Menopause, HRT and oral contraception Flashcards
What is menopause?
Menopause is the permanent cessation of menstruation resulting from the loss of ovarian follicular activity.
What is the average age of menopause?
51 (but it can range from 45-55)
What is the climacteric period?
It is the period of transition from predictable ovarian function through the post-menopausal years.
What is premature ovarian failure/ insufficiency?
this is when menopause occurs before the age 40 and occurs in 1% of women
What are the possible causes for ovarian failure/ insufficiency?
Causes for this can be autoimmune or secondary to surgery, chemotherapy or radiation.
What is the main difference between menopausal and non-menopausal women?
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.
What are some of the symptoms of menopause?
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
What are some of the complications of menopause?
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.
Why is hormone replacement therapy given? (HRT)
In order to control vasomotor symptoms (hot flushes)- it is given to women who cannot function with the flushes (debilitating)
What do estrogen and progesterone do in HRT?
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).
When is it ok to give only oestrogen for HRT?
If the woman has had hysterectomy (removal of uterus- no endometrium), then oestrogen on its own is fine.
What are the administration routes of HRT
Orally, transdermally, transvaginally
What is the cyclical doses of HRT?
E(every day) + P (12-14 days)- (E= oestrogen and P=progesterone)
Why is oestrogen given at a higher dose orally?
This is because oestrogen has low bioavailability. It undergoes fast metabolism.
What are the side effects of HRT?
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.
What are the beneficial/ negative effects of oestrogen?
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.
HRT: what is tibolone
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.
What are SERMs
Selective oestrogen receptor modulators
What is raloxifene?
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.
What is tamoxifen?
Another SERM- Anti-oestrogenic on breast tissue and used to treat oestrogen-dependent breast tumours and metastatic breast cancer.
What is the combined oral contraceptive?
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
when are progesterone only contraceptives used?
Used when oestrogens are not a good idea (when their side effects will cause real problems)
Give an example of someone who would need to have the progesterone only oral contraceptive?
Smokers
How are progesterone oral contraceptives taken?
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.
What are the unwanted side effects of oestrogen?
- Nausea
- Headache
- Increased weight
- CVS problems- stroke/ VTE
- Breast/ endometrium proliferative effects and cancers
How is the progesterone only drug administered?
Long-acting preparations may be given by deep IM injection via intra-uterine system. Or can be administered orally (POP- progesterone only pill)
What are the different emergency post-coital contraceptions?
copper IUD (intrauterine contraceptive device)
Levonogestrel
Ulipristal
What is copper IUD?
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
What is levonorgestrel?
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.
What is ulipstral?
Use up to 120 hours after intercourse - anti-progestin activity, delay ovulation by as much as 5 days.Impairs implantation.
