MENOPAUSE AND HRT
What is the menopause and perimenopause?
Perimenopause is the time from when
the ovaries begin to fail (symptoms may
begin eg irregular periods or hot flushes)
until 12 months after the final menstrual
period
Menopause is when menstruation ceases
permanently. Occurs with the final
menstrual period, and can therefore be
diagnosed with certainty only after 12
months' spontaneous amenorrhoea
Who is affected and when?
Why do patients present?
Affects 80% of women
45% find symptoms distressing
Mean age in UK 52y old
Usually self-limiting (2-5 years)
Some have symptoms for many years
Premature - symptoms begin <45y
Menstrual irregularity
Hot flushes and sweats
Sleep disturbance
Urinary and vaginal symptoms
Mood changes
Loss of libido
What do we need to assess?
History
Examination
Confirm it is menopause?
Discuss symptoms and their effects?
Bleeding – when last occurred / PCB / PMB
Age of the woman
Is the uterus intact?
Risk factors for osteoporosis, CHD, breast Ca
BP
Height and weight
Bimanual (only if Hx indicates)
Health promotion
Potential CI to HRT
Smoking and alcohol
Diet and exercise
Up to date smears?
Breast self-examination
Breast screening
Pregnancy / breast feeding
Undiagnosed abnormal vaginal bleeding
VTE
Recent angina / MI
Past, suspected, current, breast Ca
Endometrial/other oestrogen dependent Ca
Active liver disease with abnormal LFTs
Further Ixs
FSH – only if premature menopause suspected
Thrombophilia screen if FH VTE
If indicated – bone density scan, CV risk assessment, Ix of abnormal bleeding
What are the treatment options?
Do nothing – natural process
HRT – Systemic or local – cyclical or continuous
Tibolone
Clonidine
SSRIs
Gabapentin
Testosterone
Phytooestrogens
Complementary therapies
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Understanding HRT
No uterus
No need for progestogen protection
Either tablet, patch or gels or implants
eg Elleste solo (low dose tablet) or Premarin (medium dose tablet)
eg Evorel patch (low dose or medium dose version)
Periods still happening (Perimenopausal)  cyclical combined HRT
Either monthly or three monthly
Take oestrogen everyday and then progestogen added for 14 days of 28 day cycle
therefore regular bleed every 28 days
OR
oestrogen everyday then progestogen for 14 days every 13 weeks giving a bleed
every 3 months
eg Elleste duet 1mg (low dose) or Prempak-C 0.625 (medium dose)
eg Femapak 40 transdermal patch (2x weekly medium dose)
Periods stopped > 1 year ago (Postmenopausal)  continuous combined HRT
Usually do not have a monthly bleed
eg Premique low dose tablets.
eg Evorel conti transdermal patch (2x weekly)
If sub total hysterectomy then because unsure if any endometrial tissue left usually
start with cyclical combined HRT if no bleeding after a 3 months then can stop progestogen
and continue oestrogen only HRT
Explaining indications for HRT
Short term
Relief of vasomotor symptoms
Long term
Prevention / Rx of CVD and osteoporosis
(where premature menopause until aged 50y)
Explaining benefits of HRT
Helps vasomotor symptoms
Help urogenital symptoms
Prevents osteoporosis (use HRT in premature menopause for this indication)
Reduced colorectal Ca risk
Explaining potential side effects
Oestrogen
Breast tenderness
Leg cramps
Bloating
Nausea
Headaches
Progestogen
PMS like symptoms
Breast tenderness
Backache
Depression
Pelvic pain
Explaining risks to patients
Main controversy surrounding HRT is as a result of the Women’s Health Initiative, a US
based study, and the Million Women Study based in the UK published between 20022004.
Increased risks of:
Breast cancer - Risk lower with oestrogen only HRT, risk increases with use
Endometrial cancer - Adding cyclical progestogen effectively eliminates risk
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Ovarian cancer – Risk increases with use
VTE - Risk higher with combined HRT
CHD - If starting combined HRT >10y after menopause
Stroke
*IMPORTANT*
DO NOT USE HRT if history of above cancers, VTE, CVD, abnormal vaginal bleeding,
pregnancy or severe liver disease.
Important to explain these risks carefully as generally all women as they get older have
increased risks of the above and when you compare groups of women on HRT and a group
of women not on HRT the increased risk is very slight.
For example for breast cancer
In a group of 1000 women aged 50-59 in a 5 year period
-10 will get breast cancer
-12 will get breast cancer if on oestrogen only HRT (therefore 2 extra cases)
-16 will get breast cancer if on combined HRT (therefore 6 extra cases)
Generally the risks are greater the longer you take HRT
Is contraception required?
HRT does not suppress ovulation
In those with intact uterus use contraception
For 1y after LMP if >50y
For 2y after LMP if <50y
How to start treatment
-
Aim to start on lowest dose that controls symptoms
After 1-3 years think about HRT break to see if symptoms have settled
Vaginal symptoms  vaginal cream or pessary
Think about whether perimenopausal, post menopausal and whether they have a
uterus as this will decide what sort of HRT they will have
Then need to decide how to give each hormone as there are various options
o
Oestrogen options

Tablets (remember to start at low dose)

Transdermal patch or gel, gel useful if skin irritation occurs with
patches

Oestrogen implants (usually last resort)

If just using local oestrogens initial dose is nightly for 2/52
followed by twice weekly for maintenance
o
Progestogen options

In combined tablets

Progestogen tablets separately (provera or utrogestan)

Mirena coil: particularly useful if contraception is needed,
persistent progestogenic s/e from systemic HRT or when
withdrawal bleeds are heavy on sequential HRT and serious causes
have been excluded.
What about tibolone?
Selective oestrogen receptor modulator (SERM)
Has oestrogen, progestogenic and androgenic properties
Improves sexual function and vasomotor symptoms
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Increases stroke risk in older women
Generally risks outweight benefits if >60y
Increases risk of breast Ca recurrence in those with a previous Hx
Alternatives
Lots of options available with varying levels of evidence:
-Evidence for reducing hot flushes  Clonidine, SSRI’s (venlafaxine, fluoxetine and
paroxetine), Gabapentin, High dose progestogens (MPA- usually only hospital prescribed
due to strict criteria)
- Lots of herbal remedies on offer. Have to be careful as many of them have oestrogenic
properties so wary in people who shouldn’t have oestrogen. Most evidence is for red clover
and acupuncture.
-Others to consider black cohosh, evening primrose oil, dong quai, ginkgo biloba or
ginseng.
*Note: Current CKS guidelines does not recommend complementary therapies.
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