RANZCOG q menopause Flashcards
A 60 year old post menopausal woman is referred to your clinic. She is very concerned because of a strong family history of osteoporosis. a. What risk factors for osteoporosis should you explore in her history? (4 marks)
• BMI: low BMIs are correlated with risk for osteoporosis • Caucasian ethnicity • Previous fracture • Steroid use e.g. long-term glucocorticoid use • Family history: specifically parental history of hip fracture • Current cigarette smoking • Excessive alcohol consumption • Rheumatoid arthritis • Diet • Conditions which may cause secondary osteoporosis e.g. hypogonadism premature menopause, malabsorption, chronic liver disease, inflammatory bowel disease
Your investigations diagnose osteoporosis and you recommend HRT, but she is concerned about what she has read about the side effects and would like to enquire about alternatives. b. Describe the LIFT trial and your understanding of the benefits and risks of Tibolone in this setting. (Cummings S. The Effects of Tibolone in Older Postmenopausal Women. NEJM. 2008; 359:697-709). (5 marks)
Description of the LIFT trial: Randomised double-blind placebo-controlled study of 4538 women between the ages of 60-85 years with a bone mineral density T score of -2.5 or less at the hop or spine or a T score of -2.0 or less and radiologic evidence or a vertebral fracture to receive a once-daily dose of tibolone (1.25mg) or placebo. Annual spine radiographs were used to assess for vertebral fracture. Rates of cardiovascular events and breast cancer were also recorded. All patients also received calcium and vitamin D supplements. Benefits of Tibolone: • Improvement in vasomotor symptoms • Reduction in bone loss and spinal fractures • Provides endometrial protection • Improves vulvovaginal atrophy and may improve low libido • Does not increase risk of VTE, breast cancer, endometrial cancer or cardiovascular disease Risks of Tibolone: • Side effects may include headache, acne, increased hair growth, and irregular bleeding • There may be an increased stroke risk in women over the age of 60
c. Describe the non-hormonal management options for osteoporosis that you could offer her. (6 marks)
• Dietary modification: Avoiding alcohol and caffeine, healthy diet which is rich in dietary calcium • Supplements: Vitamin D supplements if deficient, calcium supplements may increase the risk of cardiovascular disease so these should only be used if women are severely calcium deficient and at low risk of CVD • Exercise: 30 minutes of exercise 3 times a week is recommended for women with osteoporosis to reduce fractures • Smoking cessation: Smoking increases the risk of osteoporosis so cessation is recommended • Oral bisphosphonates (alendronate or risendronate) are recommended as initial therapy unless there is a contraindication e.g. oesophageal disorders, previous bariatric surgery, chronic kidney disease. If these are not tolerated, then IV zoledronic acid is recommended treatment unless there are contraindications. • Recombinant parathyroid hormone (teriparatide) can be used for severe osteoporosis but it is not first line treatment.
What are the proven clinical benefits of HRT to menopausal women? (4 marks)
• Reduced risk of osteoporosis and hip fracture • Reduced risk of colorectal cancer • Relief of vasomotor symptoms and genitourinary atrophy of menopause • Increase in quality of life • Improvement in all cause mortality
b. List three different types of HRT and explain one association with breast cancer for each different type. (3 marks)
Oestrogen-only HT No increased risk of breast cancer (in women who have never had breast cancer) Combined oestrogen-progesterone HT Increase in breast cancer 6:10,000 women, related to the progesterone component of the HT Tibolone No increased risk of breast cancer
You are seeing a 53 year old woman who presents with significant hot flushes and vaginal dryness for the last six months. She was treated for an oestrogen dependent breast cancer six years ago and is currently on no medication. Her symptoms are interfering with her quality of life and sexual functioning.
c. Four treatment options are available to improve her symptoms: complementary, conservative, non-hormonal medical and hormonal. Within each of these categories provide a specific example and state the advantage and disadvantage associated with its use. You may use a table. (8 marks)
Advantage
Disadvantage
Complementary
Acupuncture
Non hormonal
No evidence for efficacy
Conservative
Vaginal lubricants, moisturisers
Effective for localised vaginal dryness
No relief of vasomotor symptoms
Non-hormonal medical
Gabapentin
As effective as HT without the increased risk of VTE, breast cancer, stroke
Sedation
No effect on vaginal symptoms
Hormonal
Tibolone
Lower risk of breast cancer than other types of HT
Not proven to be safe in women with previous breast cancer and may decrease the efficacy of cancer drugs
Vaginal oestrogen
Minimal systemic absorption
Effective treatment of vaginal dryness
Safety uncertain in ER positive breast cancer
a. List 4 proven clinical benefits of hormone replacement therapy (HRT) to a post-menopausal woman. (4 marks)
- Reduced risk of osteoporosis and hip fracture
- Reduced risk of colorectal cancer
- Relief of vasomotor symptoms and genitourinary atrophy of menopause
- Increase in quality of life
- Improvement in all cause mortality
A 60 year old healthy post menopausal woman (BMI 27.5) has been on HRT for 8 years. b. If she is taking oral combined HRT, what are the 3 major risks associated with continued therapy? (3 marks)
*
- Breast cancer: increased risk of breast cancer 6 cases per 10,000 women
- Stroke: increased risk stroke 5 cases per 10,000 women
- Thrombosis: increased risk PE 6 cases per 10,000 women
c. If she is unable to cease therapy due to vasomotor symptoms, list 4 management options to minimize her risks but still provide effective treatment. Give a justification for each management option. (8 marks)
Change type of oestrogen
Transdermal oestrogen has lower risks of thrombosis than oral oestrogen
Change type/dose of progesterone
Lower doses of progesterone should be considered- micronised progesterone probably carries the lowest risk of breast cancer. A Mirena IUS can also provide low-dose progesterone.
Lower dose
Lowest dose to control symptoms should be used, aim to progressively lower dose and review every 6 months
Hysterectomy
If uterus removed then no need for endometrial protection and oestrogen-only HRT does not increase the risk of breast cancer, CVD, or stroke
Smoking cessation
Reduces the risk for VTE, stroke and cancer. Smoking also decreases the efficacy of HRT in preventing osteoporosis
Stop and change to alternative therapy
Gabapentin provides relief of vasomotor symptoms with equivalence efficacy to HT without risks associated with HT
Change to tibolone
Lower breast cancer risk than HT but higher stroke risk >60 years
A healthy 55 year old woman (BMI 28) with amenorrhoea for 2 years presents with hot flushes that are causing h_er sleepless nights and difficulty functioning at work_ during the day. She has not had any treatment for these symptoms to date. She has never had any previous gynaecological conditions or surgery. Her history and examination are otherwise normal.
a. Outline the principles you apply when deciding to treat and instigate an optimal oral hormone therapy (HT) treatment regime for this woman. (4 marks)
- The most effective hormone therapy for women with vasomotor symptoms is systemic oestrogen therapy and associated sleep disturbances
- As she has not had a hysterectomy, this would need to be combined with progesterone therapy for endometrial protection
- Contraindications in the history should be evaluated
- Studies have investigated the risks of combined HRT. Many of these studies were performed in older women (over the age of 60), who were not properly screening for medical problems (like hypertension and CVD) and the risks that these studies found may not be applicable to younger women. The studies found an:
- Increased risk of stroke and coronary heart disease
- Increased risk of thrombosis
- Increased risk of breast cancer
- The aim for giving HRT would be to give the lowest dose for the shortest duration possible. Re-evaluation of the risks and benefits would need to occur every 6 months
- There is evidence that suggests that the ideal combination of HRT is that of a transdermal oestrogen patch (lower risk of stroke and thrombosis than oral therapy) and oral micronised progesterone (may decrease the breast cancer risk which is attributable to the progesterone)
- Continuous combined hormonal therapy as she is 2 years post menopausal, rather than sequential
b. Outline four (4) additional proven clinical benefits of optimal HT in a woman of this age. (4 marks)
- Reduction in hip fracture and osteoporoesis
- Reduction in risk of Alzheimer’s dementia
- Reduced risk of colon cancer
- Improved quality of life
- Reduction in all-cause mortality
- Reduced genito-urinary symptoms
c. The treatment you prescribe is effective in treating her symptoms. She returns at 60 years of age after 5 years still taking the same oral hormone therapy that you originally recommended. The medication has been prescribed by her GP.
(i) Discuss the change in her risk profile for serious health complications. (3 marks)
- Risk of breast cancer increases with the use of combined HRT for longer than 5 years
- This is related to the use of progesterone and the duration of therapy
- Risk of health complications also increases in women over the age of 60 who are taking HRT, including risks of:
- Stroke (increased over the age of 60)
- Thrombosis (highest risk when first starting HT and lower with transdermal therapy)
- Cardiovascular disease
- Breast cancer
(ii) Discuss how you may minimise some or all of the above risks but still provide effective treatment if the vasomotor symptoms recur after a trial period off HT. (4 marks)
- Consider change to the mode of delivery of oestrogen to transdermal oestrogen as this decreases the risk of thrombosis
- Consider tibolone, which doesn’t have an increased VTE risk but still has a breast cancer risk
- Change the type of progesterone to micronised progesterone, which carries lower breast cancer risk
- Consider hysterectomy and oestrogen-alone HRT if she has another indication for hysterectomy
- Alternative therapies to HT can provide effective treatment without the use of HT:
- SNRIs and SSRIs are not as effective as HT but can provide good relief in vasomotor symptoms
- Gabapentin is equally effective to low dose oestrogen therapy for vasomotor symptoms, but is sedating and may conflict with other medications in older patients
- Clonidine is not as effective as HT but there is a benefit for some women
- CBT, mindfulness and relaxation therapy may improve symptoms for some women
Vaginal dryness can be treated with vaginal lubricants and moisturisers
