22/02/2015
Menopausal Hormone Therapy & Contraception
Dr Warren SW Chan BSc(Med) (Hons I) MBBS (Hons I) FRANZCOG MRMed CREI
Fertility & IVF (CREI) | Gynaecology | Laparoscopy | Robotic Surgery
25 February 2015
SAN Suite 207, SAN Clinic Tulloch
Disclosures
• Co‐director of AEVAFEM
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Advanced Gynaecological Surgery & Fertility Specialists • Fertility & Reproductive Endocrinology Subspecialist (CREI)
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Genea
Westmead Fertility Centre
Royal Prince Alfred Fertility Unit
• Advanced Gynaecological Surgeon
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SAN & Norwest Private Hospitals
Westmead & Royal Prince Alfred Hospitals
Menopausal Hormone Therapy
Balancing your patient needs with current controversies
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22/02/2015
MHT – The Beginnings • 1966 – MHT popularized by publication of “Feminine Forever”
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“When you see a woman of 50 looking like 30, or a woman of 60 looking and acting like 40, chances are she is one of the lucky ones who have benefited from the new technique of menopause prevention” (Science Digest, 1966)
• Widely promoted as the panacea for youth and vitality by both medical professionals & pharmaceutical companies
Women’s Health Initiative • WHI I (JAMA, 2002)
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Women who used MHT (E + P)
“The research found that combined HRT led to a 26% increase in breast cancer …. the link was so significant that the arm of the study using combined HRT had to be stopped” •
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“Stop your HRT and ring your doctor” Daily Telegraph, 2002
“1 in 4 women on HRT would develop breast cancer”
Sydney Morning Herald, 2002
WHI 2 (JAMA 2004)
• E only vs placebo
• No significant differences except
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CVA (↑ risk)
Hip fractures (↓risk)
• Trend towards lower breast cancer
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MHT – Where are we in 2015?
MHT – Cardiovascular Risks
LaCroix A et al, JAMA 2011
MHT – Cardiovascular Risks
• For women in their 50’s, taking MHT will not harm their cardiovascular health. MHT may even be beneficial for cardiovascular health for women in their 50’s but should not be prescribed for this indication alone (de Villiers TJ et al, Climacteric 2013)
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MHT – Breast Cancer
WHI Follow Up Data
Placebo
• Post‐intervention follow up
CEE only
Placebo
CEE only
• CEE only vs placebo
• Breast cancer RR = 0.77 (95%CI 0.62‐0.95)
LaCroix A et al, JAMA 2011
MHT – Breast Cancer
Further WHI Follow Up Data
Manson J et al, JAMA 2014
MHT – Breast Cancer
• The risk of breast cancer and MHT use is complex
• The risk of breast cancer over 50 years attributable to MHT is small
• The increased risk of breast cancer is primarily associated with the addition of a progestogen to estrogen containing MHT and is related to duration of use
• The risks of breast cancer decreases after stopping MHT de Villiers TJ et al, Climacteric 2013
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MHT – VTE Risks
BMI
Thrombophilia
Straczek C et al, Circulation 2005
Canonico M et al, Circulation 2007
MHT – VTE Risks
Oral MHT
Transdermal MHT
• Absolute risk of VTE in MHT is low below age 60
• Risk is highest in first year of use
• Observational studies suggest lower risk with non‐
oral therapy
(Laliberte F et al, Menopause 2011)
de Villiers TJ et al, Climacteric 2013
MHT Prescribing Cheat Sheet
Hysterectomy
Estrogen only
Still menstruating
Sequential Estrogen + Progestogen
Peri‐menopausal contraception
Low dose COCP, Mirena IUCD
Endometriosis
Continuous Estrogen + Progestogen, Mirena IUCD + Estrogen
Early menopause
Higher Estrogen doses
Older woman
Lower Estrogen doses, Non‐Oral Therapy
Obese, high triglycerides, diabetes
Non‐Oral Therapy
Hypertension
Non‐Oral Therapy, consider Drosperinone containing MHT
Local symptoms
Local therapy
Low libido, dense breasts
Tibolone
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The Future • Tissue Specific Estrogen Complex (TSEC)
• Estrogen (CEE) + SERM (Bazedoxefine)
• Advantages
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Decreases vasomotor symptoms
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Improves bone mineral density
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Protects endometrium
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Does not stimulate breast tissue
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No increase in DVT risk compared with E alone
Key Messages
• The principal indication for prescribing MHT is troublesome menopausal symptoms
• MHT is the most effective treatment for vasomotor symptoms associated with menopause
• MHT use in women in their 50’s is very safe – the benefits are more likely to outweigh risks for symptomatic women less than 60 years of age or within 10 years after menopause
de Villiers TJ et al, Climacteric 2013
Useful Resources
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22/02/2015
Contraception
The Fourth Generation
COCP – Mechanisms of Action
• Progestogen
• Cervical ‐ mucous
• Endometrium
• Tubal
• Ovary – prevents ovulation by suppressing LH
• Estrogen
• Suppresses FSH
• Potentiates effect of Progestogen
• Stabilises endometrium – less BTB
Generations of COCP
• First Generation (red)
• Second Generation (yellow)
• Third Generation (green)
• Fourth Generation
• Dienogest
• Nomegestrol acetate 7
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Fourth Generation COCP
• Combines • 4th Generation Progestogens
• “Bio‐identical” Estrogens
• Marketed in Australia
• Qlaira® – Estradiol Valerate + Dienogest (quadraphasic)
• Zoely® – Estradiol (1.5mg) + NOMAc (2.5mg)
• 24 active pills, 4 inactive pills
Key Messages
• Advantages
• Licensed for use in Heavy Menstrual Bleeding (Qlaira®)
• Profound effect on endometrium
• Theoretical reduced risk of VTE
• Awaiting results of long term prospective studies • Theoretical improved efficacy • Shorter pill free period
Key Messages
• Disadvantages
• Increased amenorrhea & break‐through bleeding
• Profound effect on endometrium
• More complex in “missed pill” and “extended use regimens”
• Not on PBS
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Thank You – Any Questions?
Dr Warren SW Chan BSc(Med) (Hons I) MBBS (Hons I) FRANZCOG MRMed CREI
Fertility & IVF (CREI) | Gynaecology | Laparoscopy | Robotic Surgery
25 February 2015
SAN Suite 207, SAN Clinic Tulloch
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