Oral contraceptives, menstruation and HRT

Question 1

What is the menopause?

Which phase of the ovarian cycle is lost

Answer 1

Permanent cessation of menstruation
-climacteric: period of transition
Loss of ovarian follicular activity

Question 2

What is the average age of the menopause?

Answer 2

51 (45-55)

Question 3

How does menopause normally develop?

Answer 3

You have normal regular cycles every month and then they get longer (oligomenorrhoea) and then this progresses to amenorrhoea

Question 4

What are the symptoms of the menopause?

Answer 4

Hot flushes
Urogenital atrophy and dyspareunia
Sleep disturbance
Depression
Decreased libido
Joint pain
Symptoms usually diminish/disappear with time

Question 5

What is dyspareunia?

Answer 5

It is painful to have sex

Question 6

What hormonal changes occur during the menopause?

Answer 6

There is follicular atresia which leads to low levels of oestradiol and inhibin B, this means that there is less negative feedback so gonadotrophin levels go up

Question 7

What is the major complication of the menopause?

Answer 7

Osteoporosis

Question 8

Why does osteoporosis occur in the menopause?

Loss of what

Answer 8

It is caused by oestrogen deficiency- An anabolic hormone so reduced oestrogen will result in osteoporosis

Loss of bone matrix resulting in an increased risk of fracture

Question 9

What happens to cardiovascular risk due to the menopause?

How do you contorl vasomotor symptoms - hot flushes

Answer 9

Before the menopause it is lower than men but afterwards it’s the same by the age of 70

HRT

Question 10

What do you give in HRT normally and why?

Answer 10

Oestrogen and progesterone
Oestrogen- endometrial proliferation
There is a risk of endometrial carcinoma so you give progesterone to prevent endometrial hyperplasia.
You don’t have to give progestrogen if they had a hysterectomy

Question 11

What are the normal ways that HRT is given?

Answer 11

Cyclical- take estradiol every day and for the last 12-14 days take progesterone
or
Everyday take oestrogen and progesterone in small amounts

Question 12

Why does oestrogen have a low bioavailability?

Answer 12

Extensive first pass metabolism when given orally so high doses needed

Question 13

How is the problem of the high first pass metabolism dealt with in oral contraceptives?

Answer 13

Oestrogen is given as ethinyl estradiol which is semi-synthetic and the ethinyl group protects the oestrogen

OR 
Estrone sulphate (conjugated oestrogen)

Question 14

What is another common way of administering most oestrogens?

Another practical way

Answer 14

Transdermal skin patches

intravaginally

Question 15

What are side effects of oestrogen?

Answer 15

Breast cancer
Coronary heart disease
Deep Vein thrombosis
Stroke
Gallstones

Question 16

What is tibolone?

Answer 16

Synthetic pro hormone that has oestrogenic, progestogenic and weak androgenic effects

Question 17

What does tibolone reduce the risk of?

Answer 17

Fracture

Question 18

What does tibolone increase the risk of?

Answer 18

Stroke and breast cancer

Question 19

What is raloxifene?

Answer 19

Selective oestrogen receptor modulator (SERM)

Question 20

How does raloxifene work?

Answer 20

It is tissue selective
In bone- it has oestrogenic effects- reduces the risk of fracture
In breast and uterus- it has anti-oestrogenic effects- reduces risk of breast cancer

Question 21

What is raloxifine associated with increased risk of? What does it not deal with

Answer 21

Fatal stoke and VTE

Vasomotor symptoms

Question 22

What does tamoxifen do?

Answer 22

It is anti-oestrogenic on breast and is used to treat oestrogen dependent breast tumours and metastatic breast cancers

Question 23

What is premature ovarian insufficiency?

Answer 23

Menopause occurring before the age of 40

Question 24

What can cause premature ovarian insufficiency?

Answer 24

Autoimmune
Surgery
Chemotherapy
Radiation

Question 25

What forms of oestrogen and progesterone are used in oral contraceptive?

Answer 25

Oestrogen- ethinyl oestradiol

Progesterone- Levonorgestrel or norethisterone

Question 26

How does oral contraceptive work?

Answer 26

Suppress ovulation
-Suppression of negative feedback at hypothalamus and pituitary (both e and p do this)
-Progesterone also thickens the cervical mucus which makes it harder for sperm to get through
You take it for 21 days and stop for 7

Question 27

When is progesterone only contraceptive used?

How is it taken

Answer 27

When use of oestrogen is contraindicated- e.g. if there is a risk of thrombosis because oestrogen is a procoagulant

Must be taken at the same time each day

• Short half-life
• Short duration of action

Long acting preparations may be given via an intra-uterine system

Question 28

What is MIRENA?

Answer 28

Intra-uterine progesterone device

Question 29

What are the three types of emergency (post coital) contraception?

Answer 29

Copper IUD
Levonorgestrel
Ulipristal

Question 30

How does a copper IUD work?

Within time frame

Answer 30

Affects sperms viability and function and inhibits fertilisation

5 up to 7 days after unprotected

Question 31

What is levonorgestrel?

Answer 31

High dose of progesterone

within 72 hours

Question 32

How does ulipristal work?

Answer 32

Anti-prostegin activity
Delays ovulation by 5 days
Impairs implantation
up to 120 hours after intercourse