Hormone Replacement Therapy Flashcards
(44 cards)
1
Q
What is the purpose of HRT and how does it work?
A
- it is given to perimenopausal / menopausal women to alleviate their symptoms
- their symptoms are caused by a decline in oestrogen
- exogenous oestrogen is given to alleviate the symptoms
2
Q
How is HRT different in women who have a uterus?
A
- progesterone needs to be given in addition to oestrogen
- progesterone prevents endometrial hyperplasia + endometrial cancer secondary to “unopposed” oestrogen
3
Q
What are the non-hormonal treatments for menopausal symptoms that may be trialled prior to HRT?
A
- lifestyle changes
- CBT
- clonidene
- SSRI antidepressants
- venlafaxine (SNRI)
- gabapentin
SNRI = selective serotonin-norepinephrine reuptake inhibitor
4
Q
How does clonidene work?
A
- it is an agonist of alpha-2 adrenergic receptors + imidazoline receptors in the brain
- it lowers the BP + reduces HR
5
Q
When is clonidene used?
A
- it can be used to relieve the vasomotor symptoms + hot flushes associated with menopause
- particularly where there are contraindications to HRT
- it is also used as an antihypertensive medication
6
Q
What are the side effects associated with clomidene?
A
- dry mouth
- headaches
- dizziness
- fatigue
- sudden withdrawal can result in rapid increases in BP + agitation
7
Q
What advice is given about alternative remedies for menopausal symptoms?
A
NOT RECOMMENDED
- their safety / efficacy is unclear
- many have significant adverse effects and interact with other medications
8
Q
What are the 4 indications for HRT?
A
- replacing hormones in premature ovarian insufficiency (even without symptoms)
- reducing vasomotor symptoms
- improving symptoms such as low mood, poor sleep, decreased libido + joint pain
- reducing the risk of osteoporosis in women < 60
9
Q
What is the advice given about the risks / benefits of HRT in younger women?
A
the benefits generally outweigh the risks in women < 60
10
Q
What are the key benefits of HRT that should be highlighted to the patient?
A
- improvement of vasomotor symptoms + others (e.g. mood, joint pain, etc.)
- improved quality of life
- reduced risk of osteoporosis / fractures
11
Q
What are the risks associated with HRT that it is important to make the patient aware of?
Who is more affected by these risks?
A
- increased risk of breast cancer (particularly with combined HRT)
- increased risk of endometrial cancer
- increased risk of VTE by 2-3x
- increased risk of stroke / coronary artery disease in older women with long-term use
- the risks are more significant in older women
- the risk increases with a longer duration of treatment
12
Q
Which groups of individuals may not be affected by the risks of HRT?
A
- the risks are NOT increased in women < 50 compared with other women their age
- there is no risk of endometrial cancer if the woman does not have a uterus
- there is no increased risk of coronary artery disease with oestrogen-only HRT
13
Q
How can the risk of endometrial cancer / VTE be reduced?
A
- the risk of endometrial cancer is reduced by adding progesterone in women with a uterus
- the risk of VTE is reduced by using patches rather than pills
14
Q
What are the contraindications to starting HRT?
A
- undiagnosed abnormal bleeding
- endometrial hyperplasia / cancer
- breast cancer
- uncontrolled hypertension
- VTE
- active angina / MI
- liver disease
- pregnancy
15
Q
What 5 things must be assessed prior to starting HRT?
A
- take a full history to identify any contraindications
- assess family history of oestrogen-dependent cancers + VTE
- BMI and BP
- ensure cervical + breast screening is up to date
- encourage lifestyle changes that will improve symptoms / reduce risks
16
Q
What are the 3 steps that must be considered when choosing the HRT formulation?
A
1 - Do they have local or systemic symptoms?
- local - consider topical treatments
- systemic - move to step 2
2 - Do they have a uterus?
- no - use continuous oestrogen only HRT
- yes - use combined HRT (with progesterone) + move to step 3
3 - Have they had a period in the last 12 months?
- yes - use cyclical combined HRT
- no - use continuous combined HRT
17
Q
What are the 2 options for delivreing systemic oestrogen?
A
- oral through tablets
- transdermal through patches / gels
18
Q
What are the 2 options for delivreing systemic oestrogen?
A
- oral through tablets
- transdermal through patches / gels
19
Q
In which women may patches be a better alternative to pills?
A
- women with poor control over oral treatment
- women at higher risk of VTE, cardiovascular disease or headaches
20
Q
What are the 2 options for progesterone delivery?
A
- cyclical progesterone
- continuous progesterone
progesterone is only required in women who have a uterus
21
Q
How is cyclical progesterone given and who is this recommended for?
A
- given for 10-14 days each month
- used for women who are perimenopausal (have had a period in the last 12 months)
- cycling the progesterone allows patients to have a monthly breakthrough bleed during the oestrogen-only part of the cycle
22
Q
When is continuous progesterone used?
A
- if a woman < 50 has not had a period in the last 24 months
- if a woman > 50 has not had a period in the last 12 months
23
Q
Why should continuous combined HRT not be used prior to the menopause?
A
- it can lead to irregular breakthrough bleeding
- this often leads to investigation for an underlying cause of the bleeding
24
Q
When can a switch from cyclical to continuous HRT be made?
A
- after at least 12 months of treatment in women > 50
OR
- after at least 24 months of treatment in women < 50
- the switch needs to be made during the withdrawal bleed
25
What is the purpose of switching from cyclical to continuous HRT?
continuous HRT has better **endometrial protection** than cyclical HRT
26
What are the 3 options for delivering progesterone for endometrial protection?
* oral through **tablets**
* transdermal through **patches**
* intrauterine system (**Mirena coil**)
27
For how long does the Mirena coil provide endometrial protection for?
**4 years**
* after this time it needs replacing
28
What are the added benefits of using the Mirena coil?
* it provides contraception
* it can treat heavy menstrual periods
29
What is important to tell women about the Mirena coil?
* it can cause **irregular bleeding / spotting** in the first few months after insertion
* this usually settles with time and most women become **amenorrhoeic**
30
What are the 2 progestogen classes used in HRT?
**C19 and C21 progestogens**
* this refers to the number of carbon atoms
* if a woman experiences **side effects**, consider **switching** progestogen classes
31
When are C19 progestogens usually chosen?
| What are some examples?
* they are derived from **testosterone** and are more "male" in their effects
* helpful for women with **reduced libido**
* including **norethisterone**, **levonorgestrel** and **desogestrel**
32
When are C21 progestogens typically chosen?
| What are some examples?
* they are derived from **progesterone** and are more "female" in their effects
* useful for side effects such as **acne** or **low mood**
* includes **dydrogesterone** and **medroxyprogesterone**
33
What are the "best" ways to deliver oestrogen and progesterone?
* it is best to deliver oestrogen **through a patch** due to the decreased **risk of VTE**
* it is best to deliver progesterone via the **Mirena coil** as it does not produce progestogenic side effects
34
What is tibolone?
* a synthetic steroid that stimulates **oestrogen + progesterone receptors**
* it also stimulates **androgen receptors**
* it is a form of ***continuous combined HRT***
## Footnote
women must be 12 months without a period ( or 24 months if < 50) before considering this
35
Who might tibolone be suitable for?
its weak stimulation of **androgen receptors** means it can be helpful for patients with **reduced libido**
36
What is the drawback of using tibolone?
it can cause irregular bleeding
| this can result in further investigations to exclude other causes
37
When might testosterone be given?
* this is an androgen
* it can **increase energy** and **improve libido**
* given through a **transdermal route**
* initiated and monitored by a specialist
38
When should women be followed up following HRT being started?
How long does it take to have an effect?
* it can take **3-6 months** to gain the full effects
* women should be **followed up 3 months after** starting HRT to review symptoms / SEs
* side effects settle with time so it is worth **persisting for 3 months** with each regime
39
When should a women taking HRT be referred to a specialist?
if there is problematic or irregular bleeding
40
What are the guidelines around surgery and HRT?
ALL *HRT* or *oestrogen-containing contraceptives* should be **stopped 4 weeks prior** to surgery
41
What discussion should be had with women about contraception when starting HRT?
* HRT does **NOT** provide contraception
* **perimenopausal** women need to have adequate contraception with the **Mirena coil** or **POP**
* the POP is given ***in addition*** to HRT
42
What are the oestrogenic side effects associated with HRT?
* nausea
* bloating
* breast swelling
* breast tenderness
* headaches
* leg cramps
43
What are the progestogenic side effects associated with HRT?
* mood swings
* bloating
* weight gain
* fluid retention
* acne / greasy skin
44
What advice is given regarding stopping HRT?
* there is no regime for stopping HRT
* it can be stopped **gradually or abruptly**
* it is recommended to **gradually reduce HRT** to minimise the risk of **symptoms recurring suddenly**
