- close to 60, so low dose
D
- uterus in situ - needs combined
- PMS and young: high dose needed
- Progestogen needs to be Mirena or uterogestan, which is more tolerable
G
A
- mentions insomnia
D
J - - not meant to recommend, but the one that has effect is Black Cohosh
- kava Kava detrimental for liver
C
- Tamoxifen: no HRT, no SRI (although not depression)
G
E
- Provoked DVT. If menopause confirmed, for thrombophilia screen and second opinion
H
