The menopause and HRT Flashcards
What is the menopause?
Occurs when oestrogen levels decline and menstruation ceases.
The finite number of ovarian follicles becomes depleted.
Oestrogen and progesterone levels fall and LH and FSH increase in response.
Diagnosed retrospectively in women over 45 years old who have not has a period within the last 12 months (and are not using hormonal contraception).
Also in women without a uterus who have menopausal symptoms.
What factors are associated with onset of the menopause?
Smoking and low socio-economic factors are associated with premature menopause.
Some ethnic groups experience menopause at slightly different ages.
Family history – age at which mother experienced menopause is likely to affect the age at which the menopause occurs for the patient.
What are the menopausal symptoms?
Vasomotor symptoms such as hot flushes and night sweats.
Joint and muscle pain.
Menstrual irregularity.
Urogenital symptoms (dyspareunia, vaginal dryness and discomfort, incontinence).
Sleep disturbance secondary to vasomotor symptoms or psychological.
Psychological or mood changes, cognition problems.
Osteoporosis (oestrogen is protective against bone loss).
Coronary heart disease.
Redistribution of body fat to abdomen.
What lifestyle interventions can be put into place to relieve symptoms?
Minimise caffeine and alcohol.
Maintain a healthy weight.
Avoid smoking (damages ovaries and can lead to earlier menopause).
150 minutes of moderate intensity exercise per week.
Why are non hormonal treatments sometimes chosen?
Women may have contraindications or choose not to use HRT for various reasons.
Non hormonal treatments will only treat vasomotor symptoms and are normally less effective than HRT but generally act fairly quickly.
Will not help with other symptoms of oestrogen deficiency such as vaginal dryness, libido etc.
Not recommended as first line for vasomotor symptoms by NICE.
What is clonidine?
An alpha-adrenergic agonist that works as an antihypertensive, causing peripheral vasodilation therefore helping hot flushes/night sweats.
Useful to treat vasomotor symptoms.
Some women do experience significant benefit but not commonly used due to many side effects e.g. constipation, nausea, postural hypotension and sleep disorders.
Not suitable for patients with a low baseline BP.
What are SSRIs/SNRIs?
Antidepressants that can help vasomotor symptoms.
Examples include fluoxetine (SSRI) and venlafaxine (SNRI).
No clear evidence that they will help with low mood in menopausal women who have not been diagnosed with depression.
Some can interact with tamoxifen and reduce it’s efficacy.
Can also be associated with significant side effects and withdrawal effects.
Why are pregabalin and gabapentin used for treatment?
Can help neuropathic pain, migraine and vasomotor symptoms including night sweats and hot flushes.
However, they have significant side effects including sedation.
Risk of addiction.
What are the types of HRT?
Oestrogen only:
Carries a significant risk of endometrial hyperplasia which can result in cancer, therefore only used in women without a uterus.
Combined oestrogen and progestogen:
Sequential:
For women who still have periods (i.e. perimenopausal) or are within one year of last period.
Consists of oestrogen every day and progestogen taken in luteal phase (day 15-28) which helps to regulate bleeding.
Continuous:
Daily oestrogen and progestogen.
For women without periods i.e. more than 12 months after last period.
What are the side effects of HRT?
Unscheduled vaginal bleeding especially early in treatment.
Oestrogen related – bloating, breast tenderness, nausea, leg cramps, swelling and headaches.
Progestogen related – caused by activation of aldosterone and androgen receptors e.g. bloating, weight gain, mood disturbance and acne.
Side effects are common in first few weeks and should resolve within six to eight weeks.
If they do not, a change in type, dose or route of HRT can be necessary.
When should HRT be stopped?
Sudden severe chest pain.
Sudden breathlessness.
Cough with blood stained sputum.
Unexplained swelling or severe pain in calf of one leg.
Severe stomach pain.
Serious neurological effects e.g. unusual severe headache, vision or hearing problems, unexplained seizure, motor disturbance, numbness of one side.
Hepatitis, jaundice, liver enlargement.
Blood pressure >160/95.
What are the risks and benefits of HRT?
Benefits:
Symptom relief.
Improvements in bone strength/prevention of further bone loss.
Enhanced self esteem and quality of life.
Risks
Increased risk of some cancers, venous thromboembolism and cardiovascular disease but very much linked to individual patient history and concomitant risk factors.
Recommended to be used for max 5 years due to risks and the minimum effective dose for the shortest possible time.
How can HRT lead to breast cancer?
All types of HRT increase the risk of breast cancer but especially oestrogen plus progestogen.
Baseline risk of breast cancer depends on other risk factors that carry a greater risk than HRT e.g. genetics, obesity, alcohol and late menopause.
Increased risk from HRT is related to duration of use.
Oestrogen leads to development and growth of breast tissue - it stimulates growth and inhibits apoptosis of cells.
However, in cells that have been deprived of oestrogen (e.g. in the menopause when oestrogen levels fall), oestrogen may induce apoptosis of breast cancer cells.
Progestogens can inhibit this oestrogen induced apoptosis of breast cancer cells. They can also have oestrogenic properties which can stimulate breast cancer cell growth.
How can HRT lead to endometrial cancer?
Increased risk when using oestrogen only HRT.
Prescribing oestrogen only HRT to a woman with a uterus is a GP ‘never event’.
However, risk of endometrial cancer is reduced by the addition of progestogen in combined preparations.
Risk is reduced by cyclical (sequential) use and excess risk eliminated when progestogens are used continuously in combined preparations.
Oestrogen drives the growth of uterine tissues leading to cystic hyperplasia which can progress to cancer.
Unopposed oestrogen at least doubles the risk of endometrial cancer but addition of progestogen either in sequential or continuous preparations reduces the risk.
Some progestogens help to protect the uterus from oestrogen induced cancer so there is a reduced risk of endometrial cancer – needs to be weighed against increased risk of breast cancer.
How can HRT lead to cardiovascular disease?
Incidence of coronary heart disease in women increases after the menopause since oestrogen is protective against CVD.
Studies to investigate a role for HRT in secondary prevention of CVD find no benefit.
Data for primary prevention is not robust and trials are ongoing – HRT is not licensed for prevention of CVD.
HRT does not increase risk of CVD if started before age of 60, may be associated with a decreased risk if used within 10 years of last period.
If started more than 10 years after menopause there is an increased risk of CVD.
