T2 L7 Menopause and HRT Flashcards
What is menopause?
Permanent cessation of menses (no periods) following loss of ovarian activity
What proportion of the average female lifespan is spent in menopause?
About 1/3 - 1/2
What is happening to the gap between the age of menopause and the average life expectancy?
The gap is getting wider
More women are living for many years post-menopause
What is perimenopuase?
Transition from reproductive cycles to post menopause
Few ova remain – less responsive to hormones
At what age does perimenopuase usually start?
45-50 years
What is the mean duration of perimenopause?
3.8 years
Which symptoms occur during perimenopause?
Irregular menstrual cycles
Occasional heavy bleeding
Hot flushes
Nervousness, irritability
List the primary symptoms of menopause
Menstrual cycle changes
-oligomenorrhea, amenorrhea
Vasomotor symptoms (this may be burdensome to most women) -hot flushes, night sweats
Vaginal dryness
List the secondary symptoms of menopause
- Urinary stress/urge incontinence
- Cystitis-like symptoms
- Depression/irritability changes
- Musculoskeletal pains (joint aches & osteoporosis- this can be an issue in women who have menopause early)
- Dry skin, hair thinning, nail changes
- Decreased concentration
- Decreased libido
How many women were included in the British Prospective Cohort study?
695 women followed up from birth (1946)
Name the 4 menopausal symptoms groups identified in the British Prospective Cohort study?
Psychological (severe in 10% of women)
Somatic
Vasomotor
Sexual discomfort
What % of women in the British Prospective Cohort study had “early severe” vasomotor symptoms?
14%
What % of women in the British Prospective Cohort study had “late severe” vasomotor symptoms?
11%
Which subgroup of women had less severe vasomotor symptoms in the British Prospective Cohort study?
Women of higher social class and better educational qualifications
Name the two hormones involved in Hormone Replacement Therapy (HRT). What are they required for?
Oestrogen required for symptoms
Progestogens required to prevent endometrial cancer
COMPLETE THE SENTENCE
Women that have undergone a _____________ do not need progestagens
HYSTERECTOMY
What are the alternative drugs (to HRT) that can be used to treat osteoporosis?
Biphosphonates
Alendronate
Risedronate
What are the alternative drugs (to HRT) that can be used to reduce vasomotor symptoms?
Progesterone
SERMs (Selective estrogen receptor modulators) – Raloxifene
Beta-blocker
Clonidine
List the other forms of alternative treatement/drugs (to HRT) used to treat menopausal symptoms
-Phyto-oestrogens (soya bean)
-Herbalism Black Cohost St John’s Wort Gingseng Oil of Evening Primrose
- Progesterone Cream
- Homeopathy
- Acupunture
- Reflexology
What choices do patients have regarding their HRT?
Choice of route
Choice of dose and type of drug
Choice of regimen
What are the different routes used to administer HRT drugs?
- Oral
- Patches
- Implants
- Vaginal rings
- Transdermal gel
- Nasal
How is HRT given?
1) Continous oestrogen - there is no tablet break and no bleeding due to lack of uterus
2) Continuous sequential HRT - oestrogen is given continuously but progestogen is given at day 14. There is regular bleeding at the end of the cycle
3) Continuous combined HRT - combined therapy without a tablet break. There is no bleeding at the end of the cycle
Why is Continuous Combined HRT (CC HRT) preferred for older women?
Older women have an increased risk of endometrial neoplasia
REMEMBER: Progestogens prevent endometrial cancers
What does of oestradiol is given in Continuous oestrogen (HRT)?
1 mg
Taken continuously as symptoms would return if not taking the oestrogen
Is the dose of oestradiol given in Continuous oestrogen enough to act as a contraception?
NO
Name the absolute contraindications to HRT
- Pregnancy
- Active venous thromboembolism
- Severe active liver disease
- Endometrial carcinoma with recurrence
- Breast carcinoma with recurrence
BONUS: Why is a breast cancer with recurrence a contraindication to HRT?
About 70% of breast cancers are oestrogen-receptor positive
Giving oestrogen “stimulates” this cancer type, causing it to grow
Name the relative contraindications to HRT
- Abnormal bleeding
- Breast lump (prior to investigation)
- Previous endometrial cancer
- Previous breast cancer
- Strong family history breast cancer
- Family history of thromboembolism
List the side effects of HRT
- Tender or painful breasts
- Fluid retention causing bloating and weight gain
- Nausea
- Headaches
- Leg cramps
- Mood swings/Low mood
- Acne
- Backache
- Lower abdominal ache
- Bleeding
- Stomach upset (indigestion)
What are the short term benefits of HRT?
Reduces vasomotor symptoms (eg hot flushes)
Improves psychological symptoms (eg mood swings)
What are the long term benefits of HRT?
- Maintains bone mass and reduces the risk of fracture
- Reduces urogenital problems (eg dry vagina)
- Improves skin (cosmetic)
- Reduces the risk of bowel cancer
- May improve balance and reduce falls – less fractures
- May reduce tooth loss
- May protect against arthritis
What are the risks associated with HRT?
Endometrial Cancer (if unopposed oestrogen used)
Breast Cancer
Cardiovascular disease (stroke and MI)
Venous thrombo-embolic disease (VTE)
Under which age is endometrial cancer rare?
45 years
What is the most common presentation of endometrial cancers?
Post menopausal bleeding
Which investigation is used to determined endometrial cancer?
Trans vaginal USS
Measure the endometrial thickness (>5mm)
What procedure is used to diagnose endometrial cancer?
Endometrial sample/biopsy
What is the treatment for endometrial cancer?
Hysterectomy and oophorectomy
Possible radiotherapy
What are the risk factors for endometrial cancer?
- Obesity (endogenous oestrogens)
- Unopposed HRT (oestrogens without progestagens)
- Nulliparity
- Late menopause
- Diabetes
- Family history of breast, colon and ovary Ca (genetic)
- Tamoxifen
What are the characteristics of COCP?
- Ethinyl oestradiol (not natural)
- Massive first pass metabolism by the liver
- Increased clotting factors
- High dose oestrogen suppressing GnRH/ FSH/LH
- Stops ovulation
- Progestagen given to prevent hyperplasia of endometrium not really to add to contraception
What are the characteristics of HRT?
- Oestradiol (natural)
- Lower dose to the body
- Some increased clotting factors
- Doesn’t suppress the FSH and LH to the same degree as the COCP
- Doesn’t stop ovulation
- Progestagen given to prevent hyperplasia of endometrium
What was the overall aim of the Women Health Initiative (WHI) study?
Assess the overall balance of HRT risk and benefits
via a mix of population studies and RCT (randomised controlled trial)
Who funded the WHI study?
Funded by the US government (with Pharma support) to resolve the HRT risk/benefit issue
$800 million budget
When was the WHI study launched? How long did it last?
Launched in 1991
Lasted 15 years
What was the population sample for the WHI study?
161,808 generally healthy postmenopausal women
What other factors did the WHI study examine?
Studied effects of dietary fat, vit D, calcium
What were the main outcome measures of the WHI study?
Coronary heart disease (CHD)
Invasive breast cancer
