SEX HORMONE RESPONSIVE CONDITIONS: HRT Flashcards
Perimenopause
- Periods still present in some sort of pattern
- Age 45
Post menopause
- 1 year after last period
Health risks associated with menopause
- Osteoporosis
- CVD
- TIIDM
- Depression
- Cognitive decline, early dementia
- Other: dry hair and skin, headaches
Onset of symptoms
- Female oestrogen levels decline and menstruation ceases
- Symptoms can start several years before final menstrual period and continue for up to 12 yrs
Symptoms
Vasomotor symptoms - hot flushes and sweats
Musculoskeletal symptoms - joint and muscle pain
Effect on mood - low mood, anxiety
Urogenital symptoms - vaginal dryness
Sexual difficulties - low sexual desire
Oestrogens
- Natural Ostrogens (estradiol, estrone and estriol)
- Synthetic Ostrogens (ethinylestradiol and mestranol)
Progestogens
norethisterone
levonorgestrel
desogestrel
Tibolone
ostrogenic, progestogenic and weakly androgenic
HRT risks (cancer)
Breast cancer
Endometrial cancer
Ovarian cancer
Breast Cancer
- Increased risk after 1 year - longer use = higher risk
→ Risk higher in combined HRT over ostrogen only - Excess risk persists for more than 10 years
Endometrial Cancer
Increased risk in oestrogen only
Increased risk in tibolone
Ovarian Cancer
Small increase which disappears a few years after stopping
HRT risks (CVD)
Venous Thromboembolism
Stroke
Coronary Heart Disease
Venous Thromboembolism
Increase risk of DVT with both ostrogen-only and combined HRT
Increase risk with prolonged bed rest, obesity, trauma, family history
Coronary Heart Disease
Increased risk in combined HRT when started more than 10 years after menopause
Stroke
- Slight increase with both ostrogen-only and combined HRT
- Tibolone increases risk by 2.2 times in first year of treatment
HRT (with uterus)
Combined - oestrogen + progestogen
- cyclical (sequential)
- continuous
Tibolone avoided in perimenopausal phase or if within 12 months of last menstrual period
Cyclical (sequential)
for women who are still having monthly bleed, or last period was less than a year ago = require progesterone
* Oestrogen continuously and cyclical progesterone (last 12-14 days of cycle)
- progestogen added to trigger a bleed
Continuous
for women whos last menstrual period was more than 12 months ago
* Same amount of oestrogen and progestogen everyday
HRT (without uterus)
e.g. hysterectomy
oestrogen only
If endometriosis occurs - consider an addition of progesterone
Gols standard HRT
- Body identical or regulated bio-identical hormones
- Oestrogen through skin
o Patch, gel, spray - +/- micronized progesterone
- +/- testosterone – can help to improve mood, energy, stamina
- Combo of all 3 is not something seen in GP, would be specialist care
Woman with uterus - cyclical (sequential) HRT (ORAL)
Elleste duet - 1mg or 2mg estradiol + 1mg norethisterone
Prempak-C 0.625mg or 1.25mg conducted oestrogen + norgestrel 150mcg
progestognenic side effects offer:
Femoston 1/10 or 2/10 1mg or 2mg estradiol + dyhydrogesterone 10mg
Woman with uterus - Continuous combined HRT (ORAL)
Elleste duet conti: 2mg estradiol + 1mg norethisterone
Premique: conjugated oestrogen 655mcg + medoxyprogesterone acetate 5mg
Kilofem: 2mg estradiol + 1mg norethisterone
Tibolone
Progestogenic side effects offer:
Femoston conti: 1mg estradiol + 5mg dydrogesterone
Woman with no uterus - oestrogen only (ORAL)
Elleste solo: 1mg or 2mg estradiol
Premarin: 0.624 or 1.25mg conjugated oestrogen
Woman with uterus - cyclical (sequential) combined (PATCHES)
Evorel Sequi patches: Change
TWICE per week 50mcg estradiol + 170mcg norethisterone
FemSeven Sequi patches:
Change ONCE weekly 50mcg estradiol + 10mcg levonorgestrel
Woman with continuous - combined (PATCHES)
Evorel conti patches: chance twice a week 50mcg estradiol + norethisterone
if progestognenic side effects offer:
Femseven conti patches: change once weekly 50mcg estradiol + 7mcg levonorgestrel
oestrogen only (PATCHES)
Evorel patches: change twice per week
Estradot patches - change twice per week
Oestrogen: 2 measures = standard regime
Clonidine
vasomotor symptoms
larger side effect profile
CI
History of breast cancer or other ostrogen-dependent cancers.
Active or recent arterial thromboembolic disease, e.g. angina or MI.
Current venous thromboembolism or thrombophlebitis, or history of recurrent VTE
Thrombophillic disorder.
Undiagnosed vaginal bleeding.
Untreated endometrial hyperplasia.
Liver disease (with abnormal LFTs).
Dubin-Johnson and Rotors syndromes, unless monitored closely (rare genetic disorders leading to increased bilirubin).
Lifestyle advice
Eat a healthy balanced diet
Maintain a healthy BMI
Ensure sufficient dietary calcium (700mg/day)
Undertake regular weight-bearing exercise
stopping smoking, reducing alcohol intake
Treatment optimisation of other conditions
Stopping HRT
- Unscheduled vaginal bleeding is common
- Choice of gradually or immediately stopping
Elective surgery
Stop HRT 4-6 weeks before
Reinitiate when fully mobile
Non-elective surgery
Prophylactic heparin
Graduated compression stockings
Reasons to stop HRT
Sudden severe chest pain / breathlessness
Unexplained swelling or severe pain in calf of one leg (DVT)
Severe stomach pain (hepatotoxicity)
Serious neurological effects: Unusual severe, prolonged headache, fainting, first unexplained epileptic seizure, motor disturbances, numbness
Hepatitis / jaundice
BP > 160 mmHg systolic or 95 mmHg diastolic
Prolonged immobility
Testosterone
Sexual libido in postmenopausal women
Replacement therapy in androgen deficiency
(Hypogonadism due to androgen deficiency)
Why would testosterone be used in androgen deificnecy
Hypogonadism due to androgen deficiency
testosterone side effects
Masculinisation
Virilisation in women
Acne
Anxiety
Male pattern baldness
-Sexual development in pre-pubescent males
Male sex hormone antagonism
Cyproterone
