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Endocrinology > Oral Contraceptives, Menopause and HRT > Flashcards

Oral Contraceptives, Menopause and HRT Flashcards

1
Q

What is menopause?

A

Permanent cessation of menstruation - amenorrhoea for more than 12 months
NOTE: usually happens between 45-55 yrs

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2
Q

What is the term given to the period of transition just before menopause? Describe this period of transition.

A

Climacteric period
You go from having normal regular cycles and then it becomes a little irregular (oligomenorrhoea) and then it progresses to amenorrhoea.

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3
Q

State some symptoms of menopause.

A
  1. Hot flushes
  2. Urogenital Atrophy (leads to dyspareunia – difficult or painful sexual intercourse)
  3. Sleep disturbance

Decreased libido
Depression
Joint pain

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4
Q

What do the ovaries produce that feeds back on the HPG axis?

A

Oestradiol and Inhibin B

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5
Q

How does this feedback change in menopause?

A

There is a loss of ovarian follicular activity so you get a decreased production of oestradiol and inhibin

This means that there is less negative feedback on the HPG axis

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6
Q

What would you expect the LH and FSH levels of a menopausal woman to be?

A

High – because of the loss of oestrogen and inhibin production

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7
Q

What are the main complications of menopause?

A
  1. Osteoporosis
    - Oestrogen deficiency
    - Loss of bone matrix
    - 10-fold increased risk of fracture
  2. Cardiovascular disease
    - protected against CVD before the menopause
    - have the same risk as men by the age of 70
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8
Q

What are the risks of giving oestrogen as part of HRT?

A

Endometrial hyperplasia, which increases the risk of endometrial carcinoma

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9
Q

How is this effect of oestrogen prevented?

A

You give progesterone as well as oestrogen
The progesterone blocks this effect of oestrogen on the endometrium and, hence, prevents endometrial hyperplasia -reduces risk of cancer

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10
Q

In which subset of patients would you give oestrogen only HRT?

A

Patients who have had a hysterectomy

There is no uterus so there is no endometrium to stimulate with oestrogen

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11
Q

Describe the 2 different formulations of HRT.

A
  1. Cyclical – take oestradiol every day and then for the last 12-14 days you take progesterone
  2. Combined continuous – take a little oestrogen and progesterone every day
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12
Q

State 4 different types of oestrogen preparations.

A
  1. Oral oestradiol (1 mg)
  2. Oral conjugated equine oestradiol (0.625 mg)
  3. Transdermal oestradiol (50 mcg/day)
  4. Intravaginal
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13
Q

Describe the absorption and metabolism of oestradiol.

A

Oestradiol is absorbed well but it is heavily metabolised in the liver (first pass) so the bioavailability is very low.

This means that in oral preparations, you must give a high dose of oestradiol.

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14
Q

Name a semi-synthetic oestrogen that’s used in oral contraceptives.

A

Ethinyl oestradiol

The ethinyl group protects the drug from hepatic first pass metabolism.

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15
Q

What is the difference between the types and dose of oestrogen given in HRT compared to the oral contraceptive?

A

In HRT you are just giving a little bit of oestrogen to prevent the symptoms of menopause.
In contraception, you are trying to suppress the HPG axis so you give a more potent type of oestrogen.

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16
Q

State some side-effect/risks of HRT.

A 
Breast cancer  
Venous thromboembolism (VTE)
DVT
Stroke  
Gallstones

NOTE:
The absolute risk of complications for healthy symptomatic postmenopausal women in their 50s taking HRT for five years is very low.

17
Q

How does HRT affect cardiovascular disease risk?

A

There is an increased risk of coronary heart disease

The timing of exposure is important in terms of cardiovascular disease risk – older patients who are started on HRT have an increased risk of CHD but in younger women there was no increased risk

18
Q

Name a synthetic prohormone that has oestrogenic, progestogenic and weak androgenic effects.

A

Tibolone

19
Q

What is this drug Tibolone used for and what are the risks?

A

It reduces the risk of fracture

It increases the risk of stroke

20
Q

What is raloxifene and how does it work?

A

It is a selective oestrogen receptor modulator (SERM)
In bone it has oestrogenic effects and reduces the risk of fracture
In breast and uterus it has anti-oestrogenic effects and reduces the risk of breast cancer

21
Q

What are the problems with raloxifene?

A

It is associated with an increased risk of fatal stroke and VTE

22
Q

What is tamoxifen?

A

Anti-oestrogenic on breast tissue

23
Q

What is tamoxifen used for?

A

Treatment of oestrogen-dependent breast tumours and metastatic breast cancers

24
Q

What is the term given for menopause before the age of 40?

A

Premature Ovarian Insufficiency

25
Q

What could POI be caused by?

A
  1. Autoimmune
  2. Surgery
  3. Chemotherapy
  4. Radiotherapy
26
Q

What type of oestrogen is in the combined oral contraceptive pill?

A

Ethinyl oestradiol

27
Q

What types of progestogen is used in the combined oral contraceptive pill?

A

Levonorgestral or

Norethistrone

28
Q

What other effect do progestogens have that reduces the chance of conception?

A

It thickens cervical mucus meaning that it is more difficult for sperm to penetrate it

29
Q

When would you use the progesterone only pill?

A

If oestrogen is contraindicated – this is if there is an increased risk of thrombosis (oestrogen has pro-coagulant effects)

30
Q

What is an important point to remember about when to take the progesterone only pill?

A

It must be taken at the same time every day due to

  • short half life
  • short duration of action
31
Q

What is the name given to the long-acting intra-uterine progesterone device?

A

Mirena

32
Q

What 3 things can you use for emergency (post-coital) contraception?

A
  1. Copper IUD (affects sperm viability and function and inhibits fertilisation)
  2. Levonorgestral (within 72 hours – high dose progesterone)
  3. Ulipristal (within 120 hours)
    - Anti-progestin activity
    - Delays ovulation by as much as 5 days
    - Impairs implantation
33
Q

What effects do oestrogen and progestogen have that reduces the chance of conception?

A

negative feedback actions at hypothalamus/pituitary, suppress ovulation

34
Q

How is the Combined oral contraceptive pill taken?

A

COC taken for 21 days (or 12 weeks) and is stopped for 7 days

35
Q

Describe some unwanted effects of oestrogen

A
  1. Increased weight- water retention and fat deposition
  2. CVS problems- increased risk of fatal stroke and VTE
  3. Breast - oestrogen dependant cancers
  4. Endometrium- causes proliferative effects

Endocrinology (18 decks)

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