Sex Hormone Responsive Conditions

Question 1

What is oestrogens and HRT

Answer 1

Oestrogens
-natural oestrogens (estradiol, estrone and estriol)
Synthetic oestrogens (ethinylestradiol and mestranol)

Progesterone (norethisterone, levonorgestrel, desogestrel)

Tibolone: oestrogenic, progestogenic and weakly androgenic

Question 2

What is meant by hormone replacement therapy

Answer 2

Oestrogens (combined with progesterone if patient has uterus) alleviates menopausal symptoms such as:
Vaginal atrophy (topical )
Vasomotor instability (systemic)
Can also reduce post menopausal osteoporosis

Clonidine can also be used for vasomotor symptoms but has a large side effect profile

Question 3

What are the risk of HRT

Answer 3

The benefits should always outweigh the risks, especially if patients aged under 60

Breast cancer
- increased risk after 1 year-longer use= higher risk
-risk higher in combined HRT over oestrogen only
Excess risk persists for more than 10 years

Endometrial cancer
Women with uterus- risk is lower with combined than using oestrogen only
Tibolone also increases risk

Ovarian cancer
Small increase which disappears a few years after stopping

Venous thromboembolism
- increased risk of DVT with both oestrogen only and combined HRT
-increase risk with prolonged bed rest, obesity, trauma, family history

Stroke
-slight increase with both oestrogen only and combined HRT
Tibolone increases the risk by 2.2 times in first year of treatment

Coronary heart disease
Increased risk in combined HRT when started more than 10 years after menopause

Question 4

How do you choose the correct HRT?

Answer 4

Women with a uterus:
- oestrogen with cyclical progesterone for the last 12-14 days of the cycle
-continuous administration of an oestrogen and progesterone
— continuous combine and Tibolone avoided in perimenopausal phase or if within 12 months of last menstrual cycle

Women without a uterus:
Continuous oestrogen ONLY
- if endometriosis occurs- consider an addition of progesterone

Question 5

What do you do if you are on HRT and having surgery

Answer 5

Elective surgery
- stop HRT 4-6 weeks before surgery
-reinitiate after fully mobile

Non-elective surgery
-prophylactic heparin
-graduated compression stockings

Question 6

What are the reasons to stop HRT

Answer 6

Stopped pending investigation and treatment

-Sudden severe chest pain/ breathlessness (pulmonary embolism)
-Unexplained swelling or severe pain in the calf of one leg (DVT)
-Severe stomach pain (hepatotoxicity)
-Serious neurological effects: unusual severe, prolonged headaches, fainting, first unexplained epileptic seizure, motor disturbances, numbness
- hepatitis/ jaundice
-BP >160mmHg systolic or 95 mmHg diastolic
-prolonged immobility - DVT