Menopause and HRT

Question 1

Symptoms of menopause?

Answer 1

Flushing, nightsweats, insomnia

Sexual dysfunction: dryness, dyspareunia, decreased libido

MSK: joint aches, fat redistribution

Psychological: depressed mood, anxiety, irritability, lethargy, difficulty concentrating

Question 2

Long term consequences of menopause?

Answer 2

Osteoporosis
CVS disease and stroke
Increased risk of UTI
Vaginal atrophy
Urinary incontinence

Question 3

How to diagnose menopause?

Answer 3

Clinical, history alone.
Woman has no periods for 12 months

FSH used only if diagnostic doubt: >30iu/L then make menopause diagnosis

TFTs if confused about symptoms

Question 4

Menopause management?

Answer 4

Lifestyle advice: avoid hot caffeinate drinks, stop smoking, use of vaginal moisturisers, no evidence that diet affects symptoms.

OTC remedies: Black cohosh (oestrogen like effect), St John’s Worst (recognised antidepressant effects). These can interact with medications so check,

Clonidine for hot fluses (lots of SEs like insomnia, dry mouth), SSRIs, SNRI, gabapentin for MSK sx

HRT

Question 5

Benefits of HRT?

Answer 5

Proven to relief menopausal sx
Prevents osteoporosis
Reduced risk of colorectal cancer

Question 6

RIsks of HRT?

Answer 6

Small increase risk of breast cancer

Increase risk of VTE

Question 7

Contraindications to HRT?

Answer 7

Hormone dependent cancer- endometrial cancer

Google more

Question 8

Different types of HRT?

Answer 8

Local (vaginal dryness, dysparaenia): vaginal oestrogen (cream or pessary). Low risk

For systemic symptoms: If have uterus then need oestrogen and progesterone replacement

Question 9

Different types of HRT?

Answer 9

Local (vaginal dryness, dysparaenia): vaginal oestrogen (cream or pessary). Low risk

For systemic symptoms: If have uterus then need oestrogen and progesterone replacement (combined HRT)

IF no uterus then can have oestrogen alone

If perimenopausal then give sequential or cyclical HRT

If post menopausal (>12months since LMB) give continuous HRT

Question 10

Management for local symptoms like vaginal dryness etc of menopause?

Answer 10

Local oestrogen preparation:
Pressaries- Orhto-Gynsest
Cream- Gynest, Ovestin
Tablets- Vagifem
Rings- Estring
Some damage latex condoms

Question 11

Examples of non oral oestrogens?

Answer 11

All estradiol 17 beta

Potentially more suitable for women with:

Question 12

Examples of oral oestrogens?

Answer 12

3 types:
Conjugate quine oestrogens
d…

Question 13

What levels of hormones do you expect to see in menopause?

Answer 13

Menopause is lack of ovarian follicular function, so get:

Low oestrogen and prosterone

High LH and FSH

Question 14

When should women still be taking contraception during menopause?

Answer 14

Must use contraception if:

2 yrs since last menstrual period in women under 50

One year after last menstrual period in women over 50

Question 15

Contraceptive options for women approaching menopause?

Answer 15

Barrier methods
Mirena or copper coil
Progesterone only pill/implant
Progesterone depot injection
Sterilisation

Question 16

Management options for perimenopausal symptoms?

Answer 16

HRT
SSRIs
Testosterone for decreased libido
Vaginal oestrogen creams
Vaginal moisturisers 
Clonidine (alpha adrenergic agonist)

Question 17

What kind of HRT options are available?

Answer 17

Exogenous oestrogen is given.

Must give progesterone also if women as a uterus (to protect against unoposed oestrogen –> endometrial cancer)

Question 18

Contraindications to HRT?

Answer 18

Undiagnosed abnormal bleeding
Endometrial hyperplasia or cancer
Breast cancer
Uncontrolled hypertension
VTE
Liver disease
Active angina or MI
Pregnancy

Question 19

How to choose the right HRT formula?

Answer 19

1. Do they have systemic sx (yes = systemic tx, no = topical tx like ostrogen creams)
2. Does the women have a uterus (no= use continuous oestrogen only HRT, yes = used combined HRT)
3. Have they had a period in last 12 months
   (yes = cyclical combined HRT, no = continouse combined HRT)