Menopause HRT

Question 1

What is the menopause?

Answer 1

The last menstrual period (LMP)

Question 2

When do FSH levels peak?

Answer 2

Peak around the time of the menopause

Question 3

FSH levels diagnostic of ovarian failure?

Answer 3

FSH > 30 IU/L on 2 separate occasions = menopause

Question 4

Ovaries and responsiveness to LH/FSH in the lead up to menopause

Answer 4

The ovaries become less responsive to FSH/LH in the lead up to menopause

Question 5

Which type of oestrogen is predominant in pre-menopausal women?

Answer 5

E2 (oestradiol) is predominant in pre-menopausal women

-produced in the ovaries

Question 6

Where is E2 produced?

Answer 6

The ovaries

Question 7

Which oestrogen is predominant in post-menopausal women?

Answer 7

E1 (Oestrone) is predominant in post-menopausal women

-produced by the peripheral conversion of androgens in the adipose tissue

Question 8

Where is E1 (oestrone) produced?

Answer 8

Produced by the peripheral conversion of androgens in the adipose tissue

Question 9

Which is less biologically active, E1 or E2?

Answer 9

E1 is less biologically active

Question 10

What makes hot flushes worse?

Answer 10

Smoking

High BMI

Question 11

Menopause effects on the urinary tract?

Answer 11

• increased frequency/nocturia
• urgency
• stress/urge incontinence
• recurrent UTI

Question 12

Long term effects of the menopause

Answer 12

• cardiovascular effects
• cerebrovascular effects
• osteoporosis

Question 13

Lifestyle measures to improve menopause symptoms

Answer 13

• healthy diet
• regular exercise
• stop smoking

Question 14

Who do you give sequential HRT to?

Answer 14

Peri-menopausal women (they will still get a bleed, mimics the normal menstrual cycle)

Question 15

Who do you give continuous HRT to?

Answer 15

Post-menopausal women (they won’t get a bleed)

Question 16

When can you start sequential HRT and how long can you use it for?

Answer 16

• can be started when required

- but can only be used for max 5 years (because increased risk of endometrial cancer)

Question 17

When can continuous combined HRT be started?

Answer 17

-should not be started till 1 year since LMP

Question 18

Over 54 and more than 1 year since LMP, which HRT should you use?

Answer 18

Continuous (CCT)

Question 19

Under 54, which HRT should you use?

Answer 19

Use sequential for 2 years and then switch to continuous (CCT)

Question 20

What is tibolone and what is it licensed for?

Answer 20

Tibolone is an alternative to CC HRT

-licensed for vasomotor, psychological and libido problemds

Question 21

Tibolone risk:benefit ration

Answer 21

Over 60 = increased risk of stroke

Question 22

Tibolone and bone mass

Answer 22

Tibolone preserves bone mass and prevents fractures (not hip)

Question 23

This helps general feeling of well-being and improves libido

Answer 23

Testosterone

Question 24

Which forms is testosterone available in?

Answer 24

• Patch

- implant

Question 25

What are local systemic oestrogen preparations used for?

Answer 25

- used for bladder and vaginal symptoms in women who do not want systemic treatment - rings, creams, tablets -low systemic absorption so don't need to add progesterone

Question 26

HRT helps reduce the risk of which type of cancer?

Answer 26

Colorectal -likely due to the anti-oxidant effect of oestrogen

Question 27

Major risk factors for osteoporosis

Answer 27

- prolonged steroid use - early menopause - prolonged amenorrhoea

Question 28

Which type of HRT has greatest risk of breast cancer?

Answer 28

Combined HRT | oestrogen only - the lowest risk

Question 29

Which type of risk gives greatest risk of venous thromboembolism?

Answer 29

``` Combined HRT (but oestrogen only still has risk) -risk may be lowered by transdermal route/changing progestogen ```

Question 30

Which type of HRT increases risk of endometrial cancer?

Answer 30

Use of oestrogen-only HRT in women with uterus substantially increases the risk of endometrial hyperplasia/carcinoma Dependent on dose/duration Risk reduced with sequential HRT and eliminated with CC HRT

Question 31

If you're using HRT, which preparation could you use to ELIMINATE the increased risk of endometrial cancer?

Answer 31

Continuous HRT (so oestrogen and progesterone continuously)

Question 32

What is premature ovarian failure?

Answer 32

Periods stop and complete/partial loss of ovarian activity before age 45

Question 33

Consequences of premature ovarian failure?

Answer 33

Short term – oligomenorrhoea or 2° amenorrhoea, menopausal symptoms Longer term – bone loss, CVS and stroke risk, cognitive decline/dementia, infertility*, ↓ life expectancy

Question 34

Infections which could cause premature ovarian failure?

Answer 34

TB, mumps

Question 35

Treatment for premature ovarian failure

Answer 35

- HRT or OCP up to age 52 - testosterone (patch or implant) - additional vaginal oestrogen may be needed