Menopause Management

Dr Manju Navani

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Definition

• Menopause: 12 months after LMP • Average age of menopause is 51 yrs

• Peri-menopause: start of symptoms to 12 m after LMP

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Menopause – Men…o….Pause

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Signs and Symptoms

Vasomotor SymptomsSleep DisordersMood ChangesJoint pains, aches, tiredForgetfulness

Urogenital AtrophyReduced sex drive

OsteoporosisAtherosclerosisCoronary Heart DiseaseDementia-POI

40 yrs 50 yrs

Menopause

60 yrs

Adapted from Van Keep PA et al. Maturitas 1990;12:163–70. Slide donated by Mylan

Menstrual Disorders

Assessment in Primary care

• History – symptoms • Exclude other causes of symptoms: thyroid ,

depression, Iron deficiency • Medical history/Family Hx - R/O Contra-indications• Discuss benefits & personalise risks• Discuss Rx options • Info on websiteswww.menopausematters.co.uk, www.womans-health-concern.org.uk

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Role of Blood test(FSH)to diagnose menopause

NOT NEEDED IN OVER 45 yrs (Qualilty Standard 1)

Indication for measuring FSH (<45 yrs)QS21. Under 40 yrs2. Age 40-45 yrs , symptoms • FSH > 30 mIU/L (Repeat in 6-8 weeks), levels

pulsatile DO NOT Measure if • On COCCan check FSH if on on Depo Provera injections –but do around 10 weeks

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Premature Ovarian Insufficiency (POI)

• Menopause < 40 years ( 1%)

• Causes: Idiopathic, F/Hx , chromosomal , Auto-immune, iatrogenic

• Investigations- Baseline BMD, repeat if osteopenia/osteoporosis

• Management – COC/HRT till 51 (QS 3) • Contraception• Consequences- QoL, IHD, Osteoporosis, Dementia,

Parkinsonism

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Support Group for POIwww.daisynetwork.org.uk

www.womens-health-concern.org

History & Examination HISTORY

SymptomsRx tried

Menstrual HxContraception

Gynae HxSexual History

Medical HxFamily Hx

Mental healthAlcohol, smoking,

ex , diet Occupation

LMP, Periods- ?heavyHave they stopped ?

Gynae Hx: Endometriosis, fibroids, Hysterectomy, BSO, Gynae cancers

CVD /Stroke & Risk Factors,• VTE

• Cancers: Breast , ovarian ,Bowel Osteoporosis

• Migraines+/- aura, epilepsy , Thyroxine, Malabsorption

EXAMN: BMI, BP Investigations: if indicated –TFT, DEXA scan,

lipid profile, FSH (<45)

of HRT• Symptom relief• POI , early menopause• Prevention & RX of

osteoporosis under 60• In early post menopausal

years: window of opportunity & protects from CVD

• Reduces risk of colorectal cancer

• HRT doubles risk of VTE • Oral HRT has higher risk

>transdermal • Risk with Transdermal

HRT no greater than baseline

• Risk factors: age, BMI>30, smoking ,F/Hx , immobility

• If high risk VTE : refer to Specialist , Heamatologist

HRT and breast cancer risk

HRT has similar risks to late menopauseWoman’s risk breast cancer with late menopause• 2.8% increase per year • With HRT: 2.3% increase per year

• E only HRT: li le/no ↑ risk• E + P – slight ↑ risk related to

duration, reduces after stopping , and baseline risk varies from one woman to another depending on underlying risk

• 1/1000 per year over 5 yrs

CVD / Stroke / Ovarian Cancer

• Re-analysis of WHI study: within 10 yrs of menopause HRT is cardio-protective (window of opportunity)

• Risk increases with age, depends on risk factors.

• Increased risk of stroke with Oral HRT, risk is 1:1000 under 60 .

• Over 60: risk of stroke 4.5/1000

IMS recommendation on womens midlife health and MHT- Climacteric 2016:19(2)109-50Danish Osteoporosis Prevention Study (DOPS study) :2012, 17B E2 + NETA in early post menopausal yearsFinnish Study: Hodis HN et al. Vascular effects of Early v late post menopausal Rx with E . New Eng J of Med 2016;374(13)1221-31ELITE study, KEEPS trial

• 2015 meta-analysis of 52 studies• Increased risk with HRT• 1/5000 per year • 1 additional death per 1700 users

Ovarian Cancer

Condition %age Extra/1000.yr

Heart Attack +29% +0.7

Stroke +41% _0,8

All VTE +100% +1,8

PEs +113% +0.8

Breast Cancer +26% _0.8

Endometrial cancer

0 nil

Ovarian cancer

0 nil

Colorectal Cancer

-37% -0.6

Hip fracture -34% -0.5

• Higher mortality rate from heart disease (53%) vs mortality rate from breast cancer (3%)

Management : Life style advice

Management

Diet, Lifestyle changesHRT options- Local , Systemic

Non HRT options ( Alternatives to HRT) RCOG leaflet 1. Pharmacological Rx (SSRI, SNRIs) 2. Non - pharmacological Rx• Phytoestrogens• Herbal Psychological – CBTComplementary therapy

When to Say No…..No to HRT?

• Breast Cancer• Endometrial Cancer beyond Stage 1 • Undiagnosed genital bleeding• Current thromboembolic disease/ IHD• Active liver disease

• CAUTION STARTING OVER 60• Migraine • Hypertension• Past Hx of VTE/Family HX of VTE• Hyperlipidemia• Fibroids• Endometriosis

Types of HRT

Progestogen

Oestrogen EstrogenOnly(no uterus)

Oestrogen17-28

CyclicalBleed (Sequential)

Oestrogen

No BleedContinuous combined HRT (CCHRT)

Estrogen

Progestogen

Which HRT?

Systemic HRT Local HRT

HAS UTERUS/ENDOMETRIAL PROTECTION NEEDED

NO YESE+P

E ONLY Periods<1 yr

Sequential HRT E + IUS

Periods>1 yr or age 54CCHRT

TiboloneE+IUS

Indication for CCHRT

• If LMP>1 yr back

• At age 54-55

• >3-4 yrs on Sequential HRT

HORMONES

Oestrogens • Oestradiol

• Conjugated equine Oestrogens

• Oestradiol Valerate

• +/- Testosterone

ProgestogensC19 – Nor-ethisterone, levonorgestrel

C21 – MPA, Dydrogesterone

Natural Progesterone: Uterogestan

IUS – LNG x 5 yrs

Progestogens1. Androgenic : Norethisterone(NET) , Levonorgestrel

PMS , less lipid friendly

2. Non - Androgenic : DydrogesteroneIndication: if has PMS with NET, DM , Raised cholesterol

3. Uterogestan – Complex medical problems , Risk factors of VTE , F/Hx of breast cancer (less androgenic, less thrombogenic, less carcinogenic on breast)

4. IUS- no safety data on breast

5. Drosperinone (Angelique)- anti- mineralocorticoid activity

Women with a uterus (Seq HRT)1st line HRT (Oral) NET • Elleste Duet 1mg • Elleste Duet 2 mg

2nd line HRT ( Oral) DG• Femoston 1/10• Femoston 2/10

Women with a uterus ( CCHRT)No periods x 1 yr

• Elleste Duet Conti 2 mg ( E + Norethisterone)

• Femoston Conti - I mg ( E + Dydrogesterone )• Femoston Ultra Low dose ( 0. 5mg) • Tibolone (improves sex drive, endometriosis)• IUS x 5 years

Oestrogen only – No Uterus

• Oral Estradiol - Elleste Solo ( 1 mg, 2 mg )

• E2 patches ( 25, 37.5 , 40 , 50, 75, 80, 100 mcg )

• Oestrogel (2 measures =1.5 mg)

• Sandrena gel ( 0.5mg , 1 mg sachets)

50 mcg patch= 1mg oral E2 =1- 2 measures of Oestrogel

Implant E2- Hysterectomy , poor response to above

Indications for transdermal HRT

• Migraines• BMI>30• HT• Diabetes• Hx of VTE• On Thyroxine, anti-

epileptics• Crohn`s disease• Poor relief with oral HRT• Hypertriglyceridemia• Gall Bladder disease

Oestrogel

• 1-2 measures daily, can increase dose to 3-4

Uterogestan• 100 mg cap daily (CCHRT)• 200mg x12 days • At bedtime , on empty

stomach • Drowsy, somnolence

COMPOUNDED BIO-IDENTICAL HORMONES(unregulated)

BODY-IDENTICAL (Regulated)

Duration & F/U of systemic HRT

• POI - until age 51 at least• >51 yrs : Informed choices ,

No arbitrary time limit (under 5 yrs – safety data)

• Discontinue gradually-makes no difference

• Individualise Rx: - 50-60 yrs- Benefits

outweigh risk- 60-70 Benefits = risk, - Over 70 Risk outweigh

benefits

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1 At 3/12, followed by Annual review (QS4)2. BP, BMI3. Check Bleeding pattern, symptom control4. Risk Benefit Analysis5.Any changes in Medical History6. Dose reduction with age When to stop??

Indication to refer to Specialist

• Uncertainty about Rx options• Side Effects on HRT• Multiple Rx failures• Tried 2-3 preparations• Abnormal bleeding on HRT• Premature Ovarian Insufficiency ( POI) <40 yrs• Complex medical problems• Personal /Family Hx of VTE & Breast Cancer • Endometriosis , fibroids, focal migraines• Age over 60 • Safety concerns/CI to HRT

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HRT and contraception

• SEQ HRT is not a contraceptive • CCHRT – post menopausal • POP- Micronor/Norgeston• IUS will be best option

• Implant or Depo Provera• Barrier Method

Case 1

• Age 52, C/O hot flushes night sweats , for past 6 months and is unable to sleep. Has low sex drive.

• Periods are irregular every 6-8 weeks and lasts for 4-5 days

• Keen to start HRT • BP-120/80, BMI=28, non smoker, Alcohol 2 bottles of

wine/week• Has Googled about HRT and keen to start HRT• What advice, HRT options ?• Contraception?

Management• History taking, Counsel about HRT , Benefits and Risks of HRT• Examination?• HRT- Oral or Transdermal • Sequential or Combined HRT• Elleste Duet 1 mg or Oral Estrogen and IUS • Follow up – Review when?• Still has some hot flushes , low mood on Elleste Duet 1 mg -

Which HRT will you prescribe?• Elleste Duet 2 mg • Has PMS symptoms in second half of cycle ?• Which HRT?• Femoston 2/10, Now age 55 – which HRT can you change to?

Case 2

• Age 52, IUS fitted 2 year back • No periods • Gaining weight and wants IUS removed • C/O hot flushes few, foggy head - 6 months• Sex is painful, dryness, recurrent thrush • BMI=31 , BP 120/80

When can contraception be stopped ?Which HRT?What if she was HT ?What blood test if she has poor response to HRT ?

Vaginal Oestrogens (LOCAL EFFECT ONLY)

Tablets Cream Ring

Small to insert, licensed for long term use

For vulvalirritation , messy , licensed 3-6 months

Remains in vagina x 3 months , licensed for 2 years

Nightlyx2 wks follby twice a wk

Same regime Changed 3 monthly

Vagifem 10 mcg Oestriol 0.1% and 0.01%

Estring 7.5 mcg /day

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Vaginal Moisturisers

• Pjur Med ( silicone based)• Yes, oil based lubricant • ReplensWater based – not so effective• Regelle, Replens, Hyalofemme• With Tamoxifen- can have very low dose local

E but need to liase with Breast cancer surgeons

Case 3

• Age 42 , No periods for 6 months after stopping COC (x8yrs) • Has 2 children - 5yrs, 7 yrs• Hot flushes, feels tired , low mood, loss of sex drive• Started on Citalopram by GP- slight improvement in

symptoms • FHx – early menopause mother in 40`s• BMI =26, BP 120/80

Rx options

• COC/HRT till age 50• Zoely/Qlaira- natural hormones(cont/extended regimes) • IUS+ E2 (estradiol) tablets (IUSx5 years)• HRT- Seq HRT- Elleste Duet 1 mg tablets daily and use

condoms• HRT – as above and Micronor pill (POP) • FU in 3/12 and thereafter yearly • When will you change her HRT to CCHRT?• Age 51 – Do you stop her HRT ??

Case 4

• Age 55, no periods for 3 years• Has hot flushes , night sweats x 2-3 yrs, • BMI=30, BP 120/80• Non smoker , good health, • Alcohol - 18 units/wk• Her mother in law died of breast cancer on HRT • Would like further information on

Alternatives to HRT

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Alternatives to HRT

RCOG – Pt info leaflet www.rcog.org.uk• CBT

Paroxetine /Fluoxetine 10 mg vs 20 mg- less side effects, effective Potent CYP2D6 inhibitor- reduces efficacy of Tamoxifen

Sertraline50 mg daily

Citalopram 10-20 mg daily

Venlaflaxine – 37.5 mg daily, can increase dose to 75 mg

Can be given with Tamoxifen, take in the morning to avoid insomnia Clonidine, Gabapentin

Herbal Remedies & Diet

• Red Clover : Promensil

• Black Cohosh

• Sage, alfa alfa

• Phytoestrogens in diet

Case 5

• Age 52, TAH with BSO at 50• Menopausal symptoms , low sex drive , tiredness• She is worried about risk of breast cancer with

HRT .• How can you reassure her?

• NICE Guidance : E only HRT – no increased risk or lower risk compared with Combined HRT , as no progestogen

• Which HRT??

Why NICE?

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1.Menopausal symptoms >45- Don’t send FSH2. If low mood- don’t start on anti-depressants, consider CBT, HRT3. Individualise HRT Rx- dose , type, with age lower doses 5. Risk Benefit Analysis 6. HRT within 10 yrs of menopause or under 60 – benefits outweigh risks7. POI, Early menopause – HRT till age 51 8. Vaginal E low dose – licence for indefinite use 9.BMS vision for menopause care

Training

• http://www.pcwhf.co.uk/(Primary Primary Womans Health Care Forum)

• www.menopauseacademy.co.uk

- Mylan Webinars • BMJ learning• Management of The

Menopause- 6th edition -BMS • Special Skills Module in

Menopause ( British Menopause Society website)

• Patient info leaflet ( NICE)• Menopause & me leaflet • www.menopausematters.co.u

k• www.womens-health-

concern.org.uk• www.bms.org.uk• www.managemymenopause.co.

uk• www.menopausedoctor.co.uk• www.nice.org.uk

Thank you for your attention

Questions ?