SEX HORMONE RESPONSIVE CONDITIONS: HRT

Question 1

Perimenopause

Answer 1

• Periods still present in some sort of pattern
• Age 45

Question 2

Post menopause

Answer 2

• 1 year after last period

Question 3

Health risks associated with menopause

Answer 3

• Osteoporosis
• CVD
• TIIDM
• Depression
• Cognitive decline, early dementia
• Other: dry hair and skin, headaches

Question 4

Onset of symptoms

Answer 4

• Female oestrogen levels decline and menstruation ceases
• Symptoms can start several years before final menstrual period and continue for up to 12 yrs

Question 5

Symptoms

Answer 5

Vasomotor symptoms - hot flushes and sweats
Musculoskeletal symptoms - joint and muscle pain
Effect on mood - low mood, anxiety
Urogenital symptoms - vaginal dryness
Sexual difficulties - low sexual desire

Question 6

Oestrogens

Answer 6

• Natural Ostrogens (estradiol, estrone and estriol)
• Synthetic Ostrogens (ethinylestradiol and mestranol)

Question 7

Progestogens

Answer 7

norethisterone
levonorgestrel
desogestrel

Question 8

Tibolone

Answer 8

ostrogenic, progestogenic and weakly androgenic

Question 9

HRT risks (cancer)

Answer 9

Breast cancer
Endometrial cancer
Ovarian cancer

Question 10

Breast Cancer

Answer 10

• Increased risk after 1 year - longer use = higher risk
  → Risk higher in combined HRT over ostrogen only
• Excess risk persists for more than 10 years

Question 11

Endometrial Cancer

Answer 11

Increased risk in oestrogen only
Increased risk in tibolone

Question 12

Ovarian Cancer

Answer 12

Small increase which disappears a few years after stopping

Question 13

HRT risks (CVD)

Answer 13

Venous Thromboembolism
Stroke
Coronary Heart Disease

Question 14

Venous Thromboembolism

Answer 14

Increase risk of DVT with both ostrogen-only and combined HRT
Increase risk with prolonged bed rest, obesity, trauma, family history

Question 15

Coronary Heart Disease

Answer 15

Increased risk in combined HRT when started more than 10 years after menopause

Question 15

Stroke

Answer 15

• Slight increase with both ostrogen-only and combined HRT
• Tibolone increases risk by 2.2 times in first year of treatment

Question 16

HRT (with uterus)

Answer 16

Combined - oestrogen + progestogen
- cyclical (sequential)
- continuous
Tibolone avoided in perimenopausal phase or if within 12 months of last menstrual period

Question 17

Cyclical (sequential)

Answer 17

for women who are still having monthly bleed, or last period was less than a year ago = require progesterone
* Oestrogen continuously and cyclical progesterone (last 12-14 days of cycle)
- progestogen added to trigger a bleed

Question 18

Continuous

Answer 18

for women whos last menstrual period was more than 12 months ago
* Same amount of oestrogen and progestogen everyday

Question 19

HRT (without uterus)

Answer 19

e.g. hysterectomy
oestrogen only
If endometriosis occurs - consider an addition of progesterone

Question 20

Gols standard HRT

Answer 20

• Body identical or regulated bio-identical hormones
• Oestrogen through skin
  o Patch, gel, spray
• +/- micronized progesterone
• +/- testosterone – can help to improve mood, energy, stamina
• Combo of all 3 is not something seen in GP, would be specialist care

Question 21

Woman with uterus - cyclical (sequential) HRT (ORAL)

Answer 21

Elleste duet - 1mg or 2mg estradiol + 1mg norethisterone
Prempak-C 0.625mg or 1.25mg conducted oestrogen + norgestrel 150mcg

progestognenic side effects offer:
Femoston 1/10 or 2/10 1mg or 2mg estradiol + dyhydrogesterone 10mg

Question 22

Woman with uterus - Continuous combined HRT (ORAL)

Answer 22

Elleste duet conti: 2mg estradiol + 1mg norethisterone
Premique: conjugated oestrogen 655mcg + medoxyprogesterone acetate 5mg
Kilofem: 2mg estradiol + 1mg norethisterone
Tibolone

Progestogenic side effects offer:
Femoston conti: 1mg estradiol + 5mg dydrogesterone

Question 23

Woman with no uterus - oestrogen only (ORAL)

Answer 23

Elleste solo: 1mg or 2mg estradiol
Premarin: 0.624 or 1.25mg conjugated oestrogen

Question 24

Woman with uterus - cyclical (sequential) combined (PATCHES)

Answer 24

Evorel Sequi patches: Change TWICE per week 50mcg estradiol + 170mcg norethisterone FemSeven Sequi patches: Change ONCE weekly 50mcg estradiol + 10mcg levonorgestrel

Question 25

Woman with continuous - combined (PATCHES)

Answer 25

Evorel conti patches: chance twice a week 50mcg estradiol + norethisterone if progestognenic side effects offer: Femseven conti patches: change once weekly 50mcg estradiol + 7mcg levonorgestrel

Question 26

oestrogen only (PATCHES)

Answer 26

Evorel patches: change twice per week Estradot patches - change twice per week Oestrogen: 2 measures = standard regime

Question 27

Clonidine

Answer 27

vasomotor symptoms larger side effect profile

Question 28

CI

Answer 28

History of breast cancer or other ostrogen-dependent cancers. Active or recent arterial thromboembolic disease, e.g. angina or MI. Current venous thromboembolism or thrombophlebitis, or history of recurrent VTE Thrombophillic disorder. Undiagnosed vaginal bleeding. Untreated endometrial hyperplasia. Liver disease (with abnormal LFTs). Dubin-Johnson and Rotors syndromes, unless monitored closely (rare genetic disorders leading to increased bilirubin).

Question 29

Lifestyle advice

Answer 29

Eat a healthy balanced diet Maintain a healthy BMI Ensure sufficient dietary calcium (700mg/day) Undertake regular weight-bearing exercise stopping smoking, reducing alcohol intake Treatment optimisation of other conditions

Question 30

Stopping HRT

Answer 30

* Unscheduled vaginal bleeding is common * Choice of gradually or immediately stopping

Question 31

Elective surgery

Answer 31

Stop HRT 4-6 weeks before Reinitiate when fully mobile

Question 32

Non-elective surgery

Answer 32

Prophylactic heparin Graduated compression stockings

Question 33

Reasons to stop HRT

Answer 33

Sudden severe chest pain / breathlessness Unexplained swelling or severe pain in calf of one leg (DVT) Severe stomach pain (hepatotoxicity) Serious neurological effects: Unusual severe, prolonged headache, fainting, first unexplained epileptic seizure, motor disturbances, numbness Hepatitis / jaundice BP > 160 mmHg systolic or 95 mmHg diastolic Prolonged immobility

Question 34

Testosterone

Answer 34

Sexual libido in postmenopausal women Replacement therapy in androgen deficiency (Hypogonadism due to androgen deficiency)

Question 35

Why would testosterone be used in androgen deificnecy

Answer 35

Hypogonadism due to androgen deficiency

Question 36

testosterone side effects

Answer 36

Masculinisation Virilisation in women Acne Anxiety Male pattern baldness -Sexual development in pre-pubescent males

Question 37

Male sex hormone antagonism

Answer 37

Cyproterone