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pre reg afsha endocrine > sex hormones - oestrogen and HRT > Flashcards

sex hormones - oestrogen and HRT Flashcards

1
Q

natural oestrogens or synthetic - which ones have a more appropriate profile for HRT

A

natural

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2
Q

natural oestrogens: (3)

A

estradiol, estrone, estriol

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3
Q

synthetic oestrogens:

A

ethinylestradiol, mestranol

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4
Q

ethinylestradiol - synthetic or natural?

A

synthetic oestrogen

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5
Q

mestranol - synthetic or natural?

A

synthetic oestrogen

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6
Q

estradiol, estrone, estriol - synthetic or natural?

A

natural oestrogens

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7
Q

if long term oestrogen therapy is required in women with a uterus, also add the following to reduce risk of cystic hyperplasia of endometrium (or of endometirotic foci in women who have had hysterectomy) and possible transformation to cancer

A

add progestogen

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8
Q

are oestrogens used to suppress lactation and why?

A

no longer used to suppress lactation because of their association with thromboembolism

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9
Q

treatment for menopausal women with vaginal atrophy or vasomotor instability

A

HRT with small doses of an oestrogen (together with a progestogen in women with a uterus) is appropriate for alleviating menopausal symptoms such as vaginal atrophy or vasomotor instability

vasomotor instability = edema, abnormal skin color, and temperature differences, and it can contribute to sweating abnormalities

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10
Q

what effect does oestrogen given systemically in the perimenopausal and postmenopausal period or tibolone given in the postmenopausal period have on postmenopausal osteoporosis

A

they diminish postmenopausal osteoporosis, but other drugs are preferred

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11
Q

treatment of menopausal atrophic vaginitis

A

may respond to short course of topical vaginal oestrogen preparation used for a few weeks and repeated if necessary

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12
Q

systemic therapy with an oestrogen or drugs with oestrogen properties alleviates which symptoms?

A

alleviates symptoms of oestrogen deficiency such as vasomotor symptoms

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13
Q

what are the characteristics of tibolone and how is tibolone given i.e. what cycle and what progestogen

A
  • it combines both oestrogen and progestognenic activity with weak androgenic activity
  • given continuously without cyclical progestogen
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14
Q

can HRT be given to women with early natural or surgical menopause (before 45 years) and why?

A

yes since they are at high risk of osteoporosis

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15
Q

for early menopause, HRT can be given until the approx age of …

A

natural menopause (i.e. until age 50 years)

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16
Q

if osteoporosis is the main concern, should you give HRT

A

no consider alternatives

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17
Q

When can clonidine be used and what are the drawbacks

A
  • can be used to reduce vasomotor symptoms in women who cannot take an oestrogen
  • but it can cause unacceptable SE
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18
Q

HRT increases the risk of the following….

A
  • VTE
  • stroke
  • endometrial cancer (reduced by progestogen)
  • breast cancer
  • ovarian cancer
  • CHD in women who started combined HRT >10y after menopause
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19
Q

for women who started combined HRT >10 years after menopause, there is an increased risk of

A

CHD

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20
Q

which cancers does HRT increase the risk of (3)

A

endometrial, breast and ovarian

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21
Q

the risk of this cancer with HRT can be reduced by a progestogen

A

endometrial

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22
Q

what types of HRT increase the risk of breast cancer after 1 year of use

A

ALL types - systemic (oral or transdermal)

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23
Q

increased risk of breast cancer is higher for which types of HRT?

A

combines oestrogen-progestogen HRT (esp continuous HRT preps where both O and P are taken throughout each month)

risk increases with longer duration of HRT

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24
Q

What further increases the risk of breast cancer - longer duration of HRT use or age at which HRT is started?

A

longer duration of HRT use

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25
Q

Although the risk of breast cancer is lower after stopping HRT than it is during current use, the excess risk persists for…

A

more than 10 years after stopping compared with women who have never used HRT.

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26
Q

do vaginal preparations containing low doses of oestrogen to treat local symptoms also have an effect on breast cancer risk?

A

not thought to

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27
Q

why is radiological detection of breast cancer more difficult with HRT use, esp combined O-P treatment?

A

can be made more difficult as mammographic density can increase with HRT use especially oestrogen-progestogen combined treatment, but this is not thought to be the case with tibolone.

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28
Q

tibolone risk of breast cancer

A

associated with an increased risk of breast cancer during treatment, although the extent of risk and its persistence after stopping is currently inconclusive.

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29
Q

HRT - risk of endometrial cancer depends on…

A

dose and duration of oestrogen-only HRT

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30
Q

in women with a uterus, addition of a progestogen cyclically (for at least 10 days per 28 day cycle) reduces the risk of….

A

endometrial cancer.

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31
Q

if a progestogen is given continuously, this eliminates the risk of endometrial cancer but this must be weighed against..

A

the increased risk of breast cancer

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32
Q

the risk of endometrial cancer in women who HAVE NOT used HRT increases with….

A

BMI

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33
Q

the increased risk of endometrial cancer in users of oestrogen-only HRT or tibolone is more apparent in women who are… (to do with weight)

A

not overweight

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34
Q

is there an increased risk of endometrial cancer with tibolone

A

yes

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35
Q

risk of ovarian cancer with HRT and does this persist

A
  • long term use of combined HRT or oestrogen-only HRT is associated with a small increased risk of ovarian cancer
  • this increased risk disappears within a few years of stopping
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36
Q

risk of VTE

A
  • increased risk of DVT and PE in pt using combined or oestrogen-only HRT, especially in the first year of use
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37
Q

when are HRT users most at risk of VTE

A

first year of use

38
Q

in women who have predisposing factors of VTE, what should you do

A

it is prudent to review the need for HRT, as in some cases the risks of HRT may exceed the benefits

39
Q

what further increase the risk of DVT

A

travel involving prolonged immobility

40
Q

is the risk of VTE lower for transdermal route?

A

Although the level of risk of thromboembolism associated with non-oral routes of administration of HRT has not been established, it may be lower for the transdermal route compared to the oral route

41
Q

risk of stroke - who is most likely

A

Risk of stroke increases with age, therefore older women have a greater absolute risk of stroke

42
Q

HRT and stroke risk

A

Combined HRT or oestrogen-only HRT slightly increases the risk of stroke.
But risk of stroke increases with age regardless so older women have greater absolute risk of stroke

43
Q

Tibolone and risk of stroke

A

increases the risk of stroke about 2.2 times from the first year of treatment; risk of stroke is age-dependent and therefore the absolute risk of stroke with tibolone increases with age.

44
Q

which drug is associated with a 2.2x increased risk of stroke from the first year of treatment?

A

tibolone

45
Q

does HRT prevent CHD

A

no so do not prescribe for this purpose

46
Q

which population is at increased risk of CHD?

A

women who start combined HRT more than 10 years after menopause

47
Q

choice of HRT for a women with a uterus

A
  • normally requires O with cyclical P for the last 12-14 days of the cycle
  • or a prep which involves continuous administration of both O + P
  • or a prep which provides both O and P activity in a single prep
48
Q

which preparations are NOT suitable for use in perimenopause or within 12 months of the last menstrual period and why?

A

continuous combined preparations or tibolone
women who use this may bleed irregularly in early stages of treatment
if bleeding continues endometrial abnormality should be ruled out and consideration given to changing to cyclical HRT

49
Q

what HRT is suitable for continuous use in women without a uterus

A

oestrogen alone

50
Q

when should progestogen also be considered in addition to oestrogen for women without a uterus

A

in endometriosis, endometrial foci may remain despite hysterectomy and the addition of a progestogen should be considered in these circumstances.

51
Q

use of oestrogens in elderly pt is potentially inappropriate (STOPP) is prescribed in pt with…

A

history of breast cancer or venous thromboembolism (increased risk of recurrence)

52
Q

in the elderly, oral oestrogens may be inappropriate if…

A

prescribed without concurrent progestogen in those with an intact uterus (risk of endometrial cancer).

53
Q

when to stop HRT before major surgery under GA, including orthopaedic and vascular leg surgery, and why ? and when to restart HRT?

A

predisposing factor for venous thromboembolism and it may be prudent to stop HRT 4–6 weeks before surgery
should be restarted only after full mobilisation

54
Q

what to do if HRT is continued or if discontinuation is not possible (e.g. in non-elective surgery) in surgery

A

prophylaxis with unfractionated or low molecular weight heparin and graduated compression hosiery is advised.

55
Q

Stop HRT (pending investigation and treatment) if any of the following occur

A
  • sudden severe chest pain (even if not radiating)
  • sudden breathlessness (or cough with blood stained sputum)
  • unexplained swelling or severe pain in calf of one leg
  • severe stomach pain
  • serious neurological effects
  • hepatitis, jaundice, liver enlargement
  • BP >160 systolic or >95 diastolic
  • prolonged immobility after surgery or leg injury
  • detection of RF which contraindicates treatment
56
Q

if a pt on HRT gets any of the following serious neurological effects they must stop HRT

A
  • unusual severe prolonged headache esp if first time or progressively worse
  • sudden partial or complete loss of vision
  • sudden disturbance of hearing or other perceptual disorder
  • dysphasia (impaired speech)
  • bad fainting attack
  • collapse
  • first unexplained epileptic seizure
  • weakness, monitor disturbances
  • very marked numbness suddenly affecting once side or one part of body
57
Q

if a patient has the following BP readings they must stop HRT

A

systolic about 160
diastolic above 95

58
Q

what is ethinylestradiol licensed for

A

short-term treatment of symptoms of oestrogen deficiency, for osteoporosis prophylaxis if other drugs cannot be used and for the treatment of female hypogonadism and menstrual disorders.
licensed for palliative treatment of prostate cancer

59
Q

what is raloxifene licensed for

A

treatment and prevention of postmenopausal osteoporosis

60
Q

does raloxifene reduce menopausal vasomotor symptoms

A

no

61
Q

what are the two main groups of progestogen

A

progestogen and its analogues
testosterone analogues

62
Q

name the 2 progesterone and its analogues

A

dydrogesterone and medroxyprogesterone acetate

63
Q

name the two testosterone analogues

A

norethisterone and norgestrel

64
Q

the newer progestogens desogestrel, norgestimate and gestodene are all derivatives of…

A

norgesterol which is a testosterone analogue

65
Q

levonorgestrel is the active isomer of ….. and has …. its potency

A

norgestrel
twice

66
Q

progesterone and its analogues are less ….. than the testosterone derivatives

A

androgenic

67
Q

what is virilisation

A

female develops characteristics associated with male hormones (androgens), or when a newborn has characteristics of male hormone exposure at birth

68
Q

do progesterone or dydrogesterone virilisation

A

no

69
Q

where endometriosis requires drug treatment, it may respond to ……..

A

a progestogen, e.g. norethisterone, administered on a continuous basis

70
Q

although oral progestogens have been used widely for menorrhagia, they are relatively ineffective compared with

A

tranexamic acid, or particularly where dysmenorrhoea is also a factor, mefenamic acid

71
Q

Why does a progestogen need to be added to long term oestrogen therapy for HRT in women with a uterus, and on what basis is it administered?

A

to prevent cystic hyperplasia of the endometrium and possible transformation to cancer; it can be added on a cyclical or a continuous basis.

72
Q

this EHC can be used to treat moderate to severe symptoms of uterine fibroids in premenopausal women where surgery and uterine artery embolisation are unsuitable, or have failed

A

intermittent ulipristal acetate

73
Q

side effect (bleeding) on cyclical HRT where a P is taken for 12-14 days of each 28 day O treatment cycle

A

usually results in regular withdrawal bleeding towards the end of the progestogen.

74
Q

side effect (bleeding) of continuous combined HRT

A

commonly produces irregular breakthrough bleeding in the first 4–6 months of treatment. Bleeding beyond 6 months or after a spell of amenorrhoea requires further investigation to exclude serious gynaecological pathology.

75
Q

A woman who is under 50 years and free of all risk factors for venous and arterial disease can use the following to provide both relief of menopausal symptoms and contraception

A

low-oestrogen combined oral contraceptive pill

recommended that the oral contraceptive be stopped at 50 years of age since there are more suitable alternatives

76
Q

does HRT provide protection and how long is a woman considered potentially fertile for

A

HRT does not provide contraception and a woman is considered potentially fertile for 2 years after her last menstrual period if she is under 50 years, and for 1 year if she is over 50 years

77
Q

where on the body should HRT patches be applied

A

clean, dry, unbroken areas of skin on trunk below waist line e.g. thigh, buttock
do not apply on or near breasts
do not apply under elasticated or tight areas of clothing or folds in skin or on skin directly exposed to sunlight

Generally, HRT patches should be applied below the waistline, ideally on the lower abdomen, hips, or buttocks, because these areas provide optimal absorption and minimize the risk of irritation and unwanted side effects. Applying patches above the waistline, particularly near the chest, shoulders, or arms, is not recommended, especially because applying them on or near the breasts may increase the risk of localized side effects.

78
Q

lenzetto how to use

A

Apply to dry, healthy skin of the inner forearm or alternatively the inner thigh and allow to dry for 2 minutes before covering with clothing
Avoid skin contact with another person (particularly children) or pets and avoid washing the area for at least 1 hour after application.
If a sunscreen is needed, apply at least 1 hour before Lenzetto®.

79
Q

a patient is going on holiday and also uses Lenzetto transdermal spray. she asks you if she can apply suncream at the same time as her sprays

A

If a sunscreen is needed, apply at least 1 hour before Lenzetto®.

80
Q

how to use oestrogel

A

Apply gel to clean, dry, intact skin such as arms, shoulders or inner thighs and allow to dry for 5 minutes before covering with clothing.
Not to be applied on or near breasts or on vulval region
Avoid skin contact with another person (particularly male) and avoid other skin products or washing the area for at least 1 hour after application.

81
Q

how to use sandrena

A

Apply gel to intact areas of skin such as lower trunk or thighs, using right and left sides on alternate days
Wash hands after application
Not to be applied on the breasts or face and avoid contact with eyes
Allow area of application to dry for 5 minutes and do not wash area for at least 1 hour.

82
Q

unlicensed vaginal use of estradiol pessaries or tablets and estring

A

used for the prophylaxis of recurrent urinary-tract infection in postmenopausal women, but are not licensed for this indication.

83
Q

contraindications of HRT

A

FHx breast cancer
Hx VTE
oestrogen dependent cancer
recent arterial thromboembolic disease e.g. angina, MI
thrombophilic disorder
undiagnosed vaginal bleeding
untreated endometrial hyperplasia
active arterial thromboembolic disease e.g. angina or MI

84
Q

name an anti-oestrogen

A

clomifene

85
Q

MOA clomifene

A

anti oestrogen that induces gonadotrophin release by occupying oestrogen receptors in the hypothalamus, thereby interfering with feedback mechanisms

86
Q

what is clomifene indicated for

A

female infertility due to ovulatory dysfunction

87
Q

why should clomifene not normally be used for longer than 6 cycles

A

possible increased risk of ovarian cancer

88
Q

incidence of multiple birth is increased with this drug

A

clomifene which is used for female infertility due to ovulatory dysfunction

89
Q

what is tibolone indicated for - 2

A

short term treatment of symptoms of oestrogen deficiency (including women being treated with gonadotropin releasing hormone analogues)

osteoporosis prophylaxis in women at high risk of fractures where other prophylaxis is CI or not tolerated

90
Q

what is raloxifene indicated for - 2

A

treatment and prevention of postmenopausal osteoporosis
breast cancer (chemoprevention in postmenopausal women at moderate to high risk, specialist supervision !!) - not licensed for this in UK

pre reg afsha endocrine (29 decks)

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