Hormone Replacement Therapy — MCQs
Which among the following is an absolute contraindication of Hormone replacement therapy?
Which of the following is NOT effective in controlling the hot flushes of menopause in a woman?
The established benefits of estrogen replacement therapy in menopausal women include a reduction in all of the following EXCEPT
Absolute contraindication of hormone replacement therapy is:
Hormone Replacement Therapy (HRT) in postmenopausal women is beneficial in all these except
Which of the following is an established benefit of Hormone Replacement Therapy (HRT)?
Which of the following is an indication for use of Hormone Replacement Therapy in menopausal women:-
Which of the following is a beneficial effect of hormone replacement therapy in early menopause?
Hormone Replacement therapy is not indicated in:
Which among the following is an absolute contraindication of Hormone replacement therapy?
Hormone Replacement Therapy Indian Medical PG Practice Questions and MCQs
Question 1: Which among the following is an absolute contraindication of Hormone replacement therapy?
- A. Endometriosis
- B. Heart disease
- C. Breast carcinoma (Correct Answer)
- D. Osteoarthritis
Explanation: ### Breast carcinoma - Hormone replacement therapy (HRT) is **contraindicated** in breast carcinoma because many breast cancers are **estrogen-receptor positive**, meaning estrogen can stimulate their growth [1]. - Using HRT in patients with a history of breast cancer significantly increases the risk of **recurrence** or **progression** of the disease [1]. *Endometriosis* - Endometriosis is not an **absolute contraindication**; HRT can sometimes be used in women with a history of endometriosis, especially if a hysterectomy and bilateral oophorectomy have been performed. - However, unopposed estrogen therapy might **exacerbate** remaining endometrial implants, so a combined estrogen-progestin regimen is typically preferred [1]. *Heart disease* - While HRT has been shown to have **risks** in women with established coronary heart disease, it is not an absolute contraindication for all forms of heart disease. - The **Women's Health Initiative study** demonstrated increased cardiovascular events in older women initiating HRT, but current guidelines suggest that timing of initiation is crucial and benefits may outweigh risks for younger postmenopausal women. *Osteoarthritis* - Osteoarthritis is **not a contraindication** to HRT; in fact, some studies suggest that estrogen may have protective effects on cartilage [2]. - HRT is neither a treatment nor a contraindication for osteoarthritis and does not significantly impact its progression or severity [2].
Question 2: Which of the following is NOT effective in controlling the hot flushes of menopause in a woman?
- A. Raloxifene (Correct Answer)
- B. Isoflavones
- C. Hormone replacement therapy
- D. Tibolone
Explanation: ***Raloxifene*** - **Raloxifene** is a selective estrogen receptor modulator (SERM) that acts as an estrogen agonist in bone tissue, helping to prevent osteoporosis, but it is an estrogen antagonist in other tissues and can actually worsen or induce **hot flushes**. - Its primary indications are for the prevention and treatment of **osteoporosis** in postmenopausal women, and for the reduction of risk of invasive breast cancer in high-risk women. *Isoflavones* - **Isoflavones** (e.g., from soy) are phytoestrogens that can have weak estrogenic effects, and some women find them helpful in reducing the frequency and severity of **hot flushes**, though efficacy varies. - They bind to estrogen receptors, potentially mitigating the sudden drops in estrogen that lead to **vasomotor symptoms**. *Hormone replacement therapy* - **Hormone replacement therapy (HRT)**, which involves estrogen with or without progestin, is the most effective treatment for **menopausal hot flushes**. - By replacing declining estrogen levels, HRT directly addresses the underlying cause of **vasomotor instability**. *Tibolone* - **Tibolone** is a synthetic steroid that has estrogenic, progestogenic, and androgenic properties, and it is effective in relieving **menopausal hot flushes**. - It specifically targets estrogen receptors in the hypothalamus, which helps to stabilize **thermoregulatory control** and reduce hot flushes.
Question 3: The established benefits of estrogen replacement therapy in menopausal women include a reduction in all of the following EXCEPT
- A. Hot flushes
- B. Mood depression (Correct Answer)
- C. Atrophic vaginitis
- D. Osteoporosis
Explanation: ***Mood depression*** - While some women may experience mood changes during menopause, estrogen replacement therapy does not consistently or significantly reduce **mood depression**. - The relationship between estrogen and mood is complex, and depression in menopausal women often has **multifactorial causes** beyond hormonal changes. *Hot flushes* - Estrogen replacement therapy is highly effective in alleviating **vasomotor symptoms** such as hot flushes and night sweats [1, 2]. - These symptoms are directly linked to declining estrogen levels. *Atrophic vaginitis* - Estrogen therapy effectively treats **genitourinary syndrome of menopause** (GSM), including symptoms of atrophic vaginitis. - It restores the **vaginal epithelium**, increasing lubrication and reducing dryness, itching, and dyspareunia. *Osteoporosis* - Estrogen plays a crucial role in **bone density maintenance** and its decline at menopause contributes to accelerated bone loss. - Estrogen replacement therapy is a known treatment to prevent and manage **postmenopausal osteoporosis** by reducing bone turnover [1].
Question 4: Absolute contraindication of hormone replacement therapy is:
- A. Fibroadenoma
- B. Thrombosis (Correct Answer)
- C. Fibrocystic disease
- D. Hemorrhage
Explanation: ***Thrombosis*** - A history of **thrombosis** (e.g., DVT, pulmonary embolism) is an **absolute contraindication** to hormone replacement therapy (HRT) due to the increased risk of further **thromboembolic events**, as estrogen can promote coagulation [1], [2]. - HRT can increase the risk of **blood clot formation**, making it unsafe for individuals with a prior or current thrombotic condition [1]. *Fibroadenoma* - **Fibroadenomas** are **benign breast lumps** and are generally not considered an absolute contraindication for HRT. - While HRT can potentially cause some **breast density** changes, fibroadenomas do not typically preclude its use, though monitoring may be advised. *Fibrocystic disease* - **Fibrocystic breast disease** is a common **benign breast condition** characterized by lumpy, tender breasts, and it is **not an absolute contraindication** for HRT. - HRT might occasionally exacerbate breast tenderness in some women with fibrocystic changes, but it does not pose a severe health risk. *Hemorrhage* - Acute or uncontrolled **vaginal hemorrhage**, especially of undetermined etiology, is a contraindication to initiating HRT until the cause is identified and managed. - However, once the hemorrhage is controlled and its cause is determined not to be uterine cancer, previous hemorrhage itself is **not an absolute contraindication** to long-term HRT.
Question 5: Hormone Replacement Therapy (HRT) in postmenopausal women is beneficial in all these except
- A. Vaginal atrophy
- B. Osteoporosis
- C. Vasomotor symptoms
- D. Prevention of CAD (Correct Answer)
Explanation: ***Prevention of CAD*** - While HRT was initially thought to be cardioprotective, large-scale studies like the **Women's Health Initiative (WHI)** demonstrated that it does **not prevent coronary artery disease (CAD)** and may even increase the risk of cardiovascular events, especially in older postmenopausal women or those initiating therapy years after menopause. - The potential benefits regarding CAD prevention are outweighed by risks such as **stroke** and **venous thromboembolism**. *Vaginal atrophy* - **Estrogen deficiency** in postmenopausal women leads to thinning, dryness, and inflammation of the vaginal walls, causing symptoms like dryness, irritation, and painful intercourse. - **Local or systemic estrogen therapy** effectively reverses these changes by restoring vaginal tissue health. *Osteoporosis* - **Bone loss** accelerates after menopause due to declining estrogen levels, increasing the risk of osteoporosis and fractures. - HRT, particularly estrogen, is effective in **preventing and treating osteoporosis** by inhibiting bone resorption and preserving bone mineral density. *Vasomotor symptoms* - **Hot flashes** and **night sweats** are common and often debilitating symptoms of menopause, directly linked to fluctuating and declining estrogen levels. - HRT, especially systemic estrogen, is the **most effective treatment** for alleviating these symptoms by stabilizing thermoregulatory control.
Question 6: Which of the following is an established benefit of Hormone Replacement Therapy (HRT)?
- A. Decreased risk of endometrial cancer
- B. Decreased risk of breast cancer
- C. Decreased risk of colon cancer
- D. Decreased risk of vertebral fracture (Correct Answer)
Explanation: ***Decreased risk of vertebral fracture*** - HRT is **one of the most well-established benefits** for **prevention of osteoporosis and fractures**, including vertebral fractures. - Estrogen plays a crucial role in maintaining **bone mineral density** by inhibiting osteoclast activity and promoting osteoblast function. - Multiple studies, including the **Women's Health Initiative (WHI)**, have demonstrated a **significant reduction in hip, vertebral, and other osteoporotic fractures** in women taking HRT. - This benefit is recognized by **ACOG, NAMS, and international menopause societies** as a primary indication for HRT in appropriate candidates. *Decreased risk of endometrial cancer* - **Unopposed estrogen therapy** actually **increases the risk of endometrial cancer** due to hyperplasia of the endometrium. - To counteract this, **progestin is added** in women with a uterus receiving HRT, which reduces but does not eliminate the risk increase. - Combined HRT does not provide a net decreased risk below baseline. *Decreased risk of breast cancer* - Combined **estrogen-progestin HRT** has been consistently associated with an **increased risk of breast cancer**, especially with longer durations of use (>5 years). - This was clearly demonstrated in the **WHI trial** and remains a major consideration when prescribing HRT. - Estrogen-only HRT might have a neutral or slightly increased risk, but never a decreased risk. *Decreased risk of colon cancer* - While some observational studies and the **WHI trial** initially showed a reduced incidence of colorectal cancer with HRT, this is **not considered an established or primary indication** for HRT. - Subsequent analyses have shown **inconsistent results**, and any benefit is offset by increased risks. - Current guidelines do **not recommend HRT** for colorectal cancer prevention.
Question 7: Which of the following is an indication for use of Hormone Replacement Therapy in menopausal women:-
- A. Post menopausal bleeding
- B. Hot flushes (Correct Answer)
- C. Cardiovascular protection
- D. Pyelonephritis
Explanation: ***Hot flushes*** - Hormone Replacement Therapy (HRT) is highly effective in alleviating **vasomotor symptoms** like hot flushes and night sweats, which can severely impact quality of life in menopausal women. - The primary goal of using HRT is to manage these **menopausal symptoms** when they are bothersome. *Post menopausal bleeding* - **Postmenopausal bleeding** is a contraindication, not an indication, for new HRT initiation as it requires investigation to rule out endometrial pathology, including cancer. - If a woman on HRT experiences bleeding, it warrants immediate investigation to determine its cause and may necessitate stopping or changing the HRT regimen. *Cardiovascular protection* - While earlier beliefs suggested HRT offered cardiovascular protection, current evidence, particularly from the **Women's Health Initiative (WHI) study**, showed that HRT does not provide primary or secondary cardiovascular protection. - In fact, HRT may increase the risk of **cardiovascular events** like stroke and venous thromboembolism, especially when initiated many years after menopause. *Pyelonephritis* - **Pyelonephritis** is an infection of the kidney, typically caused by bacteria, and is not directly related to menopausal symptoms or hormonal status. - Treatment for pyelonephritis involves **antibiotics** and supportive care, not HRT.
Question 8: Which of the following is a beneficial effect of hormone replacement therapy in early menopause?
- A. Increased Endothelin
- B. Increased TNF-α
- C. Increased Nitric oxide (Correct Answer)
- D. Decreased COX-2
Explanation: ***Increased Nitric oxide*** - **Estrogen** in HRT increases the production and bioavailability of **nitric oxide (NO)** by upregulating endothelial nitric oxide synthase (eNOS). - Increased NO leads to **vasodilation**, contributing to cardiovascular benefits and improved endothelial function. *Increased Endothelin* - **Endothelin-1** is a potent vasoconstrictor, and increased levels are generally associated with **endothelial dysfunction** and cardiovascular risk. - HRT, particularly estrogen, tends to decrease endothelin-1 levels or counteract its effects, leading to beneficial vascular responses. *Increased TNF-α* - **Tumor Necrosis Factor-alpha (TNF-α)** is a pro-inflammatory cytokine, and elevated levels are linked to chronic inflammation and increased risk of various diseases. - HRT, especially estrogen, typically has **anti-inflammatory effects**, potentially reducing TNF-α levels or mitigating its inflammatory actions. *Decreased COX-2* - **Cyclooxygenase-2 (COX-2)** is an enzyme involved in inflammation and pain pathways; its decrease is generally anti-inflammatory. - However, the primary beneficial vascular effect of HRT is not through direct inhibition of COX-2 but rather through mechanisms like increasing nitric oxide.
Question 9: Hormone Replacement therapy is not indicated in:
- A. Vaginal atrophy
- B. Osteoporosis
- C. Prevention of CAD (Correct Answer)
- D. Hot flashes
Explanation: ***Prevention of CAD*** - Hormone replacement therapy (HRT) is **not indicated** for the primary or secondary prevention of **Coronary Artery Disease (CAD)**. While observational studies initially suggested a benefit, large randomized controlled trials (e.g., WHI) showed no cardiovascular protection and even an increased risk of stroke and venous thromboembolism. - The benefits of HRT for menopausal symptoms generally outweigh the risks only in select women, and CAD prevention is not one of them. *Vaginal atrophy* - **Vaginal atrophy**, characterized by dryness, irritation, and painful intercourse, is a common menopausal symptom effectively treated with **local estrogen therapy**. - Systemic HRT can also alleviate these symptoms, but local therapy is often preferred for isolated vaginal symptoms to minimize systemic exposure. *Osteoporosis* - HRT, particularly estrogen therapy, is an effective treatment for the **prevention and management of postmenopausal osteoporosis**, preventing bone loss and reducing the risk of fractures. - However, it is generally considered a second-line option for osteoporosis, after non-hormonal therapies, due to potential risks. *Hot flashes* - **Hot flashes** (vasomotor symptoms) are one of the most common and bothersome symptoms of menopause, and **systemic HRT** is the **most effective treatment** available. - Estrogen therapy significantly reduces the frequency and severity of hot flashes, improving quality of life for many women.
Question 10: Which among the following is an absolute contraindication of Hormone replacement therapy?
- A. Heart disease
- B. Breast carcinoma (Correct Answer)
- C. Endometriosis
- D. Osteoarthritis
Explanation: ***Breast carcinoma*** - **Breast carcinoma** is an absolute contraindication for HRT due to the potential for exogenous hormones to stimulate the growth of hormone-sensitive cancer cells. - Exogenous estrogens, particularly, can promote the proliferation of estrogen-receptor positive breast cancer, thus **increasing the risk of recurrence** or progression. *Heart disease* - While HRT is generally not recommended for **primary or secondary prevention of cardiovascular disease**, it is considered a relative contraindication rather than an absolute one. - The decision to use HRT in women with heart disease is complex and depends on the type of disease, risk factors, and individual patient assessment, often involving a **risk-benefit analysis**. *Endometriosis* - Endometriosis is a **relative contraindication** for HRT, especially for unopposed estrogen therapy, as estrogen can stimulate the growth of endometrial implants. - However, combined estrogen-progestin therapy can sometimes be cautiously considered, particularly if all endometriotic tissue has been **surgically removed**. *Osteoarthritis* - **Osteoarthritis** is not a contraindication for HRT; in fact, some studies suggest that estrogen may have a protective effect on cartilage, though this is not a primary indication for HRT. - HRT is primarily used to manage menopausal symptoms and prevent **osteoporosis**, and its use in relation to osteoarthritis is not a concern for contraindication.
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