W13 Hormone Replacement Therapy (JD) Flashcards
What is the mean natural age of menopause?
What indicates that a woman is experiencing menopause?
51 years.
Menopause is when menstruation stops permanently due to the loss of ovarian follicular activity. It occurs with the final menstrual period and is usually diagnosed clinically after 12 months of amenorrhoea (no period).
4 Stages?
Premenopause - no vasomotor symptoms
Perimenopause - decline in oestrogen level
Menopause
Postmenopause
What is perimenopause?
- Perimenopause is the period before the menopause characterized by irregular cycles of ovulation and menstruation and ends 12 months after the last menstrual period.
What is postmenopause?
Postmenopause is the time after a woman has not had a menstrual period for 12 consecutive months.
Menopause symptoms
Vasomotor symptoms
* Hot flushes, night sweat (70 – 80%)
* Cognitive impairment and mood changes
* Anxiety, mood swings, irritability, sleep disturbance, and reduced quality of life
Urogenital symptoms
* Burning, itching, and/or dryness, urinary
frequency, UTIs
Other symptoms
* Joints and muscle pain, headache, fatigue
Which of the following is/are routinely considered to diagnose perimenopause?
A. Symptoms (including hot flashes and night sweat)
B. A change to the menstrual pattern
C. Serum follicle-stimulating hormone (FSH)
D. Pelvic Examination
A,B
C- not helpful as it can fluctuate monthly
Indications of HRT? (4)
- Menopausal symptoms
- Endometriosis
- Premature ovarian insufficiency
- Heavy menstrual bleeding
Indication of HRT in perimenopause and menopause
- Relief of short-term vasomotor symptoms e.g., hot flushes
- Alleviate low mood as a result of the menopause
- Urogenital atrophy (vaginal preparation)
- Prevention of osteoporosis in postmenopausal women- at high risk of future fractures (not 1st line)
How effective is HRT?
What is the Main component of HRT?
- Most effective intervention for managing menopausal symptoms.
- Oestrogen- effective in controlling menopausal symptoms
-Available in different dosage forms
-Patients’ preference, risk factors, etc. determine which is the most suitable
dosage form to be used - Progestogens are available in the form of:
-natural micronised progesterone tablets
-synthetic progestogens – oral tablets, patches, intrauterine progestogen releasing system.
HRT:
Testosterone replacement therapy in female:
what is it used for?
- improve symptoms of low libido and low sexual drive and improve mood and low
energy levels - There are NO testosterone preparations available that are licensed for female use in
the UK - Gel – common practice to use gel preparation in female replacement doses (licensed for use in men)
- Implants (off license, limited availability)
(can be added to other HRT if not effective as monotherapy)
Factors that determine the type of HRT? (Oestrogen-only versus combined HRT): (5)
- Whether patient has an intact uterus or not (e.g., subtotal or radical hysterectomy)
- Whether patient is still having periods
- Past medical and family history (e.g., cardiovascular risk factors)
- Past medications history
- Individual preferences
HRT is associated with what risk?
=Increased risk of clot formation
oral oestrogen may alter clotting factor in the liver (goes through first pass effect)
transdermal oestrogen reduces this effect (gel,patch,spray)
What is the best formulation of systemic HRT to choose, oral or transdermal (patch/gel)?
Multiple factors can be considered when determining which route of administration is best for the patient.
* Patient co-morbidities/risk factors
* Transdermal route preferred in the following circumstances:
* Oral HRT associated with adverse effects (e.g., nausea)
* Increased risk of VTE (e.g., smokers, overweight)
* Cardiovascular risk factors (e.g., hypertension, hypertriglyceridemia, diabetes)
* Impaired liver function
- Patient preference
- Prescriber preference
HRT:
Risks (2)
Benefits (3)
- Reduction of vasomotor symptoms.
- Maintenance of bone mineral density and reduced risk of osteoporotic fractures.
- Depend on age and duration of use and dose
- Increased risk of breast and endometrial cancer
-The risk of endometrial cancer is reduced (back to baseline) by the addition of a progesterone - Increased risk of clotting (VTE, PE, stroke)
Risk of serious complications due to HRT: how to prevent this?
- Overall, the risk of serious complications due to HRT increases with increasing age, dose and duration of treatment.
- Patients should be prescribed the lowest effective dose for the shortest duration possible
- Patients should be regularly reviewed by their doctor (at least yearly) and reassessed as to whether treatment needs to be continued.
Contraindication
DO NOT prescribe HRT in women:
- Current, past, or suspected breast cancer.
- Known or suspected oestrogen-dependent cancer.
- Undiagnosed vaginal bleeding.
- Untreated endometrial hyperplasia.
- Previous idiopathic or current VTE (deep vein thrombosis or pulmonary embolism),
unless the woman is already on anticoagulant treatment. - Active or recent arterial thromboembolic disease (for example angina or myocardial
infarction). - Active liver disease with abnormal liver function tests.
- Pregnancy.
- Thrombophilic disorder.
Prescribe HRT WITH CAUTION in women with:
- Porphyria cutanea tarda (photosensitivity).
- Diabetes mellitus (increased risk of heart disease).
- Factors predisposing to venous thromboembolism (recent major surgery, major
injury, recent infectious disease). - History of endometrial hyperplasia.
- Migraine and migraine-like headaches.
- Increased risk of breast cancer (older age, low socioeconomic background).
Counselling points of HRT
- Explain the risks and benefits of HRT
- Explain to patients about bleed patterns
- Emphasise the importance of treatment adherence
- Advise patients that symptoms will usually start to improve by 4 weeks after HRT initiation.
- Weight gain is very common around the time of the menopause – HRT does not cause significant further weight gain.
- Counsel patients on continuing need to engage in national screening programmes including breast and cervical screening programmes.
- Menopause women are at increased risk of osteoporosis – encourage
healthy diet (rich in calcium), vitamin D supplementation, weight-bearing
and resistance exercise. - Isoflavones (soy), black cohosh and red clover may help relive vasomotor
symptoms – safety is unknown - Patients with vaginal dryness
-OTC vaginal moisturisers and vaginal lubricants - Lifestyle modifications should be implemented at the same time as medical management – they should not delay treatment initiation
Tibolone Livial®
- Tibolone is used as an alternative to combined
continuous HRT in postmenopausal women - Has both agonist and antagonist properties:
- Estrogenic effect on thermoregulatory centres in the brain, vagina and bone. Hence helps with vasomotor symptoms, urogenital symptoms and osteoporosis
- Progestogenic and anti-estrogenic effects on endometrium
and breast. Therefore, does not require opposition with progesterone, and its use is associated with a reduced incidence of mastalgia (breast pain) - Androgenic effects which help decrease high density
lipoproteins and triglycerides and increase libido - Tibolone has the same indications and contraindications as the systemic oestrogen HRTs
- its use is limited by its side effects (increased risk of
stroke and breast cancer recurrence)
Combined oestrogen/bazedoxifene acetate (Duavive® )
- Bazedoxifene acetate is a third-generation selective oestrogen receptor modulator (SERM)
- Bazedoxifene has oestrogen-receptor agonist effects on bone, and antagonist effects on uterine and breast tissue.
- Duavive® is used for the treatment of menopausal symptoms and
prevention of osteoporosis in post-menopausal women with a uterus if progestogen containing therapy is inappropriate. - No sufficient data to support its routine use in the UK.
Non hormonal therapy
Indication of non-hormonal therapy? (2)
For vasomotor symptoms what is given? (4)
- Patient’s preference
- HRT is not tolerated or contraindicated
- Selective serotonin reuptake inhibitors (SSRIs, off-label) or serotonin and norepinephrine reuptake inhibitors (SNRIs, off-label)
- Clonidine (an alpha-2 adrenergic receptor agonist)
- Gabapentin (off-label)
- Cognitive Behavioural Therapy (CBT)
Do the benefits of using HRT outweigh the risks?
Yes
- for the treatment of menopause, short-term outweighs the risks in majority of women, especially in >60yrs.
Does HRT increase the risk of CVD?
CVD is the commonest cause of death in postmenopausal women.
Not in women <60yrs
HRT may be cardioprotective in younger postmenopausal women (<10 years from last menstrual period) but the evidence is not currently strong enough to reccomend for primary prevention of CVD
How long can menopausal woman take HRT for?
- For symptoms such as hot flushes, 2-5 years but can be longer in some cases
- no greater than 5 years, it is generally considered that the risks of continuing the treatment outweigh the benefits after that period.
