Sex Hormones

Front 1

Hormone Replacement Therapy

Back 1

Replaces oestrogen with or without progesteron to relieve symptoms of menopause associated with low hormone levels

Front 2

What are some natural oestrogens?

Back 2

Estrone, estradiol, estriol

Front 3

What are synthetic oestrogens?

Back 3

Ethinylestradiol, mestranol

Front 4

What is tibolone ('combined' HRT taken continuously)?

Back 4

Oestrogenic, progestogenic and weak androgenic

Front 5

What is vaginal atrophy?

Back 5

Vaginal walls thinning, drying and inflammation. Topical oestrogens; vaginal creams, tablets (Vagifem 10mcg OD for 2 weeks. Then reduced to 10mcg twice a week) and rings (replace after 3 months. Max continuous treatment: 2 years)

Front 6

What are Vasomotor symptoms of hormone disorders?

Back 6

Hot flushes, night sweat. Systemic oestrogens such tablets or patches (apply patch below waistline away from waist band or breast). If contra-indicated, give Clonidine. Vasodilator antihypertensive (but has unacceptable side effects)

Front 7

What is the choice of HRT for a woman without a uterus?

Back 7

Oestrogen alone continuously (oral or transdermal). Oral: daily continuous. Transdermal: may be twice a week, leave on for 3-4 days before changing to a new spot away from breast area and not below waistline

Front 8

What is the choice of HRT for a woman with a uterus?

Back 8

Oestrogen and progesterone cyclically (for 12-14 days of each cycle) or continuously (avoids withdrawal bleeding).

Front 9

Continuous combined HRT is unsuitable in...

Back 9

Peri-menopause or <12 months after last periods = irregular bleeding. Rule out endometrial cancer if irregular bleeding continues after stopping continuous combined-HRT

Front 10

Does HRT provide contraception?

Back 10

No!

Front 11

If one is under 50 years, she may still be fertile for 2 years after last period...

Back 11

Use a low-oestrogen combined contraceptive; if free from venous/arterial disease risk factors

Front 12

If over 50 years, she may still be fertile for 1 year after last period...

Back 12

Use condoms (barrier protection)

Front 13

Side effects of hormone therapy;

Back 13

Ovarian cancer, breast cancer (increased risk with HRT use >1 year), cervical cancer, endometrial cancer (add progesterone reduces additional risk - at least 10/28 day cycle or given continuously eliminates additional risk). Coronary heart disease (if combined HRT started 10 years after menopause)

Front 14

What's a venous thromboembolism reason to stop?

Back 14

Sudden severe chest pain, sudden breathlessness or cough with blood-stained Sputum (pulmonary embolism).

Unexplained swelling or severe pain in calf of one leg (deep vein thrombosis).

Greater risk with oral compared to transdermal preparations

Front 15

What's a neurological reason to stop taking HRT?

Back 15

Unusual severe prolonged headache, sudden partial or complete loss of vision or sudden disturbance of hearing or other perceptual disorders. Dysphasia - slurred speech, bad fainting attack, collapse, first unexplained epileptic seizure, weakness, motor disturbances, very marked sudden numbness of one side or one part of the body

Front 16

What liver dysfunction can HRT cause?

Back 16

Jaundice, hepatitis, liver enlargement. Severe stomach pain

Front 17

What blood pressure is an indication for people to stop taking HRT?

Back 17

Above 160/95

Front 18

Risk factors that contra-indicate HRT

Back 18

Prolonged immobility after surgery or leg injury (risk of VTE)

Thrombophlebitis (inflammation of blood vessel walls)

Angina, myocardial infarction

Venous thromboembolism (VTE)

Recurrent VTE (unless anticoagulated)

Thrombophilic disorder (tendency to cause blood clots)

Liver disease

Untreated endometrial hyperplasia (endometrial cancer risk)

Undiagnosed vaginal bleeding (endometrial cancer?)

Oestrogen-dependent cancer

History of breast cancer

Front 19

What are the 2 uses of Clomifene (ovulation stimulant)?

Back 19

Infertility in women due to oligomenorrhea (infrequent menstrual periods - <6-8 periods a year). Secondary amenorrhea due to PCOS

Front 20

How long should Clomifene be used for?

Back 20

Only 6 cycles due to risk of ovarian cancer. Side effects: multiple pregnancies

Front 21

What is testosterone used for?

Back 21

Replacement therapy in androgen deficiency

Front 22

What are 6 side effects of testosterone?

Back 22

Masculinisation and virilisation in women. Male pattern baldness. Acne, anxiety. Special development in pre pubescent males. Don't apply testosterone gels to genital area

Front 23

What is an anti-androgen drug?

Back 23

Cyproterone 50mg BD after food - used for severe hypersexuality and sexual deviation. Inhibits spermatogenesis and produces reversible infertility (not a male contraception). Abnormal sperm forms. MHRA risk: Rare association with meningioma (single or several CNS tumours) in dose over 25mg/day including co-cyprindiol

Front 24

What is peri-menopause?

Back 24

Menopausal transition - period before menopause. Characterised by irregular cycles of ovulation and menstruation and ends 12 months after the last menstruation

Front 25

Diagnosing peri-menopause

Back 25

Menstrual cycle shortens to 2-3 weeks or increases by months. Symptoms (neurological: depression, anxiety, memory loss. Physical: weight gain, hot flushes, vaginal dryness, painful sex)

Front 26

Diagnosing menopause

Back 26

If healthy woman over 45 hasn't had a period in 12 months. No need to use serum levels unless under 45, (and not taking contraception) or over 45 with atypical symptoms

Front 27

What is premature ovarian insufficiency?

Back 27

Transient or permanent loss of ovarian function before the age of 40 characterised by menstrual disturbances (amenorrhea or oligomenorrhea) and potential spontaneous resumption of ovulation, menstruation and spontaneous pregnancy

Front 28

Diagnosing premature ovarian insufficiency

Back 28

If a woman is under 40 (and not taking combined hormonal contraception), infrequent or no periods and elevated serum FSH levels (>30 IU/L) on two blood samples taken 4-6 weeks apart. Don't use the anti-Müllerian Hormone testing or pelvic examination

Front 29

Assessing whether a woman has menopause. Ask about:

Back 29

Menstrual cycle, symptoms, medical history, lifestyle (alcohol, smoking - smokers get menopause earlier and experience worse Symptom, exercise), (family) history of cancer, treatment goals, current medications

Front 30

Lifestyle advice for menopausal symptoms

Back 30

Hot flushes (exercise, weight loss, wear lighter clothes, sleep in a cool room, reduce Stress and triggers like spice, alcohol, smoking, caffeine). Sleep disturbances (don't exercise late in the day and have a steady sleeping pattern). Low mood/anxiety (adequate sleep, regular physical activity, relaxation exercises). Cognitive symptoms: exercise and good sleep hygiene

Front 31

A woman should use [type of contraception] if over 50

Back 31

Progesterone only contraception

Front 32

If a menopausal woman has risk of breast cancer

Back 32

Don't give HRT, at most give low dose vaginal oestrogen e.g. Vagifem pessaries (seek specialist advice). Suggest non hormonal treatment (e.g. Citalopram 20mg OD, fluoxetine 20mg OD, paroxetine 10mg OD (SSRIs for two weeks then review). Venlafaxin 37.5mg OD (SNRI for a week then review, increase to 75mg). Don't take fluoxetine or paroxetine with Tamoxifen (used in breast cancer - reduces efficacy)

Front 33

When to consider giving transdermal HRT instead of oral?

Back 33

increased CVD (tested using QRISK score: >10%). Tibolone increases stroke risk 2.2x from first year of treatment. Stroke risk is also age dependent. Or increased VTE/BMI >30 kg/m2 (obese) - risk increased in the first year.

Front 34

Do women with type two diabetes need a different HRT?

Back 34

If there aren't other co-morbidities e.g. CVD, then HRT doesn't effect glucose levels, so it's fine.

Front 35

For women with hypothyroidism...

Back 35

The levothyroxine dose may have to increase - HRT may decrease effects of levothyroxine (moderate and theoretical interaction). TSH (thyroid stimulating hormone) would need to be monitored every 6-12 weeks after starting HRT.

Front 36

What drug is used for postmenopausal osteoporosis (prevention and treatment)?

Back 36

Raloxifene 60mg daily. It doesn't reduce Vasomotor symptoms