Menopause and HRT
Aims and Objectives
• Aims
– To be able to diagnose menopause and know when it is
appropriate to investigate
– To feel confident in discussing the management of
menopausal symptoms with patients
– To be able to prescribe HRT safetly
• Objectives
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Review subject of menopause
Discuss management of menopausal symptoms
Look in more depth at HRT preparations
Look at the first consultation for HRT
Discuss clinical scenarios
Menopause Definitions
• Menopause is defined as the permanent cessation of
menstruation resulting from the loss of ovarian follicular
activity.
• Amenorrhoea for 1 year in patients > 50 or for 2 years in
patients <50
• Perimenopause is the period leading up to the
menopause when the features of menopause commence
• Premature menopause occurs under age 45 years
Physiology
• Each ovary has a certain number of oocytes from birth which
steadily decreases until we are approximately 50 years old
when the stock becomes exhausted
• During the perimenopause follicular activity fails, oestrogen
levels decrease and the pituitary gland produces increased
amounts of LH and FSH due to negative feedback.
• Cycles become anovulatory, follicular development stops, the
endometrium is no longer stimulated and amenorrhoea
occurs
Communication
• ‘A natural menopause occurs because as you
get older, your ovaries stop producing eggs
and make less of the main female hormone
oestrogen. The symptoms you are
experiencing are due to low levels of
oestrogen’
• ‘It signals the end of the fertile phase of a
woman’s life’
Incidence of Symptoms
• What proportion of women;
– experience some menopausal symptoms in their lifetime?
• 80%
– find their menopausal symptoms distressing?
• 45%
– experience hot flushes?
• 80%
– experience vaginal symptoms in the early postmenopausal period?
• 30%
– experience vaginal symptoms in the late postmenopausal period?
• 47%
– seek medical advice?
• 10%
Symptoms of Menopause
• Natural history;
– Symptoms start and increase from 2 years prior to the final menstrual
period, peak at one year following it and return to normal after 5 years
– Varies widely
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Menstrual irregularity
Hot flushes and sweats
Sleep disturbances
Vaginal dryness
Urinary symptoms
Mood changes
Loss of libido
• Osteoporosis and CVD and stroke risk increase
Investigations
• Not necessary in most cases
• FSH
– Levels vary in perimenopause so single measures
unreliable.
– >30 IU/L – postmenopausal range
– >12 IU/L – raised in women still menstruating
• Other hormone tests – not useful
• TFTs
When is FSH Helpful?
•
Premature menopause
– Measure on day 3-5 of cycle
– If amenorrhoeic take 2 samples 2 weeks apart
•
Hysterectomy with conservation of ovaries
– Measure on 2 or more occasions at least 1-2 months apart
•
Women using hormonal contraception
– Must be off COCP for at least 6 weeks before testing. Can start
progestorone only preparation.
– Measure on 2 or more occasions at least 1-2 months apart
– A level in the menopause range in 2 or more occasions suggests ovarian
failure
– May still be at risk of becoming pregnant!
Premature Menopause
• Defined as menopause before age 45
• Causes;
– Primary ovarian failure
– Surgically induced menopause
– Radiation induced
– Chemotherapy induced
– May be linked with smoking, lower socioeconomic groups, BMI,
family history
• Refer any women under 40
• Prescribe HRT for osteoporosis prevention
• Stop HRT at normal age of menopause (50)
Management of Menopause
• Reassurance
• Education, lifestyle changes
• HRT
• Alternatives
Lifestyle changes
• Hot flushes and night sweats
– Regular exercise, lighter clothing, sleep in a cooler room, stress
management
– Avoid triggers
• Sleep disturbances
– Avoid exercise late in the day
– Maintain regular routine
• Mood and anxiety
– Adequate sleep, regular exercise, relaxation exercises
• Cognitive symptoms
– Adequate sleep, regular exercise
Benefits of HRT
• Effective for;
– Treating vasomotor symptoms
– Treating urogenital symptoms
– Treating sleep or mood disorders if associated
with flushes or night sweats
– Preventing osteoporosis
– Reducing risk of colon cancer
• Improves quality of life and sexual function in
symptomatic women
Side Effects
• Oestrogen related
– Nausea, headaches, breast tenderness, fluid retention,
headaches
– If side effects occur advise to persist for 3/12
– Try reducing dosage
– Try swapping oestrogen types (estradiol/conjugated oestrogens)
– Try changing mode of delivery
• Progestogen related
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Bloating, Mood swings, headaches, backache
Less androgenic progestogens produce less side effects
Change to continuous therapy if postmenopausal
If problem is bleeding then change to more androgenic
progestogen or increased progestogen dose
Risks
Risk
Background
incidence per 1000
women in Europe
not using HRT
Additional cases per
1000 women using
oestrogen only HRT
(estimated)
Additional cases per
1000 women using
combined (oestrogenprogestogen) HRT
(estimated)
Over 5
years
Over 10
years
For 5
years’ use
For 10
years’ use
For 5
years’ use
For 10
years’ use
50–59
10
20
2
6
6
24
60–69
15
30
3
9
9
36
Endometrial
cancer
50–59
2
4
4
32
NS
NS
60–69
3
6
6
48
NS
NS
Ovarian cancer
50–59
2
4
<1
1
<1
1
60–69
3
6
<1
2
<1
2
Venous
thromboembolis
m
50–59
5
2
7
60–69
8
2
10
Stroke
50–59
4
1
1
60–69
9
3
3
70–79
29–44
NS
15
Breast cancer
Coronary heart
disease
Age
range
(years)
Contraindications
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Breast cancer
Endometrial cancer
Untreated endometrial hyperplasia
Undiagnosed vaginal bleeding
Thromboembolic disease
Arterial disease
Active thrombophlebitis
Liver disease where LFTs not returned to normal
Pregnancy and breastfeeding
Stop 4-6 weeks prior to surgery and restart when fully mobile
Which Type of HRT??
HRT
With Uterus
Without Uterus
Perimenopausal
Postmenopausaal
Cyclical
Combined
Continuous
Combined
Unopposed
Oestrogen
Urogenital Symptoms
Local
Oestrogen
Start at lowest dose possible for shortest period of time
Systemic Oral HRT
• Cyclical combined
– Use in perimenopause
– Have monthly withdrawl bleeds
– Eg Prempak C, Elleste Duet
• Continuous combined
– Use if >1 year after last period
– No bleed
– If bleeding beyond 3-6 months, needs
further ix
– Eg Premique, Nuvelle continuous
• Unopposed oestrogen
– Only use if no uterus
– Eg Elleste solo, Premarin
Other Preparations
• Transdermal patches
– Available as unopposed oestrogen,
cyclical and continuous
– May have a lower thromboembolic
and stroke risk
– May have skin reactions
– Apply to buttock
• Vaginal preparations
– Pessaries, creams, rings
– Eg vagifem tablets, premarin
• Implants, gels
Alternatives
Alternatives
• General rule is to advise against herbal medications.
• Many may contain oestrogenic compounds.
• Women may be taking more hormones by using these than they would
with HRT.
• They are often not regulated by a governing body.
• Some studies suggest diet high in soy and isoflavones reduces severity and
frequency of symptoms. They are safe.
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Foot massage, reflexology – no evidence
Evening primrose oil – no evidence
Black Cohosh – limited evidence
Red Clover – limited evidence, no health concerns
Dong Quai – no evidence
• RCOG – SAC Paper 6 – alternatives to HRT for the management of
symptoms of the menopause
Medical Alternatives
• Tibolone – synthetic steroid with weak oestrogenic, progestogenic
and androgenic properties.
• Clonidine – alpha 2 agonist which helps with vasomotor symptoms.
Useful for patients with hx of breast cancer.
• SSRIs can reduce vasomotor symptoms.
• Gabapentin reduces severity and frequency of hot flushes
• Progestogens – may improve hot flushes but there are concerns
about risk of breast cancer
• Replens – vaginal bio adhesive moisturiser
First Consultation
• History
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confirm menopause clinically
LMP
Symptoms
Gynae history – smears, mammograms
Risk factor for osteoporosis
PMH/FH breast ca/CHD/thromboembolism
Contraception
• Examination
– Blood pressure
– Height and weight
– Breast exam?
First Consultation Ctd
• ICE – Depression, anxiety, effect on life
• Investigations?
• Management
– Lifestyle changes
– If starting HRT
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discuss benefits, risks, side effects
Ensure no contraindications
Discuss different preparations
Discuss contraception
– Alternatives
• Safety net – investigate PCB, bleeding 1 year after LMP
• Arrange follow up
Follow Up
• Reassess after 3 months then annually
• Follow up consultations should cover;
– Assessing effectiveness
– Enquiring about side effects
– Ask about bleeding pattern
– Check weight and BP
– Ensure she examines her breasts regularly
• If on cyclical treatment, consider changing to continuous if she is
considered to be postmenopausal. This is usually considered to be
– If she is over 54 years or;
– If they have had previous raised FSH levels or amenorrhoea or;
– If they have been on cyclical regimes for at least 2 years
Stopping HRT
• General rule is to stop after 1-2 years to see if
symptoms have gone.
• If they recur, can try lower dose or try different
method.
• Stop HRT 4-6 weeks prior to major surgery.
• If started for early menopause, stop at age 50.
Scenario 1
•
Deidre (54) has been on
continuous combined HRT
for a year. She describes
an episode of
postmenopausal
bleeding.
•
•
You should reassure her that breakthrough
bleeding on HRT is normal. T/F
– False
If the bleeding occurred in the first 2 months
you could....
– Reassure
– Consider changing to a more androgenic
progestogen-containing HRT
– Consider changing to transdermal route
– Consider changing to cyclical to make
more predictable
– Combine with the IUS
Scenario 2
• Susan (49) presents with • Topical oestrogen is contraindicated as she
pain on intercourse. She
is already taking oral oestrogen. T/F
had a total abdominal
– False
hysterectomy with
• What are your treatment options?
oophorectomy 8 years
– Vaginal lubricants
ago. She currently takes
– Vaginal moisturisers
1mg estradiol. O/E –
atrophic vaginitis
– Topical oestrogen
• Topical oestrogen can be used for a
maximum of 5 years. T/F
– False
• She re-presents complaining of reduced
libido. Treatment options include;
– Psychosexual counselling
– Change HRT to a patch
– Testosterone replacement?
Scenario 3
• Peggy (67) comes to see you • You must stop her HRT immediately. T/F
for a repeat prescription of
– False
her HRT. She has been using • What could you do?
Premique for 15 years. She
– Trial decreased oestrogen dose
also takes
– Change to a patch
bendroflumethiazide for
hypertension.
– Stop HRT gradually
– Continue with current dose with
annual review
• Should she have annual mammograms?
– No – continue routine screening
every 3 years. Will need to continue
with screening as long as remains on
HRT.
Scenario 4
•
Bianca (31) presents with
a 6 months history of
amenorrhoea after
stopping her pill. She is
otherwise well and denies
any stress or other
symptoms. She wants to
try to get pregnant.
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•
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Amenorrhoea in should be investigated after;
– 6 weeks
– 6 months
– 1 year
– 2 years
Appropriate investigations include
– FSH/LH
– TFTs
– Prolactin
– Pregnancy test
FSH is found to be 45. What should you do?
– Refer
– Offer HRT or COC
– Note – she could still become pregnant.
AKT Question
• Which statements are correct regarding
menopause?
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Defined as >18 months since last period
Diagnosed if >6 months since last period
Clonidine can be used to treat hot flushes
Diabetes is an absolute contraindication to HRT
Breakthrough bleeding whilst on HRT is of no concern
Increased frequency of UTIs occur
Decreased risk of IHD
Increased risk of osteoporosis
Can cause depression
Help for patients
• British Menopause Society
• Daisy Network Premature Menopause
Support Group
• National Prescribing Centre website for risk
charts (decision aids)
Summary
• Menopause symptoms can be managed with
lifestyle advice and medical treatment
• HRT is the most affective treatment but is
associated with risks so should be used at the
lowest dose for the shortest time necessary
• Women should be allowed to make an informed
decision regarding starting and continuing HRT
• More data is needed on complementary
therapies