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

– 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• 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– 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

RisksRisk Age

range (years)

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 (oestrogen-progestogen) HRT (estimated)

Over 5 years

Over 10 years

For 5 years’ use

For 10 years’ use

For 5 years’ use

For 10 years’ use

Breast cancer 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 thromboembolism

50–59 5   2   7  

60–69 8   2   10  

Stroke 50–59 4   1   1  

60–69 9   3   3  

Coronary heart disease

70–79 29–44   NS   15  

Contraindications

• 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 Urogenital Symptoms

Perimenopausal

Postmenopausaal

Cyclical Combined

Continuous Combined

Unopposed Oestrogen

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.

• 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– 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

• 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

pain on intercourse. She had a total abdominal hysterectomy with oophorectomy 8 years ago. She currently takes 1mg estradiol. O/E – atrophic vaginitis

• Topical oestrogen is contraindicated as she is already taking oral oestrogen. T/F– False

• What are your treatment options?– Vaginal lubricants– Vaginal moisturisers– 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 for a repeat prescription of her HRT. She has been using Premique for 15 years. She also takes bendroflumethiazide for hypertension.

• You must stop her HRT immediately. T/F– False

• What could you do?– Trial decreased oestrogen dose– Change to a patch– 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.

• 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?– 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