HRT in practice Flashcards
define peri menopause
time before last menstrual period when ovarian activity slows and oestrogen levels start to fall –this time can last several years
define menopause
the time when menstruation ceases permanently due to the loss of ovarian follicular activity. It occurs with the final menstrual period -diagnosed clinically after 12 months of amenorrhoea
define post menopause
time after last menstrual period
what is the menopause?
Ovaries have a finite number of oocytes
•Decrease till about 50 years old then have none left•
During the peri-menopause ovarian activity slows
•Oestrogen levels drop
•Oestrogen is protective in a number of different body systems: brain, skin, bones, heart, urinary functions and the genital area –low levels of oestrogen can affect all these body areas
•This disrupts the menstrual cycle and causes menopausal symptoms
what does a decrease in oestrogen levels do during menopause?
causing reduced negative feedback to the pituitary… FSH and LH levels rise
it begins to disrupt the menstrual cycle and may cause other menopausal symptoms such as hot flushes and night sweats
what happens to estradiol during the menopause?
Estradiolproduction, which occurs in the granulosa and the cal cells surrounding the oocyte, becomes insufficient to stimulate the endometrium, and amenorrhoea occurs.
what is early /premature ovaruarian insufficiency menopause defined as?
- Early menopause = before the age of 45 years
* Premature Ovarian Insufficiency = menopause before the age of 40 year
what are the causes of early menopause?
- Family history
- Premature ovarian failure
- Radiotherapy and chemotherapy
- Hysterectomy
- Infection (TB, mumps, malaria, varicella, shigella. Very rare!)
how do you diagnose early menopause?
•For patients 45 years + with irregular periods and other menopausal symptoms no tests required.
can use apps to track
if u45 may need FSH test
what are the symptoms of menopause?
- 45% get distressed•70-80% get hot flushes -usually present for less than 5years
- Vaginal symptoms (including dryness, discomfort, itching, and dyspareunia) generally persist or worsen with ageing
how long do menopause symptoms last?
2-5 years
what are the long term physical effects of menopause?
- Thinningof skin and hair.
- Bone mass is lost and bones more liable to breaking.
- Dryness of eyes mouth and throat.
- Atrophy of breasts; endometrium; vagina; vulva; pelvic muscles.
what are the symptoms of menopause?
- Hot flushes and night sweats.
- Anxiety and depression.
- Irritability.
- Poor memory and concentration…Brain fog•Insomnia.
- Sexual changes.
- Urinary problems.
- Headaches, joint and muscle pains.
what are the assoicated problems with menopause?
- Increased risk of osteoporosis, CVD (especially in smokers), dementia, cognitive decline, and parkinsonism
- Breast cancer risk decreases
is HRT recommended for prevention of osteoporosis in menopausal women?
no
what are the treatment options for menopausal women?
- Weight management and exercise
- There is evidence that smoking cigarettes and having a BMI >30 kg/m2increases the likelihood of flushing.
- Discuss risks and benefits when deciding to introduce HRT
what management is there for menopause without HRT?
•Lifestyle advice •Exercise •Wear lighter/cooler clothes •Avoid triggers to hot flushes –caffeine, spicy foods etc •Sleep hygiene •Sleep in a cooler room •Relaxation techniques •Reduce stress •Antidepressants? •Vaginal moisturiser e.g. Replens® •Clonidine 50-75mcg bd •Self-help groups •Psychotherapy •Counseling •Supplements/homeopathy etc –evidence base for any of these is very poor
what are the benefits of HRT?
Treating vasomotor symptoms eg. hot flushes and night sweats
•Treating urogenital symptoms eg. vaginal dryness etc
•Managing sleep or mood disturbances caused by hot flushes and night sweats
•Preventing osteoporosis…..risks associated with long term use
what are the risks for HRT orally?
- There is a small increased risk of breast cancer, coronary events, VTE, and stroke
- There is some evidence suggesting that combined HRT may be associated with an increased risk of ovarian cancer
how does hrt work/ differ in preperation?
- All types deliver a set dose of oestrogen into the bloodstream.
- However, oestrogen alone would cause the lining of the uterus to proliferate….
- This increases the risk of uterine cancer therefore -usually combined with a progestogen
when is progestogen not required in an HRT?
Hysterectomy
what considerations are there when prescribing? combined
considerations with combined products
- less flexibility if alteration in oestrogen dose is needed
they all contain older porgestogens
what considerations are there when prescribing oral oestrogens?
- There is VTE risk with oral oestrogen.
- Oral oestrogen increases sex hormone binding globulin (SHBG) so reducing free androgen index (lowers libido even more)
- There is less reliable absorption.
- More contraindications (for example obesity, diabetes, gallbladder disease, migraine etc).
what effect does transdermal oestroegn have?
•There is robust evidence demonstrating that transdermal oestrogenin association with micronised progesterone represents the optimal HRT regimen, particularly in women at risk of cardiovascular events
