HRT

Question 1

What blood test levels are suggestive / diagnostic of menopause?

Answer 1

low oestradiol (<70 pmol/L) despite high LH and FSH

Question 2

Why do we try to avoid the systemic use of HRT?

Answer 2

It causes endometrial hyperplasia → possibility of malignancy

*therefore, if needed (symptom assessment/impact on life), use minimal doses for short period of time

Question 3

How do we divide (2) the women patients for the purpose of treatment with HRT?

Answer 3

1. Those with uterus
2. Those who had a hysterectomy

Question 4

What HRT would be recommended in a woman with a uterus who have bled within last year (perimenopausal)?

Answer 4

Cyclical combined HRT

(progesterone on the last 12 out 28 days)

Result: regular post-progesterone withdrawal bleed → protective for endometrium

* given for max 5 years (as prolonged use increases the risk of endometrial cancer)

* once a patient has been amenorrhoeic for 1 year / or reaches 54 → transfer to continous combined therapy

Question 5

When do we change cyclical combined HRT into continuous combined HRT?

Answer 5

Once a patient has been amenorrhoeic for 1 year / or reaches 54 (whichever is sooner)→ transfer to continuous combined therapy

Question 6

What HRT to prescribe for a woman with uterus, who has not bled for 1 year (postmenopausal) ?

Answer 6

Continuous combined HRT

(continuous oestrogen and progesterone)

• endometrial atrophy is caused → women should not bleed on that
• progesterone protects the endometrium from hyperplasia (and reduces risk of endometrial cancer)
• unwanted SEs of progesterone: withdrawal bleeds, premenopausal-like symptoms

Question 7

Do we expect a bleed in a woman on continuous combined HRT?

Answer 7

• endometrial atrophy is caused → women should not bleed on that
• progesterone protects the endometrium from hyperplasia (and reduces risk of endometrial cancer)
• unwanted SEs of progesterone: withdrawal bleeds, premenopausal

Question 8

What HRT can we give in women who have had a hysterectomy?

Answer 8

Oestrogen only HRT

• doses can be titrated to their symptoms
• progesterone is not required → if hysterectomy, there is no risk of unopposed oestrogen-induced endometrial hyperplasia

Question 9

(3) indications for HRT

Answer 9

• menopausal-related symptoms
• early menopause
• prevention of osteoporosis

Question 10

• Contraindications (strong) for HRT (4)
• Relative contraindications for HRT

Answer 10

Strong:

• endometrial cancer
• liver disease (e.g. active hepatitis)
• suspected pregnancy
• inherited thrombophilias

Relative: (referral to specialist)

• hypertension
• previous personal or family Hx of thromboembolism
• breast cancer

(close consideration for risk-benefit analysis)

Question 11

Indications for specialist referral in terms of starting/not HRT

Answer 11

Relative contraindications:

• hypertension
• previous personal or family Hx of thromboembolism
• breast cancer

Other:

• menopause before 40 yo
• confirmed risk of osteoporosis
• high risk of personal Hx of oestrogen-dependant ca (e.g. breast, endometrium)
• abnormal bleed before the start of HRT/while using cyclical HRT or more than 6 months after start of continous combined HRT

Question 12

MoA and use of Bisphosphonates

• examples of drugs

Answer 12

MoA: inhibit the osteoclast-mediated bone resorption → prevent osteoporosis

Examples: Pamidronate and Alendronate

*oral calcium and vitamin D supplements often given in addition to bisphosphonates

Question 13

What’s Tibolone?

Answer 13

Tibolone

• synthetic steroid
• agonist → oestrogenic, progestogenic and androgenic effects
• Use: to relieve post-menopausal symptoms and protect the bones
• it doesn’t cause endometrial proliferation (but may cause irregular bleeding within few months)

Question 14

What’s Raloxifene?

Answer 14

Raloxifene

• new class of selective-oestrogen-receptor-modulators (SERMs)
• MoA: selective stimulation of oestrogen receptors → to prevent osteoporosis and have beneficial effect on lipid profile
• SERMs do not relieve menopausal symptoms

Question 15

Benefits of HRT (3)

Answer 15

• relieve in menopausal symptoms
• 50% reduction in osteoporosis risk
• it may delay onset of Alzheimer’s (no effect on established disease)

Question 16

Risks of HRT (4)

Answer 16

HRT increase risk of:

• breast cancer
• endometrial cancer
• venous thromboembolism
• CVS disease (with combined HRT)

Question 17

Do we follow up women on HRT?

Answer 17

Yes. Women on HRT should be followed up 6-monthly to:

• assess symptoms improvement
• assess side effects

Question 18

Postmenopausal bleed (6-12 months after the menopause). What to do?

Answer 18

Immediate referral for endometrial biopsy