Menopause, HRT and oral contraception

Question 1

What is menopause?

Answer 1

Menopause is the permanent cessation of menstruation resulting from the loss of ovarian follicular activity.

Question 2

What is the average age of menopause?

Answer 2

51 (but it can range from 45-55)

Question 3

What is the climacteric period?

Answer 3

It is the period of transition from predictable ovarian function through the post-menopausal years.

Question 4

What is premature ovarian failure/ insufficiency?

Answer 4

this is when menopause occurs before the age 40 and occurs in 1% of women

Question 5

What are the possible causes for ovarian failure/ insufficiency?

Answer 5

Causes for this can be autoimmune or secondary to surgery, chemotherapy or radiation.

Question 6

What is the main difference between menopausal and non-menopausal women?

Answer 6

Menopausal women have a low estradiol whereas normal women have high oestradiol. Women in menopause will lack the negative feedback effect on the hypothalamus and LH/FSH.

Question 7

What are some of the symptoms of menopause?

Answer 7

 Hot flushes (head, neck, upper chest)
 Urogenital atrophy and dyspareunia (painful sex)
 Sleep disturbance
 Depression
 Decreased libido
 Joint pain
Symptoms will usually disappear with time

Question 8

What are some of the complications of menopause?

Answer 8

Osteoporosis- oestrogen deficiency leads to loss of bone matrix and there is a 10-fold risk of fracture (loss of 1-3% of bone mass per year).
Cardiovascular disease- women protected against CVD before menopause but have the same risk as men by the age of 70.

Question 9

Why is hormone replacement therapy given? (HRT)

Answer 9

In order to control vasomotor symptoms (hot flushes)- it is given to women who cannot function with the flushes (debilitating)

Question 10

What do estrogen and progesterone do in HRT?

Answer 10

E- is needed to replace what is lost but it also causes endometrial proliferation and causes a risk of carcinoma. Progesterone is therefore given to prevent endometrial hyperplasia (and to reduce the risk of cancer).

Question 11

When is it ok to give only oestrogen for HRT?

Answer 11

If the woman has had hysterectomy (removal of uterus- no endometrium), then oestrogen on its own is fine.

Question 12

What are the administration routes of HRT

Answer 12

Orally, transdermally, transvaginally

Question 13

What is the cyclical doses of HRT?

Answer 13

E(every day) + P (12-14 days)- (E= oestrogen and P=progesterone)

Question 14

Why is oestrogen given at a higher dose orally?

Answer 14

This is because oestrogen has low bioavailability. It undergoes fast metabolism.

Question 15

What are the side effects of HRT?

Answer 15

	Breast cancer
	Coronary heart disease
	Deep Vein thrombosis
	Stroke
	Gallstones

Note that the absolute complications for a woman in her 50s is actually very low.

Question 16

What are the beneficial/ negative effects of oestrogen?

Answer 16

Oestrogen has a beneficial effect on lipid profile and endothelial function.
In older women who have atherosclerosis, oestrogen has pro-inflammatory and pro-thrombotic effects. Giving oestrogen to an older woman might increase CHD risk but not in a 50 year old.

Question 17

HRT: what is tibolone

Answer 17

it is a synthetic prohormone- has oestrogen and progestognenic (and weak androgenic functions)- it reduces fracture risk but there is an increased risk of stroke and breast cancer associated with it.

Question 18

What are SERMs

Answer 18

Selective oestrogen receptor modulators

Question 19

What is raloxifene?

Answer 19

It is a SERM
• Oestrogenic in bone: good effect in bone
– Reduces risk of vertebral fractures
• Anti-oestrogenic in breast & uterus
– reduces breast cancer risk
• Does not reduce vasomotor symptoms- there is an increased risk of VTE (venous thromboembolism) & fatal stroke
Able to change its oestrogenic effects in different tissues.

Question 20

What is tamoxifen?

Answer 20

Another SERM- Anti-oestrogenic on breast tissue and used to treat oestrogen-dependent breast tumours and metastatic breast cancer.

Question 21

What is the combined oral contraceptive?

Answer 21

Similar to HRT, it is the combination of E and P. It supresses ovulation (E and P negative feedback actions at pituitary and hypothalamus).
Progesterone thickens cervical mucus (harder to get pregnant)
Oestrogen upregulates progesterone receptors and oestrogen counteract the androgenic effects of synthetic progestogens

Question 22

when are progesterone only contraceptives used?

Answer 22

Used when oestrogens are not a good idea (when their side effects will cause real problems)

Question 23

Give an example of someone who would need to have the progesterone only oral contraceptive?

Answer 23

Smokers

Question 24

How are progesterone oral contraceptives taken?

Answer 24

Taken for 21 days (or 12 weeks) and stop for 7 days. They have a short half-life and so need to be taken at the same time every day.

Question 25

What are the unwanted side effects of oestrogen?

Answer 25

• Nausea
• Headache
• Increased weight
• CVS problems- stroke/ VTE
• Breast/ endometrium proliferative effects and cancers

Question 26

How is the progesterone only drug administered?

Answer 26

Long-acting preparations may be given by deep IM injection via intra-uterine system. Or can be administered orally (POP- progesterone only pill)

Question 27

What are the different emergency post-coital contraceptions?

Answer 27

copper IUD (intrauterine contraceptive device)
Levonogestrel
Ulipristal

Question 28

What is copper IUD?

Answer 28

Intrauterine contraceptive device- you need to exclude preganancy first before putting it in. Affects sperm viability and function and its effectiveness is not reduced if the woman is obese.
5 (up to 7) days after unprotected intercourse

Question 29

What is levonorgestrel?

Answer 29

Needs to be used within 72 hours of intercourse. Combined E+P- or P-only. Use 2 doses 12 hours apart use a single one-dose double strength also available- may cause nausea or vomiting.

Question 30

What is ulipstral?

Answer 30

Use up to 120 hours after intercourse - anti-progestin activity, delay ovulation by as much as 5 days.Impairs implantation.