HRT Flashcards
(30 cards)
When is HRT used and why?
Used in perimenopausal & postmenopausal women to alleviate symptoms associated with menopause. The symptoms are caused by a declined level of oestrogen so exogenous oestrogen is given to alleviate the symptoms.
What needs to be given in addition to oestrogen?
Progesterone in women who have a uterus to prevent endometrial hyperplasia & endometrial cancer.
What is given to women who still have periods?
Cyclical HRT with cyclical progesterone and regular breakthrough bleeds.
Who goes on continuous combined HRT?
Postmenopausal women with a uterus and more than 12 months without periods.
What non-hormonal treatments can be used for menopausal symptoms?
- Lifestyle changes - improving diet, exercise, weight loss, reducing caffeine & alcohol
- CBT
- Clonidine - agonist of alpha adrenergic and imidazoline receptors
- SSRI antidepressants eg fluoxetine
- Venlafaxine - SNRI
- Gabapentin.
What does clonidine do?
Agonist of alpha-2 adrenergic receptors and imidazoline receptors in brain. Lowers blood pressure & reduces heart rate so can be helpful for vasomotor symptoms and hot flushes.
What are common alternative remedies do people tend to try?
- Black cohosh → may cause liver damage. 2. Dong quai → may cause bleeding disorders. 3. Red clover → may have oestrogenic effects. 4. Evening primrose oil → clotting disorders & seizures. 5. Ginseng → mood & sleep benefits.
What are 4 indications for HRT?
- Replacing hormones in premature ovarian insufficiency, even without symptoms (premature menopause)
- Reducing vasomotor symptoms such as hot flushes & night sweats
- Improving symptoms such as low mood, decreased libido, poor sleep & joint pain
- Reducing risk of osteoporosis in women under 60 years.
Benefits of HRT?
Improved vasomotor and other symptoms of menopause. Improved quality of life. Reduced risk of osteoporosis & fractures.
Risks of HRT?
Increased risk of breast cancer (increased by addition of progesterones). Increased risk of endometrial cancer (do not give oestrogen as HRT alone to women with a uterus, give with progesterone). Increased risk of VTE (increased by addition of progesterone, reduced risk with transdermal HRT). Increased risk of stroke & coronary artery disease. Evidence is inconclusive about ovarian cancer.
Do the risks apply to all women?
Risks are not increased in women under 50 years. No risk of endometrial cancer in women without a uterus. No increased risk of coronary artery disease with oestrogen-only HRT.
How can you reduce the risks?
Risk of endometrial cancer is greatly reduced by adding progesterone in women with a uterus. Risk of VTE reduced by using patches rather than pills.
Contraindications to HRT?
Undiagnosed abnormal bleeding, endometrial hyperplasia or cancer, breast cancer, uncontrolled hypertension, VTE, liver disease, active angina or MI, pregnancy.
What do you need to do before initiating HRT?
Full history to check for contraindications. Family history to assess risk of oestrogen dependent cancers and VTE. Check BMI & blood pressure. Ensure cervical & breast screening is up to date. Encourage lifestyle changes.
What are the options for oestrogen delivery?
Oral (tablets), transdermal (patches or gels). Patches are more suitable for women with poor control on oral treatment, higher risk of VTE, CVD and headaches.
What are the options for progesterone delivery?
Cyclical progesterone given for 10-14 days per month for women who have had a period within the past 12 months (perimenopausal). Continuous progesterone if woman has not had a period in the past 24 months if under 50 years or 12 months if over 50 years.
How do you give progesterone for endometrial protection?
Oral (tablets), transdermal (patches), intrauterine system (Mirena coil).
What else can you give for endometrial protection?
Mirena coil is licensed for 4 years for endometrial protection, after which time it needs replacing. Mirena has added benefits of contraception and treating heavy menstrual periods.
What are progestogens?
Any chemicals that target and stimulate progesterone receptors.
What is progesterone?
Hormone produced naturally in the body.
What are progestins?
Synthetic progestogens.
What are the 2 classes of progestogen classes used in HRT?
- C19 progestogens → derived from testosterone & may be helpful for women with reduced libido eg norethisterone, levonorgestrel. 2. C21 progestogens → derived from progesterone & may be helpful for women with depression or acne eg progesterone, dydrogesterone.
What would you give someone with no uterus?
Oestrogen only pills eg. Elleste Solo or Premarin. Oestrogen only patches eg. Evorel or Estradot.
What would you give a perimenopausal woman with periods?
- Cyclical combined tablets eg. Elleste-Duet, Clinorette or Femoston
- Cyclical combined patches eg. Evorel Sequi.
- Mirena coil + oestrogen only pills eg. Elleste Solo or Premarin
- Mirena coil + oestrogen only patches eg. Evorel or Estradot.
