Menopause, HRT and Oral Contraceptive

Question 1

What is menopause

Answer 1

Permanent cessation of menstruation
Loss of ovarian follicular activity
Average age = 51 (45-55)

Question 2

What are the symptoms of menopause

Answer 2

Hot flushes (head, neck, upper chest)
Urogenital atropin and dyspareunia 
Sleep disturbance 
Depression 
Decreased libido 
Joint pain

Question 3

What are the complications of menopause

Answer 3

Osteoporosis
- oestrogen deficiency
- Loss of bone matrix
- 10-fold increased risk of fracture
Cardiovascular disease
- protected against CVD before the menopause
- have the same risk as men by the age of 70

Question 4

What is hormone replacement therapy

Answer 4

Controls vasomotor symptoms i.e. hot flushes

HRT = Oestrogen (E) + Progestogens (P)

Question 5

How do you treat menopause if the patient has had a hysterectomy

Answer 5

Oestrogen only, no risk of endometrial carcinoma

Question 6

What are the HRT formulations

Answer 6

Cyclical -
E every day
P every 12-14 days
Continuous = combined

Question 7

How may oestrogen be prepared for HRT

Answer 7

Oral oestradiol (1mg)
Oral conjugate equine oestrogen (0.625 mg)
Transdermal (patch) oestradiol (50microg/day)
Intravaginal

Question 8

Describe the types of oestrogen

Answer 8

oestradiol - well absorbed, low bioavailability (first pass met.)

Oestrone sulphate - conjugate

Ethinyl oestradiol - semi-synthetic oestrogen (ethynyl group protects from first pass met.)

Question 9

What are the side effects of HRT for menopause

Answer 9

Breast cancer
Coronary heart disease
Deep vein thrombosis 
Stroke
Gallstones 
(absolute risk in the 50s is very low)

Question 10

Describe the risk of coronary heart disease from HRT

Answer 10

Mean age = 63
But timing of exposure is important
No excess risk in younger menopausal women
Women <10 years since menopause or 50-59 years have no excess risk

Question 11

What are the effects of oestrogen and progesterone

Answer 11

oestrogen - beneficial on lipid profile and endothelial function
progestins - negates these effects

Women >60 = atherosclerosis and susceptible to prothrombotic and proinflammatory effects oestrogen

Question 12

What is tibolone

Answer 12

Synthetic pro hormone
Oestrogen, progestogenic and weak androgenic actions
Reduces fracture tisk

Question 13

What are the side effects of tibolone

Answer 13

Increased risk of stroke

Increased risk of breast cancer

Question 14

What is raloxifene

Answer 14

Selective oestrogen receptor modulator
Oestrogenic in bone - reduces risk of vertebral fractures
Anti-oestrogenic in breast and uterus - reduces breast cancer risk

Does not reduce vasomotor symptoms :
Risk of venous thrombosis and Fatal stroke increases

Question 15

What is tamoxifen

Answer 15

Used to treat oestrogen-dependent breast tumours and metastatic breast cancers
Anti-oestrogenic on breast tissue

Question 16

Describe premature ovarian insufficiency

Answer 16

Menopause occurring before age 40

1% of women

Question 17

What are the causes of premature ovarian insufficiency

Answer 17

Autoimmune
Surgery
Chemotherapy
Radiation

Question 18

Described combined oral contraceptives

Answer 18

Oestrogen (ethinyl oestradiol) + progestogen
e.g. levonorgestrel or norethisterone

Suppresses ovulation

• E+P: -ve feedback actions at the hypothalamus/pituitary
• P thickens cervical mucus

Take for 21 days (or 12 weeks)< stop for 7

Question 19

Describe the progesterone only contraceptive

Answer 19

When oestrogen are contra-indicated e.g. smokers, >35, migraine with aura

Must be taken at the same time each day (short half life and duration of action)

Long acting preparations may be given via intra-uterine system

Question 20

What are the options for emergency contraception

Answer 20

Copper intrauterine contraceptive device (5-7 days after unprotected intercourse)
Levonorgestrel (within 72 hours)
Ulipristal (up to 120 hours after intercourse)

Question 21

Describe the copper IUD

Answer 21

Copper intrauterine contraceptive device
Exclude pregnancy first
Affects sperm viability and function
Effectiveness not reduced in overweight/obese women

Question 22

Describe ulipristal

Answer 22

Anti-progestin activity
Delays ovulation by as much as 5 days
Impairs implantation

Question 23

Why is oestrogen not prescribed solely

Answer 23

Causes the endometrial lining to grow - risk of endometrial carcinoma

Question 24

Why os progesterone given in HRT

Answer 24

Prevents endometrial hyperplasia